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Be Careful About Guidelines " Part One"

Guidelines. Guidelines. Guidelines. We are inundated with guidelines, telling us how to do this, how to do that, how to manage this condition and that condition. Many clinical groups look like they are re-inventing the wheel. Do we need another set of guidelines on how to assess and manage acute low back pain? The review and publication of these documents is becoming an industry all of its own. In the UK we have the National Institute for Clinical Excellence (NICE), which reviews medical evidence and makes recommendations. No doubt NICE will be renamed before long in the never ending change in acronyms which seems so much a part of the health care industry.

With NICE guidelines, Chartered Society of Physiotherapy (CSP) guidelines and all the others, those of us in the business of managing clinical caseloads on a day to day basis have a lot of reading to do! And it could be important. Recently a spinal treatment and rehabilitation clinic in the UK was successfully prosecuted by the Health Care Commission (HCC), soon to become the Care Quality Commission (CQC), for not offering spinal physiotherapy to its patients. This contravenes the CSP recommendations for the rehabilitation of spinal patients and the clinic was found guilty of transgression and ordered to comply.

The implication of this case is that we all have an obligation to be aware of the recent analysis and recommendations for the conditions that we manage and show that we are applying them to patient care. We are expected to follow the pathways laid down to some extent and could be asked some very uncomfortable questions about why we chose the treatment approach we did should there be a complaint or legal case involved. We also have to ask ourselves why we would not follow the recommendations of an established body that have produced a serious document. Just not doing so is not good enough.

Then there is the business of our clinical judgment. This often brings up passionate arguments about our rights to decide on the treatments we think, from our experience, are clinically appropriate. Professionals are supposed to absorb the secret mysteries of their craft and then deploy their healing powers to help those who do not belong to their club. The protectionism and the sense of a closed shop of some of our professions can be surprisingly strong and resistant to change. Any criticism can be met with immediate and sustained, often personal, attack as if a central tenet of the whole right of the profession to exist has been threatened.

The limits of our knowledge and effectiveness are now important things to establish if we are to stand up to scrutiny. The physiotherapy paradigm, in which I was educated, thinks about the function and dysfunction of the body in a specific way. This colours our view of what to do when we treat patients and some of my views are therefore:

Normal function in individuals is common and they need no input from professionals like us and this is good.

Time and nature improves many conditions as they are self limiting and do not 

The intensely subjective nature of therapists' examinations, analysis and treatments, even within professions, makes them hard to validate objectively.

Validated measures of outcome have not been used across much of our work, making our effectiveness hard to ascertain.

Many of the changes to patients may not be as a result of our interventions.

Our clinical judgment is of core importance but we have not yet done enough to prove we are secure in our belief.

Technical treatments are seductive and often suggested rather than the less concrete work needing to be done to help an individual change.

None of this is to have a negative view of our professions, which I am sure will continue to contribute greatly to the comfort and health of many people in our communities. We need to have faith in our clinical judgments and our training paradigms but also to scrutinize them for errors and ways to improve our therapeutic approaches.

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