Best Practice Recommendations: Translating Evidence Into Action
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Tuesday, July 30, 2019

Best Practice Recommendations: Translating Evidence Into Action

By Anna-Marie Schmidt, MM, DC, and Robert Vining, DC, DHSc

Research evidence suggests following guideline recommendations can improve quality of care and clinical outcomes.1–3 However, translating recommendations into clinical care for individuals can be challenging because guidelines, by nature, tend to inform care on a general level.

Further complicating guideline adherence is confusion caused by inconsistent terminology, the existence of multiple guidelines for single conditions, poor transparency in describing how evidence is interpreted, and a failure to describe or recommend implementation strategies.4,5 Inconsistent recommendations within guidelines raises the question, “Is there common ground among guidelines for musculoskeletal conditions?” To answer this question,  researchers identified 11 recommendations that consistently appear within current guidelines (Table 1).4 In this article, we address three commonly occurring recommendations.

Table 1: Best practice recommendations for musculoskeletal care4

Recommendation
Description
  1. Ensure care is patient centered

Care that accounts for individual preferences and incorporates shared decision making

  1. Screen for red flag conditions

Identify possible serious pathology

  1. Assess psychosocial factors

Includes emotions, fears, social support, and recovery expectations

  1. Use imaging selectively

Consider when serious pathology is suspected, or there has been limited response to care

  1. Undertake a physical examination

Assess mobility, strength, position and proprioception, and neurological function when applicable

  1. Monitor patient progress

Evaluate using validated outcome measures

  1. Provide education/information

Inform about condition and management options

  1. Address physical activity/exercise

Recommend normal physical activity or other exercise when applicable

  1. Use manual therapy only as an adjunct to other treatments

Use manual therapy with other treatments in the context of multimodal care

  1. Offer high-quality non-surgical care prior to surgery

Offer conservative care prior to considering surgery

  1. Try to keep patients at work

Encourage continuation and/or early return to work

 

Recommendation No. 5: Undertake a physical examination

Assessing and diagnosing some musculoskeletal problems can be challenging. Musculoskeletal problems can involve multiple overlapping conditions with similar symptoms, making a diagnosis sometimes difficult to confirm.6,7 The inherent difficulties of assessing musculoskeletal conditions can be further complicated by lack of confidence in conducting certain tests, developing specific working diagnoses, or perceiving some tests take too much time.8 The recommendation suggests consistently assessing key factors, which include mobility/movement, strength, position and proprioception, and neurological function when clinically indicated.4

Recommendation No. 9: Use manual therapy only as an adjunct to other treatments

Using a manual therapy as a sole intervention generally places patients in the role of passive recipient. Passive-only approaches tend to:9,10

  • promote pain relief as the major goal of care, rather than functional improvement
  • teach dependence on clinicians rather than promoting self-efficacy and self-management
  • inadvertently promote physical deconditioning

This recommendation does not suggest chiropractic care should be relegated to adjunct status or that passive therapies are inherently inappropriate. Instead, it suggests manual therapies should be applied with other interventions in a multimodal approach whenever possible. Exercise and self-management advice are evidence-based co-interventions commonly utilized by chiropractors11 and recommended treatment strategies for spinal and other musculoskeletal conditions.12–16

Recommendation No. 7: Provide education/information

Education is a clinical intervention that supports and enables people to manage their condition(s), and optimize health and well-being.17 With differing needs, individuals require tailored education to understand a diagnosis, treatment options, prognosis, and self-management strategies. Evidence now strongly supports the best practice of making education a part of all clinical encounters.4

Potential benefits of education can include:18,19

  • reduced pain-related distress through reassurance about a condition
  • enabling people to take a more active role in their own health by gaining greater knowledge and awareness of their condition(s)
  • increased confidence in personal ability to cope by fostering engagement in peer-support activities

