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Are You Turned Off by Evidence-Based Care?By Craig Liebenson, DC 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:
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:
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
Craig Liebenson, DC Click here for more information about Craig Liebenson, DC.
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