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Chiropractic Journal of Australia : CJA September 2013
96 Chiropractic Journal of Australia Volume 43 Number 3 September 2013 the ultimate outcome of the effectiveness of the treatment and may also infuence the transition from the acute to the chronic stage of disease. The transition from acute to chronic LBP is complex and may be approached from many different perspectives including physical, psychosocial, and work related.4,14 Similarly, the way in which practitioners approach their clinical work is based on a complex of beliefs, perceptions and infuences that may have taken years to develop. The clinical behaviour of professionals of any discipline involved in the management of chronic pain syndromes is dependent upon: their beliefs in the factors associated with the transition from acute to chronic pain; and their perceptions of current research data about those factors. These beliefs and perceptions are based on: professional training; clinical experience; opinions of authority fgures in their feld; personal perspectives; and current research data. However, such beliefs, and the practices in which they result, may vary considerably from current research fndings.35 For instance, it has been reported, in as recently as 2004, that physiotherapists in the United Kingdom were able to identify psychosocial risk factors in LBP clinical scenarios. However the perceptions of the same physiotherapists towards LBP were still based on the biomedical model causing an inclination in them to advise their patients not to work.36 A relatively recent qualitative study of general practitioners in New Zealand has reported that these practitioners' "worldview" and "orientation to the biopsychosocial model of pain" determined their detection and management of psychosocial yellow fags in cases of acute LBP.37 A general practitioner with many years of clinical experience may believe that the only effective way to treat chronic pain is through analgesics, even though the literature would inform him/her that analgesic medications often produce drug dependence or lose their effectiveness over time. In this case, the beliefs are subjective, based on experience; while the research fndings are objective, in the sense that they are available to all professionals involved in pain management regardless of their beliefs. Theoretically, if all treating practitioners have the same objective information available to them, they can all be expected to come to the same logical conclusions. However, this does not seem to be the case. One reason for this is that practitioners may not read the information that is available in the scientifc literature outside of their own discipline. Therefore, decisions that affect the well being of patients may simply be based on information that is readily available to each individual's profession, through a handful of professional journals or consultation with colleagues. Such information however, may not accurately represent the body of current available evidence. To overcome this challenge, various clinical guidelines and protocols have been, and are being developed by professional or government bodies for evidence-based management of LBP. However, the level of use of these guidelines by practitioners remains unknown at best. It was found for instance that general practitioners in New Zealand did not use the Accident Compensation Corporation’s guideline on yellow fags in cases of LBP.37 Similarly, approximately half of Australian chiropractors recently surveyed, have been reported not to comply with clinical guidelines, from the Australian Acute Musculoskeletal Pain Guidelines Group (AAMPGG), which recommend that LBP patients stay active.38 DECISION MAKING The literature on decision-making processes over the last 4 decades has demonstrated that there are many factors that may bias a decision. For instance an accommodation bias in which information that is supportive of ones beliefs is utilised, while other information is discarded. Additional biases include past experience and cognitive biases which involve observations and generalisations that may lead to memory errors and inaccurate judgements.35 The decision as to which strategy to use in the treatment of LBP may be similarly wrought with many biases and therefore subject to many infuences. However, the major infuence should be the current state of knowledge in the feld. Taking medical practitioners as an example, research has shown that there are a number of avenues available to these professionals for gathering information relevant to decision making. A study by Slawson39 stated that medical clinicians rely heavily on expert based systems: consultation with colleagues; journal reviews and textbooks; and continuing education. The usefulness of each source is dependent on the relevance and the validity of the information and the effort required for its acquisition. Relevance depends on the type of information being presented and the prevalence of the condition within a given practice. The most relevant information is that which tells one how to help one's patient's live functional satisfying lives free from pain and symptoms. Validity of the information is the likelihood that the information is true. Conclusions based on results of well-designed clinical trials are more likely to be valid than those drawn from observations in clinical practice.39 The amount of work required includes factors such as how long it takes to obtain the information, how much it costs, and the amount of mental energy required to analyse the information and draw proper conclusions. According to Slawson, having to work too hard to establish validity or relevance of the information lowers its usefulness.39 There are both advantages and disadvantages in the use of this type of information gathering. Certainly an expert who is specialised in a particular area may be the best person to confrm a diagnosis, however this same person may be biased by many years of individual practice towards a certain diagnosis in specifc clinical circumstances. There are other reasons why expert based information may not be accurate. Expert advice may not be based on current research. Many experts have been known to follow a particular procedure because it had always been done that way regardless of information from clinical trials.39 A second problem with expert information is that there is a tendency for authors of review articles to begin with a conclusion and then fnd supporting evidence for that conclusion, an example of accommodation bias. A third problem with expert opinion is that knowledge is often developed through experience with a select patient population, and though this information may be applicable to a group that is similar to that of the select group, it may not be applicable to the general population. CONCLUSION According to much of the literature, chronicity in LBP is more closely related to demographic, psychosocial, and occupational factors than to the medical characteristics of the low back disorder itself. It is important therefore, to evaluate these dimensions of the disorder with the goal of identifying LOW BACK PAIN: BIOPSYCHOSOCIAL PERSPECTIVE DoNNolI • aZaRI
CJA June 2013
CJA December 2013