Pain Clinical Practice Guidelines Research Articles

Low-value interventions to deimplement: A secondary analysis of a systematic review of low back pain clinical practice guidelines.

To perform a secondary review of low back pain (LBP) clinical practice guidelines (CPG) identified in a recently conducted systematic review and to synthesize and summarize low-value recommendations as practices that may be candidates for deimplementation. LBP (subacute or chronic) CPGs in English (symptom based, created by a governmental or professional society, published between January 1990 and May 2020) were previously identified using MEDLINE, EMBASE, CINAHL, Ortho Guidelines, CPG Infobase, Emergency Care Research Institute, Guidelines International Network, National Institute of Health and Care Excellence, and Scottish Intercollegiate Guideline Network. Twenty-one CPGs were reviewed from a systematic review (previously published). Full-text review of all 21 CPGs was conducted, and three recommendation categories indicative of low value (recommend strongly against, recommend weakly against, inconclusive/insufficient evidence) were identified using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) language and approach. One hundred thirty-five low-value recommendations were identified and classified under eight intervention categories: orthotics/support, traction, physical modalities, pharmacological interventions, injections, surgery, bed rest, and miscellaneous. Traction, transcutaneous electrical nerve stimulation (TENS), therapeutic ultrasound (TUS), and selective serotonin reuptake inhibitors (SSRI) had the most CPGs recommend strongly against their usage. Opioids were recommended strongly against by four CPGs. No significant difference (p > .05) was found between CPG quality and a specific deimplementation recommendation or between CPG quality and the number of strongly against, weakly against, and inconclusive/insufficient evidence recommendations. Clinicians managing patients with chronic LBP should consider deimplementing these low-value interventions (traction, TENS, TUS, and SSRI).

2021 KSCCM clinical practice guidelines for pain, agitation, delirium, immobility, and sleep disturbance in the intensive care unit.

2021 KSCCM clinical practice guidelines for pain, agitation, delirium, immobility, and sleep disturbance in the intensive care unit.

Neck pain clinical practice guidelines: a systematic review of the quality and quantity of complementary and alternative medicine recommendations.

Individuals with neck pain frequently turn to complementary and alternative medicine (CAM) to seek relief. However, conventional healthcare providers often lack adequate CAM therapy knowledge to deliver informed recommendations to patients. The purpose of this study was to identify mention of CAM in neck pain clinical practice guidelines (CPG) and assess the quality of CAM recommendations using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. MEDLINE, EMBASE and CINAHL were systematically searched from 2009 to 2020 in addition to the Guidelines International Network and National Center for Complementary and Integrative Health websites. Eligible CPGs providing CAM recommendations were assessed twicewith the AGREE II instrument, onceto assess the overall CPG and then onceto assess the CAM sections specifically. From 643 unique search results, 15 CPGs on the treatment and/or management of neck pain were identified, and 8 made recommendations on CAM therapy. Regarding scaled domain percentages, the overall CPG scored higher than the CAM section for 5 of 6 domains (overall, CAM): (1) scope and purpose (93.4%, 93.1%), (2) stakeholder involvement (81.6%, 81.9%), (3) rigour of development (70.8%, 66.3%), (4) clarity of presentation (64.9%, 60.8%), (5) applicability (39.3%, 33.6%), and (6) editorial independence (47.9%, 45.3%). Most neck pain CPGs made CAM recommendations. The quality of CAM recommendations is lower than overall recommendations across all domains with the exception of stakeholder involvement. This disparity highlights the need for CAM recommendations quality improvement. Although many patients with neck pain seek CAM therapies, few CPGs are available for healthcare providers and patients.

Quality Assessment of Cancer Pain Clinical Practice Guidelines.

IntroductionSeveral clinical practice guidelines (CPGs) for cancer pain have been published; however, the quality of these guidelines has not been evaluated so far. The purpose of this study was to evaluate the quality of CPGs for cancer pain and identify gaps limiting knowledge.MethodsWe systematically searched seven databases and 12 websites from their inception to July 20, 2021, to include CPGs related to cancer pain. We used the validated Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist to assess the methodology and reporting quality of eligible CPGs. The overall agreement among reviewers with the intraclass correlation coefficient (ICC) was calculated. The development methods of CPGs, strength of recommendations, and levels of evidence were determined.ResultsEighteen CPGs published from 1996 to 2021 were included. The overall consistency of the reviewers in each domain was acceptable (ICC from 0.76 to 0.95). According to the AGREE II assessment, only four CPGs were determined to be recommended without modifications. For reporting quality, the average reporting rates for all seven domains of CPGs was 57.46%, with the highest domain in domain 3 (evidence, 68.89%) and the lowest domain in domain 5 (review and quality assurance, 33.3%).ConclusionThe methodological quality of cancer pain CPGs fluctuated widely, and the complete reporting rate in some areas is very low. Researchers need to make greater efforts to provide high-quality guidelines in this field to clinical decision-making.

