A Tale of Two Guidelines – Part One
Clinical Practice Guidelines
First – A HUGE Announcement !!!
HUGE! So I am using this post to go public. This decision is HUGE. This HUGE innovation will be the best clinical combination the rehab world has ever known. Are you ready for something huge?
I have created an all new approach to physical and occupational therapy that is completely revolutionary. (did I mention it is going to be HUGE?):
ACV-Activated Carbon Therapy
ACV-Activated Carbon Therapy is a highly therapeutic compound; that when combined with therapy techniques it heightens the body’s own healing pathways. Thus allowing the patient to take advantage of a much larger window to recovery. These compounds are known the world over as beneficial for many common ailments.
Through painstaking efforts, I have created the optimal ratio of these compounds into a stable paste (or maybe a salve? Let’s go with salve, or even slurry). The salve can be applied directly to the affected areas during any treatments. Its versatility does not end there. It can be mixed with ultrasound gels, massage lotions, used with cupping, applied over almost any tape. Testing of both edible and sterile versions are almost complete which will then allow patients to benefit even more. You thought dry needling was cool? Try it with just a bit of this salve over the area before treatment and you will be amazed. . . .
…. What??? You don’t believe me?
Oh, you want to know what is really in it?
You also want research to back it up? No problem! The primary compounds are Apple Cider Vinegar (organic of course) and Activated Charcoal.
You think I am joking? (maybe, wink, wink)
These are HUGE in the wellness world right now! You want research? Just google “health benefits of (Apple Cider Vinegar)(Activated Charcoal) and you will get more “research” then you will know what to do with.
…. Wait again? You still have concerns about this? Where is my evidence? I think there may be some jealousy. I develop this huge new approach and you are questioning me at every turn. Oh, you say there is no strong evidence for ACV-Activated Carbon therapy? . . . what does that matter? There are tons of articles, blogs and even videos teaching the benefits of both these substances. I just put them together for an even better combo. I have a few related research articles. Everyone knows experience is strong enough. I have used ACV in cooking for years, so what is the deal? So unless you have a better argument . . . ?
You Down With CPG? Ya You Know Me
Alright, the jig is up. I was totally joking. No, I am not planning on creating a new approach based on the combined effectiveness of apple cider vinegar and activated charcoal. I needed to set the stage for this article, for you see, it may not be that blatant but there are providers practicing under similar premises with their treatments every day. It needs to come to an end. That premise is the limited use of real clinical recommendations and peer reviewed guidelines in skilled care (PT, OT, Chiropractic, etc). I am talking about the need to use Clinical Practice Guidelines in daily patient care. How about a few more applicable examples:
- Based on best current evidence and expert recommendation manual therapy is only strongly advised for short term use, yet there are providers who rely on manual therapy for every treatment for as long as they can see a patient
- Based on best current evidence and expert recommendation most electrical modality treatments (Ultrasound, stimulation, diathermy, etc) have little to no concrete support and are not recommended for regular use. However, I continue to see clinic notes with regular use of these for many patients.
- Based on best current evidence and expert recommendation regular physical therapy is not strongly supported for the treatment of adhesive capsulitis until after the shoulder range of motion starts to return on it own (the “thawing phase”) and that pushing through with therapy is not effective in the early phases. Unfortunately I see requests from providers all over the nation for high frequency therapy in the beginning phases of a “frozen shoulder”.
Now on to the reason for this article! Clinical Practice Guidelines.
Clinical practice guidelines, or often referred to as CPGs, are a huge resource to providers. I cannot recommend enough becoming more familiar with these for the areas in which you treat patients. Unfortunately, not every diagnosis or patient problem is going to have its own CPG; so at times we do need to rely on limited research and clinical knowledge. I do promise, however, that as you become familiar with CPGs you will notice patterns and develop a strong sense of what is recommended and what is not.
Peer Reviewed and Published CPGs
The golden-standard-king-of-the-crop-top-of-the-pyramid publications when it comes to evidence based health care are published clinical practice guidelines (CPGs for short). The general idea is that an organized research group compiles any applicable research on the treatment of a specific condition, go through that research, organizes it all together, checks it for strength and bias, run comparisons, create an expert panel, digest the information, give recommendations for all aspects of care for the condition, and rate the strength of those recommendations based on the strength of the referenced research and/or expert opinion. This is a long process that involves many people and thousands of hours. These are not just simple recommendations. These should be seen as what is recommended as usual and customary skilled rehabilitation.
These are generally going to published by large health care associations and their groups. Such as the American Medical Association, British National Institute of Health, Department of Labor, Department of Veterans Affairs, National Health Service of New Zealand, and one of my favorites the American Physical Therapy Association. Often these associations will work in collaboration with other groups and research teams. Like the APTA may work through their orthopedic, sports, pediatrics or neurology groups and universities or other institutions to create a finished guideline.
For this article I was able to get the inside scoop from the Academy of Orthopedic Physical Therapy (AOPT) on just what it takes to create a CPG for the Journal of Orthopedic and Sports Physical Therapy:
Brenda Johnson, their CPG coordinator told me
“it takes a village to create a guideline! All CPGs are created by a volunteer team of authors ranging from teams of 6-10 authors, 6-10 content and stakeholder reviewers, 3 CPG editors, 1 cpg coordinator, advisory panels, librarians, methodologists, workgroup leaders, volunteers helping with article screening, appraising, and data extraction, and JOSPT editorial staff, and membership reviewers and public reviewers. Authors chosen are considered PhD experts in their field with extensive research background including systematic reviews.”
