Difficulties of Using Single-Diseased Guidelines to Treat Patients with Multiple Diseases

Disciplineand disease-specific medical care is increasingly underpinned by evidence-based guidelines. The main goal of these guidelines is to give the best available diagnostic and treatment advice, to decrease variability in daily clinical practice, to reduce inappropriate practice, and to improve cost-effectiveness, ideally resulting in better health outcomes for patients (1). For example, the Royal Dutch Society for Physical Therapy (KNGF) and the Dutch College of General Practitioners (NHG) have published 17 and 96 disease-specific guidelines, respectively, all with the aim of providing a stronger scientific foundation and improve health care (2, 3). However, themajority of patients [40% at the age of 50 years and at least two-thirds of the octogenarian population (4)] simultaneously suffer from multiple medical problems. Caregivers, therefore, need to consider single-disease evidence contained in a guideline in the view of other relevant guidelines. In this matter, Hurwitz et al. (5) already warned that guidelines may encourage users to apply recommendations “rigidly or unthinkingly,” even in situations where departure from a guideline would be desirable, as might be the case with multimorbidity. Thus, when treating multi-diseased patients, physical therapists (PT) themselves have to design a customized treatment plan based on guidelines developed for patients with only one disease and in consideration of the impact of multimorbidity. Once a patient with multimorbidity is admitted to a physical therapy practice, the therapist may consider multiple treatment paths. This situation could be compared with a maze: a complex branching passage with many different pathways. To solve the maze, the PT must find a route to travel from start to finish.