Quality of clinical practice guidelines on interventional management of low back pain: A systematic review.

To appraise the quality of low back pain (LBP) clinical practice guidelines (CPG) that include interventional management recommendations and to associate their quality with characteristics including publication year and creating organization. TYPE: Systematic Review. LBP (subacute or chronic) CPGs in English (symptom based, governmental or professional society created, January 1990-May 2020) were found using MEDLINE, EMBASE, CINAHL, Ortho Guidelines, CPG Infobase, ECRI, Guidelines International Network, NICE, and SIGN. In this third order systematic review, search results were deduplicated, title and abstract screened by two independent reviewers, and full texts reviewed by four reviewers. Discrepancies were resolved by a third reviewer. Resulted CPGs were appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool by four appraisers each. Association of their quality with creating organization, geographical region, and year of creation was calculated. Seven hundred fourteen screened documents resulted in 21 final CPGs. On appraisal, average overall CPG quality was 5.2 (range 2.5-6.75). Domain 5 (applicability) had the lowest average (44%) and domain 4 (clarity of presentation) had the highest average score (82%). For overall recommendation, 16 received "yes" or "yes with modifications," six received unanimous "yes" and two unanimous "no" votes. The interrater agreement of domain scoring was excellent (0.8-1.0; p < .001). There was no association found between quality of CPG and (1) year of publication (R2 =0.0006), (2) whether the CPG was updated or new (p=.17), and (3) region of publication (p=.37). The majority of the 21 CPGs identified in this systematic review were of high quality, but overall quality and recommendation ratings were variable. The quality of appraised CPGs showed no association with their characteristics. Some domains such as "applicability" scored uniformly lower, revealing opportunity for improvement in future CPG development. LBP CPGs should be scrutinized before adopting their recommendations.

Intervention usage for the management of low back pain in a chiropractic teaching clinic

BackgroundDespite numerous low back pain (LBP) clinical practice guidelines, published studies suggest guideline nonconcordant care is still offered. However, there is limited literature evaluating the degree to which chiropractors, particularly students, follow clinical practice guidelines when managing LBP. The aim of this study was to evaluate the frequency of use of specific interventions for LBP by students at a chiropractic teaching clinic, mapping recommended, not recommend, and without recommendation interventions based on two clinical practice guidelines.MethodsThis was a retrospective chart review of patients presenting to the Canadian Memorial Chiropractic College teaching clinic with a new complaint of LBP from January to July 2019. Interventions provided under treatment plans for each patient were extracted. Interventions were classified as recommended, not recommended, or without recommendation according to two guidelines, the NICE and OPTIMa LBP guideline.Results1000 patient files were identified with 377 files meeting the inclusion criteria. The most frequent interventions provided to patients were manipulation/mobilization (99%) and soft tissue therapy (91%). Exercise, localized percussion, and advice and/or education were included in just under half of the treatment plans. Patient files contained similar amounts of recommended (70%) and not recommended (80%) interventions according to the NICE guideline classification, with half the treatment plans including an intervention without recommendation. Under the OPTIMa acute guideline, patient files contained similar amounts of recommended and not recommended care, while more recommended care was provided than not recommended under the OPTIMa chronic guideline.ConclusionsDespite chiropractic interns providing guideline concordant care for the majority of LBP patients, interventions classified as not recommended and without recommendation are still frequently offered. This study provides a starting point to understand the treatment interventions provided by chiropractic interns. Further research should be conducted to improve our understanding of the use of LBP guideline recommended care in the chiropractic profession.Trial registrationOpen Science Framework # g74e8.

