Clinical Guidelines for the Management
of Low Back Pain in Primary Care:
An International ComparisonThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Spine (Phila Pa 1976) 2001 (Nov 15); 26 (22): 2504–2513 ~ FULL TEXT
Bart W. Koes, PhD; Maurits W. van Tulder, PhD; Raymond Ostelo, MSc;
A. Kim Burton, PhD, DO; Gordon Waddell, DSc, MD, FRCS
Department of General Practice,
Erasmus University, Rotterdam
Study Design: Descriptive study.
Objectives: To compare national clinical guidelines on low back pain.
Summary of Background Data: To rationalize the management of low back pain, clinical guidelines have been issued in various countries around the world. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment.
Methods: Guidelines were included that met the following criteria: the target group consisted of primary care health professionals, and the guideline was published in English, German, or Dutch. Only one guideline per country was included: the one most recently published.
Results: Clinical guidelines from 11 different countries published from 1994 until 2000 were included in this review. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features were the early and gradual activation of patients, the discouragement of prescribed bed rest, and the recognition of psychosocial factors as risk factors for chronicity. However, there were discrepancies for recommendations regarding exercise therapy, spinal manipulation, muscle relaxants, and patient information.
Conclusion: The comparison of clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations were generally similar. Updates of the guidelines are planned in most countries, although so far produced only in the United Kingdom. However, new evidence may lead to stronger conclusions and enable future guidelines to become even more concordant.
Key words: clinical guidelines; low back pain; evidence based medicine; systematic reviews
From the FULL TEXT Article:
Background
Low back pain (LBP) is a major health problem in all developed countries and is most commonly treated in primary health care settings. The diagnostic and therapeutic management of acute as well as chronic LBP seems to vary substantially among general practitioners (GPs), medical specialists, and physical therapists within a country. [36] However, there are also considerable discrepancies in the management of LBP between countries. [9–11, 37]
To rationalize the approach of LBP and to take account of emerging scientific evidence, clinical guidelines on the management of LBP have been issued in various countries around the world. The development, publication, and dissemination of these guidelines is consistent with the current international trend toward evidence based medicine. This suggests that medical interventions should be based as much as possible on the results of clinical studies with sound methodologic quality. Within this context, several national and international groups are active in identifying, assessing, and summarizing all randomized clinical trials (RCTs). The results of these activities are included in systematic reviews and meta-analyses. [12, 26, 37]
Many of these activities take place within the framework of the Cochrane Collaboration, and the Cochrane Back Review Group has now published nine systematic reviews of RCTs, evaluating treatment for LBP. [12] The evidence presented in these and other systematic reviews provides, in theory, a robust basis for modern clinical guidelines. Because the available evidence is international, one would expect that each country’s guidelines would give more or less similar recommendations regarding diagnosis and treatment, although there may be some variation to take account of local resources and practice.
Since 1994, national clinical guidelines on LBP have been issued in at least 11 different countries that the authors have been able to identify. In this article, these guidelines are compared regarding the content of their recommendations, the target group, the guideline committee and its procedures, and the extent to which the recommendations were based on the available literature (the scientific evidence).
Methods
The search for clinical guidelines consisted of a search in Medline (key words: low back pain, clinical guidelines). Because guidelines are only infrequently published in medical journals, the search was extended to the Internet (key words: back pain, guidelines), and guidelines were identified by personal communication with experts in the field.
To be included in this review, the guidelines had to meet the following criteria: (1) the guideline concerned the clinical management of LBP, (2) the target group consisted of primary care health professionals, and (3) the guideline was available in English, German, or Dutch (or had been translated into those languages). Only one guideline was included per country (i.e., the one most recently issued).
