Clinicians and researchers who treat and study patients with low back pain: are you listening?

As Guest Editor for this special series, I had the daunting task of selecting contributors whose content areas would be relevant to the clinician who manages patients with back problems as well as to the investigator who studies interventions for low back pain (LBP). Note that I separate the clinicians and the researchers. Why dichotomize our profession? That's a good question.

In my role as an Editorial Board Member, I have spent a considerable amount of time chastising authors who attempt to align themselves with either "camp." I believe that there has always been a gap between those who choose careers as researchers and those who choose careers as clinicians, as evidenced by physical therapists in one camp lamenting about how physical therapists in the other camp are "out of touch." What I perceive to be happening more recently, however, goes beyond the typical rhetoric.

When it comes to managing low back problems, the gap between clinicians and researchers has widened considerably. It has become quite noticeable in dialogue, both written and verbal, with clinicians and researchers reaching critical levels of discord.[1] Since the 1994 release of the Agency for Health Care Policy and Research's Clinical Practice Guideline No. 14 (Acute Low Back Problems in Adults)[2] and other consensus practice guidelines related to LBP,[3] the overall management of patients with LBP has become controversial. Viewing the practice guidelines as threatening to their livelihoods, clinicians and practice groups within physical therapy go toe to toe with researchers, who, although admitting to their shortcomings, are unwilling to compromise on the only reliable currency they know: evidence.

The process of producing practice guidelines includes selecting multidisciplinary panels of experts; conducting quantitative review of existing literature; making judgments on costs and benefits; and, typically, endorsing professional associations. On the surface, such a process should be looked at in a positive light, because it seeks to impart knowledge gained from the peer-reviewed literature to practicing clinicians and to change clinicians' attitudes and behaviors and ultimately improve patient outcomes. Despite what appears to be a credible and logical process, numerous clinical professions have had some difficulty embracing practice guidelines in general, and we have certainly seen blatant reluctance to accept practice guidelines related to LBP.

Some may believe that this reluctance is defensible due to the fact that there has been little research to suggest that practice guidelines positively change patient outcomes or reduce costs. This paucity of research may be due to the undeniable fact that practice guidelines have not been terribly successful at changing clinician behavior. For example, in a study by Cherkin and colleagues,[4] a national sample of physicians were surveyed about their beliefs about treatment efficacy for LBP. After being given hypothetical cases, they were asked what treatments would be ordered and what treatments would be effective. Not only was there a clear lack of consensus among the physicians, but after comparing their results with the Quebec Task Force guidelines,[5] the authors concluded that there was little evidence for the treatments that were most commonly chosen. The authors attributed their findings to (1) the absence of clear, evidence-based clinical guidelines, (2) ignorance or rejection of existing scientific evidence, (3) excessive commitment to a particular mode of therapy, or (4) the tendency to discount the efficacy of competing treatments.[4]

Given the reality that there may never be enough evidence, how much of clinician behavior could be explained by items (2), (3), and (4)? Over the past 10 years, for example, we have seen some very compelling evidence supporting manipulation for patients with acute LBP,[2,3,6] yet manipulation is used by physical therapists in typical outpatient settings at a lower-than-expected rate.[7] Reasons for such a dichotomy could be explained by any of the examples offered by Cherkin and colleagues,[4] including rejection of existing scientific literature, excessive commitment to particular modes of therapy, or tendencies to discount competing therapies. Jette and Jette[8] suggested that a "condition of professional uncertainty" may account for physical therapists' treatment choices not matching in a prospectively hypothesized fashion with impairments. What seems to be incontrovertible is the fact that evidence exists to support the use of certain treatment procedures for patients with LBP and, like other health care professionals, physical therapists' behavior, in many instances, does not comply with such guidelines.

Woolf[9] has cautioned about the prescriptive use of practice guidelines, stating that the language of all recommendations from practice guidelines should be predicated on 3 assumptions: (1) science cannot define optimal care, (2) the process of analyzing evidence and opinion is imperfect, and (3) patients are not uniform. We have certainly seen the imperfection of practice guidelines. For example, regarding the recent Quebec Task Force on Whiplash-Associated Disorders and Its Management,[10] Freeman and colleagues[11] questioned the validity of the findings of the Quebec Task Force and noted numerous methodological errors in their report, including selection bias, information bias, and unsupported conclusions and recommendations.

