Elsevier

The Spine Journal

Volume 10, Issue 6, June 2010, Pages 514-529
The Spine Journal

Review Article
Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines

https://doi.org/10.1016/j.spinee.2010.03.032Get rights and content

Abstract

Background Context

Low back pain (LBP) is a prevalent, costly, and challenging condition to manage. Clinicians must choose among numerous assessment and management options. Several recent clinical practice guidelines (CPGs) on LBP have attempted to inform these decisions by evaluating and summarizing the best available supporting evidence. The quality and consistency of recommendations from these CPGs are currently unknown.

Purpose

To conduct a systematic review of recent CPGs and synthesize their recommendations on assessing and managing LBP for clinicians.

Study Design/Setting

Systematic review.

Methods

Literature search using MEDLINE, National Guidelines Clearinghouse, National Institute for Clinical Excellence, Internet search engines, and references of known articles. Only CPGs related to both assessment and management of LBP written in English were eligible; CPGs that summarized evidence from before the year 2000 were excluded. Data related to methods and recommendations for assessment and management of LBP were abstracted independently by two reviewers. Methodological quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument by two reviewers.

Results

The search uncovered 669 citations, of which 95 were potentially relevant and 10 were included in the review; 6 discussed acute LBP, 6 chronic LBP, and 6 LBP with neurologic involvement. Methods used to develop CPGs varied, but the overall methodological quality was high as defined by AGREE scores. Recommendations for assessment of LBP emphasized the importance of ruling out potentially serious spinal pathology, specific causes of LBP, and neurologic involvement, as well as identifying risk factors for chronicity and measuring the severity of symptoms and functional limitations, through the history, physical, and neurologic examination. Recommendations for management of acute LBP emphasized patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy. For chronic LBP, the addition of back exercises, behavioral therapy, and short-term opioid analgesics was suggested. Management of LBP with neurologic involvement was similar, with additional consideration given to magnetic resonance imaging or computed tomography to identify appropriate candidates willing to undergo epidural steroid injections or decompression surgery if more conservative approaches are not successful.

Conclusions

Recommendations from several recent CPGs regarding the assessment and management of LBP were similar. Clinicians who care for patients with LBP should endeavor to adopt these recommendations to improve patient care. Future CPGs may wish to invite coauthors from targeted clinician user groups, increase patient participation, update their literature searches before publication, conduct their own quality assessment of studies, and consider cost-effectiveness and other aspects in their recommendations more explicitly.

Introduction

Low back pain (LBP) is a common musculoskeletal condition, with a lifetime prevalence of 84% in the general adult population [1]. The severity of LBP varies from patient to patient and episode to episode, with only 15% suffering from severe disability and 20% to 25% visiting a health provider [1], [2], [3], [4]. However, the economic burden of LBP is very heavy because of direct health-care costs and indirect costs from lost productivity. Health-care costs associated with spine problems, including LBP and neck pain, were estimated at $102 billion in the United States in 2004 [5]. Data from other countries suggest that indirect costs may be five to six times higher than direct costs, bringing the total annual costs of LBP in the United States to $500 billion or more [6].

Care for LBP is fragmented. Patients may first present to a primary care provider (PCP), where it ranks as one of the top five reasons for seeking care and accounts for 5% of all PCP visits; doctors of chiropractics (DCs) and physical therapists (PTs) are also frequently consulted for LBP [3], [7], [8], [9], [10]. A sizable number of those with LBP also seek care in secondary care (2°) settings, including nonsurgical spine specialists, such as neurologists, physiatrists, and rheumatologists, and surgical spine specialists, such as orthopedic and neurologic surgeons. Allied health providers, such as acupuncturists, naturopaths, psychologists, and other health providers also play a role in managing LBP. Differences in the training, education, and scope of practice of these providers have lead to heterogeneity in the management of LBP [11], [12].

