Meta-review of Clinical Guidelines for the diagnosis and management of lower back pain

This section is a review of reviews of clinical guidelines (CGs) for the diagnosis and management of LBP – acute, sub-acute and chronic (persistent), published from 2006-2015.

 

Aim

The aim of this meta-review is twofold:

  • to provide an overview of reviews of national and international CGs for the management of LBP
  • to create a list of accepted recommendations from that in order to inform best practice

 

Method

Inclusion criteria:

Systematic reviews of national and international CGs of the management of LBP, in the English language, published between 2006 and 2014.

Search Terms:

Back pain AND review OR overview OR quality, AND guidelines.

Exclusion Criteria:

Not published in English, original guidelines, primary studies, studies focusing on one diagnostic or therapeutic component.

 

Search Strategy:

The aim was to find reviews of national and international clinical guidelines that focused on LBP – with or without neurological involvement.

Databases Searched:

MEDLINE, the Cochrane database, EMBASE, and the World Wide Web,

References of selected papers were searched for other qualifying reviews.
Data extraction:

A data extraction form was composed, in order to extract the below information –

  • Publication details
  • Nature of review
  • Review methods
  • List of included clinical guidelines
  • Results: List of recommendations
  • Comments
  • Results
  • Description of included reviews

 

Arnau et al (2006) assessed the methodological quality of 17 guidelines published between 1992 and 2002 using the AGREE tool; they then provided a brief summary of management recommendations based on this review.

 

Bouwmeester et al (2009) assessed the methodological quality of 14 guidelines published after 2001, using the AGREE tool; they then compared recommendations.

 

Dagenais et al (2010) reviewed the most recent guidelines (specifically excluding guidelines that summarized evidence from before 2000 ensuring currency), with only 10 guidelines meeting their inclusion criteria.  The AGREE tool was used to assess methodological quality.

 

Koes et al, (2010) conducted a narrative review of 15 national and international guidelines, limiting each country to one guideline; the content was presented and compared.

 

Pillastrini et al (2012) assessed the methodological quality of 17 guidelines published since 2002 using the AGREE tool; they then presented and compared the recommendations.

 

Quality appraisal of included reviews

Bouwmeester et al (2009) and Pillastrini et al (2012) were judged to be of Cochrane standard.

Arnau et al (2006) was of high standard, although no statement of declaration of interest was made.

Dagenais et al (2010) was of high standard, although while there were no acknowledgements made, there was disclosure that all authors were consultants to a private company managing health benefits on behalf of health insurers, and providing musculoskeletal spinal services.

Koes et al (2010) was of lower standard (more of a narrative review) with no allowance for bias (other reviews applied the AGREE tool), but given the majority of the included CGs they reviewed were based on Cochrane standards, there is still value in including this review.

 

Overlap of guidelines included in reviews

Within the 5 reviews included in this meta-review, 46 Clinical Guidelines had been compared; 12 of them more than once, with 8 appearing at least 3 times.  This could be considered a relatively low level of overlap given the discrete field of LBP CGs.  However, there were differing inclusion criteria (including a number of languages other than English), and guidelines dating from 1996 to 2009.

 

Combined Findings

In combining the recommendations from reviews of CGs – which in themselves are based on reviews adjusting for bias – it is hoped that the “cream will rise to the top”.  There is variation between reviews in how recommendations are presented e.g. “Red Flags”, “Triaging”, and “physical and neurological examination in order to exclude pathology” are all covering a similar diagnostic process.  The author has applied his own knowledge of LBP clinical terminology to create a common language description of the recommendations provided by the reviews of CGs, creating a list of diagnostic and management recommendations which are identifiable in each of the reviews, and then combined the reviews’ recommendations, providing 3 lists:

All – made by all reviews

50% – made by at least 50% of reviews

<50% – made by less than 50% of reviews

 

Only Dagenais et al (2010) made management recommendations specifically for LBP with substantial neurologic invovlement, and these are provided separately.