Cervical disc degeneration: important considerations for the manual therapist

ABSTRACT Cervical disc degeneration (CDD) is a progressive, age-related occurrence that is frequently associated with neck pain and radiculopathy. Consistent with the majority of published clinical practice guidelines (CPG) for neck pain, the 2017 American Physical Therapy Association Neck Pain CPG recommends cervical manipulation as an intervention to address acute, subacute, and chronic symptoms in the ‘Neck Pain With Mobility Deficits’ category as well for individuals with ‘Chronic Neck Pain With Radiating Pain’. While CPGs are evidence-informed statements intended to help optimize care while considering the relative risks and benefits, these guidelines generally do not discuss the mechanical consequences of underlying cervical pathology nor do they recommend specific manipulation techniques, with selection left to the practitioner’s discretion. From a biomechanical perspective, disc degeneration represents the loss of structural integrity/failure of the intervertebral disc. The sequelae of CDD include posterior neck pain, segmental hypermobility/instability, radicular symptoms, myelopathic disturbance, and potential vascular compromise. In this narrative review, we consider the mechanical, neurological, and vascular consequences of CDD, including information on the anatomy of the cervical disc and the mechanics of discogenic instability, the anatomic and mechanical basis of radiculitis, radiculopathy, changes to the intervertebral foramen, the importance of Modic changes, and the effect of spondylotic hypertrophy on the central spinal canal, spinal cord, and vertebral artery. The pathoanatomical and biomechanical consequences of CDD are discussed, along with suggestions which may enhance patient safety.

Identifying clinical practice guidelines for symptom control in pediatric oncology.

Children with cancer commonly experience distressing symptoms such as pain, fatigue and nausea. Improvements in patient outcomes have been associated with implementation of clinical practice guideline-consistent care across several domains. The objective of this study was to develop a process to identify symptom management clinical practice guidelines (CPGs) applicable to children and adolescents receiving cancer treatments. We focused on identifying CPGs to manage 15 symptoms. The process defined three Tiers of CPGs based upon applicability to pediatric cancer patients and ease of identification: Tier 1: endorsed by the Children's Oncology Group; Tier 2: housed in the Emergency Care Research Institute repository, or developed by the American Society of Clinical Oncology or National Institute for Health and Care Excellence; and Tier 3: identified by systematic review. We first searched for CPGs published 2015-2020 and identified Tiers 1 or 2 CPGs. If unavailable or scope was too narrow, we proceeded to Tier 3. If CPGs were not identified, we repeated these steps for CPGs published 2010-2014. There were six Tier 1 and 13 Tier 2 CPGs published 2015-2020 across the 15 symptoms. Four symptoms required progression to Tier 3 because CPGs were absent (anger) or because scope was too narrow (pain, anorexia/excessive hunger and diarrhea). The systematic review identified three CPGs for pain and none for the other three symptoms. In total, CPGs were identified for 14 of 15 symptoms. None were identified for anger. We created a process to identify supportive care CPGs for pediatric cancer symptom management and were able to identify CPGs that addressed 14 of 15 symptoms. Future work should focus on evaluating implementation techniques for these CPGs and determining the impact of these CPGs on provider and patient outcomes.

Safe Opioid Prescribing Project

The 2017 Department of Veteran Affairs and Department of Defense (VA/DoD) Opioid Therapy for Chronic Pain Clinical Practice Guidelines (CPGs), represented a paradigm shift in opioid prescribing. The guidelines highlighted the risk of adverse effects, including addiction, overdose, and effects on almost every organ system of the body. The CPGs discouraged against initiation of opioids for chronic use, and advised against exceeding 90 morphine equivalent daily dose (MEDD) for those already on chronic opioid therapy. Research question: will providers reduce their opioid prescribing, if they know that their opioid prescribing exceeds the institutions norms? Quantitative data analysis. The Defense Health Agency (DHA) tracks all military treatment facility providers on a report called the Controlled Substance Prescriber Profile (CSPP) report. A pharmacist used the quarterly CSPP report to identify the top 20 prescribers from Walter Reed, by MED. Letters signed by the Chief of Pharmacy were sent to the prescribers informing them of their MED, along with the institution's average MED. The intervention was repeated quarterly over 2 years. A paired t-test was performed on the quarterly MPA results to see if any changes occurred after the intervention. The paired t-test between 2017 and 2018 resulted in a tStat of 0.897, a p value of 0.217, and a tCritical of 2.353, suggesting there was no difference between the two populations. Comparatively, 2017 compared to 2019 resulted in in a tStat of 4.684, a p value of 0.009, and a tCritical of 2.353; the results of 2017 verses 2019 demonstrate a significant difference. When providers are aware that their prescribing exceeds the institution's norm, they realign their prescribing habits to that of their institution. This study could also be replicated through the prescription drug monitoring program for a group practice, or within a health system.

Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines.