Guidelines from the following agencies and countries (year of publication) were included:
Agency for Health Care Policy and Research (AHCPR), United States (1994) [3]
Dutch College of General Practice (NHG), Netherlands (1996) [13]
Israeli Low back Pain Guideline Group, Israel (1997) [5]
National Advisory Committee on Health and Disability, New Zealand (1997) [2]
Finnish Medical Association (Duodecim), Finland (1999) [23]
National Health and Medical Research Council, Australia (1999) [4]
Royal College of General Practitioners (RCGP, United Kingdom (1999) [30]
Swiss Medical Society (FMH), Switzerland (1999) [20]
Drug Committee of the German Medical Society in Germany (2000) [16]
Danish Institute for Health Technology Assessment, Denmark (2000) [25]
The Swedish Council on Technology Assessment in Health Care (2000) [26]
The information used for the comparison was directly extracted from the publications of these guidelines. The comparison focused on the content of the recommendations for diagnosis and therapy, the membership of the guideline committee responsible for the content of the guideline, the target population, and the extent to which the recommendations were based on the evidence in the literature. If relevant information on one or more of these topics was not presented in the guideline, the authors of the guidelines at issue were contacted for additional information.
Guidelines were excluded if they were not available in English, Dutch or German, [17, 19, 28, 33, 34] if they specifically focused on the management of LBP in occupational health care, [7, 18, 27, 35, 38, 39] if they dealt primarily with health care delivery [29] or social policy, [15] if they were limited to activity/ exercises only, [1] if they were specifically for the management of lumbosacral radicular syndrome, [8, 32] or if they dealt with chronic nonmalignant pain and not exclusively with LBP. [31] Reports that mainly provided reviews of the evidence were also excluded. [37]
Results
Patient Population
An important difference between the guidelines concerns the patient group at issue. The guidelines from the United Kingdom (UK), the United States (USA), New Zealand, and Australia all focus on patients with acute LBP (,12 weeks), whereas the others also include recommendations for the management of chronic LBP (.12 weeks). The differentiation between acute and chronic, based on the cutoff point of 12 weeks, is not always fully clear. For instance, most guidelines do not clearly differentiate between 12 weeks from onset and 12 weeks from presentation to the health care professional.
Diagnostic Recommendations
Table 1 compares the diagnostic classification and the recommendations on diagnostic procedures in the various guidelines. All guidelines propose some form of diagnostic triage in which patients are classified as having (1) nonspecific LBP, (2) specific LBP (“red flag” conditions such as tumor, infection, or fracture), and (3) sciatica/ radicular syndrome. In some guidelines, sciatica is not considered as a separate classification but is variously included for management in the category of nonspecific or specific LBP.
All guidelines are consistent in their recommendations that diagnostic procedures should focus on the identification of red flags and the exclusion of specific diseases (sometimes including radicular syndrome). Red flags include, for example, age at onset (,20 or .55 years), significant trauma, thoracic pain, weight loss, widespread neurologic changes. [40] The types of physical examination and physical tests that are recommended show some variation. Neurologic screening, which is largely based on the straight leg raising test, plays an important role in most guidelines.
The guidelines are consistent in their recommendation that plain radiographs are not useful in acute nonspecific LBP and that radiographs should be restricted to patients suspected of having specific underlying pathologic changes (based on red flags). In some guidelines (e.g., US, UK, Denmark, and Israel), radiographs are suggested as optional in case of persistent LBP (.4–6 weeks). [3, 5, 25, 30] None of the guidelines recommend any form of radiologic imaging for acute, nonspecific LBP, whereas the US and UK guidelines overtly advise against it. [3, 30]
All guidelines, with varying emphasis, mention the importance of considering psychosocial factors as risk factors for the development of chronic disability. There is, however, considerable variation in the amount of detail given about how to assess psychosocial factors or the optimal timing of the assessment, and specific tools for identifying these factors are scarce. The UK guideline gives a list describing four main groups of psychosocial risk factors, whereas the New Zealand guideline gives by far the most attention to explicit screening of psychosocial factors, using a standardized questionnaire. [2, 21] None of the guidelines (with the exception of some general principles in the New Zealand Yellow Flags) give any specific advice on what to do about psychosocial risk factors that are identified.
Summary of Recommendations for Diagnosis of Low Back Pain
Diagnostic triage (nonspecific LBP, radicular syndrome, specific pathologic change).
