This is part 2 of discussion of the new NICE guideline on low back pain and sciatica. Part 1 looked at the content of the guidelines – what you should/shouldn’t be doing. Part 2 considers how the guideline applies to osteopaths.
Do we have to follow guidelines?
It is probably not a coincidence that an article was published in Manual Therapy in October titled Quiet Dissent: The attitudes, beliefs and behaviours of osteopaths who reject low back pain guidance. This is an excellent piece of research for providing an insight into osteopathic opinion, it is full of what I found to be some quite shocking opinions regarding evidence based practice and other professions – plenty of revealing quotes from osteopaths. As a caveat all the osteopaths came from the European School of Osteopathy so it could be argued that it is one school of thought but from conversations with other osteopaths I strongly doubt that the ESO cohort are unique in their views.
As most osteopaths will be aware following NICE guidelines is not mandatory. However, NICE states very clearly that their views are arrived at from consideration of available evidence. Practitioners are expected to take these evidence-based guidelines fully into account alongside individual needs, preferences and values of patients.
The osteopathic practice standards state that:
B4 Keep your knowledge and professional skills up to date
Osteopaths are to use the research and evidence to enhance patient management. An osteopath would need a strong case to justify why they choose not to follow evidence based guidelines.
The researchers found that osteopaths strongly believe in ‘Precedence of Osteopathy’ therefore they consider that osteopathic opinion and experience is far superior to evidence based practice. This has been termed an ‘eminence’ based model of practice. Osteopaths are proud of their unique approach and the underpinning philosophy of osteopathy and strongly rely on these to justify treatment approaches. There is a dominance of a paternalistic approach to patients. Paternalism is supposed to be a thing of the past in healthcare. For many years there has been a striving towards shared-decision making and a patient-practitioner partnership in achieving health improvements.
There is a well-known description of evidence based medicine as a three-legged stool:
1 best available research
2 clinical judgement
3 patient values and preferences
The researchers identified that osteopaths appear to rely solely on clinical judgement, underpinned by expert opinion and paternalism. What has happened to patient-centred osteopathy?
Quiet dissent – is it professional arrogance? Are osteopaths blinkered in their historical approach and methods? Where is our patient-centred approach? Are many osteopaths solely biomedical? Are osteopaths beyond change/education/evidence?
There is a culture of neglect of reflective practice and striving for improvement. “If there are patients booking appointments – I must be doing the right things” – this, I would suggest, is a false confidence.
Guidelines are written as a summation of best practice care through consideration of all available evidence. Practitioners striving for the best for their patients will read and apply to practice.
What the guideline means for osteopaths?
If we agree to conclude that osteopaths should be complying with clinical guidance as best practice wherever possible, let’s consider how the new NICE guidelines might look in practice.
If you are keeping up to date with research and in particular the great advances in pain science over the past few years you will recognise much of the recommended procedures in the guideline.
Osteopaths under the guise of manual therapy using manipulation, mobilisation and soft tissue techniques are a recommended approach for low back pain but not in isolation. Manual therapy is to be used in conjunction with exercise and/or psychological therapies.
Have you considered using a risk stratification tool such as the STarT Back Risk Assessment. It is a very easy tool to use and provides a good way to identify those patients who are at a higher risk of chronicity and therefore require more involved treatment. It’s a 9-question assessment that gives you a score for each patient – very easy to implement in practice.
Do you have some good self-management tools and advice? The STarT Back tool enables identification of ‘low-risk’ patients who will benefit from self-management advice and are likely to make a quick recovery.
Do you incorporate exercise into your treatments? Prescribing exercise is a must for low back pain patients. This could be individually prescribed biomechanical exercises but with a view to progressing to group exercise. The key component for exercise is that the patient will enjoy the exercise and therefore continue to attend. Maybe you could make links with a local exercise class leader or gym so you have people you trust to understand and take care of your back pain patients.
Do you offer any form of psychological therapy – particularly CBT? There are several courses available that assist manual therapists to be equipped with CBT skills.
In an ideal world patients should have access to manual therapy, exercise and CBT when they visit a clinic for low back pain treatment. Who delivers these three entities is another question. Osteopaths have the potential to be trained and confident in all three aspects.
One of the questions several people have asked about the new guideline is ‘does it include osteopathy?’ Well the answer is – it does, but only under the umbrella of manual therapy.
This may just be a simple way to be inclusive or it could have greater significance to the osteopathic profession. For decades osteopaths have struggled to describe what osteopathy is. The diverse nature of the profession has led to difficulties encompassing everyone’s style of practice in one description. Until now this has just seemed an academic exercise causing division between those of a evidence-based, biopsychosocial mindset versus those of a philosophical, ‘art-based’ approach.
Now osteopathy is encompassed under the umbrella of manual therapy along with physiotherapy and chiropractic is there a danger of three professions merging to become manual therapy. The three professions has long caused confusion for the general public in determining who they should see and for what problem. For many the unique characteristics between the professions are very blurred, the diversity between the professions can be as diverse as being treated by different osteopaths within one practice.
There are murmurings in the government Department of Health about reforming regulation. There are currently 9 healthcare regulators and the government deems them to be costly and ineffective. If there is a merging of regulators, how might that pan out. Would/could professions be merged too?
Now is the time for osteopaths to work together to show that the osteopathic profession has a distinct offering. The GOsC is an exceptionally high performing regulator, fulfilling all its performance targets for the last 5 years. The sterling work of the Osteopathic Development Group should be supported and encouraged wherever possible. We uniquely have our own research organisation in NCOR. Osteopaths need to be pulling together emphasising Unity in Diversity. There is much to be celebrated about the osteopathic profession but it is up to us as a profession to pull together and make sure we don’t disappear under the umbrella of manual therapy. We need to show the skills we have to offer and the ability we have to provide evidence based treatment to an exceptionally high standard.
Adhere to guidelines and prove that osteopaths are well-equipped to provide the best in treatment – gather evidence to demonstrate this through your own practice statistics or using PROMs. Support the Osteopathic Development Group projects, support the work of NCOR, shout out about osteopathy – join in the #osteopathyworks groups on facebook and twitter. Now is the time to act.
Share your opinion on the new NICE guidelines and your reflections on its significance to the osteopathic profession.