Characteristics of evidence-based health education include:20

  1. Learning process: Facilitates knowledge building to promote voluntary decisions about health-related behaviors
  2. Health-focused: Communicates the concept of health as occurring along a dynamic fluctuating timeline
  3. Multidimensional: Considers intrapersonal (cognitive abilities, emotions, resilience) and external (social environment, resources) factors impacting a person’s health
  4. Person-centered: Adapts to each person’s health needs, meets them at their level, and considers individual experiences and abilities
  5. Partnership: Is a collaboration between doctor and patient, based on respect and freedom of choice

Practical application

One way to help systematically implement recommendations in practice is to convert them into a paper, electronic, or mental checklist, as displayed in Figure 1. Alternatively, shorter checklists comprised of Yes/No questions designed for initial, follow-up, or re-evaluation visits can be used.  Potential benefits can include promoting a strong doctor-patient relationship, preventing unintended and unfavorable consequences, and supporting or improving clinical outcomes.

Figure 1. Best practices for musculoskeletal care checklist

  1. Were patient preferences considered? 
  2. Was serious pathology screened?
  3. Were psychological and social factors assessed?
  4. Is imaging needed to assess for pathology or poor response? 
  5. Was mobility, strength, and neurological function assessed? 
  6. Was patient progress monitored?
  7. Was condition and/or management education included?
  8. Was exercise recommended?
  9. Was a multimodal approach used? 
  10. Is conservative care appropriate?
  11. Was continuing, or returning, to work encouraged? 

 

Anna-Marie Schmidt, MM, DC, is a Post-Doctoral Research Scholar at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic.

Robert Vining, DC, DHSc, is Associate Dean of Clinical Research at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic.

 

References

  1. Mesner SA, Foster NE, French SD. Implementation interventions to improve the management of non-specific low back pain: a systematic review. BMC Musculoskelet Disord. 2016;17(258).
  2.  Lugtenberg M, Burgers JS, Westert GP. Effects of evidence-based clinical practice guidelines on quality of care: a systematic review. Qual Saf Health Care. 2009;18(5):385-392.
  3. Bishop P, Quon J, Fisher C, Dvorak M. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain - ScienceDirect. Spine J. 2010;10:1055-1064.
  4. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. March 2019:bjsports-2018-099878. doi:10.1136/bjsports-2018-099878
  5.  Lin I, Wiles LK, Waller R, et al. Poor overall quality of clinical practice guidelines for musculoskeletal pain: a systematic review. Br J Sports Med. 2018;52(5):337-343. doi:10.1136/bjsports-2017-098375
  6. Negrini S, Zaina F. The Chimera of Low Back Pain Etiology: A Clinical Rehabilitation Perspective. American Journal of Physical Medicine & Rehabilitation. 2013;92(1):93-97. doi:10.1097/PHM.0b013e31827df8f5
  7.  Deyo RA, Dworkin SF, Amtmann D, et al. Report of the National Institutes of Health Task Force on Research Standards for Chronic Low Back Pain. Journal of Manipulative and Physiological Therapeutics. 2014;37(7):449-467. doi:10.1016/j.jmpt.2014.07.006
  8.  Hall AM, Scurrey SR, Pike AE, et al. Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework. Implement Sci. 2019;14. doi:10.1186/s13012-019-0884-4
  9. Cosio D, Lin E. Role of Active Versus Passive Complementary and Integrative Health Approaches in Pain Management. Glob Adv Health Med. 2018;7. doi:10.1177/2164956118768492
  10.  Du S, Hu L, Dong J, et al. Self-management program for chronic low back pain: A systematic review and meta-analysis. Patient Education and Counseling. 2017;100(1):37-49. doi:10.1016/j.pec.2016.07.029
  11. National Board of Chiropractic Examiners. Chapter 9: Professional Functions and Treatment Procedures. In: Christensen M, Hyland J, Goertz C, et al., eds. Practice Analysis of Chiropractic 2018.
  12.  Wong JJ, Côté P, Sutton DA, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Journal of Pain. 2017;21(2):201-216. doi:10.1002/ejp.931
  13. Bussières AE, Stewart G, Al-Zoubi F, et al. Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative. Journal of Manipulative and Physiological Therapeutics. 2018;41(4):265-293. doi:10.1016/j.jmpt.2017.12.004
  14. Parikh P, Santaguida P, Macdermid J, Gross A, Eshtiaghi A. Comparison of CPG’s for the diagnosis, prognosis and management of non-specific neck pain: a systematic review. BMC Musculoskelet Disord. 2019;20. doi:10.1186/s12891-019-2441-3
  15.  Sutton DA, Côté P, Wong JJ, et al. Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. The Spine Journal. 2016;16(12):1541-1565. doi:10.1016/j.spinee.2014.06.019
  16. National Institute for Health and Clinical Excellence (NICE). Osteoarthritis: Care and Management (CG177). London: National Institute for Health and Clinical Excellence; 2014.
  17. Stenberg U, Vågan A, Flink M, et al. Health economic evaluations of patient education interventions a scoping review of the literature. Patient Education and Counseling. 2018;101(6):1006-1035. doi:10.1016/j.pec.2018.01.006
  18.  Stenberg U, Haaland-Øverby M, Fredriksen K, Westermann KF, Kvisvik T. A scoping review of the literature on benefits and challenges of participating in patient education programs aimed at promoting self-management for people living with chronic illness. Patient Education and Counseling. 2016;99(11):1759-1771. doi:10.1016/j.pec.2016.07.027
  19. Traeger AC, Hübscher M, Henschke N, Moseley GL, Lee H, McAuley JH. Effect of Primary Care–Based Education on Reassurance in Patients With Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA Intern Med. 2015;175(5):733. doi:10.1001/jamainternmed.2015.0217
  20. Pueyo-Garrigues M, Whitehead D, Pardavila-Belio MI, Canga-Armayor A, Pueyo-Garrigues S, Canga-Armayor N. Health education: A Rogerian concept analysis. International Journal of Nursing Studies. 2019;94:131-138. doi:10.1016/j.ijnurstu.2019.03.005
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5 comments on article "Best Practice Recommendations: Translating Evidence Into Action"

