A Physiotherapist Approach to Clinical Guidelines

A Physiotherapist Approach to Clinical Guidelines

“Guidelines do have a role, but they should remain what they were supposed to be: handrails, not handcuffs.” (Canino and Baglioni, 2008) With reference to the physiotherapy profession, this paper discusses the issues and dilemmas raised within this quote.

Clinical guidelines have been defined by the Institute of Medicine (1990) as ‘systematically developed statements to assist practitioner decisions about appropriate health care for specific clinical circumstances’. Clinical guidelines are able to be used to decrease the amount of unsuitable differences in practice and to encourage the use of high quality, evidence based health care (Clinical resource and Audit Group (CRAG) 1993). Clinical guidelines have proven to be beneficial (Grimshaw and Russell, 2003) but they need to be evidenced based, reviewed frequently, dispersed appropriately and accessible to all. There is good reasoning to support clinical guidelines as they have the ability to provide recommendations for the treatment and care of people by health professionals; to be used to develop standards to assess the clinical practice of individual health professionals; to be used in the education and training of health professionals; to help patients to make informed decisions and to improve communication between patient and health professional (NICE (2010). They are designed to be handrails to professionals in the health care system.

However there are limitations to clinical guidelines which can cause them to become handcuffs in certain situations. Budget holders could use clinical guidelines to restrict practice by not supplying certain facilities if they have not been researched well enough in the clinical guidelines; novice practitioners who are lacking the clinical reasoning to make autonomous decisions in a complex situation may feel handcuffed by clinical guidelines which should be adapted to different the situation. Clinical guidelines should not to be used as rules and applied to every service user who has the same underlying condition because each patient is individual. The limitations of clinical guidelines should not cause clinical guidelines to become handcuffs. However for novice practitioners in situations which are more complicated, until they have developed their clinical reasoning, they may find it difficult to use clinical guidelines as handrails as doubts over treatment can lead a novice practitioner, through fear of clinically reasoning, to comply with clinical guidelines.

There are also problems when clinical guidelines have not got enough evidence to support the treatment that is being recommended as the most ideal treatment. This means that the service user may not receive the most optimum treatment that could be on offer to them. Problems also arise when there is conflicting evidence between clinical guidelines both locally, nationally and worldwide. This makes it difficult for busy practitioners to know what treatment has been recommended as the best treatment to be used to ensure their patients receive the best quality of care. Here clinical guidelines become handcuffs and limit the chance of optimal treatment being received by the service user.

The National Institute for Clinical guidelines (NICE) joint with Woolf et al (1999) indicate that clinical guidelines are a stratagem for making care more consistent and efficient. The expectation is that clinical guidelines will reduce incongruous practice and therefore increase effectiveness (Irvine, 1991) providing appropriate handrails for practitioners. Studies around the world have shown that there are huge differences in the treatment service users receive depending on what doctor they have, which hospital they are treated at and in what area, irrespective of the condition (Chassin et al 1986). This increases the chance of receiving substandard treatment. Clinical guidelines increase the chance of all service users being treated in the same way (Woolf et al, 1999) as the clinical guidelines offer regulation and direction on treatment for service users which therefore aids Healthcare Professionals (HCP’s) in decision making thus providing up-to-date and effective handrails.

Clinical guidelines can improve the quality of clinical decisions (Tong, 2001) producing effective handrails for practitioners. This is because the clinical guidelines close the gap between what clinicians do and what scientific evidence supports (reference) and enables all HCP’s to access up to date treatment when clinicians may otherwise have been too busy to read or research themselves. They alert clinicians to interventions unsupported by good science, reinforce the importance and methods of critical appraisal, and call attention to ineffective, dangerous, and wasteful products (nurse’s web). Due to this, clinical guidelines ensure optimal treatments which provide functional handrails for HCP’s and enable the National Health Service (NHS) to be more cost effective. This is because clinical guidelines that improve the efficiency of healthcare in this current economic climate free up resources needed for other healthcare services increasing the cost effectiveness of the NHS (Tong, 2001). If the NICE clinical guidelines for non-specific lower back pain (NSLBP) state that exercise is the best treatment, then a Physiotherapist can issue this highly rigorously evidence based treatment being sure that it will work. This reduces the clinical time needed with a Physiotherapist as they would have spent more time with the patient originally finding out which treatment will be optimal for the service user. In this instance the clinical guidelines provide handrails for practitioners but can easily be misconstrued as handcuffs if the condition is more complex.