History taking and physical examination to exclude red flags.
Physical examination for neurologic screening (including straight leg raising test).
Consider psychosocial factors if there is no improvement.
Radiographs not useful for nonspecific LBP.
Therapeutic Recommendations
Table 2 compares therapeutic recommendations given in the various guidelines. Patient advice and information play an important role in most guidelines. In general, patients should be reassured that they do not have a serious disease and that the prognosis is generally favorable, even recognizing that many patients continue to have some persistent or recurrent symptoms. Patients should be advised to stay active and to progressively increase their activity level. There are some differences in the recommendations. The UK guidelines, for example, give specific advice on messages the general practitioner should give under different circumstances. [30]
Recommendations for the prescription of medication are generally consistent. Paracetamol/acetaminophen is recommended as a first choice because of the lower incidence of gastrointestinal side effects. Nonsteroidal antiinflammatory preparations are the second choice in cases where paracetamol is not sufficient. There is some variation in the recommendation of muscle relaxants (optional in some guidelines and not recommended in others), opioids, local anesthetic, and compound medication. Some guidelines explicitly recommend a time-contingent prescription of the pain medication (e.g., UK and Netherlands). [13, 30]
There now appears to be a broad consensus that bed rest should be discouraged as a treatment for LBP. Some guidelines state that if bed rest is indicated because of severity of pain, than it should not be advised for more than 2 days (e.g., Germany, Netherlands). [13, 16] Others suggest that some patients may be confined to bed for a few days, but that should be regarded as a consequence of their pain and should not be considered a treatment (e.g., UK). [30]
There also appears to be a consensus that the vast majority of cases of LBP should be managed in a primary care setting. Referral to a medical specialist (hospital setting) is restricted to patients in whom a specific pathologic change is suspected from the presence of red flags or those with sciatica/radicular syndrome or neurologic problems that require surgical assessment or investigation.
Summary of Recommendations for Treatment of Low Back PainAcute or Subacute Pain
Reassure patients (favorable prognosis).
Advise to stay active.
Prescribe medication if necessary (preferably timecontingent): paracetamol, nonsteroidal antiinflammatory agents, consider muscle relaxants or opioids.
Discourage bed rest.
Consider spinal manipulation for pain relief.
Do not advise back-specific exercises.
Chronic Pain
Refer for exercise therapy
Recommendations regarding exercise therapy also show some variation. In several guidelines, back-specific exercises are considered not useful during the first weeks of an episode (Netherlands and UK guidelines). [13, 30] Other guidelines state that low-stress aerobic exercises are a therapeutic option in acute LBP (USA). [3] The Danish guidelines specifically mention McKenzie exercise therapy as a therapeutic option in some patients with acute or chronic LBP. [25] Those guidelines that extend their advice beyond the acute stage all recommend exercise therapy as a useful intervention (Netherlands, Germany, Denmark, UK). [13, 16, 25, 30] However, recommendations regarding the type and intensity of the exercises are not consistent.Recommendations regarding spinal manipulation for acute LBP show some variation. In most guidelines, spinal manipulation is considered to be a therapeutic option in the first weeks of an LBP episode. In the Dutch, Australian, and Israeli guidelines, spinal manipulation is not recommended for acute LBP. However, spinal manipulation is considered a useful therapeutic option for chronic LBP in the Dutch and Danish guidelines [13, 25] but not in the others (in part because chronic LBP was not included).
