Introduction
Methods
Country | Patient population | Diagnostic classification | Physical examination | Imaging | Psychosocial factors |
---|---|---|---|---|---|
Australia (2003) | Acute (<3 months) | Non-specific low back pain (divided into acute, subacute and chronic) Specific low back pain | Conduct physical examination to assess for the presence of serious conditions Neurological examination in case it is suspected. (Physical examination such as inspection, range of motion and posture may have low reliability and validity and should be used with caution) | Not recommended unless alerting features of serious conditions are present | Yellow flags associated with the progression from acute to chronic should be assessed early to facilitate intervention |
Austria (2007) | Acute (0–6 week), subacute (6–12 week) chronic (>12 week), and recurrent | Non-specific LBP Specific LBP (based on list of red flags) Including high-grade spondylolisthesis, facet arthrosis, severe degenerative disc disease | Inspection, palpation, range of motion testing of lumbar spine, neurological screening (strength, reflexes, sensibility, SLR) | Not useful in the first 4 weeks of an episode After 4–6 weeks may be indicated in search for a specific cause | Evaluate psychosocial factors in patients who do not show improvement over time (with recommended treatment) and in patients with recurrent LBP |
Canada (2007) | Acute, subacute and persistent | Simple back pain Back pain with neurological involvement Back Pain with suspected serious pathologies All divided into acute, subacute and persistent | Physical examination in patients with back pain and neurological involvement includes SLR, motor, sensitivity, reflex signs | Not recommended for simple low back pain but recommended for pain with neurological involvement and suspected serious pathology. MRI and CT scans recommended if surgery is in question | Assess patients’ perceived disability and probability to return to usual activity after 4 weeks of disability or at first consultation if patient has a history of long-lasting back-related disability (Symptom Check List Back Pain Prediction Model) |
Europe (2006) | Acute (<6 weeks) and subacute (6–12 weeks) LBP | Serious spinal pathology Nerve root pain/radicular pain Non-specific low back pain | Physical assessment including neurological screening when appropriate | Diagnostic imaging tests (including X-rays, CT and MRI) are not routinely indicated for non-specific low back pain | Assess for psychosocial factors and review them in detail if there is no improvement |
Europe (2006) | Chronic LBP (>12 weeks) | Specific spinal pathology Nerve root pain/radicular pain Non-specific low back pain | Diagnostic triage, neuro-screening ‘We cannot recommend spinal palpatory and range of motion tests in the diagnosis of chronic low back pain’ | No radiographic imaging MRI in case of red flags X-ray in case of suspected structural deformities | ‘We recommend the assessment of prognostic factors (yellow flags) in patients with chronic low back pain’ |
Finland (2008) | Acute, subacute and chronic LBP | Non-specific LBP Nerve root dysfunction (sciatic syndrome, intermittent claudication) Possible serious or specific disease | Inspection, palpation, spinal mobility (flexion), SLR-test, strength, reflexes | No imaging in first 6 weeks Plain lumbar X-ray is basic investigation before other imaging studies MRI is first-line imaging investigation if special examinations are needed | A list of psychosocial factors (yellow flags) is included in the guideline Assess illness behaviour, depression in subacute LBP |
France (2000) | Acute low back pain <3 months Chronic “uncomplicated” low back pain >3 months | Acute & Chronic: Non-specific low back pain So-called symptomatic acute low back pain with or without sciatica (fracture, neoplasm, infection, inflammatory disease) Diagnostic and therapeutic emergencies (hyperalgesic sciatica, paralysing sciatica, cauda equina syndrome) | Acute: To rule out “so-called symptomatic acute low back pain” or emergencies Rating of muscle strength Chronic: Musculoskeletal and neurological examination to identify specific cause Assessment of function, anxiety and/or depression using validated measure | Acute: Not to be ordered in the first 7 weeks except when the treatment selected (manipulation, infiltration) requires formal elimination of specific form of low back pain Chronic: X-rays not repeated. CT/MRI only in exceptional circumstances | Acute and Chronic: Recommended to assess psychosocial factors |
