Original articleAn updated overview of clinical guidelines for chronic low back pain management in primary care
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.
Section snippets
Data sources
CPGs were identified using specific search strategies in various sources:
- •
MEDLINE and PubMed, CINAHL, EMBASE (from 2002 to December 2010). The search included combinations of the following keywords (MeSH terms): low back pain plus guideline or practice guideline or clinical practice guideline and the same combination using the plural form “guidelines”.
- •
Guideline databases (up to December 2010), including the National Guideline Clearinghouse, Canadian Medical Association InfoBase, Guidelines
Selection of guidelines
Our search strategy identified 34 guidelines, of which 21 were potentially relevant but were excluded for different reasons (Fig. 1). Ultimately, 13 guidelines for primary care management of CLBP were included, listed below indicating country and year of publication:
- •
Institute for Clinical Systems Improvement (ICSI); United States, 2008 [20].
- •
American College of Physicians (ACP); American Pain Society Low Back Pain Guidelines Panel (APS); United States, 2007 [21].
- •
Institute of Health Economics,
Discussion
Currently, many guidelines have directed their attention to CLBP, providing specific recommendations for this particular condition, which still remains a very important clinical challenge in medicine [32]. After the evaluation of 13 international CPGs on the management of nonspecific CLBP using the validated AGREE instrument, this study presents an overview of the most important diagnostic and therapeutic recommendations found within five high-quality guidelines [15], [21], [26], [27], [28].
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
Acknowledgements
The authors would like to thank Angela Longo and Judith Herlemann for technical support, Chiara Scardoni and Cristian Mugnai for English language editing.
References (40)
- et al.
Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines
Spine J
(2010) - et al.
National Practice Guideline for the physiotherapeutic management of patients with low back pain
Physiotherapy
(2003) - et al.
The prognosis of chronic low back pain is determined by changes in pain and disability in the initial period
Spine J
(2010) - et al.
Exercise therapy for chronic nonspecific low-back pain
Best Pract Res Clin Rheumatol
(2010) - et al.
The epidemiology of low back pain in primary care
Chiropr Osteopat
(2005) - et al.
Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions
Spine
(1997) - et al.
Low back pain: what is the long-term course? A review of studies of general patient populations
Eur Spine J
(2003) Management of back pain
Disabil Rehabil
(2002)- et al.
Evidence-based medicine. How to practice and teach EBM
(2000) - et al.
Scientific approach to the assessment and management of activity-related spinal disorders: a monograph for clinicians–report of the Quebec Task Force on Spinal Disorders
Spine
(1987)
Clinical guidelines for the management of low back pain in primary care. An international comparison
Spine
Quality of primary care guidelines for acute low back pain
Spine
A critical review of guidelines for low back pain treatment
Eur Spine J
Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project
Qual Saf Health Care
An updated overview of clinical guidelines for the management of non-specific low back pain in primary care
Eur Spine J
Quality of low back pain guidelines improved
Spine
Reliability and validity of the AGREE instrument used by physical therapists in assessment of clinical practice guidelines
BMC Health Serv Res
Making the AGREE tool more user-friendly: the feasibility of a user guide based on Boolean operators
J Eval Clin Pract
Users’ guides to the medical literature. VIII. How to use clinical practice guidelines. A. Are the recommendations valid? The Evidence-Based Medicine Working Group
JAMA
Cited by (143)
The use of a biopsychosocial model in the treatment of patients with chronic
2024, Patient Education and CounselingInfluence of low back pain characteristics on the healthcare procedures prescribed by general practitioners for adult patients: ancillary analysis of the French ECOGEN study
2022, Revue d'Epidemiologie et de Sante PubliqueAssociation between patient independence in performing an exercise program and adherence to home exercise program in people with chronic low back pain
2021, Musculoskeletal Science and PracticeEffectiveness of osteopathic interventions in chronic non-specific low back pain: A systematic review and meta-analysis
2021, Complementary Therapies in Medicine
- 1
Website: www.unibo.it.