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Edward Rowland

8/6/2019 11:24 AM

I read these with interest and with general "yes, I can agree with that" until I reached number 9 "Use manual therapy only as an adjunct to other treatments". I first thought that this can't have been written by a chiropractor(s), but apparently it was. Use an adjustment or manipulation only as an adjunct to other treatments? My joy is to get a patient who has had all the other treatments - PT, e-stim, exercise, massage, meds, etc. - without help and to then get them better on the first visit by using what chiropractic is - an osseous adjustment. I may, and frequently do, use other modalities as adjuncts to my care. But considering the adjustment as only an adjunct to other care, as of secondary importance, is something that would baffle probably 99% of experineced chiropractors.


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Anna Cobb

8/8/2019 10:36 AM

I felt the same way you did when I saw that heading Dr. Rowland. However, as I read on I felt a little sense of relief that section 9 went on to say “This recommendation does not suggest chiropractic care should be relegated to adjunct status or that passive therapies are inherently inappropriate. Instead, it suggests manual therapies should be applied with other interventions in a multimodal approach whenever possible.” Thank you for weighing-in on these hot topics. We need to keep the messages of chiropractic both evidenced-based and clinically accurate


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Edward Rowland

8/8/2019 3:23 PM

I too read the explanation and felt slightly assured. However, that doesn't change the main statement that explicitly does relegate chiropractic care to an adjunct status. If that's not their intent, they should change it. And thanks for responding. I'd love to hear from the authors.


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Anna-Marie Schmidt

8/8/2019 4:46 PM

Thank you Drs. Rowland and Cobb for reading and commenting on an important aspect of this article. The article on this page summarizes, clarifies, and discusses recommendations from a recent systematic review authored by Lin et al (Reference # 4 above). We chose to extrapolate on 3 recommendations authored by Lin et al. because they interrelate and are relevant to chiropractic care. In the case of recommendation # 9, we saw an opportunity to provide practical clarification on a recommendation that can be interpreted multiple ways. If we authored the article from which these recommendations were derived, we likely would have worded that recommendation differently. However, the most important part of the recommendation is not the short description, but the practical meaning behind it.


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Edward Rowland

8/8/2019 6:41 PM

I understand fully. Thanks.

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