A NICE example of study quality appreciation

Dr. Carl Clarkson
Dr. Carl Clarkson April 25, 2020
Dr Carl Clarkson teaching

And there you were, minding your own business, thinking (hoping, praying) that I had said all that needed to be said about those pesky LBP guidelines. Ha ha ha ha, I laugh at your naivety. Why, I hear you cry, what more could be said?!

‘The GDG considered that there was a substantial body of evidence relating to acupuncture in this review and that further research was unlikely to alter conclusions.'(p.498)

If the acupuncture literature reviewed was consistently of a very high standard, and / or findings produced were consistent, then the advice to not do any further research would have been appropriate. The main reason we attempt to assess study quality is to gauge the foundations on which to trust the findings (although this is subjective, there exists a general consensus on what could reduce bias in quantitative work). If you have a poor quality (high risk of bias) study, you are less able to wholly trust the findings. Think of it like a black cloaked individual telling you, through extremely noisy breathing apparatus, that the gigantic spherical space station he hangs around in is nowt to worry about. You might take his word for it, but you would probably look for some further corroborative evidence from a source who is not the Supreme Commander of the Empire.

In the LBP guidelines, for acupuncture and manual therapy, the quality range was from high (Jedi) to very low (Emperor Palpatine) (p.497); and most literature for self-management, exercise, CBT, MBR and NSAIDS was moderate (perhaps an early life Anakin) to very low. This provides an insight into the overall quality of research that has been conducted for non-invasive interventions for LBP, and serves to highlight that even for those interventions that were included, the evidence base was rarely considered of the highest caliber. This point alone should stress how important it is to NOT blindly follow the recommendations outlined, as we are far from confident that positive effects observed in the vast majority of interventions were purely down to the intervention being investigated.

However, if we are to assume that the panel have excised great care in their assessment of study quality, and that their appraisal is fair, then acupuncture studies are NOT consistently of high quality, and the outcomes of the studies ARE NOT consistent. These two points actually ADVOCATE further study, not recommend halting further research. As with the previous NICE Sham-bles blog, it would seem that some obvious, basic research considerations have been overlooked.

So, the take home messages: the strength of acupuncture literature quality was comparable to all other interventions advocated in the guidelines; those interventions included are done so on a less than secure footing, and; the quality and inconsistency of findings in acupuncture LBP studies indicates MORE work needs to be done, NOT halted. And, most importantly, all scenarios can be tenuously linked to events that happened a long time ago, in a galaxy far, far away.

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