Germany (2007) | Acute, subacute, chronic/recurrent LBP | Non-specific LBP Radicular pain Specific LBP (based on red flags) Patients at risk for chronicity (based on yellow flags) | Inspection, palpation, neurological screening; reflexes, SLR/Lasegue, sensibility, strength Further investigation (e.g. lab testing) is based on red flags | X-ray not useful in acute non-specific LBP CT, MRI only in cases with suspected radicular pain, or stenosis, or specific pathology such as tumours After 6 weeks persistent pain X-ray may be indicated or after 6–8 weeks an MRI | Evaluate risk factors for chronicity (yellow flags); including biological, psychological, occupational, lifestyle, and iatrogenic factors |
Italy (2006) | Acute, subacute and chronic LBP | Non-specific LBP Specific LBP Sciatica | Pain/functional limitation on trunk movement Palpation Postural evaluation Neurological exam is recommended (SLR, sensibility) | Useless for non-specific acute LBP Option after 4–6 weeks if surgery is indicated (sciatica) | Screening after 2 weeks: yellow flags, Waddell test (for pain behaviour) |
New Zealand (2004) | Acute LBP (<3 months) | Non-specific LBP Specific pathologic change | Neurological screening Establish degree of functional limitation caused by the pain | Investigations in first 4–6 weeks do not provide clinical benefit unless Red Flags present There are risks associated with unnecessary radiology | Screen for yellow flags with the Acute Low Back Pain Screening Questionnaire, and if at risk, clinical assessment |
Norway (2007) | Acute and subacute (<3 months) Chronic (>3 months) | Non-specific LBP Radicular pain Serious pathologies/acute neurological conditions (Cauda equina syndrome) | Inspection, posture, deformity, Spinal mobility, including finger-to-floor distance, Neurological screening (SLR/Lasegue) if radicular pain is suspected | Not recommended in acute, subacute chronic LBP and radicular pain in the absence of red flags, Recommended in case of red flag First choice is MRI | A list of yellow flags is presented as risk factors for chronicity, sick leave |
Spain (2005) | Non-specific acute, subacute and chronic | Specific spinal pathology Nerve root pain/radicular pain Non-specific low back pain | Clinical history, red flags. Do not recommend palpation and tests of intervertebral mobility | Not useful in non-specific LBP; X-rays, CT and MRI use only in case of red flags | Assess psychological factors in 2–6 weeks after treatment if not improving. Assess physiological factors as prognostic factor only |
The Netherlands (2003) | Acute (0–12 week) and chronic (>12 week) LBP | Non-specific LBP Specific LBP (based on a list of red flags) | SLR-test, neurological inspection; loss of motor control, sensibility, miction. Palpation of spine, Inspection of lumbar kyphosis or flattened lumbar lordosis | Not useful in non-specific acute LBP | Assessment of psychosocial factors (yellow flags) is recommended. These include emotional reaction, cognitions and behaviour |
United Kingdom (2008) | Acute <6 weeks, sub acute 6–12 weeks, chronic >3 months | Non-specific low back pain: Mechanical low back pain Inflammatory low back pain and stiffness Serious pathology | Rule out serious pathology (identify red flags) Confirm pain is in the lower back, is mechanical, not inflammatory | Does not inform management of non-specific low back pain but may be indicated to rule in/out serious pathologies | Recognise and manage psychosocial barriers (yellow flags) to recovery |
United States (2007) | Acute and chronic LBP | Non-specific LBP LBP due to specific causes LBP-Radiculopathy/Spinal Stenosis | Neurological screening (including SLR, strength, reflexes, sensory symptoms) | Only where progressive neurological or serious pathology is suspected Discouraged for non-specific LBP Recommended for radiculopathy or spinal stenosis only if patients are potential candidates for further intervention | Assessment of psychosocial risk factors strongly recommended |
Most apparent changes since 2001
| |||||
