06.2 How Are Clinical Practice Guidelines Formed and What Is Their Purpose?

The second part of episode six takes a tour into the scientific world of clinical research, exploring how clinical guidelines are created and looking at why they are important.

Clinical guidelines promote evidence-based practice by giving out recommendations according to available evidence from systematic research and can therefore have a great impact on your recovery plan.

 

How is a guideline formed?

Firstly a vast amount of scientific literature is systematically searched from within clinical databases and then checked for relevance.

The next step critically grades all the studies according to their methodological quality (a very good study has more impact than a study with potential for bias).

These steps are usually all undertaken parallel by at least two people and then the results are compared. These findings are then finally summarized and recommendations are drawn.

If you want to take a closer look into the world of research, I recommend you check out the Grade Handbook on the gdt.guidelinedevelopment.org webpage. This is a good in-depth explanation how guidelines are created.
The handbook can also be found through the Internet by searching for "Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach".

 

Selecting the best information available when creating a guideline

Every single study that contributes to a guideline or systematic review, is a scientific piece of work with high standards (some higher or lower, hence the grading system).

Therefore scientists and researchers try hard to control every little detail within their studies and here are a couple of examples of how they do that:

 

If you want to find out if strength-training works for people with LBP you can’t just ask people with LBP to sign up for a strength-training class because this could result in selection bias: Only people who believe in strength training would participate, and this group of people is not representative for the average LBP-patient.

The group has to be selected from real patients with LBP ideally randomly assigned to one of two groups, a strength-training group and a control group.

In order to control the study results for a placebo effect, both groups should undergo active intervention of equal activity time. For example the control group could undertake a stretching routine.

Wherever possible the patients should not know which group they are in (this is called blinding of patients). The therapists should also not be aware which group is which, this is because it could also have an effect on the treatment outcome! (Don’t believe me? Check out the "rosenthal- or hawhorne- or helo-effect). This is however not always possible, but would be the ideal.

The ‘blinding’ should also include those recording and adjudicating the outcomes for both groups.

Furthermore the endpoint of the study should be defined in advance. The study must always continue up to the predefined end, neither lengthened nor shortened as this can lead to a distortion of the results.

As positive study results are more likely to be published, researchers searching of systematic reviews try to evaluate possible publication bias. For example, if a study is sponsored by a specific company or industry the results could be considered biased and the evidence is down graded.

 

Why is it important to read guidelines?

Researchers know about all the problems mentioned above, and they also try to tackle them in the best possible ways.

I think it is really important to be informed and know about the limitations of research and at the same time value its results, since it’s the only real evidence, along with your own personal experience, and the personal experience of the medical professionals trying to be of service to you, that you have in helping you make an informed decision about which treatment to take.

 

All in all a lot of effort goes into the creation of a guideline!

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