Finding the Right Treatment for Chronic Pain: Are We Using the Right Evidence?
Scientists around the world are looking for the best way to treat chronic pain patients. But finding evidence that supports the best practice model isn't always easy. In this article, researchers from the Netherlands ask the question, Are we measuring what we need to measure?
Many quality studies with high levels of evidence don't provide guidance for real life situations. Patients may be given one type of treatment for the duration of the study. If the symptoms get worse or they aren't helped, they must still finish out the study. In clinical practice, changes are made right away in treatment based on patient needs, wants, and individual characteristics.
Sometimes research results reported depend on how the study was conducted. How the data was collected, measured, and analyzed can make a difference. It's not uncommon for different approaches to yield different results for the same group. How do we know which interpretation is correct?
Because of these problems and other research dilemmas, there's no best evidence for the treatment of chronic pain at this time. It's agreed that the goal is to find the right treatment for the right patient at the right time. Sometimes the best way to do that is to take a look back at results after the fact.
By looking at the patients who had the best results, it may be possible to identify common factors for success. These may be physical, behavioral, social, or a specific combination of these three variables. The presence of such characteristics may lead to the development of a clinical prediction rule (CPR).
A clinical prediction rule says that patients with the identified factor have the best chance of a good result with treatment. This is how subgroup classifications of patients are formed. Once the subgroups have been found, then researchers try to match treatment to the patients in those groups.
Experts working with chronic pain patients rely on various tools, surveys, and questionnaires. They use these to assess level of disability, presence of behavioral factors, or impaired movement. Any one of these items can interfere with physical activity and function. But there is not a screening instrument that can be used to help match patients to treatment yet.
Patient preferences must be taken into consideration. Their beliefs and attitudes can affect how they respond to treatment. Even the best practice approach recognizes that pain doesn't always improve when evidence-based treatment is applied. Individuals experience and respond to pain in different ways based on cultural beliefs and values.
And finally, doctors use their clinical expertise and experience combined with best evidence to formulate their practice. But studies show that their treatment approach is often based on what they learned during their formal training. They may not be keeping up with the most recent best practice guidelines.
Having reviewed the many difficulties in today's search for best practice and evidence-based practice, the authors remind us of the importance of the patient. We must seek evidence but use it to guide (not dictate) clinical practice. Each patient must be evaluated one at a time. But don't expect one size (treatment) to fit all.
Harriet Wittink, PhD, MS, PT, et al. Are We Measuring What We Need to Measure? In The Clinical Journal of Pain. May 2008. Vol. 24. No. 4. Pp. 316-324.
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