Best Practice Recommendations: Translating Evidence Into Action

July 30, 2019
By , DC, DHSc

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

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