It has been proven by Grimshaw and Russell (2003), who reviewed 59 published appraisals of clinical guidelines that satisfied the well-defined criteria for scientific rigour, that clinical practice guidelines can improve the quality of care when introduced in the context of rigorous evaluations. However, the size of the improvements in performance varied considerably (Grimshaw and Russel 1993). Some of the studies where doctors (or hospitals) were randomised to the guideline groups were at risk of bias by the Hawthorne effect than controls. The Hawthorne effect is the “beneficial effect on performance of taking part in research” (Grimshaw and Russell). This means that the evaluation may overvalue the real effects of clinical guidelines. They did try to reduce this by performing controlled before-and-after studies which were designed to find a non-randomised control group that would undergo trends and variations comparable to those of the study population but it did not eliminate the full effect of the Hawthorne effect which would reduce the effectiveness of the study.

If a patient presents with non-specific lower back pain (NSLBP) there are clinical guidelines indicating the best treatment to be used, depending on current evidence. However if the patient also has dementia causing confusion and irrational actions the clinical guidelines have to be used as what they were made to be: handrails not handcuffs to ensure the best treatment for the service user depending on the situation. The uniqueness of patient’s diagnosis should be paramount to decision making, as although patients may fall under the same diagnostic term, each patients underlying set of circumstances may be very different (Ter Meulen et al 2005). An experienced practitioner would be able to use the original NSLBP clinical guidelines as handrails when faced with a complex situation. On the other hand some novice practitioners may end up relying too much on the clinical guidelines, causing the guidelines to become handcuffs when they are unsure what else to do. This is where the service user may suffer as a reduced clinical autonomy regarding decision making can adversely threaten the art of patient care.

Joint with reducing costs to the National Health Service (NHS) clinical guidelines can also increase the bond between the patient and clinician as the patient is able to make informed decisions on their treatment. The service user is able to access clinical guidelines which can help to provide them with appropriate education on their condition. By providing service users with the appropriate education for long term conditions it can empower the patient and help them ‘self manage’ their problem consequently helping the service user to reduce and prevent hospital admissions (Brosnal et al 2010). Lay guidelines indicate the benefits and potential risks associated with certain treatments in a summarised fashion and also provides estimations for the chances of complications. (Entwistle et al 1998) These clinical guidelines therefore permit the service user to make cognizant decisions about their treatment. On the other hand, a mismatch between patient and clinician can occur when the patient has read about their condition. A guideline may state what treatment is best advised, however an experienced clinician may make an informed decision to use another treatment which they feel will be more effective due to the circumstance. This could reduce relations between the service user and clinician.

The Department of Health (DOH) specified that recommendations contained in clinical guidelines are to be based on comprehensive scientific evidence provide by high quality randomised controlled trials as opposed to the subjective opinion of individual practitioners (NHS Executive, 1996). Where there is poor evidence to support a guideline or if the guideline is just based on ‘expert opinion’ the focus may be based upon traditional treatment not on what is effective. The DOH therefore aims to deliver a more research-based and meticulously reviewed guide to clinical decision-making (Tong, 2001). Many clinical guidelines still do not have strong enough evidence to support them due to a lack of high-quality randomised controlled trials (Dickson, 1996) and have been scrutinized for damaging the trustworthiness of many other clinical guidelines.

Diagnosing and treating acute and chronic lower back pain (LBP) varies significantly among general practitioners (GPs), medical specialists, and physical therapists in the same country and in different countries (Koes et al 2001). Some clinical guidelines contradict each other which make it problematic for a busy practitioner as difficulties arise when discrepancies in recommendations have been identified. With regards to using spinal manipulation as a treatment for LBP, some clinical guidelines i.e. the Dutch and Australian clinical guidelines do not recommend using it (Koes et al 2001). On the other hand other clinical guidelines do recommend using spinal manipulation as a treatment but have different views on the length of time that should be used to provide the treatment. The Danish clinical guidelines suggest spinal manipulations as being a good idea for treatment after 2- 3 days, the US clinical guidelines recommend using spinal manipulation within 4 weeks, the New Zealand clinical guidelines advise between 4 and 6 weeks where as the UK clinical guidelines only advise using manipulation as a treatment for patients who need “additional” assistance with pain relief or if they are unable to get back to normal activities (Kohl et al 2001). This could lead to clinical guidelines being seen as handcuffs rather than handrails as the clinical guidelines are saying such different things, leaving the practitioner confused with what to do regarding providing the optimal treatment for a patient. This therefore reduces patient choice and denies access to an effective intervention.

