Guest Commentary
     Maurits van Tulder, PhD

In preparation for next year's 12^th International Conference in Mechanical Diagnosis and Therapy "Pushing the Boundaries of Musculoskeletal Care" in Austin, Texas, October 6-8, this is the first in a series of interviews with a few of our keynote speakers -

Meet Maurits van Tulder, PhD*

1. What led you to present at the MII conference in Austin and what do you hope to achieve?
   I enjoyed participating in the last conference in Rio de Janeiro and look forward to a similar great experience of mixing clinical and scientific expertise. I hope that participants get a better understanding of the usefulness of scientific research for their clinical practice.
   
   
2. Since the international conferences primarily focus on research, there are often varying opinions on the best evidence for musculoskeletal pathology. What advice do you give to clinicians trying to obtain the most accurate evidence available?
   My advice would be to use reliable sources, such as the Cochrane Library or BMJ Clinical Evidence. It is especially important to utilize clinical guidelines, as it is very difficult for clinicians to critically read and understand scientific evidence. In clinical practice, other aspects play an important role as well; for example, patient preferences, clinical experience and costs. Guideline committees have weighed the evidence against these other aspects and developed recommendations that are relevant to and feasible in clinical practice.
   
   
3. How has literature on the effectiveness of treatments for low back pain changed over the last 15 years? Do you think we are getting closer to understanding the best way to treat this population, and if so, in what way?
   The most important changes over the last 15 years are that there are more randomized controlled trials that have an adequate sample size and a low risk of bias, that have a pragmatic study design, that have evaluated multimodal treatments, and that have a more specifically defined population of low back pain. We have improved our understanding of what the best treatment is for specific subgroups of low back patients, but there is still a need to better identify subgroups and target treatment to these subgroups.
   
   
4. What advice do you have for clinicians reading the literature and how do you translate research to clinical practice?
   My advice would be to always critically read scientific papers and ask the question: What is the relevance for your practice? The best way to translate the literature to clinical practice is through clinical guidelines (see above).
   
   
5. During the conference, you will be discussing the behavioral interventions for LBP. Is there a particular tool to measure biopsychosocial issues that you would recommend?
   No, the problem is that you would need different tools to measure the 'bio', the 'psycho' and the 'social' aspects. For each of these domains, many tools are available. The most important factor when choosing a tool is that it is a valid and reliable tool.
   
   
6. Since your forum will be focusing on biopsychosocial issues, is there any material participants should read before preparing for your discussion?
   I do not expect participants to read any material before the meeting, but people who are interested in the biopsychosocial model could read two papers that debate the model:
   
   Weiner BK. Spine update: the biopsychosocial model and spine care. Spine 2008;33(2):219-23.
   
   And a response to this paper by -
   
   Gatchel RJ, Turk DC. Criticisms of the biopsychosocial model in spine care: creating and then attacking a straw person. Spine 2008;33(25):2831-6.
   
   
7. Is there an outcome survey that you frequently use in the clinic? If so, how do you recommend that it is applied in the clinical setting?
   I am not a clinician, so I do not use any surveys in clinical practice. However, be careful when choosing a tool because most are developed for and tested in research and not in clinical practice.
   
   
8. Why is it necessary to measure outcomes in clinical practice if applying evidence-based physical therapy to your patient population?
   It is necessary to measure outcomes because they can help you to better target treatment. Knowing what the important outcomes are for a patient and knowing that a patient has or has not improved on these important outcomes should be an essential part of clinical practice. For example, measuring improvement in flexibility or range of motion may not be important in a patient who wants to return to work and be able to play tennis again. It might be important as an intermediate step to reaching the ultimate goal of returning to normal daily activities.
   
   
9. With your interest in the cost related to chronic diseases, how do you see the management of back pain changing with health care reform?
   This question is difficult to answer because, being from the Netherlands, I probably don't have enough insight in the US health care system and in the plans to reform the system. However, if the ultimate goal of this reform is to "lower health care costs while improving the quality of life for those who did not receive health care insurance through their jobs", I think it should mean that management of back pain in the US will shift from care driven by medical specialists in hospitals with a tremendously high surgery rate towards care driven by primary care health professionals with a much lower surgery rate and higher rate of conservative treatments. This would increase quality and decrease costs. However, I think it would be naive to believe that this change will occur on the short term.