1. Consuelo B. Gonzalez-Suarez, MD, PhD University of Santo Tomas Philippine Academy of Rehabilitation Medicine

2. Objectives To be able to match the evidence from the guidelines to the part of the patient journey To be able extract data (recommendations and references ) from guidelines To be able to synthesize the recommendations using PARM Writing guide and Level of Evidence To be understand the importance of Context Points To be able to write Context Points

3. Recognition of nomenclature and methodology issues Inconsistent nomenclature, with guidelines, recommendations, care pathways and protocols Adapting or Contextualising?????

4. What constitutes contextualization? Key elements –Typical Filipino patient journey –Typical Filipino workforce and service delivery available

5. What constitutes contextualization? Key Elements –Whether recommendations were available for each step of the journey and to workforce –What implementing recommendations meant in terms of healthcare workforce, resources, training and willingness to change practice

6. What constitutes contextualisation? PARM writing guide was established –Available evidence relative to the patient journey –Summarise different approaches to presenting the available evidence –Construct ‘PARM endorsements’ of the existing recommendations –Construct PARM Context Points

7. Considered use of available tools Did not “recreate the wheel” Assess the generalisability and applicability For any confusion or contradictory recommendation, group went back to the original references for clarification

8. Parameters used for grading the Level of Evidence Consistency of evidence levels Volume of references Age of references Uniformity of thought

9. Parameters used for grading the Level of Evidence PARAMETERDESCRIPTION CONSISTENCY OF EVIDENCE LEVELS CONSISTENTINCONSISTENT Consistently high Consistently low Mixture of high and low VOLUME OF REFERENCES LOWMODERATEHIGH < 3 References4-7 References> 8 References AGE OF REFERENCES CURRENTNON-CURRENT Within 5 years when CPG is being developed More than 5 years when CPG is being developed UNIFORMITY OF THOUGHT UNIFORMVARIABLE Consistent thought (Example: recommend, recommend,do) Variable thought (Example: recommend,does not recommend,do)

10. PARM GUIDE FOR EVIDENCE RATING There is strong evidence There is evidence There is some evidence There is conflicting evidence There is insufficient evidence There is no evidence

11. PARM GUIDE FOR EVIDENCE RATING THERE IS STRONG EVIDENCE CONSISTENTLY HIGH QUALITY EVIDENCE + UNIFORM THOUGHT + MODERATE TO HIGH VOLUME REFERENCES

12. PARM GUIDE FOR EVIDENCE RATING THERE IS EVIDENCE MIX OF HIGH AND MODERATE QUALITY EVIDENCE + UNIFORM THOUGHT + LOW VOLUME REFERENCES MIX OF HIGH AND LOW QUALITY EVIDENCE + UNIFORM THOUGHT + HIGH VOLUME REFERENCES ONE LEVEL I PAPER + MODERATE VOLUME REFERENCES HIGH LEVEL EVIDENCE + GPPS + MODERATE VOLUME OF REFERENCES

13. PARM GUIDE FOR EVIDENCE RATING THERE IS SOME EVIDENCE SINGLE LEVEL II PAPER MIX OF HIGH AND LOW QUALITY EVIDENCE + UNIFORM THOUGHT + MODERATE VOLUME REFERENCES CONSISTENT LOW LEVEL EVIDENCE + UNIFORM THOUGHT + MODERATE VOLUME REFERENCES

14. PARM GUIDE FOR EVIDENCE RATING THERE IS CONFLICTING EVIDENCE MIX OF LEVEL OF EVIDENCE + NON-UNIFORM THOUGHT + ANY VOLUME OF REFERENCES

15. PARM GUIDE FOR EVIDENCE RATING THERE IS INSUFFICIENT EVIDENCE CONSISTENT LOW LEVEL EVIDENCE + UNIFORM THOUGHT + LOW VOLUME REFERENCES INCONSISTENT LEVEL EVIDENCE + UNIFORM THOUGHT + LOW VOLUME REFERENCES

16. PARM GUIDE FOR EVIDENCE RATING THERE IS NO EVIDENCE ABSENCE OF EVIDENCE

17. PARM guide for writing recommendations Level of Evidence Recommendation There is STRONG EVIDENCE Strongly Endorses There is EVIDENCE Endorses There is SOME EVIDENCE Recommends There is INSUFFICIENT EVIDENCE There is CONFLICTING EVIDENCE Suggests There is NO evidence Does Not Endorse

18. Example Recommendation Guideline Level of evidence Reference There is CONFLICTING that therapeutic exercise is useful in managing acute non- specific low back pain TOP SR (Effective!) ICSI 2006 Van Tulder et al 2004 WORKCOVERSA B (Effective!) WorkCoverSA 2010 APS-ACP GOOD (Not effective!) Hayden et al. 2005 CONSISTENT levels of evidence MODERATE volume NON-CURRENT (current/non-current) VARIABLE thought

19. Example Recommendation Guideline Level of evidence Reference There is CONFLICTING that therapeutic exercise is useful in managing acute non- specific low back pain TOP SR (Effective!) ICSI 2006 Van Tulder et al 2004 WORKCOVERSA B (Effective!) WorkCoverSA 2010 APS-ACP GOOD (Not effective!) Hayden et al. 2005 CONSISTENT levels of evidence MODERATE volume NON-CURRENT (current/non-current) VARIABLE thought Therefore, PARM SUGGESTS therapeutic exercises in the management of patients with acute low back pain.

20. Context Points Generalizability and applicability are addressed Provide a framework in which the PARM endorsed recommendation can be applied, considering local service delivery issues Structure and Process are considered order to define the important elements of service delivery underpinning evidence-based care (practice context) 20

21. Context Points A standard framework was developed with minimum best-practice and advanced standard care were considered Included essential equipment, standards and resources, training and workforce 21

22. Evaluation of Non-specific low back pain Minimum standard care of practice Additional standard care of practice Practice method Medical history Physical examination Neurologic examination Functional status Psychosocial risk assessment Diagnostic triage Red flag signs (appendix 1) Yellow flag signs (appendix 2) No diagnostic imaging tests are needed, ie. LS spine x-rays, CT scans, MRI Equipment X-ray after 4-6 weeksCT or MRI after 4-6 weeks Workforce Attending physician Radiologist Physiatrist Radiologist Training Within competency When is it done Upon consultationNone Reassessment using at least one standard outcome measure Four to six weeks * if not improving, may request for LS spine x-rays (AP and lateral views) Four to six weeks * if not improving, may request for LS spine x-rays (AP and lateral views), MRI or CT scan

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