Challenges in using evidence to inform your clinical practice in low back pain.

The aim of evidence-based medicine (EBM) from its early days was to provide the appropriate means for making effective clinical decisions, not only for avoiding habitual practice but also for enhancing clinical performance. It is, however, unrealistic to simply assume that the results of research will soon evolve into practice. In this article, when aiming to translate results from research into practice, we focus on certain challenges, which can be broadly categorised into two: how the evidence is generated, and how the evidence is implemented. When focussing on generating evidence, a major barrier to the rapid passage of research into clinical practice is that the 'practice' in trials or research settings could be a long way from the setting, circumstances, patient groups and resources available in the daily practice of many clinicians. This is the consequence of the several choices that researchers have to make in designing a trial regarding population, measurement tools and interventions. For implementing the evidence, clinical guidelines appear to be one of the most promising and effective tools for improving the quality of care. Although the importance of implementing clinical guidelines is widely recognised, little is known about the optimal implementation strategy. We present two examples of implementing low back pain guidelines, illustrating that it remains difficult to develop effective implementation strategies. Finally, we discuss some future directions that have been proposed for EBM, which aim to overcome the essential tension between internal validity and external validity (generalisability), specifically in fields where complex syndromes and complex interventions are the focus of attention. Copyright 2009 Elsevier Ltd. All rights reserved.