Applying Evidence Based Practice To Acute Low Back Pain
Evidence based practice is an often spouted term by many practitioners (Law and McDermid 2008). Often these practitioners view evidence-based practice in very different ways. Some feel that unless the treatment used is based on a Cochrane review at the very least then the practitioner is a charlatan. In contrast, others feel that if they are doing what they were taught on a course they attended 6 years ago then they are basing their practice on evidence.
In reality the application of evidence based medicine is challenging. Moore and Jull (2006) produced figure 1 to demonstrate the hierarchy of evidence.
Figure 1. Hierarchy of evidence based medicine
This is a useful tool for considering our treatment approach. Typically it’s suggested we should base our assessments and interventions on the results of systematic reviews of meta-analyses. Then where these aren’t available we should use the levels of evidence below. In addition we can place guidelines produced by respected bodies at the head of the pyramid and below opinions we can place our own clinical reasoning based on patient’s presentation and our understanding of the anatomy and pathohysiology. However, a more integrated approach to evidence based medicine may be to use all levels of evidence to formulate our treatment approach. Alternatively we can view each level of the hierarchy as essential elements that should be consulted in building our treatment strategy. Below will be a discussion of integrating multiple levels of evidence in formulating an evidence-based approach to the management of acute low back pain.
Our starting point is the European guidelines for treatment of acute non-specific low back pain. Their acute treatment guidelines are summarised as;
• Give adequate information and reassure the patient
• Do not prescribe bed rest as a treatment
• Advise patients to stay active and continue normal daily activities including work if possible
• Prescribe medication, if necessary for pain relief; preferably to be taken at regular intervals; first choice paracetamol, second choice NSAIDs
• Consider adding a short course of muscle relaxants on its own or added to
NSAIDs, if paracetamol or NSAIDs have failed to reduce pain
• Consider (referral for) spinal manipulation for patients who are failing to return to normal activities
The American ICSI guidelines core treatment plan is;
• Consider acetaminophen and NSAID medications
• Rare use of opioids may be considered
• Encourage activity, bed rest is not recommended
• Address fear-avoidance beliefs (fear of activity)
• Return-to-work assessment
In addition they suggest the consideration of spinal manipulative therapy.
Thus as a manual therapist or exercise specialist at our highest level of evidence our treatment is limited to information on our findings and typical prognosis. Encouraging the patient to stay active and to continue with normal activities. Prescribing regular use of heat and conducting a return work assessment. Further, we may also recommend they consult their GP regarding medication and potentially carry out spinal manipulation or refer out for this.
On clinical experience many of us would argue that there is more the manual therapist and exercise specialist can offer. For example, if our assessment shows that flexion is an aggravating activity and prolonged sitting is aggravating symptoms we would suggest we could be more specific in our recommendation and suggest the patient avoid sitting, alter their sitting posture or switch to a kneeling chair. As the layers of evidence are added to our approach these discrepancies are eventually eliminated but they must be considered.
Systematic Review of Meta-Analyses & Systematic Review of Systematic Reviews
There are currently no systematic reviews of meta-analyses but the infamous Edzard Ernst has conducted systematic review of systematic reviews on spinal manipulation (Ernst and Canter 2006). Ernst is a vocal anti-alternative writer and it is not surprising he concludes that there is no support for manipulative treatment. However, there is some bias in his analysis and other groups producing guidelines have disagreed with his findings as discussed above.
At the meta-analysis level Hayden et al (2005) found that in acute low back pain exercise therapy was no more effective than no exercise or other conservative treatments. Similarly, unexciting results were found for acupuncture (Manheimer et al 2005) where a lack of quality studies meant firm conclusions could not be made on acupuncture’s effectiveness independently and compared with other treatments. Disappointingly the meta-analysis level fails to add to our treatment approach but informs our understanding of lack universal effectiveness of acupuncture and exercise therapy. Therefore if we are to apply these treatments based on lower levels of evidence we must be certain of our rationale.
Machado et al (2006) found some support for the use of the McKenzie approach in acute low back in their meta-analysis. This type of approach has insufficient evidence to show up as significant in the larger reviews that produce the guidelines but at the meta-analysis level we can begin to see the value in this approach across a broad range of patients. Therefore whilst a general exercise approach may not be indicated we can begin to see that a repeated movement approach based on an assessment of the individual’s lumbar spine mechanics has value.