Setting
Table 3 shows some background variables related to the development of the guidelines in the various countries. Most of the guidelines focus exclusively on primary care physicians. The UK guideline, although led by and usually referenced to the Royal College of General Practitioners, is actually a common guideline for all primary care health professionals, including GPs, physiotherapists, osteopaths, and chiropractors. [30] Furthermore, the Dutch guideline is mostly focused on a GP setting. [13] The Finnish guidelines cover secondary as well as primary care settings, [23] and the Swiss guidelines consider occupational health care as well as primary care. [20]
Guideline Committee
The various committees responsible for the development and publication of guidelines appear to be different in size and in the professional disciplines involved. Most committees are characterized by their multidisciplinary membership. However, the Dutch guideline committee consisted of only five GPs and one epidemiologist/ methodologist. [13] The number of members varied from 6 to 23. Only two committees included consumer representation (UK and Australia). [4, 30]
Evidence-Based Review
All guidelines are more or less based on a comprehensive literature search. Some committees based their recommendations, entirely or in part, on previously issued guidelines (e.g., the AHCPR guidelines published in December 1994). [3] Most guidelines use an explicit weighing of the strength of the evidence by a 3-point or 4-point rating scale. The Dutch, UK, and Australian guidelines give direct links between the actual recommendations and the evidence (via specific references) on which the recommendations are based. [4, 13, 30] The UK and Australian guidelines present an extensive evidence table, in which the evidence for the most important recommendations is given in a comprehensive way. [4, 30] Most committees used some form of consensus method for situations where the evidence was not convincing or not available.
Dissemination and Implementation
The activities related to the publication and dissemination of the various guidelines show some differences and some similarities. In most cases, the guidelines are accompanied by easily accessible summaries for practitioners and booklets for patients.
Systematic implementation activities are rare. In most cases, the printed versions of the guidelines are published in national journals and/or disseminated through professional organizations to the target practitioners. In the Netherlands, specific courses are offered to GPs to provide training in the knowledge and skills required for use of the guidelines. In many countries, regular updates of the guidelines are planned, but only the UK has actually produced a new edition as new evidence became available. In the UK, local ownership is seen as being an important part of implementation, and various local health care groups have issued their own versions of the core recommendations.
Discussion
In general, clinical guidelines in all the countries studied give similar advice on the management of LBP. Because of the differences in health care systems and culture in the various countries, and because of the differences in membership of the guideline committees, it might have been anticipated that there would have been rather more differences. The scientific evidence regarding diagnostic and therapeutic interventions is apparently sufficiently strong and transparent to enable all these groups in such different settings to reach similar conclusions. In previous articles, one of which was published in Dutch only, and based on a limited number of guidelines, the present authors came to broadly similar conclusions. [6, 22] Common recommendations of all guidelines are the diagnostic triage of patients with LBP, restricted use of radiographs, advice on early and progressive activation of patients, and the related discouragement of bed rest. The recognition of psychosocial factors as risk factors for chronicity is also consistent across all guidelines, though with varying emphasis and detail.
Use of Available Evidence
On the whole, the various guidelines were based on the same body of literature. Of course, it has to be acknowledged that there are differences in the dates of issue. For example, the USA guidelines were based on the literature up to 1991, whereas the most recently issued UK and Australian guidelines were based on the literature up to 1999. This difference in time frame may account for differences in recommendations because of new evidence and new insights. For example, there is a general shift from recommending 2 to 3 days of bed rest to actually recommending against bed rest as stronger evidence has become available. Further, after 1991, new RCTs evaluating the efficacy of exercise therapy (back-specific exercises as opposed to general exercise) for acute LBP indicated that this therapy was not effective. [14, 24]
Most guideline committees performed some literature searches themselves, although with the increasing amount of evidence available it is increasingly difficult to review all the relevant evidence de novo. Almost all guideline committees now increasingly rely on information from published systematic reviews and metaanalyses in the area of concern, together with earlier clinical guidelines from other countries. There are not yet any references to Cochrane reviews of treatments for LBP in any of the guidelines reviewed because these have become available only since 1999. Reviewers of future guidelines should consider the evidence from Cochrane reviews. [12]
In some guidelines, the use of the evidence was not always appropriate. For instance, the US guidelines for acute LBP based part of the recommendations—for example, for antidepressants and biofeedback — solely on literature evaluating the effectiveness of these interventions for patients with chronic LBP. There was a great deal of variation in the amount and detail of evidence and references given, the use of strength rating of the evidence, and the use of explicit linking between the evidence and the recommendations.
