Need of evidence-based practice in chronic pain.

“Medicine is the art of probability”

The modern day practice of medicine is getting simpler with the availability of newer advanced diagnostic modalities along with the availability of medicines and many therapeutic options. At the same time, it becomes more challenging for the clinician to keep themselves updated about the advancements and using them in appropriate manner. Thus, the paradigm shift is from opinion-based medicine to evidence-based medicine (EBM). EBM is defined as a conscientious, explicit, and judicious use of current best evidence in making decisions about care of individual patients.[1] The evidence-based practice of medicine requires the physician to use his clinical expertise gained by him along with the background of specific contextual application of knowledge, in concert with the best available external evidence reported in the literature.[2] In other words, the steps for evidence-based practice require the following:[3]

Recognition of the patient's problem and construction of a structured clinical question

Thorough search of the medical literature

Critical analysis of the searched evidence, and finally

Integrating the searched evidence in light of clinical scenario to reach a clinical decision in best interest of the patient care.

To make available such evidence-based clinical practice, “practice guidelines” are developed and proposed by various societies in fields of medicine to assist clinicians in deciphering an appropriate decision for clinical care for specific clinical circumstances. Clinical practice guidelines are systemically developed statements by a group of experts based on thorough evaluation of the evidence from the published literature on a particular topic. These statements are expected to be objective, unbiased, up-to-date, evidence based, rather than authority based and free from conflict of interest.[4] These must incorporate validity, reliability, reproducibility, clinical applicability, flexibility, clarity, development through a multidisciplinary process, scheduled reviews, and documentation.[4] At times, there are limitations of these guidelines in pain medicine including a paucity of the reported literature, lack of updates, and conflicts in preparation of systematic reviews and guidelines.[5] Also, concerns have been raised regarding non-applicability across populations.[4] The specialty of pain medicine is still emerging and faces some peculiar problem for evidence-based practice due to limited available evidence and variance in the definition and the practice of pain medicine.[6-10]

A hierarchy of strength of evidence for treatment decisions provided by Guyatt and Drummond is as follows:[11]

N-of-1 Randomized controlled trial (RCT)

Systematic reviews of randomized trials

Single randomized trial

Systematic review of observational studies addressing patient-important outcomes

Single observational study addressing patient-important outcomes

Physiological studies (studies of blood pressure, cardiac output, exercise capacity, bone density, and so forth)

Unsystematic clinical observations.

The N-of-1 RCT has the highest strength of evidence for treatment decisions but is limited in the pain medicine.[11] The next best evidence is based on systematic review and meta-analysis of the published well-conducted RCTs. EBM practice requires the amalgamation of guidelines, systematic reviews, meta-analyses, RCTs, observational studies, and diagnostic studies. The evid ence in pain practice is quite variable and many aspects are still lacking. In this issue, the authors have reviewed the present evidence related to pain management practice. They have reviewed the available evidence regarding various aspects of pain management.

I urge the pain physician to conduct randomized clinical trials for various aspects of pain management including assessment tools and the pain management modalities, so that a good evidence be created for practice of pain management.