1Clinical guidelines for low back pain: A critical review of consensus and inconsistencies across three major guidelines
Introduction
Low back pain (LBP) is the leading cause of disability worldwide. This is now as apparent in low-income countries as it is in the more affluent and developed countries across the globe. Disappointingly, despite a significant increase in back pain expenditure over the last decade, the levels of disability associated with back pain over the same period have remained virtually unchanged [1]. In addition, the healthcare resource and economic burden that back pain and related disability present remain the same. A recent survey of nearly 200,000 people across 43 countries showed that people with back pain are at least twice as likely to have one of five mental health conditions (depression, anxiety, stress, psychosis and sleep deprivation) when compared to those without back pain [2].
Given the scale of the problem, it is imperative that healthcare professionals involved in the care of people with LBP have access to up-to-date, evidence-based information to assist them in treatment decision-making. Over the last few decades, a myriad of treatment options for back pain and an ever expanding repository of clinical trial data and scientific publications have emerged. The results of this global research effort into the causes and treatment of back pain are often conflicting and of variable quality. This heterogeneity in the data and its sheer scale imply that for an individual clinician in the pursuit of best clinical practice, making sense of the literature can be difficult and bewildering.
To assimilate and formally evaluate this information, an increasing number of clinical practice guidelines (CPGs) have been developed by different countries. Since the publication of the first LBP CPG by the Quebec Task Force in 1987 [3], more than a dozen ‘national’ multidisciplinary LBP guidelines that were sponsored by professional societies, government agencies and healthcare payers within their parent countries have emerged [4]. Each of the LBP guidelines is created by an expert panel through consensus.
In this chapter, we compare three clinical guidelines for the management of LBP. We outline where they agree on what comprises best practice for LBP. We consider inconsistencies in recommendations between these guidelines and some of the possible reasons for these; we also discuss the challenges faced in implementing the recommendations of guidelines and consider controversies and future directions of clinical guidelines for LBP.
We have selected three major, recent, well-recognised, multidisciplinary back pain guidelines. The three guidelines are as follows:
2016 NICE Guideline on Low Back Pain and Sciatica NG59 – United Kingdom [5]
2015 Evidence-Informed Primary Care Management of Low Back Pain – Canada [6]
2007/2009/2017 Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society – USA *[8], *[9], *[10]
These three guidelines were chosen either because they were judged as high-quality guidelines in a recent systematic review of clinical guidelines for back pain [4] or because at the time of writing they represented the most up-to-date clinical guidelines available. We illustrate the differences and similarities between these clinical guidelines in terms of development and their recommendations as well as the challenges faced in guideline implementation.
Section snippets
What is a clinical practice guideline?
CPGs have been defined as ‘ … systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances’ [11] and ‘statements that include recommendations, intended to optimise patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options’ [12]
Clinical guidelines make an important contribution to effective dissemination and implementation science;
Consistent recommendations across the three guidelines
In many areas, the guidelines essentially speak with a single voice and produce broadly similar recommendations. In this section, we outline these key similarities in terms of diagnosis and management.
Inconsistencies between guidelines
While there are clear commonalities across these guidelines, there are numerous examples where their recommendations diverge. There are many potential reasons for these inconsistencies.
Guideline development groups in LBP are required to generate recommendations in the face of substantial uncertainty. Where the evidence of benefit is marginal or inconsistent across studies and study quality is mixed, as is often the case across interventions for LBP, there is a large capacity for interpretive
Challenge of implementation
The challenge of implementing back pain guidelines in clinical practice is substantial. Indeed, recognition of issues relating to implementation within clinical guidelines is included in the AGREE II quality assessment tool [28]. It is important to recognise that clinical guidelines are just one component in a more complex process of translating research into clinical practice [13]. Strategies are needed to successfully bring guidelines into clinical practice, but the potential barriers to
Controversies and future directions
We have seen how inconsistencies arise from uncertainty regarding the value of many interventions for LBP. This uncertainty is likely the product of many factors including issues with the quality and size of many studies, diagnostic uncertainty, the largely unmet challenge of adequately targeting treatments to appropriate populations and marginal or absent treatment effects. It is sobering that across all the interventions reviewed by the NICE group, no intervention was considered to have
Conclusions
In this narrative review, we have selected and reviewed three major interdisciplinary clinical guidelines for LBP. As such, our review does not represent a systematic review of current guidelines, but rather aims to use selected guidelines to inform a discussion of where they concur and diverge on what represents the best practice. In addition, at the time of writing, the ACP published a new guideline for non-invasive treatment. Here, we have discussed selected changes in that new guideline,
Declarations of interest
NOC, BW and CC are qualified physiotherapists.
SW was the Chair of the recent NICE guideline development group for low back pain and sciatica, and NOC was a member of that guideline development group.
SW is a consultant in pain medicine and practices in both the public and private healthcare sectors.
This work was undertaken in part by Neil O'Connell and Stephen Ward, member and chair respectively of the NICE guideline committee (NG59 Low back pain and sciatica in over 16s: assessment and
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