An updated overview of clinical guidelines for chronic low back pain management in primary care

Abstract

Objectives

In the past decade many countries around the world have produced clinical practice guidelines to assist practitioners in providing a care that is aligned with the best evidence. The aim of this study was to present and compare the most established evidence-based recommendations for the management of chronic nonspecific low back pain in primary care derived from current high-quality international guidelines.

Methods

Guidelines published or updated since 2002 were selected by searching PubMed, CINAHL, EMBASE, guidelines databases, and the World Wide Web. The methodological quality of the guidelines was assessed by three authors independently, using the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. Guideline recommendations were synthesized into diagnostic and therapeutic approaches that were supported by strong, moderate or weak evidence.

Results

Thirteen guidelines were included. In general, the quality was satisfactory. Guidelines had highest scores on clarity and presentation and scope and purpose domains, and lowest scores on applicability. There was a strong consensus among all the guidelines particularly regarding the use of diagnostic triage and the assessment of prognostic factors. Consistent therapeutic recommendations were information, exercise therapy, multidisciplinary treatment, and combined physical and psychological interventions.

Conclusion

Compared to previous assessments, the average quality of the guidelines dealing with chronic low back pain has improved. Furthermore, all guidelines are increasingly aligning in providing therapeutic recommendations that are clearly differentiated from those formulated for acute pain. However, there is still a need for improving quality and generating new evidence for this particular condition.

Introduction

Low back pain (LBP) is a common problem affecting both genders and most age groups such that about one in four adults seeks care in a six-month period. LBP has substantial direct and indirect costs to the person, workplace and society [1]. Although most episodes of LBP appear self-limiting [2], recurrence with a variable course is common [3], with 10–15% of cases leading to chronic pain [4]. In order to decrease this burden, the use of interventions with demonstrated effectiveness is essential [5]. Clinical practice guidelines (CPGs) can be powerful tools for promoting evidence-based practice (EBP), as they integrate research findings in order to support decision-making. Following the publication of the first LBP guideline in 1987 by the Quebec Task Force, which also highlighted the absence of high-quality evidence [6], there has been a steady worldwide interest on this subject, culminating with the publication of specific CPGs in many countries over the past few years.

Nevertheless, previous reviews [7], [8], [9] reported disappointing results with regard to the methodological quality of guidelines assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument [10]. Furthermore, although many guideline recommendations were similar with respect to diagnosis and therapeutic interventions especially for acute LBP, researchers repeatedly indicated the need to place additional emphasis on differentiating acute from chronic LBP (CLBP) and providing more consistent recommendations for the management of this distinct condition [9]. Recently, separate reviews by Koes et al. [11] and Dagenais et al. [12] structured their findings to provide comprehensive guidance to clinicians. However some important mono- and multidisciplinary guidelines dealing with the management of CLBP were not included. The purpose of the present study was to assess the literature and rate the methodological quality of currently available guidelines for the management of nonspecific CLBP in primary care using the validated AGREE tool, and to provide a specific, updated and evidence-based overview of the most important clinical recommendations regarding the management of this particular condition.