Clinical Practice Guidelines for the Noninvasive Management of Low Back Pain: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration
Eur J Pain. 2016 (Oct 6) ~ FULL TEXT
J.J. Wong, P. Côté, D.A. Sutton, K. Randhawa, H. Yu, S. Varatharajan, R. Goldgrub, M. Nordin, D.P.
UOIT-CMCC Centre for the Study of
Disability Prevention and Rehabilitation,
University of Ontario Institute of Technology (UOIT)
Canadian Memorial Chiropractic College (CMCC),
Oshawa, ON, Canada.
BACKGROUND:   Low back pain (LBP) is a major health problem, having a substantial effect on peoples’ quality of life and placing a significant economic burden on healthcare systems and, more broadly, societies. Many interventions to alleviate LBP are available but their cost effectiveness is unclear.
We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias.
According to high-quality guidelines:
(1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options;
(2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation;
(3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and
(4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation.
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Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed. Overall, most guidelines target nonspecific LBP and recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first-line treatments. The recommendation to use paracetamol for acute LBP is challenged by recent evidence and needs to be revisited.
SIGNIFICANCE: Most high-quality guidelines recommend education, staying active/exercise, manual therapy and paracetamol/NSAIDs as first-line treatments for LBP. Recommendation of paracetamol for acute LBP is challenged by recent evidence and needs updating.
From the FULL TEXT Article:
Introduction
More than 80% of people experience at least one episode of back pain during their lifetime (Cassidy et al., 1998; Walker, 2000). Back pain is a common source of disability, whether the pain is attributed to work, traffic collisions, activities of daily living, or insidious onset (Cassidy et al., 1998, 2005; Hincapie et al., 2010). Back pain is costly, accounting for a considerable proportion of work absenteeism and lost productivity (Carey et al., 1995, 1996). Moreover, it is the most common reason for visiting a healthcare provider for musculoskeletal complaints (Cypress, 1983; Cote et al., 2001). Although multiple clinical interventions are available to treat back pain, current evidence suggests that their effects appear small and short term (Haldeman and Dagenais, 2008).
Clinical practice guidelines are systematically developed statements that include recommendations intended to optimize patient care and improve patients’ health outcomes (Shekelle et al., 1999, 2012; Institute of Medicine Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, 2011). Guidelines aim to reduce the gap between research and clinical practice and assist policy makers with decisions that impact the population (Whitworth, 2006; Alonso-Coello et al., 2010). However, concerns have been raised about the quality of many clinical practice guidelines (Ransohoff et al., 2013). Systematic reviews report that some guidelines have methodological limitations (Shaneyfelt et al., 1999; Graham et al., 2001; Hasenfeld and Shekelle, 2003; Alonso-Coello et al., 2010; Berrigan et al., 2011; Knai et al., 2012). Common flaws include poor literature review methodology, limited involvement of stakeholders and unclear editorial independence (Alonso-Coello et al., 2010). Therefore, valid concerns exist about the potentially negative impact of biased guidelines on the care and health outcomes of patients (DelgadoNoguera et al., 2009; Shaneyfelt and Centor, 2009; Tricoci et al., 2009; Alonso-Coello et al., 2010).
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