Differences in Recommendations
Recommendations about the prescription of analgesic medication are fairly consistent, with most guidelines recommending paracetamol as the first option and nonsteroidal antiinflammatory preparations as the second option, but further recommendations about other drugs vary quite considerably. The same holds true for the recommendation whether the drug prescription should be on a time-contingent or a pain-contingent basis. There was no clear explanation for these variations: it is possible that they reflected the setting and custom in different countries, though perhaps they were influenced by personal preferences of the members of the guideline committees.
The recommendations regarding spinal manipulation differed more obviously. The Dutch, Australian, and Israeli guidelines do not recommend spinal manipulation for acute LBP. [4, 5, 13] The other guidelines do recommend manipulation, although they report different time frames for its indication. For example, the Danish guideline recommends manipulation after 2 to 3 days, the US guideline within 4 weeks, and the New Zealand guideline between 4 and 6 weeks, whereas the UK guideline advises “consider manipulative treatment for patients who need additional help with pain relief or who are failing to return to normal activities.” In general, the type of manipulation or discipline is not specified. Apparently the available evidence for this therapy is not sufficiently consistent to enable similar recommendations to be reached on whether, and at which point, manipulation is indicated for acute LBP, or by whom it should be performed.
There are also differences in the recommendations about back-specific exercises for acute LBP. The US, Swiss, and German guidelines do consider exercises as a therapeutic option, whereas other guidelines do not recommend exercise therapy for acute LBP. Part of the explanation may be in the use or not of the more recently published RCTs in this area, as previously mentioned. [14, 24] The Danish guidelines specifically mention McKenzie exercises as a therapeutic option, whereas the others do not. This may result from a different interpretation of the available evidence or from a different constitution of the guideline committee.
Recommendations in guidelines are based not only on scientific evidence but also on consensus. Guideline committees may consider various arguments such as the magnitude of the effects, potential side effects, cost effectiveness, and current routine practice and available resources in their country. Guidelines may put particular emphasis on what is perceived as a current problem in that country, e.g., overaggressive surgical investigations and interventions (e.g., US). [3] The constitution of the guideline committee and the professional bodies they represent may introduce bias, either for or against a particular treatment.
Implementation
Guidelines appear to be published in national journals and disseminated as reports, including handy summaries for practitioners. Provision of summaries and booklets for patients is variable. Beyond these dissemination activities, no systematic implementation strategies directed at changing the behavior of health care providers, patients, and policy makers seem to be scheduled in the various countries. The extent to which currently available guidelines are used and followed in the various countries remains largely unknown. Future research in this area is clearly needed. Because there are indications from other fields of medicine that the publication and dissemination of guidelines alone is not enough to change the behavior of health care providers, more effort should be put into developing and evaluating effective implementation strategies.
Future Developments in Research and Guideline Development
The present study was primary aimed at presenting the status quo regarding the clinical guidelines for the management of low back pain, not to critically assess and grade the validity of the clinical guidelines. A systematic assessment of the various guidelines using a standardized checklist might be recommended for future studies.
The present study clearly focuses on guidelines for primary care settings. Clinical guidelines aimed at, for example, secondary care settings, occupational care settings, or specific subgroups of patients with lumbosacral radicular syndrome were not considered. Separate studies need to be undertaken to present an overview for these settings.
The development of future guidelines in this field may benefit from earlier experiences, evidence-based reviews, and various national guidelines as presented in this overview. Without intending to be comprehensive, the authors suggest that future guidelines take into account the aspects listed below.
Recommendations for the Development of Future Guidelines
for the Management of Low Back Pain
Make use of available (updated) evidence-based reviews (e.g., Cochrane reviews).
Include relevant non-English publication (if available).
Determine in advance the intended target groups (health care professions,
patient population, and policy makers).Be aware that the makeup of the guideline committee may have a direct impact
on the content of the recommendations.Specify exactly which recommendations are evidence based (and supply
the correct references to each of these recommendations).Specify exactly which recommendation are consensus based (and explain the process).
Finally, and importantly, determine in advance the implementation strategy,
and set a time frame for future updates of the guideline.
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