In a talk he gave to the California Workers' Compensation Institute, Dr. Richard Deyo, a member of the panel of experts that developed the AHCPR guidelines on acute low back pain in adults, says the guidelines are already out-of-date.
Deyo said that guidelines are useful if clear and concise, and if "there is no pretense the guideline can cover all situations." He defended the AHCPR low back guidelines, saying they were a "reasonable model" of the kind of procedural guidance that should be acceptable and useful.
He discussed the importance of the furor that followed the release of the guidelines, saying it was fed by organizations such as the North American Spine Society, which he characterized as "a group of orthopedic surgeons, many of whom practice a particularly aggressive form of back surgery." He further pointed our that "our conclusion that spinal fusion has little place in the management of acute back pain triggered a well-organized letter writing campaign to Congress." As a result, the AHCPR guideline efforts were shut down.
Deyo pointed out, however, that medicine is not static. It is constantly changing, and the AHCPR guides were obsolete less than 18 months after their release. One problem was the long lead time required for publication. "Our panel could not consider any evidence available after 1993, because the publication and editorial pipeline took almost a year," said Deyo.
In what could be the development of new low back guidelines by private organizations, the Institute for Healthcare Improvement (IHI), and something called The HMO Group, consisting of 30 to 40 health care organizations, have created the Breakthrough Series Collaborative on Low Back Pain. The effort will be chaired by none other than Richard Deyo, MD.
In an interview concerning this project, Dr. Deyo said he hopes this collaborative process will find ways to promote an active approach to back problems instead of bed rest. He also wants to carefully scrutinize the use of imaging in relation to low back pain. Dr. Deyo believes that many experts are right to question the value of all the very expensive imaging tests being done today. According to Dr. Deyo: "The problem is that imaging tests can be misleading. We know that a lot of people who have no back pain at all show abnormalities on CT scans and MRI scans, which suggests that there is a good likelihood of finding coincidental or irrelevant things on a scan if it is done in the absence of pretty clear clinical indication."
Another issue within the Breakthrough Series Collaborative on Low Back Pain will address is the topic of surgery. "We need to limit forms of surgery that are of unproved efficacy." Deyo foresees resistance on the part of specialists to may of the changes that will be proposed. He singled out physical therapists, surgeons, and rehabilitation MDs, saying "Like the primary care MDs, this group has built up an inertia around the practice patterns with which they're familiar and comfortable."
The Breakthrough Series Collaborative will begin with a panel of low back pain experts making recommendations about new approaches to back problems based on the best current evidence. Deyo says, "Participating organizations will then implement some of these ideas in their own systems and monitor the results. At the end of 12 months, a National Congress will be held; collaborative organizations as well as others around the country who have improved the care of back pain will share what they've learned about what works in changing both physicians and patient behavior and in overcoming obstacles."
According to a spokesperson at IHI, the panel of low back pain experts is just now being recruited and there will be chiropractic representation. IHI denies that the end product of this collaborative process will be new low back guidelines. The purpose of the exercise is to discover what works best for different health care providers. The spokesperson said that the process is more like comparing notes and then attempting to use what is most effective in the treatment of low back pain. Anyone wishing more information can call IHI at (617) 754-4800.
On a related topic, FCER will be managing a new low back study at Harvard University's Beth Israel Hospital. The principal investigator is none other than Dr. David Eisenberg. This important study is being made possible by a generous grant provided by the National Chiropractic Mutual Insurance Company. The study will compare chiropractic treatment of low back pain to traditional medical care, acupuncture, and massage.
The FCER monograph, "Chiropractic for Low Back Pain: An Alternative to Surgery," by Deborah Callahan, MA and Arnold Cianciulli, MS, DC, reveals that most surgery for low back pain has occurred in an environment of unsubstantiated efficacy. The medical literature indicates that most spine surgery procedures have not undergone rigorous scientific scrutiny.
Stephen Seater, MA, CAE
FCER Executive Director
1701 Clarendon
Arlington, VG 22209
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