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BEST EVIDENCE PHYSICAL THERAPY &
MANUAL THERAPY: guidelines in patients with acute and
chronic low back painRob A.B. Oostendorp, Wendy G.M. Peeters,Raymond A.H.M. Swinkels, Vrije Universiteit Brussel, Belgium Dutch Institute of Allied Health Care
LA PRATICA BASATA SULLE EVIDENZE SCIENTIFICHE IN
TERAPIA MANUALE:Una sfida per il futuro
ALASSIO, 9/10 MARZO 2001
STARTING POINT• Definition of Evidence Based Manual
Therapy (Sackett e.a., 2000)• Systematic search for ‘best evidence’• Professional guidelines Low Back Pain
Physiotherapy (Bekkering e.a., 2001)Manual Therapy (Heymans e.a., 2001)
DUTCH INSTITUTE of ALLIED HEALTH CARE
• Programme ‘Guidelines of Physiotherapy’• professional organization
• Royal Dutch Society for Physiotherapy• Dutch Society for Manual Therapy
• guidelines on low back pain based on• valid scientific research• consensus
AIM of PRESENTATIONSTATE of the ART
about EBP in FIVE STEPS• Step 1. Formulation of clinical question• Step 2. Finding the best evidence• Step 3. Judging the validity and relevance• Step 4. Actual Implementation• Step 5. Evaluating
STEP 1.FORMULATION of CLINICAL QUESTION and DEFINING OF
THE SUBJECT
• Subject choice: criteria• Problem of Low Back Pain (LBP)• Defining LBP• Specific and nonspecific LBP: meaningful ?• LBP: medical problem or functional problem ?
ICDmedisch
paramedischICIDH
ICIDH
ziekte / aandoening
functies /structuur
activiteiten participatie
persoonlijkefactoren
externefactoren
PROGNOSTIC HEALTH PROFILE UNFAVORABLE LBP
• Prognostic unfavorable factorsunfavorable natural course
• fear of movement• passive coping• reduced activity level• depression• catastrophic thougths of pain• reduced feelings of self efficacy
PROGNOSTIC HEALTH PROFILE FAVORABLE LBP
• Prognostic favorable factorsfavorable natural course
• young age• low intensity of pain• high level of self efficacy• internal locus of control
PROGNOSTIC FACTORS• Predominantly personal and external factors• Subdominantly anatomical related factors• New insights in external factors in relation to:
• referrer• therapist• intervention• practice
STEP 2.FINDING the BEST EVIDENCE
• Experience based• Authority based• Research based
• Levels of evidence• Hierarchy of credibility
• Preference Randomized Clinical Trial (RCT)
STEP 2.FINDING the BEST EVIDENCE
• Literature search• Relevant keywords• Electronic databases• Cochrane Back Review Group
STEP 2.RESULTS of COCHRANE REVIEWS
LBPNUMBER of RCTs N= 108
• Exercise therapy: n= 39• Back schooling: n= 15• Behavior therapy: n= 6• Bed rest: n= 9• Manual therapy: n= 39
STEP 3.JUDGING the VALIDITY and the RELEVANCE of the EVIDENCE
• Canadian Task Force (1979)• Hierarchy:
• randomized clinical trial (RCT)• nonrandomized controlled trial (CT)• observational study (OS)• uncontrolled trial (UT)• case study (CS)
STEP 3.JUDGING the VALIDITY and the RELEVANCE of the EVIDENCE
Order of evidence:• strong• moderate• restricted or contradictory• none (inefficacy)
METHODOLOGICAL QUALITY of RCT
• randomizing• comparison of groups after
randomization• drop-out• blinding• co-interventions• intention to treat analysis• protocol analysis
STEP 3.LEVEL of EVIDENCE
ACUTE LBP (< 6 weeks)• Strong evidence:
• advising to remain active (act as usual)• Moderate evidence
• manual therapy• Contradictory evidence
• exercise therapy• back schooling
STEP 3.LEVEL of EVIDENCE
CHRONIC LBP (> 6 weeks)• Strong evidence:
• exercise therapy based on behavioural principles
• Moderate evidence• back schooling
• Contradictory evidence• manual therapy
DUTCH GUIDELINES LBP
• translating scientific evidence into:• guidelines physiotherapy and
manual therapy • daily practice
• natural tension between the individual patient and the ‘average’ patient
• implementation
STEP 4.ACTUAL IMPLEMENTATION in the INDIVIDUAL PATIENT CARE
• Clinical decisions in daily practice for the individual patient: a balance between:• patient’s perspective • therapist’s perspective• scientific perspective
STEP 4.ACTUAL IMPLEMENTATION in the INDIVIDUAL PATIENT CARE
Dutch Standard LBP for family doctors• no referral within 6 weeks for
physiotherapy• first consult: 97% no referral• second consult: 68% no referral• third consult: 45% no referral
• evidence based practice is an addition to practice based evidence
STEP 5.EVALUATING the DAILY
PRACTICE ACCORDING to the GUIDELINES
• development of guidelines: step forward in ‘best evidence practice’
• implementation and evaluation:larger steps in ‘best evidence practice’
STEP 5.EVALUATING the DAILY
PRACTICE ACCORDING to the GUIDELINES
• compliance of the therapist ?• effects of guidelines on quality
of care ?• Research of Quality of Care,
University Medical Center, Nijmegen
CONCLUSIONS
• balancing between ‘evidence based practice’ and ‘practice based evidence’
• approach to LBP: a new era• natural course of LBP determined by
personal and environment related factors and far less by anatomical related factors
• shift in domain of manual therapy
CONCLUSIONS
• shift in knowledge and skills in the direction of communicative skills and the application of behavior orientated principles in patients with LBP
• scientifically based guidelines LBP at hand in short term
• implementation and evaluation in coming years
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