| Guidelines. Guidelines. Guidelines. We are inundated | | | | which instruct us to do things in particular ways. |
| with guidelines, telling us how to do this, how to | | | | We want to make our own decisions based on |
| do that, how to manage this condition and that | | | | our experience and do not appreciate the idea |
| condition. Many clinical groups look like they are | | | | that some of that independence might be |
| re-inventing the wheel. Do we need another set | | | | removed. Our professions sometimes appear like |
| of guidelines on how to assess and manage acute | | | | exclusive clubs where the mysterious techniques |
| low back pain? The review and publication of | | | | and powers are passed down to the willing who |
| these documents is becoming an industry all of its | | | | then become club members. It can all look a bit |
| own. In the UK we have the National Institute for | | | | protectionist as we resist changes which conflict |
| Clinical Excellence (NICE), which reviews medical | | | | with our club ethos. Criticism may not be |
| evidence and makes recommendations. No doubt | | | | welcome in these circumstances as we try to |
| NICE will be renamed before long in the never | | | | resist attack. |
| ending change in acronyms which seems so much | | | | Yet we have a duty to know what we don't |
| a part of the health care industry. | | | | know. We learn to think about the way the body |
| Any physiotherapist or other clinician dealing with | | | | works in normal and dysfunctional ways in a |
| the day to day assessment and treatment of | | | | particular paradigm. Mine is the physiotherapy |
| patients has a difficult job keeping up with the | | | | paradigm. I will not speak for others in my |
| large amounts of information coming out every | | | | profession when I say that parts of the paradigm, |
| year in terms of research, reviews and guidelines. | | | | my way of thinking about the body and how to |
| Ignoring this information would be an error. A | | | | assess and manage its problems includes: |
| successful prosecution was recently obtained | | | | Normal function in individuals is common and they |
| against a spinal rehabilitation clinic in the UK by the | | | | need no input from professionals like us and this is |
| Healthcare Commission (changing soon to the | | | | good. |
| Care Quality Commission). Against Chartered | | | | Time and nature improves many conditions as |
| Society of Physiotherapy guidelines they did not | | | | they are self limiting and do not |
| provide any physiotherapy management for their | | | | Assessment and treatment is of a very |
| patients and were found guilty of transgression of | | | | subjective nature. Even within a profession there |
| the accepted approach. | | | | will be great variance in managing the same case. |
| The implication of this case is that we all have an | | | | We are not good at using validated outcome |
| obligation to be aware of the recent analysis and | | | | measures so we can show that we really have |
| recommendations for the conditions that we | | | | made a difference. |
| manage and show that we are applying them to | | | | Many of the changes to patients may not be as a |
| patient care. We are expected to follow the | | | | result of our interventions. |
| pathways laid down to some extent and could be | | | | We have not given good evidence that our clinical |
| asked some very uncomfortable questions about | | | | judgments can be objectively trusted. |
| why we chose the treatment approach we did | | | | We strongly protect our independence of clinical |
| should there be a complaint or legal case involved. | | | | judgment but do little to validate its accuracy. |
| We also have to ask ourselves why we would | | | | None of this is to have a negative view of our |
| not follow the recommendations of an established | | | | professions, which I am sure will continue to |
| body that have produced a serious document. | | | | contribute greatly to the comfort and health of |
| Just not doing so is not good enough. | | | | many people in our communities. We need to |
| Clinical judgment is very important to | | | | have faith in our clinical judgments and our training |
| professionals like physiotherapists and we are right | | | | paradigms but also to scrutinize them for errors |
| to put store in it. However, we often perceive a | | | | and ways to improve our therapeutic approaches. |
| conflict between this and the idea of guidelines | | | | |