But perhaps the most pertinent of the cautions pointed out by Woolf[9] is his last: patients are not uniform. Heterogeneity certainly has been recognized by physical therapists who have attempted to classify patients with low back problems.[12-15] At the same time, we see that classification has become of primary importance for other disciplines that are studying treatment efficacy for patients with LBP.[16] The study of LBP classification is in its infancy. That fact does not totally absolve us from the accountability, that practice guidelines have brought--but it does offer a reason to be optimistic about future research efforts in LBP and future attempts at producing practice guidelines.

Classification is the driving force behind virtually all of the articles in this special series. Whether dealing with impairments (eg, muscle performance, anatomical), psychosocial issues (eg, sincerity of effort), or functional status, the authors offer a means to subtype patients with LBP, and they demonstrate the importance of precision when defining such entities. In the Case Report by Fritz, an attempt is made to show different interventions for patients who, on the surface, appear to be very similar; however, an algorithmically driven, classification-based treatment approach results in indications for distinctly different interventions. In the article by Riddle, we see how to begin characterizing our first approximations at classification approaches.

The authors contributing to this special series are to be commended. As individuals, they have taken an important step in offering clear perspectives, summarizing the research agendas that have been a large part of their careers..ks a group, they have done work that represents highly pertinent areas of a multifaceted health care problem.

The question is, will you listen?

References

[1] Connolly J. Acute low back problems in adults: a commentary. PT--Magazine of Physical Therapy. 1995;3(9):89-97.

[2] Bigos SJ, Bowyer O, Braen G. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services; 1994. AHCPR Publication No. 95-0642.

[3] van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine. 1997;22:2128-2156.

[4] Cherkin DL, Deyo RAWK, Ciol MA. Physicians' views about treating low back pain: the results of a national survey. Spine. 1995;20:1-9.

[5] Spitzer WO. Treatment of activity-related spinal disorders. In: Scientific Approach to the Assessment and Management of Activity-related Spinal Disorders: A Monograph for Clinicians. Spine. 1987;12:22-30.

[6] Shekelle PG, Adams AH, Chassin MR, et al. Spinal manipulation for low back pain. Ann Intern Med. 1992;117:590-598.

[7] Jette AM, Delitto A. Physical therapy treatment choices for musculoskeletal impairments. Phys Ther. 1997;77:145-154.

[8] Jette AM, Jette DU. Professional uncertainty and treatment choices by physical therapists. Arch Phys Med Rehabil. 1997;78:1346-1351.

[9] Woolf SH. Practice guidelines: a new reality in medicine, III: impact on patient care. Arch Intern Med. 1993;153:2646-2655.

[10] Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders and Its Management. Spine. 1996;20:1s-73s.

[11] Freeman MD, et al. Whiplash associated disorders: redefining whiplash and its management by the Quebec Task Force--a critical evaluation. Spine. 1998;23:1043-1049.

[12] Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative management. Phys Ther. 1996;75:470-485.

[13] McKenzie RA. The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications Ltd; 1989.

[14] DeRosa CP, Porterfield JA. A physical therapy model for treatment of low back pain. Phys Ther. 1992;72:261-269.

[15] Moffroid MT, Haugh LD, Henry SM, Short B. Distinguishable groups of musculoskeletal low back pain subjects and asymptomatic controls based on physical measurements of the NIOSH Low Back Arias. Spine. 1994;19:1350-1358.

[16] Borkan JM, Cherkin DC. An agenda for primary care research in low back pain. Spine. 1996;21:2880-2884.

[Delitto A. Clinicians and researchers who treat and study patients with low back pain: Are you listening? Phys Ther. 1998; 78: 705-707.]

A Delitto, PhD, PT, is Associate Professor and Chair, Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260 (USA) ([e-mail]).