Addition of guidelines from countries such as Austria, Canada, France, Italy, Norway, Spain and a unified one from Europe | More countries (UK, US) now include recommendations for chronic LBP in addition to acute LBP. Germany now includes subacute and recurrent LBP | Almost no change in diagnostic classifications used in the guidelines | Almost no change in recommended types of physical examination | In some guidelines (Finland, Germany) now more explicit statements regarding the use of CT and MRI | In a few guidelines (Netherlands, US) the measurement of yellow flags are now more strongly recommended. In Germany the assessments is now recommended at a much earlier stage |
Results
Patient population
Diagnostic recommendations
Summary of Common Recommendations for Diagnosis of Low back pain
|
* Diagnostic triage (non-specific low back pain, radicular syndrome, serious pathology). |
* Screen for serious pathology using red flags. |
* Physical examination for neurologic screening (including straight leg raising test). |
* Consider psychosocial factors (yellow flags) if there is no improvement. |
* Routine imaging not indicated for non-specific low back pain. |
Therapeutic recommendations
Country | Education | Medication | Exercises | Manipulation | Bed rest | Referral to specialist |
---|---|---|---|---|---|---|
Australia (2003) [8] | Provide information, assurance and advice to resume normal activity (stay active) | First choice paracetamol, second choice NSAIDs, third choice oral opioids Not recommended: anticonvulsants, antidepressants, muscle relaxants | There is conflicting evidence of the effect of exercises but evidence shows that it is no better than usual care | Conflicting evidence of spinal manipulation versus placebo in first 2–4 weeks | Not advisable | When alerting features (red flags) or serious conditions are present |
Austria (2007) [9] | Acute LBP: expect a favourable course; maintain normal daily activities | Acute LBP: (1) Paracetamol; (2) NSAIDs 3) muscle relaxants or weak opioids as last option Chronic LBP: Options: NSAIDs/Coxibs; Opioids; Antidepressant; muscle relaxants; Anti-convulsion medication (for radicular pain), Capsaicin Only for short periods: (1) paracetamol, (2) tramadol or NSAID, (3) opioids | Acute LBP: Not specifically mentioned in the guideline Chronic LBP: Exercise therapy recommended as monotherapy or in combination with back school, massage | Acute LBP: Optional for patients who do not return to normal level of activity within the first weeks Chronic LBP: Optional for patients with persistent problems with performing daily activities | Acute LBP: Avoid bedrest (but if necessary, only for a short period) | In case of suspected specific LBP; Surgery is optional only after 2 years of recommended conservative treatment, persisting complaints and with a surgical indication |
Canada (2007) [10] | Reassurance and advice to return to work and usual activities | NSAIDs, muscle relaxants and analgesics for acute. Low evidence for NSAIDs and analgesics for subacute pain | Strengthening exercises, extension exercises and specific exercises are not recommended for acute but recommended for subacute and chronic with no superior form of exercise | Recommended for short- term pain reduction for acute. Recommended with low evidence for subacute and chronic | Not recommended | Refer patients with neurological signs or symptoms if functional deficits are persistent or deteriorating after 4 weeks |
Europe (2006) (acute) [11] | Reassure and advise patients to stay active and continue normal daily activities including work if possible | Prescribe medication, if necessary for pain relief; Preferably to be taken at regular intervals; first choice paracetamol, second choice NSAIDs. Third choice consider short course of muscle relaxants on its own or added to NSAIDs | Do not advise specific exercises (for example strengthening, stretching, flexion, and extension exercises) for acute low back pain | Consider (referral for) spinal manipulation for patients who are failing to return to normal activities | Do not prescribe bed rest as a treatment | Refer patients with neurological symptoms such as cauda equina syndrome |
Europe (2006) (chronic) [12] | Advice and reassurance to return to normal activities | Recommend use of NSAID for short term pain relief and opioids in case patient is not responding to other treatment. Consider the use of noradrenergic or noradrenergic-serotonergic antidepressants as co-medication for pain relief | Supervised exercise therapy is advisable specifically approaches that don’t require expensive training and machines. Cognitive behavioural approach including graded activity and group therapy are advisable | Recommend short course of spinal manipulation/mobilisation | Discouraged | Most invasive treatments not recommended Surgery not recommended unless in carefully selected patients, 2 years of all recommended conservative treatments including multidisciplinary approaches with combined programmes of cognitive intervention and exercises have failed |