I was amazed to hear of all the people involved. Since most of us are used to just seeing 3-4 names in the citation to a reference I had no idea the depth of involvement these things take. What more to hear they are volunteers!
She continued to tell me that a new CPG will take about 5 years from start to finish and a revision will take about 3 years! You thought your grad project was long! Just think, these take longer than many research projects do! Heck, some take longer than you were in grad school!
“They will involve the systematic review of anywhere from 5-35 thousand articles. Articles that are screened for specific inclusion and exclusion criteria. Those articles included will be reviewed independently by teams for quality, trustworthiness, and relevance. We follow international and national standards for CPG development, including systematic review standards. Through the whole process many various drafts are created and feedback from all involved is taken into consideration.”
I cannot wait to see what they publish in the next five years. They have published 12 CPGs so far (several are available right on their website)! According to the numbers given above, that is a ton of work. They also have another 13 either in development or planning stages. So let’s just say, these things are not taken lightly! The level of work and expertise that goes into these should speak volumes on how important they need to be in clinical practice.
As a perfect example, a team of AOPT and Academy of Hand and Upper Extremity (AHUEPT) authors just published a new CPG in The Journal of Orthopedic and Sports Physical Therapy (JOSPT) on recommended rehabilitation care for carpal tunnel syndrome.
I know each of you will go and read the published result, so I am not going to just regurgitate what it says. I do want to point out some specific things about peer reviewed CPGs using this new one as an example.
- Summary of Recommendations: Not all CPGs will publish in the same format but many I have read start off with all the highlights in a summary format. I love the summaries in JOSPT CPGs! Each area of care of a condition is listed as a subheading followed by recommendations and the strength of recommendation. Some subheadings are: Diagnosis, Examination, Interventions. In two summary pages I can already see that the strongest recommendations in the care of patients with carpal tunnel syndrome are use of monofilament testing, combined use of Phalen/Tinel/Compression testing, Use an outcome measure such as DASH or CTQ-SSS, not use grip in post-surgical care for first 3 months, use of night splints in the short term, not using laser, not using ultrasound, not using iontophoresis, etc. So easy to get quick actionable recommendations.
- Levels of Evidence, Strength of Evidence and Grade of recommendation: A real CPG will explain in the introduction how the research they reviewed was graded and how the strength of the research led them to specific grading systems. JOSPT uses a very common methodology created by Oxford’s Centre for Evidence Based Medicine. This criteria is important to note when reviewing a CPG. For example, in the CTS CPG linked above “not using low-level laser or other types of non-laser light” is graded at a B level, “performing manual therapy directed at the cervical spine and UE” was given a C level recommendation. Just like in school, A grade is the best. It means there is a large body of evidence to support the recommendation. The further you get down the alphabet the less high quality evidence there is.
- Detailed Breakdown: This makes up the rest of the CPG. Basically each summary subheading is explained in detail. The research evidence is dissected for the reader along with information on the strength of individual articles referenced. So if you wanted to go get more context as to why low-level laser is not recommended, you just go to the area (pg 44 to be exact), and you will see two level II and one level IV articles were in regards to laser treatment.
- Affiliations and Contacts: Right before the references there is a page that lists all those that played major roles in creating the CPG. Why I love this page is it gives me a chance to see the names of those helping. To see they are peers. Many of providers out in clinics. Many are professors as well, but not all are just researching 100% of the time. These really are recommendations created by clinicians for clinicians!!
- References: We should all know what references are. I just want to point out that any quality CPG must have a bibliography. This way, you can find specific research they mention and dive deeper if you would like to. Also, it is the foundation of their whole work.
I absolutely love the CPGs put out by AOPT and published in JOSPT. I have also found that most CPGs are structured somewhat similarly and the information is easy to digest. At this point, you may be wondering, “how can I find more CPGs?”. If you are a member, you can access CPGs directly from JOSPT website. There are also some posted on AOPT website .
There are two other options I can suggest, one is to just run across them in a general lit search at sites such as PubMed, EBSCOhost, Google Scholar. If you are savvy you may already know how to filter for CPGs.
A second option that I use all the time is PEDro (Physiotherapy Evidence Database). PEDro is dedicated to evidence related to rehab and physical therapy (or physiotherapy as they are based in Australia). You can easily search for just CPGs using keywords. So the only results that come up are peer reviewed CPGs! You can also do general searches. Searches for just RCT. Searches based on certain levels of evidence. It is really useful!
A huge thanks to all the authors, volunteers and members at AOPT for all their hard work. One last plug that many may be interested in. Brenda was kind enough to share a link to information on becoming a volunteer in the CPG process. You should certainly go check it out! It looks like they are 3 year commitments with up to 20 hours of work per month, but you may not be needed every month. What a great way to get into the process and help out the profession.
Please, go out and start studying those CPGs. Use them to help you make your decisions for providing skilled care. Of course the ones by AOPT, but also all the others you can find. Also, share this information with your friends and colleagues. We can all benefit from these great resources.