People don’t follow guidelines for back pain because there is no PATH to follow!
I get the opportunity to chat about back pain now and again around the world and one of the things I often talk about is the current guidelines around back pain. I will admit to often feeling a little apprehensive around this subject as the current guidelines run contrary to the way many HCP treat this common problem.
There is always a little gasp when manual therapy, acupuncture and ultrasound get relegated to adjunctive treatments. “Don’t shoot the messenger” is often my get out of jail card.
We know that clinical guidelines around most things within healthcare are not well followed. The big question is why?
We are humans!
Healthcare professionals are humans just like the people we are trying to help and suffer from exactly the same issues. For me there are parallels between getting clinicians to follow guidelines and getting people to be compliant, adherent, committed or whatever you want to call it to exercise programs or health improvement or even taking medications.
We all know that getting fitter is good for us as is reducing smoking, drinking and eating crappy foods. But that does not mean we always implement this knowledge. People still smoke and drink too much and don’t get the recommended dosages of exercise. Big societal messages are needed, but so is how to put them into practice at an individual level.
The big problem I see is how gigantically broad the guidelines are around treatment. Let’s take my favourite subjects’ activity & exercise, the guidelines are clear, movement is good, but the evidence base is not really clear when it comes to putting these recommendations into practice!
We might ask ourselves which exercise? How much? How should they do it? What should it feel like? Might it make the problem worse? How to get people to actually do it? If I look back at my clinical education in back pain treatment mostly it was based around Maitland mobilisations with little about exercise treatment and implementation.
So a simple guideline turns into a much greater clinical problem.
Providing a path
Fundamentally we cannot expect people to implement something without giving them a way to implement it. We need to provide a pathway in much the same way we need to provide a pathway for the patients we work with around exercise.
How can you guide someone in something of you have no idea how to do it yourself?
Imagine getting a bit of flat pack furniture that did not come with any instructions. The pile of pieces that lay in front of you daring you to put them together. Some hardy souls, and probably those with a heap of previous experience, might attempt to put them together. Most normal folk, myself included, would simply put them back in the box and push them to the corner of the room. This conundrum is simply too much to handle.
You have all the pieces of the puzzle, but the problem is putting them together!
Education is another prime example. Education about what? Back pain? Pain? Treatment? Prognosis? All of the above? How to do it? Again there are many questions to unpack within the broad recommendation of education. I received no education in education at undergrad or post grad as I suspect neither have many of you reading this. Again this provides a barrier to implementation at the most basic level.
In the face of uncertainty and low confidence we return to our old habits that are ingrained within us and for many that is not based on current guidelines. Uncertainty provides huge inertia to change.
Support is another factor that is often overlooked. How many people feel they cannot treat how they want to treat because of the working environment they are in and the people around them? This is something I often hear. Support again is a huge part of behaviour change and maintenance of that behaviour. A major part of self efficacy is built around social support and I doubt that it would be different in the work place.
The healthcare system that people work in can be a huge influencer of the way we practice in the same way our social systems affect our overall health and behaviours.
• Behaviour change is no different for HCPs than it is for patients
• If we want change we have to provide a path to change and support along the way
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