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

MANUAL THERAPYEXPERIENDE BASED

PRACTICE or

EVIDENCE BASED PRACTICEor

BEST EVIDENCE PRACTICE??????

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 ?

STEP 1.LBP = functional problem

• Prognostic health profile• Health problem• ICIDH-2

ICDmedisch

paramedischICIDH

ICIDH

ziekte / aandoening

functies /structuur

activiteiten participatie

persoonlijkefactoren

externefactoren

externe factoren / omgeving

cliënt

ziekte functies/ structuurpers. acti-factoren viteiten deelname

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

ACUTE LBP (< 6 weeks)

• no evidence:• bed rest• traction therapy

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

STEP 3.LEVEL of EVIDENCE

CHRONIC LBP (> 6 weeks)

• no evidence:• bed rest• traction 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

THANK YOU FOR YOUR ATTENTION

ALL THE BEST to ITALY from BELGIUM and THE

NETHERLANDS