By Roderic MacDonald
Musculoskeletal Physician to the North West London NHS Community Health Trust,
Past President of BIMM.
Having reached the tail-end of my career with my practice pruned down to dealing primarily with spinal pain, I could be in a quiet backwater thinking about retirement… but then things keep coming up that disturb my peace. One such disturbance was when I attended the recent ARMA AGM, representing the British Institute of Musculoskeletal Medicine [BIMM]. Fortunately, I could contribute this blog to respond to several points arising during this gathering of people from all viewpoints of the alliance’s family.
The importance of evidence is something that was mentioned by various people at the AGM. That, in turn, brought out the views of people dealing with less easily defined and researched conditions, those that seldom offer the commercial opportunities that stimulate private sources of research funding. A lack of research funding can mean evidence for effectiveness may not yet exist to support the provision of treatment that many people feel is helpful to them. They would support the statement: absence of evidence for a benefit does not mean evidence of its absence, especially when there has been no real possibility of collecting hard evidence.
The worldwide burden of disease assessment identifies the people with back pain that has no definite diagnosis, as suffering 50% of the total musculoskeletal disability. I would hope this realisation would lead to a shift in some of the research and treatment effort.
Next year we will have fresh NICE guidelines on back pain that can take account of research published since 2008. Many commissioning and deliberation processes are still required to accord with the 2009 guidelines which means that, by the time the 2016 version is available, evidence–based practice will have derived from information that is at least ten years old. If evidence is so important perhaps refreshing it more often would be a good idea.
Many longstanding treatments have prospered in complementary medicine for a long time with a lack of supporting evidence hampering their NHS adoption. Well-designed randomised controlled trials of osteopathic manipulation and Alexander technique suggest that between them they could provide important long-term benefits for up to half the people attending our clinics with persisting back pain. The excitement and ongoing development that should have been triggered by these results will probably have to wait for 2016.
I am reminded of my experience thirty years ago when applying to the then Department of Health for a research grant. Their response was delayed beyond their stated limit so I enquired why: I was told it was taking longer because “back pain is a priority area”.
We need to provide better services guided by better evidence, which means a commitment to asking the right questions, getting the answers and implementing them. Not to do so is costing a great deal of money – but that’s my opinion, not evidence!