 

Table 1

Recommendations for assessment of LBP

All50%<50%
Red flagsSeverity and limitationsPatient expectations
Triage Previous episodes
Yellow Flags  

“All” = all clinical guidelines agree; “50%” = at least 50% of clinical guidelines agree; “<50%” = less than 50% clinical guidelines agree

 

Table2

Recommendations for management of acute/subacute LBP

All50%<50%
Stay activeSpinal Manipulative TherapyDo NOT advise specific exercise
EducationReassuranceDiscourage bed-rest
AcetaminophenNon-specific exercise 
NSAID’sDiscourage bed-rest 
 Muscle relaxants, weak opioids 

“All” = all clinical guidelines agree; “50%” = at least 50% of clinical guidelines agree; “<50%” = less than 50% of clinical guidelines agree.

 

Table 3

Recommendations for management of chronic LBP

All50% <50%
ExercisesStay activeTake into account individual’s preferences
Spinal Manipulative TherapyEducation / Back SchoolsNo electrotherapy
Non-opioid and NSAID’sMultidisciplinary rehab 
 Cognitive Behavioural Therapy 

“All” = all clinical guidelines agree; “50%” = at least 50% of clinical guidelines agree; “<50%” = less than 50% of clinical guidelines agree

 

 

Table 4

Recommendations for management of LBP with neurologic involvement (only Dagenais et al, 2010)

Dagenais et al
Stay active
Education
Non-opioid and NSAID’s
Muscle relaxants
Exercise
Spinal Manipulative Therapy
Massage
Cognitive Behavioural Therapy
Multidiscilinary rehab
Referral to surgery
Epidural steroid injection

Recommendations, with strongest recommendations at the top

Diagnosis  – best practice guideline

 

Separating by duration of symptom

Separate clinical guidelines for acute/subacute and chronic LBP reflect the different nature of longer lasting pain.  Most cases of first onset LBP tend to resolve spontaneously within 4-6 weeks (Hestbaek, 2003), particularly if the patient follows advice based on CGs; though there is a very high rate of recurrence, with the risk of LBP being twice as high in those having had previous episodes (Hestbaek, 2003).  However, longer term LBP (chronic = >3 months), is widely accepted as a different and more clinically challenging issue.  This often reflects neural sensitization mechanisms – particularly central effects (Woolf, 2011).  As central sensitization increases, pain is less amenable to treatment strategies normally effective for pain of shorter duration e.g. paracetamol, NSAIDs (Smart et al, 2012).  Therefore, the first stage in guiding patient management is in determining duration of the problem, and whether it is a first or subsequent episode.

 

Red Flag and Triage

Lower back pain can be a symptom of underlying pathology; this must be screened  for early on.

 

Yellow Flag

LBP can be complicated (and the prognosis worsen) in the presence of a number of factors (e.g. history of anxiety or depression, work related stress) which will influence prognosis.

 

Severity and limitations

The level of pain and disability can be predictive of outcomes, and should be assessed early on.

 

Previous episodes

Previous episodes of LBP are predictive of future episodes ( Taylor et al, 2014) and should be determined by questionning.

 

Patient expectations

Self-efficacy (positive) and fear-avoidance (negative) are strong predictors of outcome in muscuoskeletal pain (Denison et al, 2004); therefore it is important to establish who is at risk and manage accordingly.

 

Management – best practice guideline

Stay active

Education

Acetaminophen (paracetamol) and NSAIDs

Exercises

SMT

Reassurance

Discourage bed-rest

Take into account individual’s preferences and needs i.e. adapt advice to patient’s profile e.g. duration of symptom, severity of symptoms, previous episodes, patient’s learning style.

CBT

Mindfulness / meditation

Multi-disciplinary rehab (secondary management)

 

Strengths and limitations of the meta-review

In providing a guideline, there are a number of strengths in this review of reviews of CGs.  Adhering to a PRISMA search strategy ensures all major reviews published in the last 8 years have been included, establishing currency of guidance.  Clear inclusion and exclusion criteria ensure only appropriate literature is included.  However, the lack of another independent reviewer is a drawback, weakening the quality assurance.

Aggregating the 5 reviews, creating a common language for recommendations based on knowledge of all the literature informs others as to the total content.

There was no statistical analysis performed on the original CGs (and original studies) included in the reviews.  Due to the diverse nature of the data and non-English languages, this may not have been possible anyway.  There was also a degree of overlap – some guidelines being included in a number of the reviews, which will have caused a degree of bias.