Finland (2008) [13] | Benign nature of condition; prognosis is good; continue ordinary daily activities. Back pain may recur but even then recovery is usually good | Acute/Subacute LBP: (1) paracetamol, (2) NSAIDs, (3) adding a weak opiate to paracetamol/NSAID. (4) muscle relaxants Antidepressant only if clear depression. Benzodiazepines not recommended Chronic LBP Analgesics used periodically, be aware of side effect of NSAIDs (gastrointestinal, cardiovascular) | Acute LBP: Active exercises not effective in early stages Light exercises (e.g. walking) can be recommended Subacute: gradually increasing exercises Chronic: Intensive training effective for pain and function | Acute LBP: some effectiveness Similar effectiveness as GP in subacute LBP Chronic LBP: similar effectiveness as GP, analgesics, physiotherapy, etc. | Avoid bedrest; a short period of bedrest may be necessary due to intense back pain, but bedrest must not be considered as a treatment of back problems | Immediate referral: Cauda equina syndrome, sudden massive paresis, excruciating pain Referral: serious, non urgent conditions Multidisciplinary (bio-psycho-social) rehabilitation focused on improving functional capacity |
France (2000) [14] | Short-term education about the back, in groups, is not beneficial | Acute & Chronic: Regular simple analgesics, non-steroidal anti-inflammatory drugs and muscle relaxants. No evidence for systemic corticosteroids Chronic: Additional recommendations for: acetylsalicylic acid, Level II following failure to respond to Level I and Level III (strong opioids) on a case by case basis. Tetrazepam, Tricyclic antidepressants | Acute: Flexion exercises have been not been shown to be of benefit. No recommendation on extension exercises Chronic: Physical exercise is recommended, no particular type is advocated | Acute & Chronic: Provides short-term benefit. No recommendation for one form of manual therapy over another | Acute and Chronic: Not recommended | Acute: No recommendation Chronic: Recommended physiotherapy/behavioural therapy/multidisciplinary programme if non-response to first-line care |
Germany (2007) [15] | Acute LBP: stimulate daily activities, explain moving is not dangerous, Chronic LBP more intense psychotherapy indicated in case of psychological co-morbidity | Acute and Chronic LBP: (1) paracetamol, (2) NSAIDs (oral or topical), (3) Muscle relaxants (in cases with muscle spasms, (4) Opioids | Acute LBP: exercise therapy not effective Subacute and Chronic LBP: Exercise therapy well supported by evidence | Acute LBP: Optional within the first 4–6 weeks Chronic LBP: option if shortlasting | Maximum of 2 days bedrest | Immediate surgery indicated for cauda equina syndrome Optional referral for surgery: therapy resistant (>6 weeks) + signs of nerve root compression Surgery may be an option if after 2 years conservative treatment, including biopsychosocial treatment programme was unsuccessful |
Italy (2006) [16] | Give information and reassurance about possible cause, provoking factors, risk factors, and structural or postural alterations, reassurance about good prognosis, keep active and if possible, stay at work | Paracetamol as preferred drug NSAIDs recommended Muscle relaxants no additional effect Steroids not recommended in acute LBP, but can be useful for a short time in sciatica Tramadol and adding light opioid to paracetamol may be useful for sciatica | Acute LBP No specific exercises recommended Chronic LBP Individual specific exercises | After 2–3 weeks and before 6 weeks, prescribed by physicians, done by trained therapists Chronic LBP: Consider for pain relief | Discouraged for acute LBP, except 2–4 days for major sciatica Contraindicated for sciatica No recommended in Chronic LBP | Radiculopathy and suspicion of specific causes Multidisciplinary psycho-social intervention for patients at high risk of chronicity and chronic pain |
New Zealand (2004) [17] | Advise to stay active and working, or early return to work, reassurance Education pamphlets not helpful | Paracetamol and NSAIDs recommended Opiates or diazepam may be harmful | Specific back exercises not helpful | First 4–6 weeks only May provide short-term symptom control | Bed rest >2 days harmful | Suspicion of specific causes (red flags), cauda equina syndrome, or after 4–8 weeks |