Ideally, all providers involved in managing LBP should be guided by the best available scientific evidence to minimize the use of ineffective, excessively costly, or even harmful procedures. However, the volume of literature related to LBP precludes clinicians reading all studies in their fields [4]. Clinical practice guidelines (CPGs) endeavor to locate, evaluate, and summarize the scientific evidence on particular topics and are considered important tools in the implementation of evidence-based medicine [8], [13], [14], [15]. However, methods for developing CPGs are not yet standardized, which may impact the perceived validity of their recommendations [15], [16]. Previous reviews of CPGs for LBP reported that although many recommendations were similar, discrepancies were noted regarding the use of medication, spinal manipulation therapy (SMT), exercise, and patient education [12], [17], [18]. Conclusions from previous reviews on this topic may no longer be valid because newer CPGs were subsequently published.

Adherence to recommendations from CPGs on the management of LBP has been associated with both improved clinical outcomes and decreased costs [19], [20], [21], [22]. However, compliance with such recommendations from CPGs has been consistently low in studies of physicians, chiropractors, PTs, and other clinicians involved in managing LBP [20], [21], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37]. Interventions aimed at increasing compliance with CPGs among health practitioners have reported mixed results [19], [28], [38], [39], [40]. Barriers noted to the adoption of CPGs have included lack of understanding about how they arrive at their recommendations, insufficient clarity to apply them, inconsistency among different CPGs, or disagreement with their recommendations [41].

The primary objective of this study was to synthesize recommendations from recent CPGs to provide guidance to clinicians on evidence-based assessment and management of acute LBP, chronic LBP, and LBP with substantial neurologic involvement, which are defined below. Secondary objectives were to compare methods used in different CPGs, rate their methodological quality, and make suggestions for developing future CPGs related to LBP.

Section snippets

Information sources

Clinical practice guidelines were primarily identified through electronic searches in MEDLINE (OVID Interface, 1996 to August Week 1, 2009). Searches of the Internet also were conducted as CPGs are rarely published in medical journals [42]. The National Guideline Clearinghouse (www.guideline.gov), Clinical Evidence (clinicalevidence.bmj.com), Intute (www.intute.ac.uk), National Institute for Health and Clinical Excellence (www.nice.org.uk), and other Web sites were searched [43]. Clinical

Methods

The search strategy uncovered 669 citations, of which 95 were potentially relevant and 10 were deemed eligible, as summarized in the Figure[7], [8], [9], [42], [46], [47], [48], [49], [50], [51]. Two CPGs represented joint efforts by several European countries, including the Netherlands, France, Germany, United Kingdom, Denmark, Finland, Switzerland, and Sweden: one on acute LBP [42] and one on chronic LBP [46]. The two CPGs from the United States originated from the same groups but were

Discussion

Most CPGs originated in Europe, where some countries not only participated in multinational efforts but also developed their own national CPGs. Reasons for doing this were unclear but may be because of a perceived need to adapt “generic” recommendations to the particular societal, cultural, legal, or economic realities of their countries. An equal number of CPGs were related acute and chronic LBP, countering previous reports that relatively few CPGs existed for the management of chronic LBP [46]

Conclusion

A total of 10 CPGs related to the assessment and management of LBP have been published in the past 10 years. Methods for conducting these CPGs varied, but most were of high methodological quality and had generally similar recommendations. Although CPGs differed in their scope with respect to acute LBP, chronic LBP, and LBP with substantial neurologic involvement, recommendations were broadly similar and erecting such barriers when formulating recommendations for clinicians appears somewhat

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    Author disclosures: SD (salary, Palladian Health; stock ownership, including options and warrants, Palladian Health; training grant, NCMIC Foundation; speaking and/or teaching arrangements, NCMIC Foundation); ACT (consulting, Palladian Health; research support: investigator salary, Palladian Health); SH (royalties, multiple publishing companies; stock ownership, including options and warrants, Palladian Health; consulting, Palladian Health, NCMIC Foundation, University of New York; speaking and/or teaching arrangements, multiple organizations; trips/travel, multiple meetings per prior field; scientific advisory board, NYCC; other office, WFC Research Council).

    The authors are consultants, employees, or officers of Palladian Health, LLC, a company that manages specialty health benefits on behalf of other health insurers.

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