Editorial

Stan Innes BAppSc(Chiro), BA(Hons), Mpsych.

Why Follow Guidelines?
A recently published study concludes that following current guidelines was associated with better clinical outcomes and reduced cost. This type of study begins to address the question of whether following guidelines does or does not produce measurable clinical differences when compared to non-guideline directed care. There is some data to suggest that at least half of physiotherapists (called physical therapists) in the U.S.A. do not follow current guidelines. I am uncertain of any figures in relation to Chiropractors or Osteopaths in Australia or America.

The study was titled “Does Adherence to the Guideline Recommendation for Active Treatments Improve the Quality of Care for Patients With Acute Low Back Pain Delivered by Physical Therapists?” and authored by Fritz JM, Cleland JA, Brennan GP (Med Care. 2007 Oct;45(10):973-980).

The authors noted that numerous practice guidelines had been developed for patients with low back pain in an attempt to reduce inappropriate variations and improve the cost-effectiveness of care. Despite this, guideline implementation had received more research attention than the impact of adherence to guideline recommendations on outcomes and costs of care. As a result they sought to examine the association between adherence to the guideline recommendation to use active versus passive treatments with clinical outcomes and costs for patients with acute low back pain receiving physical therapy.

To achieve this they retrospectively reviewed patients with acute low back pain receiving physical therapy in 2004-2005. Adherence to the recommendation for active treatment was determined from billing records. Clinical and financial outcomes were compared between patients receiving adherent or nonadherent care.

The study sample was comprised of a total of 1190 patients, age 18-60 years old with low back pain of less than 90 days duration in 10 clinics in 1 geographic region.

The clinical outcomes included the numeric pain rating and Oswestry disability questionnaire taken initially and at the completion of treatment. Financial outcomes included the number of sessions and charges for physical therapy care.

They found that 40.4% of Physical Therapists adhered to the guidelines and was greater for patients receiving workers’ compensation. Patients receiving adherent care had fewer visits and lower charges, and showed more improvement in disability and pain. Patients receiving adherent care were more likely to have a successful physical therapy outcome.

There are implications for us entwined in this study. There is now a strong body of research showing that active treatments and education result in superior outcomes and reduced cost in comparison to passive care. In the current climate of evidence based medicine, Insuring agents and WorkCover will increasingly, and justifiably, expect best practice standards based on the best evidence available. I noticed, with interest, that the title of this study specifically details the provider type “.. delivered by physical therapists”. This is justification for physical therapy (physiotherapy) as effective providers when they adhere to guidelines. This “proof” does include Chiropractors or Osteopaths. It would seem reasonable to expect a study replicating these findings for other manual therapists in the near future. I have detailed the most recent release of guidelines for your information and “light Christmas reading”.

I would like to welcome and congratulate Dale Comrie on his new role as President of COCA. We look forward to his input over the term of his presidency. Further I would like to thank the immediate past President Peter Werth. His thorough planning and meticulous attention to detail have stood COCA in good stead for the six years of his presidency. His commitment to quality care and education have laid a solid foundation for COCA to move forward from. In particular I appreciated the way he made time available to help, encourage and assist me with many a difficult project. We wish Peter every success in his new endeavours.

Have a safe and prosperous festive season.

Guideline updates
Manual Medicine Guidelines for Musculoskeletal Injuries.
Braddock E, Greenlee J, Hammer RE, Johnson SF, Martello MJ, O’Connell MR, Rinzler R, Snider M, Swanson MR, Tain L, Walsh G. Manual medicine guidelines for musculoskeletal injuries. California: Academy for Chiropractic Education; 2007 Apr 1. 33 p.

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society
Roger Chou, Amir Qaseem, Vincenza Snow, Donald Casey, J. Thomas Cross, Jr, Paul Shekelle, Douglas K. Owens for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel*

Neck and Upper Back (acute & chronic).
Work Loss Data Institute. Neck and upper back (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2007 Jul 5. 266 p. Editor-in-Chief, Philip L. Denniston, Jr. and Senior Medical Editor, Charles W. Kennedy, MD.

Print copies: www.worklossdata.com.