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Clinical Commentary

Clinical Practice Guidelines

Clinton, Susan C. PT, DScPT, OCS, WCS, FAAOMPT1; LaCross, Jennifer DPT, WCS, CLT-LANA2

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Journal of Women's Health Physical Therapy: May 2017 - Volume 41 - Issue 2 - p 100-101
doi: 10.1097/JWH.0000000000000080
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Clinical practice guidelines (CPGs) have been utilized in the practice of medicine for more than 20 years. Comparatively, their use in physical therapy (PT) remains limited to date. To ensure that our clinical practice is driven by evidence-based medicine, as opposed to “alternative facts,” CPGs are written summary recommendations based upon the most recent, quality, and scientific evidence available on a given topic.1 The Institute of Medicine defined CPGs as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of the evidence and an assessment of the benefits and harms of alternative care options.”2 The foundation of the CPG is a systematic review of the evidence of a condition. The process has a major focus on the strength of the evidence by which clinical decision-making for that condition is based. The guideline also includes a set of recommendations based on the evidence and the value judgments regarding benefits and harms of alternative care options to address patient management.2 The recommendations presented within a given CPG cover a wide variety of practice areas including, but not limited to, diagnosis, examination, and intervention strategies. Each of these recommendations is given a grade based upon the strength of available evidence as it relates to that recommendation. Very commonly, multiple grades of recommendation can be found within a single CPG and directly relate to areas with the greatest supporting evidence and, conversely, reveal areas requiring further study.

Each CPG development group should contain a group of diverse and relevant stakeholders including content experts, health care professionals, and consumers. The proposed guideline clearly describes the methods used for development in detail. Systematic review methods are used to identify and evaluate evidence related to the condition. Each recommendation is rated for the quality and reliability of the strength of the evidence. Once the clearly stated guideline recommendations are developed, they are based on scientific evidence of benefits, harm, and costs. A complete review by external stakeholders must be completed prior to publication. Each completed guideline also contains information on financial support as well as the process of revision.3

The American Physical Therapy Association (APTA) has a process for endorsing the creation of CPGs as they relate to PT topics. As stated by the APTA practice department, this process exists to ensure that each CPG is accessible, current, and consistent with APTA policy.4 The Orthopedics and Sports Sections created CPGs on topics such as heel pain, low back pain, and ankle sprains. The Pediatric Section published a CPG on the topic of torticollis. Thanks to Clinical Practice Guideline Steering Committee, the first CPG cosponsored by the Section on Women's Health (SoWH) has been accepted for print and online publication in the Journal of Women's Health Physical Therapy. The SoWH is now taking its place among the development of CPGs on conditions related to pregnancy and pelvic girdle pain, postpartum pelvic girdle and low back pain, mixed urinary incontinence, constipation, chronic pelvic pain, and inflammatory bowel disease.

The development of a CPG is a 5-year process from start to publication, requiring further revision every 5 years thereafter. There are multiple steps to ensure a quality publication at the end of the first 5-year journey. The purpose of this CPG is the establishment of concise, evidence-based recommendations on the scope of pelvic girdle pain in the antepartum population. The scope of the CPG includes etiology, risk factors, examination, evaluation, and intervention as it relates to the PT management of this condition. The CPG will impact PT practice by identifying knowledge gaps, providing a clinical framework for PT management, and recommending directions for future research. The impact will extend to other disciplines including obstetricians, primary care practitioners, nurse practitioners, midwives, and especially the consumer. Finally, it will promote physical therapists' role in the management of this condition

REFERENCES

1. Embree J. Writing clinical guidelines with evidence-based medicine. Can J Infect Dis. 2000;11(6):289–290.
2. Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Summary. In: Graham R, Mancher M, Miller Wolman D, et al, eds. Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011. https://www.ncbi.nlm.nih.gov/books/NBK209538. Accessed April 17, 2017.
3. Qaseem A, Forland F, Macbeth F, Ollenschläger G, Phillips S, van der Wees P; Board of Trustees of the Guidelines International Network. Guidelines International Network: toward international standards for clinical practice guidelines. Ann Intern Med. 2012;156(7):525–531. doi:10.7326/0003-4819-156-7-201204030-00009.
4. Clinical practice guidelines (CPGs). American Physical Therapy Association Web site. http://www.apta.org/EvidenceResearch/EBPTools/CPGs. Updated July 22, 2016. Accessed March 18, 2017.
© 2017 Section on Women's Health, American Physical Therapy Association.