Norway (2007) [18] | Stay active, return to normal activity including work asap, | (1) Paracetamol (2) NSAID (3) Paracetamol + opioid or Tramadol (4) Antidepressants in cases with depression | No specific exercises in the first weeks In chronic LBP exercises are recommended | After 1-2 weeks for pain reduction and improvement of function (for small to moderate effects) | Not recommended In rare cases, not longer than 2–3 days | Referral within primary care for cognitive behavioural treatment is optional Referral for surgical intervention after 2 years’ LBP |
Spain (2005) [19] | Reassurance and advice to stay active | Paracetamol every 6 h, can also be associated with opioids and NSAID although the last one should not be prescribed for longer than 3 months Opioids are indicated for patients with high levels of pain who did not improve with usual care | Exercise as far as pain allows including work activities. As there is no evidence for any specific type of exercise, choose the one that patients prefer. Not indicated for patients with pain for less than 6 weeks | Not recommended | Discouraged unless patient can not adopt another posture. Then bed rest for the maximum of 48 h | Refer patient in case of red flags |
The Netherlands (2003) [20] | Acute and Chronic LBP: Stay active as much as possible (despite the pain), increase activity level on a time contingent basis | Acute LBP: (1) Paracetamol (2) NSAIDs, (3) muscle relaxants or weak opioids or combinations with paracetamol/NSAIDS as last option due to side effects Chronic LBP: Only for short periods: (1) Paracetamol, (2) Tramadol or NSAID, (3) Opioids | Acute LBP: Consider after 4–6 weeks for patients who do not improve their functioning Chronic LBP: Recommended are time-contingent, varying and supervised exercises focused at improving function | Acute and Chronic LBP: Option as part of an activating strategy for patients who do not show a favourable course | Acute and Chronic LBP: Avoid bedrest | Chronic LBP: Refer patients with severe disability who do not respond to recommended conservative treatments for multidisciplinary treatment focused on functional recovery |
United Kingdom (2008) [21] | Provide information and advice to foster positive attitude and realistic expectations—back pain is not serious, temporary, tends to recur, physical not psychological, mechanical. Stay active as possible | Regular paracetamol (preferred) or NSAID as first line care. For additional analgesia combine paracetamol and NSAID or add a weak opioid (codeine or tramadol). For non-responders consider benzodiazepine, tricyclic antidepressant Not recommended: Topical NSAIDs, antiepileptic drugs (other than gabapentin), herbal remedies | Advise patient to stay as active as possible. No specific recommendations regarding exercise | No recommendations included | Acute LBP: Rest in bed is less effective than staying active | If progressive neurological deficit If pain or disability remain problematic for more than a week or two consider referral for physio/physical therapy If pain/disability continue to be a problem despite pharmacotherapy and physical therapy consider referral to multidisciplinary back pain service or chronic pain clinic |
United States (2007) [22] | Provide information on prognosis, staying active, self management Self-care education books recommended | Paracetamol, NSAIDs recommended as first-line drugs For acute (<4 weeks)—muscle relaxants, benzodiazepines, tramadol, opioids For subacute or chronic (>4 weeks)—antidepressants, benzodiazepines, tramadol, opioids | Not effective for acute LBP Recommended for subacute or chronic LBP | For acute LBP if not improving | Even if required for severe symptoms, patients should be encouraged to return to normal activities as soon as possible | For interdisciplinary intervention if chronic If suspicion of significant nerve root impingement or spinal stenosis |
Most apparent changes since 2001
| ||||||
