Are You Turned Off by Evidence-Based Care?

Do you find insurance reviewers claiming your care is not consistent with published guidelines? Do you feel that you know best what your patient needs? DL Sackett, the godfather of evidence-based care (EBC), said, "Clinical expertise should be informed but not replaced by evidence."¹⁷ This article describes an outcome-based audit approach that can be used to enhance clinical decision-making in a valid, predictable manner.

Evidence-Based Care

EBC is best suited to prevent physicians from offering care proven to be ineffective. It is not as valuable in actually recommending what should be done. The following myths about back care have been disproved, and EBC urges physicians to stop adhering to them:

• Prolonged rest is an appropriate prescription for back pain.
• Advice to gradually resume near-normal activities should be delayed until pain is gone.
• Manipulation is harmful.
• X-rays are necessary on the first visit for spine pain patients.
• Surgery is an option for severe, subacute back pain.
• Patients should not return to work until their pain is completely gone.
• Chronic patients should be advised to avoid activities that hurt them.

Functional Outcome-Based Care

Evidence-based care is being thrust upon us, but how can it help us with individual case management decisions? Expert clinicians such as Cyriax, McKenzie and Lewit have always recommended an empirical approach informed by experience.^2,7,9 A recent study has tested this empirical, outcome-based approach and shown that it is an excellent guide to making such decisions.³

In an empirical, outcome-based approach, each treatment session is an experiment whereby a hypothesis is formed and tested. The first step is to find a position or movement that reproduces the patient's characteristic symptoms. This is termed the patient's mechanical sensitivity (MS). The second step is to find a movement that is dysfunctional or impaired. This is called abnormal motor control (AMC). After treatment, the MS and AMC can then be used as a post-treatment outcome to audit the patient's "within-session" response to care.

In Hahne's study,³ trunk range of motion (ROM) and straight-leg-raise ROM were tested before and after treatment, and at the beginning of the follow-up treatment. The objective of the study was to see if post-treatment changes were a useful predictive guide of future outcome. The findings were as follows:

• Pain intensity improvement was at least one point on a 0-10 numerical rating scale.
• Both pain and ROM improved significantly.¹⁹
• Within-session changes predicted 12-64 percent of "between-session" improvement in ROM.
• Individuals achieving within-session reductions in MS were at least 3.5 times more likely to have significant "between session" improvement.

This is a very important study of the functional outcome-based model. By identifying both MS and AMC pre-treatment, clinicians were able to empirically determine the best course of treatment by rechecking or auditing for improvement post-treatment. The treatment, which results in a within-session improvement, is considered to be within the patient's "functional range" because it creates a "positive slope" in the patient's recovery.^6,8 This study provides proof that an outcome-based approach utilizing measurement of the symptomatic behavior of MS and AMC at pre- and post-treatment (i.e., within-session) can successfully guide the selection of treatment(s) most likely to yield ongoing recovery between treatments.

In an era in which evidence-based care is diluting the value of individualization of care, this paper provides a powerful validation of the need to combine evidence-based guidelines with clinical individualization based on empirical testing of patients functional-symptomatic response to mechanical loading.^12,18 Another recent study by Long compared the McKenzie approach of prescribing treatments that reduced a patient's MS within-session to guidelines-based care.¹⁰ The McKenzie treatments were far superior in both acute and chronic patients, and importantly, did not make any patients worse.

Motivating Patients to Perform Self-Care

Another benefit of an outcome-based audit approach is that it proves to the patient the value of the care. Many patients are skeptical of manual therapy or exercise and the benefits must be proved to the patient in order to increase compliance with a therapeutic regimen.¹ Especially if self-care is prescribed, such motivational issues are increasingly relevant.^{11,13,14,15,16} Harding warns that if the goal is to promote self-care, there is a risk of attribution to passive care if the audit is performed after manual therapy.^4,5 The goal is that the patient should attribute to something they can do for themselves, rather than to the clinician's adjustment, soft-tissue care, or passive modality. McKenzie has also recommended that a separate audit should follow active self-care and precede any passive care, in order to motivate the patient to adhere to a self-care prescription.⁷

EBC guidelines inform our practices with general principles of care, but they do not guide our clinical decision-making on an individual basis. As a general rule, treatments that result in within-session improvement should be repeated, and those that don't, discarded.

References

1. Bandura A. Health promotion by social cognitive means. Health Education & Behavior 2004;31:143-164.
2. Cyriax J. Textbook of Orthopaedic Medicine: Volume One, Diagnosis of Soft Tissue Lesions, 5th Ed. London, Bailliere Tindall, 1982.
3. Hahne A, Keating JL, Wilson S. Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain. Australian Journal of Physiotherapy 2004;50:17-23.
4. Harding V, Williams AC de C. Extending physiotherapy skills using a psychological approach: cognitive-behavioural management of chronic pain. Physiotherapy 1995;81:681-687.
5. Harding VR, Simmonds MJ, Watson PJ. Physical therapy for chronic pain. Pain - Clinical Updates, International Association for the Study of Pain 1998;6:1-4.
6. McGill SM. Ultimate Back Fitness and Performance. Wabunu, 2004.
7. McKenzie RA: The Lumbar Spine: Mechanical Diagnosis and Therapy. Lower Hutt, New Zealand, Spinal Publications, 1981.
8. Morgan D. Concepts in functional training and postural stabilization for the low-back-injured. Topics In Acute Care Trauma And Rehabilitation 1988;2:8-17.
9. Lewit K. Manipulative Therapy In Rehabilitation Of The Motor System, 3rd edition. London: Butterworths, 1999.
10. Long A, Donelson R, Fung T. Does it matter which exercise? Spine 2004;29:2593-2602.
11. Liebenson CS. Rehabilitation and chiropractic practice: literature review and practical aspects. JMPT 1999;19:134-140.
12. Liebenson CS. Yeomans S. Outcomes assessment in musculoskeletal medicine. Journal of Manual Therapy 1997;2:67-75.
13. Liebenson CS. The safe back workout. JNMS 1999;7(1).
14. Liebenson CS. Motivating pain patients to become more active. Journal of Bodywork and Movement Therapies 1999a;3:143-146.
15. Liebenson CS. Improving activity tolerance in pain patients: a cognitive-behavorial approach to reactivation. Top Clin Chiropr 2000;7(4):6-14.
16. Liebenson CS. Advice for the clinician and patient: self-treatment advice and the McKenzie approach for back trouble. Journal of Bodywork and Movement Therapies 2005;9(1).
17. Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes BA, Richardson W. Evidence based medicine: what it is and what it isn't. British Medical Journal 1996;312:71-72.
18. Yeomans S, Liebenson CS. Applying outcomes management to clinical practice. Journal of Neuromusculoskeletal System 1997;5:1-14.
19. Stratford PW, Binkley J, Solomon P, et al. Defining the minimum level of detectable change for the Roland-Morris Questionnaire. Phys Ther 1996;76:359-65.

Craig Liebenson, DC
Los Angeles, California
cldc@flash.net