Introduction: Low back pain (LBP) is a heterogeneous disorder that encompasses somatic, neuropathic and central pain. Little is known about the methodological quality of guidelines for LBP. Despite its high incidence and multiple therapeutic options, there is a significantly high rate of treatment failure, which leads to the chronicity of patients and increased health expenditures. This article presents a systematic review of the literature on evidence based clinical practice guidelines for the interventional management of chronic LBP and appraisal of the methodological quality of the guidelines and their recommendations.
Methods: A systematic review was conducted using electronic databases (The National Guidelines Clearinghouse, National Institute for Clinical Excellence, Cochrane Back Review Group, PubMed, Clinical Evidence and Google Scholar). Only clinical practice guidelines on chronic low back pain treatment that encompassed interventional management were included. Two individual appraisers used the AGREE-II instrument to assess the methodological quality of the guidelines and also compare the recommendations regarding the invasive management of chronic low back pain.
Results: Five guidelines met the inclusion criteria but only one was specific to interventional treatments. According to the AGREE-II, domains 1 (scope and purpose) and 6 (editorial independence) obtained the highest scores, while domains two (Stakeholder involvement) and five (Applicability) ranked lowest. Recommendations regarding diagnosis and non-invasive treatments were similar throughout the guidelines, however the evidence for interventional management was variable and inconsistent.
Conclusions: In general, guidelines achieved satisfactory results for specific quality criteria. However, more rigorous and explicit methods to develop the guidelines are needed. There was a consistent lack of clarity regarding cost-effectiveness, external peer review and implementation that we consider limit the adherence and distribution of the guidelines. Additionally, recommendations should be examined in the context of each type of pain, as per most targeted non-specific LBP, which altered the level of evidence for the interventions reviewed.
Patient Care: Ensuring and evidence-based approach through the use of systematic reviews and existing evidence-based guidelines.
Providing recommendations acceptable to a wide range of professions, while at the same time identifying ineffective interventions to limit their use.
We seek that this review will help clinicians offer patients the best available, evidence-based treatment while avoiding unnecessary interventions and higher health costs.
Learning Objectives: By the conclusion fo this session, participants should be able to identify an effective, evidence based, approach to the patient with chronic low back pain. Furthermore, they should be able to discuss the importance of implementing and adhering to clinical practice guidelines for the interventional treatment of chronic LBP. Finally, the comparison of different guidelines and appraisal of their recommendations should help clinicians determine which interventions are best suited for each case and type of pain in their daily practice.
References: 1. Butler S, Chapman C, Turk D, eds. Bonica's management of pain. 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2001.
2. Devereaux M. Low back pain. Med Clin North Am. 2009;93:477-501.
3. Golob A, Wipf J. Low back pain. Med Clin North Am. 2014;98:405-428.
4. Katz J. Lumbar disc disorders and low-back pain: Socioeconomic factors and consequences. J Bone Joint Surg Am. 2006;88:21.
5. Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24(6):769-781.
6. Borenstein D. Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain. Curr Opin Rheumatol. 2001;13:128-134.
7. Deyo R, Tsui-Wu Y. Descriptive epidemiology of low-back pain and its related medical care in the united states. Spine J. 1987;12(3):264.
8. Cassidy J, Carroll L, Côté P. The saskatchewan health and back pain survey. the prevalence of low back pain and related disability in saskatchewan adults. Spine J. 1998;23(17):1860.
9. Arnau J, Vallano A, Lopez A, Pellise F, Delgado M, Prat N. A critical review of guidelines for low back pain treatment. Eur Spine J. 2006;15:543-553.
10. Brouwers M, Kho M, Browman G, et al. AGREE next steps consortium. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Canadian Medical Association Journal. 2010;182:839-842.
11. Airaksinen O, Brox J, Cedraschi C, et al. European guidelines for the management of chronic non-specific low back pain. Eur Spine J. 2006;15(2):s192-s300.
12. Chou R, Loeser J, Owens D, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: An evidence-based clinical practice guideline from the american pain society. American pain Society Low back Pain Guideline Panel. Spine J. 2009;1(34):1066-1077.
13. Pe´rez I, Alcorta M, Aguirre L, et al. Gui´a de pra´ctica cli´nica sobre lumbalgia osakidetza. GPC. vitoria-gasteiz. http://www9.euskadi.net/sanidad/osteba/datos/gpc_07-1.pdf. Updated 2007. Accessed 08/26, 2014.
14. Savigny P, Kuntze S, Watson P, et al. Low back pain: Early management of persistent non-specific low back pain. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners. 2009.
15. Manchikanti L, Falco F, Singh V, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Pain Physician. 2013;16:S1-S283.
16. MacDermid J, Brooks D, Solway S, et al. Reliability and validity of the AGREE instrument used by physical therapists in assessment of clinical practice guidelines. BMC Health Serv Res. 2005:5-18.
17. Dagenais S, Tricco A, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J. 2010;10:514-529.