The advice to stay active remains similar. Now some guidelines (european, NZ, Canada, Italy, Norway) explicitly mention continuation/early RTW | No change regarding recommendation of paracetamol and NSAIDs as first-line treatments and recommendation regarding muscle relaxants Now more often explicit recommendations (for or against) anti-depressants, opioids, benzodiazepines and combinations of medications | The advice that exercise therapy is not useful in acute LBP has not changed Now more explicit recommendations in favour of exercise therapy in subacute and chronic LBP | Recommendations for spinal manipulation, the timing of application and target group continue to vary | The recommendation against bedrest is fairly consistent between 2001 and now | The recommendations for referral appear more explicit regarding : (1) immediate referral (cauda equina syndrome), (2) medical specialist in case of red flags, (3) referral within primary care (physiotherapy/cognitive behavioural therapy, (4) multidisciplinary treatments and (5) consider surgery if 2 years of recommended conservative care has failed |
Summary of Common Recommendations for Treatment of Low back pain |
Acute or Subacute Pain
|
* Reassure patients (favourable prognosis). |
* Advise to stay active. |
* Prescribe medication if necessary (preferably time-contingent): first line is paracetamol; second line is nonsteroidal antiinflammatory drugs, consider muscle relaxants, opioids or antidepressant and anticonvulsive medication (as co-medication for pain relief). |
* Discourage bed rest. |
* Do not advise a supervised exercise programme. |
Chronic Pain
|
* Discourage use of modalities (such as ultrasound, electrotherapy) |
* Short-term use of medication/manipulation |
* Supervised exercise therapy |
* Cognitive behavioural therapy |
* Multidisciplinary treatment |
Setting
Country | Target group | Guideline committee | Evidence base | Consensus | Presentation/Implementation |
---|---|---|---|---|---|
Australia (2003) | Primary and secondary care | Multidisciplinary: Osteopathic, Rheumatology, Physiotherapy, Chiropractic, GP, Epidemiology, consumer representative (n = 9) | Update of the previous Australian guideline using the AGREE. Comprehensive literature search (up to 2002) pubmed, cinhal embase and Cochrane for clinical evidence. All recommendations are linked to evidence level | Use of consensus method not clear | Free online version, Included in book ‘evidence-based management of acute musculoskeletal pain: a guide for clinicians’ |
Austria (2007) | Primary and secondary care (all who are involved with diagnosis and treatment of LBP) | Multidisciplinary (psychiatry, orthopaedics, general practice, physiotherapy, radiology, psychology, neurology, rehabilitation, osteology?, pain medicine, ergotherapy, rheumatology, neurosurgery (n = 17) | Based on European guidelines (2004) + updated evidence regarding massage and acupuncture. Grading of evidence was used using an explicit weighting system No direct linking between recommendations and underlying evidence | Draft guideline presented and approved at two consensus meetings | Published in national journal in Austria |
Canada (2007) | Primary care | Multidisciplinary with primary health care professionals | Based on an extensive literature review of the best available evidence and assessment of knowledge in all areas of back pain management it also combines with participant’s clinical experience | Use of consensus method not clear | Available on website |
Europe (2006) (Acute) | Primary care | Multidisciplinary: experts in the field of low back pain research in primary care (n = 14) | Literature search from 1966 to 2003 on the Cochrane Library, Medline, Embase for searches of Cochrane reviews (and on other systematic reviews if a Cochrane review was not available), additional trials published after the Cochrane reviews, and existing national guidelines. Strength of evidence was assessed based on the original ratings of the AHCPR Guidelines (1994) and levels of evidence recommended in the method guidelines of the Cochrane Back Review group | Use of consensus method not clear; “use of group discussions” | Publication in a journal with planned update after 3 years |
Europe (2006) (Chronic) | Primary care and secondary care | Multidisciplinary: experts in the field of low back pain research in primary care (n = 11) | Literature search up to 2002. Based on systematic review of systematic reviews and randomised clinical trials on CLBP. Systematic reviews were rated using the Oxman & Guyatt index and RCTs rated using the van Tulder et al. 1997 criteria | Use of consensus method not clear. Use of group discussions, no formal grading scheme used | Published on a website and in a journal. Professional associations will disseminate and implement these guidelines |
