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Does evidence based medicine currently have the answers to chronic pain?

70% of health problems presenting to clinicians involve chronic, complex medical conditions such as chronic low back pain (CLBP) (1).  The prevailing philosophy in western conventional medicine is an evidence-based biomedical model, also referred to as allopathic or orthodox medicine.  There is a suggestion that this model is insufficient to deal with chronic, complex conditions.  In this article we comment on the advantages and potential flaws of a biomedical model and implications in rehabilitative therapy.

In a biomedical model disease is seen as an independent entity that can be fully understood without regard to the person it afflicts or the environment in which it occurs.  Treatment is “of the disease rather than of the person” and is based on a diagnosis of the disease process and evidence of best practice for the target condition.  Pharmaceutical or surgical intervention is frequently used to treat or manage a patient’s condition.

In rehabilitation of musculoskeletal conditions a similar patho-anatomical model is applied, in which orthopedic testing and medical imaging (e.g. x-ray, ultrasound, CT, MRI) are used to diagnose pathology and tissues causing the patient’s pain.  Historically intervention was based on the empirical findings and clinical impressions of leaders in the field without clear confirmation that techniques were either safe, efficient or effective.  The need to confirm efficacy led to the emergence of an evidence-based model of medicine.

Evidence based medicine (EBM) uses clinical research and systematic review to objectively analyze the efficacy of therapeutic intervention.  EBM de-emphasizes intuition, unsystematic clinical experience and patho-physiological rationale as sufficient grounds for clinical decision-making (2).  The goal of EBM is to help us act on facts as opposed to opinion and effectively evaluate each therapeutic intervention based on efficacy, cost and risk to the patient, thereby protecting the public from treatment that does not work or practices that some may describe as ‘witch doctoring and faith healing’.

In EBM evidence is ordered in a hierarchy.  The gold standard is the ‘randomized control trial’ (RCT), characterized by blinded assessment, presence of a placebo, random assignment to experimental or control groups and use of inferential statistics to establish causation.

In musculoskeletal rehabilitation RCTs are performed to analyze whether certain techniques significantly reduce a patient’s symptoms when compared to a sham or ‘pretend’ treatment that works only by placebo.

However, there are flaws to EBM. There are limitations to the investigative power of available research techniques.  Chronic pain patients frequently present with multiple interacting physiological, neurological and psychosocial factors and co-morbidities linked to their condition.  For these patients the underlying assumptions of the RCT are not met.  For example, co-morbidity is often one of the first criteria for a participant being excluded from a research study.

The complex nature of chronic pain syndromes, like low back pain, makes them highly challenging to assess using conventional quantitative research methods.  The statistical and mathematical sophistication required for multi-variable analysis of patients with complex chronic illness in which symptoms change based on the patient’s perceptions and their environment does not presently exist.  For this reason acute conditions are the only medical problems that appear to predictably respond as envisioned by the conventional medical paradigm and a biomedical approach has had only moderate success in treating chronic pain.

RCTs on treatment techniques often fail to account for complex interactions between treatment protocols and there is a lack of research into complex multifaceted treatment strategies, as opposed to individual techniques.

There is a large gap between clinical practice and research.  Clinicians are required to translate research evidence to help provide meaningful conclusions regarding each individual patient, their unique presentation, situation and condition in the context of their own ideological and philosophical approach.  Clinicians are frequently left frustrated as they feel they lack the access, resources, time or knowledge to achieve this.

The majority of the research is performed by mainstream medical institutions, in line with the prevailing biomedical model.  Integrating research into practice is especially challenging for clinicians in alternative medicine or those applying differing philosophical approaches. Much of the research investigating alternative medical approaches is unsuitable for consideration because of poor quality (e.g. small sample size or failings in experimental procedure, or failure to account for experimental bias).

It is critical that institutions teaching alternative models of healthcare (e.g. osteopathy, chiropractic, functional medicine) update their tuition in the light of emerging research, and it is imperative that we find ways to help bridge the gap between evidence and practice to enable clinicians to formulate evidence based treatment plans in clinically relevant settings.

Alternative philosophies have arisen out of failure of mainstream medicine to effectively cope with complex, chronic pain.  See Bio-psycho-social and Functional Medicine models.

See www.osteopathynottingham.co.uk  for more info

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