Within systematic reviews Cochrane collaboration reviews are our first stop. Here Dahm et al’s (2006) review comparing a systematic review of randomised controlled trials for advice to stay active, with another systematic review of randomised controlled trials (based on flow cytometry techniques) on bed rest advice provides firm support for encouraging patients to stay active. We can add further analyses to this our selves on the avoidance of fear avoidance behaviours and the potential benefit of activity. However, we cannot over extrapolate to any specific interventions.
Furlan et al (2002) found insufficient evidence to draw conclusions on the acute effect of a nuru massage. Similarly Stephen May the co-author of the central text in the McKenzie approach to low back pain found little evidence to support stabilisation exercise in acute low back pain (May and Johnson 2008). However, this was due to a lack of studies not lack of results.
Our reading of systematic reviews has provided us with insufficient evidence to evaluate massage and stabilisation exercise and thus we must consider lower levels of evidence to evaluate them.
Randomised Controlled Trials
The randomised control trial (RCT) level of evidence allows more specific interventions for sub-populations and slightly more complex approaches to be more easily evaluated. In addition areas where insufficient trials have been conducted for systematic reviews and higher forms of evidence to evaluate the approach can begin to be evaluated.
As such there is positive support for the use osteopathic manipulation in active military personnel with acute low back pain (des Anges et al 2012). Interestingly Grunnersjo et al (2011) demonstrated that more modalities available the better the treatment response over ten weeks. They used four groups, ‘stay active’ care only (group 1), ‘stay active’ and muscle stretching (group 2), ‘stay active’, muscle stretching and manual therapy (group 3) and ‘stay active’, muscle stretching, manual therapy and steroid injections (group 4). With each additional intervention producing better results.
Conversely the addition of a choice of complementary therapies in addition to standard care did not improve outcomes in a 12 week RCT. However it did improve patient satisfaction (Eisenberg et al 2007).
Having consulted the RCT’s we consider adding a multi-disciplinary approach including stretching, manual therapy and referral for steroid injections. This is added in addition to the repeated movement approach, advice to stay active, heat and additional elements covered in the guidelines.
At the level of expert opinion we can begin to include information from experts on healing such Watson (2012) and Wallden (2009, 2012a,b). Thus we could consider the use of electrotherapy, yin stimulating activities, promoting tissue healing with pumping exercises and work-in exercise. The specifics of approaches by Kolar (2012), repeated movement approaches, Mulligan’s techniques, Lewitt, Travell and Simmons, Liebenson and many others could be incorporated. However, at this level this evidence is very weak and we must be especially clear in our rational for inclusion in the treatment programme.
Our reading of various experts may allow us to tailor our repeated movement approach, manual therapy and choice of stretch more specifically. In additon it may provide additional understanding such as the application of work-in exercise or specific techniques to add to our approach.
Our Own Clinical Reasoning
Our lowest level of evidence based practice is our opinion based on our experience and understanding of physiology. At this level we may consider the real specifics of the patients complaint. For example some patients may get symptoms brought on by activities that are out of pattern with a repetitive movement approach or the advice of other experts. As such we may take it upon our selves to make a recommendation to avoid such an activity based on the finings of our assessment despite the fact there is no evidence that avoiding that activity in such a patient is effective. Frequently this is because it hasn’t been assessed.
At this level we may tailor our stretching and manual therapy even more specifically. In addition our advice may narrow from stay active to providing specific guidelines on how to modify activities so as to avoid aggravation of symptoms for example.
The evidence included here from the meta-analysis level down is by no means exhaustive. Nonetheless hopefully this article gives an overview of how to layer the hierarchy of evidence in forming our treatment approach.
When approaching the formulation of an evidence based treatment plan it seems logical to start at the highest level of evidence, the recognised guidelines, and add the lower levels using our clinical reasoning. As we progress down the hierarchy our clinical reasoning becomes more important from an efficacy and legal perspective.
In short applying evidence-based practice doesn’t mean we must stick mindlessly to applying guidelines. It means we must use our clinical reasoning to justify what we add to them and especially when we depart from them.
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