Finland (2008) | Primary and secondary care | Physiatrist, radiologist, general practitioner and occupational health physician, neurosurgeon, physiotherapist, orthopaedic surgeon (n = 8) | Based on explicit weighing of evidence. Important decision points are backed up by level of evidence statements | Consensus on evidence synthesis and text during Committee meetings | A summary of the guidelines has been published in the Finnish journal (Duodecim 2008). The whole text is published on the website of the Finnish Current Care Guidelines |
France (2000) | Acute and Chronic: Non stated | Acute LBP: Multidisciplinary; Rheumatologist (2), Physiotherapist, Psychiatrist, Neuro radiologist, GP (2), Radiologist, Occupational Medicine Specialist, Orthopaedic surgeon, Specialist in Physical Medicine and Rehabilitation (11). Chronic LBP: Multidisciplinary;Rheumatologist (2), Physiotherapist, Psychiatrist, Neuro-radiologist, GP (4), Radiologist, Occupational Medicine Specialist, Orthopaedic surgeon, Specialist in Physical Medicine and Rehabilitation (13) | Acute & Chronic: Review of the literature—no further detail provided | Acute & Chronic: Use of consensus in the absence of evidence | Acute & Chronic: Guidelines commissioned from the Agence Nationale d’Accreditation d’Evaluation en Sante by CNAMTS, the French national health insurance fund. Reports published in English and French and available online |
Germany (2007) | Primary and secondary care | Multidisciplinary: Drug committee of the German medical association, including general practice, pharmacology (n = ?) | Based on European guidelines (2006). Recommendations are all supported with references | Draft guidelines are presented and discussed with various medical disciplines | Complete guidelines and summaries for practitioners are available on a website |
Italy (2006) | Primary and secondary care, particularly | Multidisciplinary: general medicine, neurology, neurosurgery, orthopaedics, rheumatology, physical medicine and rehabilitation, occupational medicine, physiotherapy, epidemiology (n = 14) | Literature search of international guidelines, systematic reviews in Medline and the Cochrane Library, weighing of evidence using a rating system based on strength of the studies | Recommendations based on level of evidence, practicality issues and own experience | Journal publication, complete version available on website, presentation at national conferences of relevant professional groups, local workshop and training days, outreach visits |
New Zealand (2004) | Primary care | Multidisciplinary: consumer representative, pain medicine, occupation medicine, chiropractor, psychologist, osteopath, occupational medicine, physiotherapy, rheumatology, GP, musculoskeletal medicine (n = 16) | Comprehensive literature search; weighing of evidence using a rating system based on strength of the studies; for all recommendations, at least moderate evidence available | Contributed by relevant professional groups | Publication of report, incorporating the guide to assessing yellow flags, endorsed by NZ Guidelines Group and relevant professional groups |
Norway (2007) | Primary and secondary care | Multidisciplinary: occupational, rehabilitation, physiotherapy, chiropractic, manual therapy, neurology, orthopaedics, radiology, general practice (n = 11) | Comprehensive search of the literature (Cochrane, Medline, Embase), quality assessment, weighing of evidence attached to the recommendations | Recommendations based on evidence and discussion in the group | Publication in Norwegian report, including a summary and a patient brochure |
Spain (2005) | Health care professionals that treat low back pain | Spanish members of the COST B13 and a multidisciplinary team composed of GP, rural medicine, rheumatology, rehabilitation, neurosurgery, orthopaedics, radiology, work medicine, public health, anxiety and stress, physical therapist, Evidence-based experts and anaesthesiologists | Adapted from the European guidelines with addition of new evidence and evidence in Spanish (systematically reviewed). Also recommendations were performed using the AGREE tool to better define the recommendation using a standardised methodology. Studies were sent to the Web de la Espalda for analysis of methodological quality | All members of the group approved the final version but consensus method is not clearly described | Summary spreadsheet with recommendations, an algorithm for diagnosis and treatment and an extensive report published online. Frequent updates are predicted |
