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Clinical practice guidelines - the minimum effective dose to best practice

Updated: Oct 19, 2020

By Ben Csiernik


Keeping up with the latest research is hard. It’s a never ending stream of new data, and trying to read through it all, let alone fully understand everything within it, is next to impossible. For example, if you’re interested in working with athletes, you may run into a few individuals with an ACL reconstruction. Good news for you, only 1380 articles on the ACL were published in 2017 (1). You surely read them all, right? Maybe you’re a chiropractor, or a physical therapist, or a personal trainer, and you work with someone who has low back pain. Luckily, from 1995 to 2016, there’s only been 50,970 articles published on the subject (2). Honestly, light work.


Regardless of what kind of practitioner you are, it’s safe to say that what you want most is the best for your patient. One of the ways you can best help your patients, is trying to stay on top of the research, and applying it in daily practice. But with all this noise and the insane volume of research, what options do we have? To answer that, let’s talk about clinical practice guidelines.


What the hell is a clinical practice guideline?


Typically, clinical practice guidelines (CPG) are evidence-based recommendations for managing various conditions, often covering the diagnosis and management of a condition. Their goal is to be the best summary of evidence possible for a condition. More or less, a well done CPG is the most intense literature review one can really have on a subject. They SHOULD guide treatment strategies and decisions for patients, and should be your first checkpoint when looking up the diagnosis and management of conditions.


As an example, in the 2016 NICE low back pain guidelines (link at the bottom of the article), the committee screened 43000 papers, and reviewed 734 papers to come up with its recommendations. Truly no small task.


Who writes and creates these guidelines?


Many existing guidelines have been created from government support, professional societies, or expert panels (3). In the creation of a well done guideline, the guideline decision committee should be composed of: researchers in the field, members from all stakeholder groups*, and arguably most importantly, patients living with this condition.

*For our example of low back pain, mainstream professionals who treat low back pain should probably be considered. Therefore, you would hope to see physicians, surgeons, outpatient MSK therapists (PT/DC/OT) etc. represented. This is HARD to do.


How do I know which guidelines are well done?


Guidelines can be evaluated using something called the “Agree II” criteria. If you want to critically evaluate a guideline, this is a good place to start. Warning: I hope you have a few hours to spare if you choose to do so. Luckily, sometimes people critically appraise guidelines for us! For example, this paper from Lin et al. in 2017 (4) evaluated a range of guidelines for common musculoskeletal conditions. You can access the article here, but I have also included direct links to the highest rated guidelines from that study at the bottom of this page.

What are the recommendations within a guideline, and what do they mean for me?


When guidelines provide their recommendations for interventions, they often have specific wording to dictate how you should use (or not use) an intervention. Commonly utilized descriptors are listed and explained below:


No recommendation: This means there is likely not enough research on an intervention to make a decision on it. In other words, we don’t know enough about an intervention, so maybe we shouldn’t use it quite yet. Recent work by Zadro, O’Keeffe, Maher (4) and Zadro and Ferreira (5), has shown an upward trend, at least among physical therapists, for the use of interventions that are unproven.


Do not offer: The evidence firmly says that this intervention is not better than usual care, or placebo. Simply, do not use.


Do not routinely use: Interventions in this category likely do not show meaningful effect sizes, or they’re only effective in a specific subgroup. More often than not, there is a more well established intervention to use than one that receives a “do not routinely use” ranking.


Consider: The TRICKIEST category. This roughly translates to “there’s some evidence but it’s probably low quality and the studies are often underpowered and the effect sizes are over inflated but low quality evidence does exist for these interventions”.


Offer: Do these interventions. They have been shown to be effective, and with consistent and meaningful effect sizes. This is good.


In some CPG’s, authors will include a letter grade for each recommendation, or a numerical grade. Most often, higher quality evidence means a higher quality recommendation. For example, a letter grade of “A”, or numerically, “Level 1/1+/1++” typically means there’s high quality Meta-analyses, Systematic Reviews, or Randomized Controlled Trials with low risk of bias for these recommendations (6). This grading system (hopefully) tells us when we are working with strong recommendations.


A common example of a strong recommendation (interventions that guidelines classify in the “Offer” category) is the use of advice, education, and reassurance for low back pain (7), or education and exercise for osteoarthritis (8).


Closing Thoughts


There are a LOT of clinical practice guidelines out there, and it can be challenging deciding which ones to use. Hopefully you can appreciate that a good guideline contains a diverse authorship committee, a large amount of evidence reviewed and provided, and appropriate grading for the recommendations, to name a few. Below are a few CPGs with high Agree 2 scores. If you’re interested in what a high quality guideline (hopefully) looks like, here are some of the top ones. Hopefully you’ll see that there’s a common theme amongst the “offer”, and “do not offer” interventions in each one. More on that another time.


Low Back Pain: Low back pain and sciatica in over 16s: assessment and management, NICE guideline [NG59] https://www.nice.org.uk/guidance/ng59


Neck Pain: Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration: https://pubmed.ncbi.nlm.nih.gov/26984876/


Osteoarthritis: NICE pathway for the Management of osteoarthritis https://pathways.nice.org.uk/pathways/osteoarthritis/management-of-osteoarthritis.pdf


OARSI osteoarthritis guidelines (sadly, not open access) https://www.sciencedirect.com/science/article/abs/pii/S1063458419311161


Patellofemoral Pain: American Physical Therapy Association guideline for Patellofemoral Pain: https://www.jospt.org/doi/full/10.2519/jospt.2019.0302#


Rotator Cuff Related Shoulder Pain: Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace https://rcs.med.unsw.edu.au/sites/default/files/rcs/page/RotatorCuffSyndromeGuidelines.pdf



References:


1. Kambhampati SB, Vaishya R. Trends in publications on the anterior cruciate ligament over the past 40 years on PubMed. Orthopaedic Journal of Sports Medicine. 2019 Jul 22;7(7):2325967119856883.


2. Wang B, Zhao P. Worldwide research productivity in the field of back pain: A bibliometric analysis. Medicine. 2018 Oct;97(40).


3. Lin I, Wiles LK, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O’Sullivan PP. Poor overall quality of clinical practice guidelines for musculoskeletal pain: a systematic review. British journal of sports medicine. 2018 Mar 1;52(5):337-43.


4. Zadro J, O’Keeffe M, Maher C. Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review. BMJ open. 2019 Oct 1;9(10):e032329.


5. Zadro JR, Ferreira G. Has physical therapists’ management of musculoskeletal conditions improved over time?. Brazilian Journal of Physical Therapy. 2020 May 5.


6. Kamel C, McGahan L, Mierzwinski-Urban M, Embil J. Preoperative skin antiseptic preparations and application techniques for preventing surgical site infections: a systematic review of the clinical evidence and guidelines.


7. de Campos TF. Low back pain and sciatica in over 16s: assessment and management NICE Guideline [NG59]. J Physiother. 2017 Apr 1;63(2):120.


8. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SM, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and cartilage. 2019 Nov 1;27(11):1578-89.