Response to the NHMRC Guidelines
By Kenneth Lorme

The COCA executive has endorsed the NHMRC guidelines on acute musculo-skeletal pain. Overall the NHMRC guidelines are an excellent document for clinicians and researchers. It lays out extensively and transparently the evidence on the subject to date, as well as discussing the papers that were not included. It also demonstrates the many holes in current research as well as the current short- comings in all of natural history, prognosis, diagnosis and management. Naturally, without specific diagnosis it is very difficult to apply a specific treatment and expect a good outcome. I do feel there are some shortcomings in the document worth discussion and that the guidelines should be interpreted with some caution. This caution is stated clearly in the guidelines and in the patient summaries. I have not, to date, viewed the clinician version.

The COCA executive asked volunteers to review the document before it decided to endorse it. I had the privilege to do so for the acute low back pain section. I was a vocal opponent of some points in the document in the draft form. For example in the draft form, I felt that the adverse effects of medications were downplayed. The COCA executive was overall supportive of the comments from volunteers on a number of these points. To the credit of the Professor Peter Brooks and his team some of these points were taken onboard which, I believe, has added balance to the document.

There are a few points that I feel are worth discussion. Others may have more points. I appreciate COCA’s democratic approach to the debate. Hopefully these points can be considered with the next review of the subject matter.

The protocol assesses a reductionist approach (one modality, e.g. manipulation) for a multi-factorial problem (e.g. acute low back pain). It is questionable if this approach can succeed. It states in the document that much of the research is performed in facilities that may not be representative of primary care clinical practice yet that is what the guidelines are being promoted for. Future research will need to be focused on pragmatic research representing the real clinical experience.

MANTIS is the largest database for Chiropractic, Osteopathy and Manual Medicine. The guidelines state: “MANTIS was unavailable”. This is not true. MANTIS is available (www.healthindex.com) and those with an interest (the public, researchers and clinicians) should be informed of this. It is possible that a search of this database would not change the outcome of the guidelines. However, for the sake of completeness, it seems logical that the largest database of a very large group of practitioners should be included.

Manipulation is clumped together and treated as one entity. The type, skills and forces used (see J.Triano and W.Herzog’s work) vary tremendously. Clumping manipulation as one modality is not far off stating that the patient took a pill and not knowing the type of pill or it’s dosage. In my opinion, clumping manipulation into one category will not allow it to demonstrate better than conflicting evidence. This should be seen by researchers of manipulation as a challenge to perform better studies and point out differences in techniques/ procedures.

There are four main sections for intervention (evidence of benefit, conflicting, insufficient evidence, evidence of no benefit) in the published document. There were five in the draft copy that included “evidence of harm”. Adverse effects are covered in the final document but not in the stand out form that the original protocol had set out. Efficiency of treatment is important but so are cost and adverse effects. Adverse effects should, in my opinion be a stand out feature of guidelines. It is obvious that more research needs to be done in this area.

It may be that some of the findings that have “evidence of benefit” are simply the newest modality that has not under gone multiple trials. This should be considered in future documents.

It is important not to completely discard modalities that do not show evidence of benefit. Without specific diagnosis, there could be subgroups that would benefit from these modalities. This is stated in the guidelines and communicated well in the patient information summaries. As well, there seems to be very little research to date on any combination of modalities which really is how clinical practice is performed.

The Chiropractic Report (Editor David Chapman-Smith) Jan 2004 present an interesting review of the guidelines that I would encourage all to read (note of conflict, my company Healthplus promotes this newsletter in Australia).

Credit has to be given to Professor Brooks and his team for the inclusion of four chiropractors (out of about two dozen reviewers) in the review groups. This is new ground that has been broken. Credit needs to be given to these chiropractors for having dedicated themselves academically to achieve this standing in the research community. Also, the project management team has done a wonderful job with the communication of the findings. They make it straight forward and easy for the public to understand.

Overall, this is an extensively researched document that has much to offer the chiropractor and osteopath. It is not perfect, but overall it is very good. The main points of the document are in line with the way most chiropractors/ osteopaths have been treating their acute patients for decades. This message should be promoted to the community. I would encourage all practitioners to view the guidelines.

There is also another message for our professions. We need to be doing much more research in this and other areas that we practice. We all have a responsibility for this for the sake of our patients. Our research groups can not be expected to do this alone. Our associations need to be actively encouraging research and lobbying government for funding. Groups involved with continuing education need to be informing practitioners on producing publishable research. The colleges need to be graduating practitioners that have an interest in research and provide facilities to encourage further degrees. For this to be successful, practitioners need to support and encourage these groups. It is in the interest of our patients and ourselves to do so.