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By: Christian Longtin

I’m a young physiotherapist working in musculoskeletal care and a PhD student at the Université de Sherbrooke that values evidence-based practice and the importance of always improving and learning new things. As a CPA member, I have the chance to engage in networking opportunities and sharing key learnings with my colleagues so we can get better, as a profession, together. Here is an example of how who I am as a member applies in my daily practice and how we can learn together.

My research focuses on the management of persistent musculoskeletal pain and, more precisely, on the management of non-specific low back pain (LBP). I have a special interest in self-management and the influence of psychosocial factors in the experience of pain and disability.

Since I graduated from physical therapy school in 2016, I had the chance to work in a variety of clinical settings, from hospital outpatient clinics to private practice, which involved working with a wide variety of patients, such as injured workers, seniors, and physically active individuals, mostly in a primary care setting. My clinical practice led me to develop a special interest in the management of non-specific LBP. In fact, it was the difficulties and challenges that I had encountered with the more complex patients presenting with non-specific LBP that convinced me to pursue clinical research on this particular topic.

For the vast majority of my caseload, I would notice good initial improvements in terms of pain and disability levels within a six-weeks’ timeframe. Then, my patient would hit a plateau or experience really modest improvements that were either not consistent or not clinically significative. Moreover, as a recent graduate, I realized that I was more comfortable adopting a biomedical approach to treat my patients’ symptoms even though I knew of the importance of implementing a biopsychosocial approach during my initial training. Yet, I felt that I was probably lacking confidence or was not equipped properly to manage “non-nociceptive drivers” of pain and disability, such as psychosocial factors. I was aware of a few tools to help detect and screen for these other factors that could help explain my patients’ persistent symptoms. However, I was hesitant to use them in my practice because I questioned their relevance or effectiveness, as they were mostly self-reported questionnaires that I believed would take too much time and prevent me from performing a relevant assessment of my patient. This issue was also shared by my colleagues since we all had very busy work schedules and wanted to be time efficient. Anxious to provide quality care to my patients, I started consulting various resources on the management of persistent and complex cases of LBP. More precisely, I wanted to know what the best practices were for the management of LBP in order to provide better clinical outcomes with my patients. Drawing on these observations, I decided to consult the literature with the aim of performing a review of the most recent and high-quality clinical practice guidelines (CPG) related to the management of LBP. I found and consulted multiple CPGs and summarized the findings and recommendations into an infographic to facilitate its appropriation and implementation in clinical settings. Yet, this was not that easy…

Why?

During my search in the literature and after having discussed my issues with other colleagues, I realized that there were significant barriers to the implementation of CPGs in clinical practice. They were mostly due to resource constraints, the sheer volume of CPGs, poor knowledge about these CPGs, and the complexity of the information contained combined with a lack of use of plain language to facilitate clear interpretation. Therefore, I knew that simply consulting and being aware of these CPGs was not enough to make a significant difference in my own practice (i.e., to change my own behaviours). As a frequent user of social media and scientific literature, I had come across multiple infographics, visual aids, and algorithms summarizing key points on best practices and management of multiple conditions frequently seen in rehabilitation. I came to realize that these tools had a more significant influence on my practice compared to lengthy and often complex scientific papers such as CPGs, systematic reviews, and meta-analyses, for instance. This prompted me to develop the infographic presented in this short blog.

What Did I Find?

The synthesis of the CPG on the management of LBP illustrated in Figure 1 aims to address these barriers and facilitate clinical implementation. A thorough search strategy of the literature was conducted with the help of a professional librarian. Only high-quality CPG were retained and recommendations were synthesized and grouped under three categories: screening, diagnostic, and treatment procedures. Only non-pharmacological approaches were considered. The CPGs retained were mostly well recognized, international, multidisciplinary LBP guidelines from groups of experts and/or institutions, such as the National Institute for Health and Care Excellence (NICE).

These infographics contain several recommendations related to the most appropriate screening, assessment, and treatment procedures to inform clinicians on best practices. Overarching principles present in all of the CPGs are also highlighted.

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What are the key points of the most recent clinical practice guidelines for the management of LBP?

 

 

What is recommended in terms of assessment and screening procedures for the management of LBP?

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Consistent with an adequate assessment of their patient, clinicians should follow these recommendations when it comes to delivering high-value interventions for the treatment of LBP.

 

 

With the ever-increasing human and socioeconomic burden associated with LBP, providing high-value care to our patients is of extreme importance. Too often do we see low-value care being carried out by health care professionals with the emergence of issues such as overuse of services that is unlikely to provide benefit or cause harm to the patient (i.e., overuse of diagnostic imaging, which can lead to nocebo effects) and underuse of modalities that are likely to result in good outcomes (i.e., active treatment approach). In order to be part of the solution and not the problem, it is essential that physiotherapists endorse an evidence-based practice that is the combined contribution of the practitioner experience, the scientific evidence, and the patient’s context, goals, and values to support the clinical decision-making process in a collaborative manner between the clinician and the patient.

So, How Did These Findings Influence My Practice? Were They Useful?

First of all, I was a lot more confident as I felt that I had the necessary knowledge to adequately manage my patients. More importantly, I felt that I was now providing high-value care based on what the most recent evidence recommended, which was a great source of motivation that I was able to transfer to my patients as well. As physiotherapists, we are fortunate to spend quality time with our patients and the way we interact with them can have great impact on their rehabilitation. Moreover, it convinced me to use different tools to screen for psychosocial factors and to engage in the appropriate treatment approach, such as adding a “cognitive-behavioural twist” to my approach when indicated, based on the patients’ needs and goals. In fact, I realized the great potential for standardized outcome measures, as the time I spent administering them to my patients led to a more complete assessment that considered the person a whole. Basically, I had a better understanding of my patients’ pain experience and disabilities which led to better clinical outcomes and an improved therapeutic alliance. I was getting better at involving my patients in setting meaningful goals and planning appropriate interventions to facilitate, which improved their sense of self-efficacy and has allowed for better control of their condition. Finally, I sincerely believe that this process has made me a better scholarly practitioner. Therefore, I invite all clinicians working with LBP patients to take action and implement these guidelines to provide high-value care to their patients.

As this is directed to clinicians and aims to facilitate the implementation of CPGs into clinical practice, I would like to hear what you have to say! Does this mean of communication/resource helps you integrate these guidelines into your practice? What are the obstacles that you face when you want to apply evidence-based practice? What do you think of these recommendations for the management of LBP? Do you feel that you are sufficiently prepared to recognize and manage significant psychosocial factors of your patient presenting with LBP? Have you had experiences with patients presenting with a more complex LBP profile that you had trouble achieving good results?
 


 

Christian Longtin completed his master’s degree in physiotherapy at the University of Sherbrooke in 2016 and he is now working with clients struggling with persistent pain at the pain clinic at the Center Hospitalier Universitaire de Sherbrooke (CHUS). He completed a master's degree in Health Sciences Research at the University of Sherbrooke in 2019, which led him to develop a particular interest in the management of persistent low back pain. In line with his interests in clinical research, he is currently pursuing doctoral studies focusing on evaluating the effectiveness of a new model aimed at optimizing rehabilitation care for patients with low back pain by rehabilitation professionals.

Email: Christian.Longtin@USherbrooke.ca