The Netherlands (2003) | Primary and secondary care | Multidisciplinary; general practice, orthopaedics, radiology, neurosurgery, rehabilitation, physiotherapy, psychology, patient representation, chiropractic, manual therapy, neurology, rheumatology, exercise therapy (Cesar, Mensendieck), anaesthesiology, occupational (n = 31) | All recommendations are supported as possible by scientific evidence up to Jan 2001. All evidence was weighted using an explicit weighting system. All recommendations are presented with their level of evidence | Recommendations were based on the scientific evidence + considerations such as patient preferences, costs, availability of health services, and/or organisational aspects | Published on website, distributed among hospitals and medical societies, summary published in the Dutch Medical Journal, presented in Finnish journal (Duodecim 1999) |
United Kingdom (2008) | Healthcare professionals working within the NHS in England providing primary health care | Unspecified multidisciplinary team | Update of previous guidelines (PRODIGY, RCGP): incorporates new evidence from electronic database search of guidelines, systematic reviews and randomised controlled trials on primary care management of low back pain | Not reported | Part of the NHS Clinical Knowledge Summaries (CKS), a freely available, online source of evidence-based information and practical ‘know how’ about the common conditions managed in primary and first-contact care CKS provides quick answers to real-life clinical questions that arise in the consultation, linking to detailed answers that clearly outline the evidence on which they are based |
United States (2007) | Primary care | Multidisciplinary 7 authors for a large multidisciplinary committee Clinical Efficacy Assessment Subcommittee of the ACP | Comprehensive literature search of English-language articles weighing of evidence using a rating system; for all recommendations, at least fair evidence available | Evidence-based and consensus-based | Journal publication, audio summary and patient summary Valid for 5 years after publication or until next update |
Most apparent change, if any, since 2001
| |||||
The current guidelines appear more often focused on primary care as well as secondary care compared to 2001 when the focus was more exclusively on primary care | The guideline committees in 2001 as well as currently consist of a multidisciplinary panel (which of course is not surprisingly since multidisciplinary guidelines were included in the current and the 2001 review) | More guidelines now explicitly state that they are based on a previous guideline (i.e. the European guidelines), furthermore almost all guidelines now explicitly state that they applied a weighting system to the evidence. In 2001 a weighting system was less often used | In 2001 and at present consensus methods were used, Usually group discussion take place, but the exact method is often not clear. This has not changed since 2001 | In most cases the guideline is published and disseminated without an active implementation programme. This has not changed since 2001 The main change is that currently almost all guidelines are available on a website whereas in 2001 more often paper versions were distributed |
Guideline committee
Evidence-based review
Presentation and implementation
Discussion
Use of available evidence
Differences in recommendations
Few changes in management recommendations over time
Implementation
Future developments in research and guideline development
Recommendations for the development of future guidelines in the field of low back pain |
1. Make use of available evidence-based reviews and previous clinical guidelines. |
2. Include relevant non-English publications (if available). |
3. Determine in advance the intended target groups (health care professions, patient population, and policy makers). |
4. Be aware that the makeup of the guideline committee may have a direct impact on the content of the recommendations. |
5. Specify exactly which recommendations are evidence-based and supply the correct references to each of these recommendations. |
6. Specify exactly which recommendations are consensus-based and explain the process. |
7. Determine in advance the implementation strategy, and set a time frame for future updates of the guideline. |