Budget holders could potentially use clinical guidelines to restrict practice. For example if a guideline does not include electrotherapy for the treatment of LBP, the budget holder may disallow the use of electrotherapy as it is an expensive treatment without the evidence to support it. This would mean that the clinical guidelines have become handcuffs instead of handrails as it is denying treatment options to practitioners. If success of a treatment is not apparent after the first few randomised trials have been conducted, then a systematic review or a meta-analysis may be mandatory before a secure conclusion can be made. However this is not often done (Grimshaw and Russell, 1993). A time when a meta-analysis or a systematic review was not conducted, after there was an initial lack of success of a treatment, was during the review of the use of spinal manipulation as treatment for back and neck pain (Grimshaw and Russell, 1993). Clinical guidelines are not yet exposed to such close inspection and examination which means that treatments that are in fact relevant may not be supported by clinical guidelines (Grimshaw and Russell, 1993). The clinical implication of this is that novice practitioners may not feel comfortable using spinal manipulation as a treatment for back or neck pain because the clinical guidelines, which have not been scrutinised enough, do not support manipulation as an effective treatment for back pain. Here clinical guidelines become handcuffs instead of handrails.

Clinical guidelines can improve the quality of clinical decisions and provide direction and handrails for practitioners on how to treat a patient providing them with the best quality of care. The more diverse the patient population and the more complex the package of healthcare delivery is the more difficult it is to apply clinical guidelines exactly to a patient. This can cause limitations to clinical guidelines. Clinical guidelines can improve quality of care (Grimshaw and Russell 2003) and can help reduce costs to the NHS by making health care more effective. Problems arise when clinical guidelines are not evidence based and are not supported by randomised control trials or meta-analysis to fully analyse the treatment. Patients have access to guidelines which can increase patient education aiding them with self-managing their condition further reducing costs to the NHS. However conflict can arise when a practitioner chooses to use an alternative treatment to the one recommended in the guidelines as a patient may not understand the reason why. It is important to ensure that clinical guidelines are used as handrails not handcuffs as they are not rules but it is equally important that the handrails are fully evidence based and reliable.

Koes, B., Van Tulder, M., Ostelo R (2001). Clinical Guidelines for the Management of Low Back:. Pain in Primary Care. 26 (22), 2504-2513.

Chassin M, Brook R, Park R, Keesey J, Fink A, Kosecoff J, . (1986). Variations in the use of medical and surgical services by the Medicare population. English Medical Journal. 314 (1), 285-290.

Field M, Lohr K, (1992). Guidelines for Clinical Practice. Washington: National Academy Press. 34-56.

Greenfield S, Anderson H, Winickoff RN, Morgan A, KomaroffAL. West J Med. (1975). Institute of Medicine. Clinical Practice Guidelines: . Directions for a. 123 (1), 350-351.

Grimshaw J and Russell I. (2003). Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations.. The Lancet.. 342 (8883), Page 1317-22.

Irvine D (1991). Managing quality in general practice. London: King Freuds

Lee, R. (1958). Developing Clinical Practice Guidelines. Available: http://www.nap.edu/openbook.php?record_id=1863&page=45.

Miller J, Petrie J.. (2000). Practice. In: Development of practice guidelines. London: Lancet. 82-83.

NICE (2010) About Clinical Guidelines [online]. Available from: http://www.nice.org.uk/Guidance/CG/Published Accessed: 27th December 2010)

Ockene JK, Zapka JG. (2000). Provider education to promote implementation of clinical practice guidelines. London: Chest. 33-39.

Tong, A. (2001). Clinical guidelines: can they be effective?. Available: http://www.nursingtimes.net/nursing-practice-clinical-research/clinical-....

Woolf S, Grol R, Hutchinson A, Eccles M, Grimshaw J. (1999). Potential benefits, limitations and harms of clinical guidelines. British Medical Journal. 318 (527), 45-250.