Aggregating already aggregated data may “flatten” any interesting outliers.

 

Discussion and conclusion

There is total agreement across the CGs on a number of recommendations, with a high level of agreement on others.  Although it is important to separate sufferers into acute and chronic LBP, as well as separate out those with neurologic involvement, there are a number of common recommendations across the diagnosis of acute and chronic – search for red flags, triage, search for yellow flags.  In the management of acute and chronic LBP, common recommendations include advice to stay active, use of acetaminophen and NSAIDs, education, SMT, exercises.  While exercise is uniformly recommended for chronic LBP, it is only recommended by 50% of the acute reviews, and Koes et al (2010) specifically state that “specific back exercises are not recommended” for acute LBP.

Interestingly, Pillastrini et al (which included 13 original clinical guidelines published after 2002), demonstrated an evolution towards patient-centred care, with the inclusion of “patient expectations” in the assessment recommendations and “patient preference” in the management recommendations; these recommendations did not appear in the earlier reviews.  This evolution is consistent with the literature charting the further progression of “person-centred care” and empowerment (Pulvirenti et al, 2014).

 

Bearing in mind the scope of practice within an exercise-based intervention for LBP sufferers, the below elements are the minimum recommended for inclusion:

Feb 2017 update:

Two recently published guidelines go further in recommending exercise as a first-line response to LBP

The American College of Physicians strongly recommend exercise.

The UK National Institute for Health and Care Excellence also strongly recommend exercise.

 

Initial diagnosis/assessment

Separate by duration (acute/chronic) – and stream advice accordingly

Triage/establish Red Flags

Establish Yellow Flags

 

 

Management

Stay active advice

Reassure

Medication advice

Pain Education

Exercise (for chronic)

CBT / behavioural component (especially for chronic)

Treatment options advice – SMT, acupuncture

 

These recommendations are explored in more detail below.

 

 

Arnau, J.M., Vallano, A., Lopez, A., Pellisé, F., Delgado, M.J., Prat, N., 2006. A critical review of guidelines for low back pain treatment. European Spine Journal: Official Publication Of The European Spine Society, The European Spinal Deformity Society, And The European Section Of The Cervical Spine Research Society 15, 543–553.

 

Bouwmeester, W., van Enst, A., van Tulder, M., 2009. Quality of Low Back Pain Guidelines Improved. Spine November 1, 2009 34, 2562–2567.

 

Dagenais, S., Tricco, A.C., Haldeman, S., 2010. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. The Spine Journal 10, 514–529.

 

Denison, E., Åsenlöf, P., Lindberg, P., 2004. Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care. Pain 111, 245–252.

 

Hestbaek, L., Leboeuf-Yde, C., Manniche, C., 2003. Low back pain: what is the long-term course? A review of studies of general patient populations. European Spine Journal: Official Publication Of The European Spine Society, The European Spinal Deformity Society, And The European Section Of The Cervical Spine Research Society 12, 149–165.

 

Koes, B.W., van Tulder, M., Lin, C.-W.C., Macedo, L.G., McAuley, J., Maher, C., 2010. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 19, 2075–2094.

 

Pillastrini, P., Gardenghi, I., Bonetti, F., Capra, F., Guccione, A., Mugnai, R., Violante, F.S., 2012. An updated overview of clinical guidelines for chronic low back pain management in primary care. Joint Bone Spine 79, 176–185

 

Pulvirenti, M., McMillan, J., Lawn, S., 2014. Empowerment, patient centred care and self-management. Health Expectations 17, 303–310. doi:10.1111/j.1369-7625.2011.00757.x

 

Smart, K.M., Blake, C., Staines, A., Thacker, M., Doody, C., 2012. Mechanisms-based classifications of musculoskeletal pain: Part 1 of 3: Symptoms and signs of central sensitisation in patients with low back (±leg) pain. Manual Therapy 17, 336–344.

 

Taylor, J.B., Goode, A.P., George, S.Z., Cook, C.E., n.d. Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis. The Spine Journal.

 

Woolf, C.J., 2011. Central sensitization: Implications for the diagnosis and treatment of pain. PAIN® 152, S2–S15.