Background and objectiveThis systematic review synthesized evidence from European neck and low back pain (NLBP) clinical practice guidelines (CPGs) to identify recommended treatment options for use across Europe.Databases and Data TreatmentComprehensive searches of thirteen databases were conducted, from 1st January 2013 to 4th May 2020 to identify up‐to‐date evidence‐based European CPGs for primary care management of NLBP, issued by professional bodies/organizations. Data extracted included; aim and target population, methods for development and implementation and treatment recommendations. The AGREE II checklist was used to critically appraise guidelines. Criteria were devised to summarize and synthesize the direction and strength of recommendations across guidelines.ResultsSeventeen CPGs (11 low back; 5 neck; 1 both) from eight European countries were identified, of which seven were high quality. For neck pain, there were consistent weak or moderate strength recommendations for: reassurance, advice and education, manual therapy, referral for exercise therapy/programme, oral analgesics and topical medications, plus psychological therapies or multidisciplinary treatment for specific subgroups. Notable recommendation differences between back and neck pain included, i) analgesics for neck pain (not for back pain); ii) options for back pain‐specific subgroups—work‐based interventions, return to work advice/programmes and surgical interventions (but not for neck pain) and iii) a greater strength of recommendations (generally moderate or strong) for back pain than those for neck pain.ConclusionsThis review of European CPGs identified a range of mainly non‐pharmacological recommended treatment options for NLBP that have broad consensus for use across Europe.SignificanceConsensus regarding evidence‐based treatment recommendations for patients with neck and low back pain (NLBP) from recent European clinical practice guidelines identifies a wide range of predominantly non‐pharmacological treatment options. This includes options potentially applicable to all patients with NLBP and those applicable to only specific patient subgroups. Future work within our Back‐UP research team will transfer these evidence‐based treatment options to an accessible clinician decision support tool for first contact clinicians.

The impact of low back pain systematic reviews and clinical practice guidelines measured by the Altmetric score: Cross-Sectional study

BackgroundAlthough Altmetric has been widely used by researchers to monitor the audience of their articles, there are no studies that have analysed factors associated with Altmetric score for systematic reviews and clinical practice guidelines. Objectives1) To analyse factors that could be associated with Altmetric scores for low back pain systematic reviews and clinical practice guidelines. 2) To describe the characteristics of these articles and their Altmetric scores. MethodsWe searched for all low back pain systematic reviews and guidelines indexed on the Physiotherapy Evidence Database published between 2015 and 2017. We extracted data related to the published paper, the publishing journal, and Altmetric scores. ResultsA total of 66 systematic reviews and 5 guidelines were included. The variable impact factor (independent variable) was associated with Altmetric mentioned score (dependent variable) with a β coefficient of 15.4 (95% CI: 0.97, 29.7) ajusted to all remaining variables. The variable number of citations normalized by year of publication (independent variable) was associated with Altmetric reader score (dependent variable) with a β coefficient of 6.4 (95% CI: 4.03, 8.72) ajusted to all remaining variables. We also found that the majority of the systematic reviews and guidelines were published in English, had a descriptive title, were published as open access, included multicenter studies, and had media release generated by the publishing journal. ConclusionMetrics related to the number of citations, such as the impact factor are associated with Altmetric scores.

Assessment of the awareness, adherence, and barriers to low back pain clinical practice guidelines by practicing physiotherapists in a low‐resourced country

Many clinical practice guidelines (CPGs) for low back pain (LBP) management have been developed, but adherence to CPGs seems to be challenging as developing them in the first place. This cross-sectional survey study was carried out to determine the awareness level, the level of adherence, and barriers to adherence to CPGs of LBP among physiotherapists in Nigeria. A total of 189 participants were recruited for this study using the convenience sampling technique. The data were collected using researcher-designed questionnaires, the data were analysed using SPSS Version 20, and barriers to adherence to CPGs of LBP was analysed using simple thematic analysis. Descriptive statistics, frequency, and percentage were used to summarize the data, whereas inferential statistic of chi square and Fisher's exact were used to test the association between sociodemographic variables and adherence. The results obtained showed that only a small percentage (27.50%) of the respondents adhered to LBP CPGs, whereas higher percentage (78.80%) was aware to the LBP CPGs. There were no significant associations between age (p = .90, χ2 = 0.72), certification courses (p = .476, χ2 = 0.508), place of practice (p = .380, χ2 = 0.845), and adherence to CPGs of LBP, respectively. However, there was a statistical significant association between specialization (p = .009, χ2 = 16.725), political zone (p = .007, χ2 = 15.243), awareness (p = .003, χ2 = 8.957), and adherence to CPGs of LBP, respectively. Small proportions of the respondents adhered to the LBP CPGs, whereas higher population were aware of the LBP CPGs, and some of the characteristics of the physiotherapists influence adherence to LBP CPGs.

Methodologic Innovation in Creating Clinical Practice Guidelines: Insights From the 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption Guideline Effort.

To describe novel guideline development strategies created and implemented as part of the Society of Critical Care Medicine's 2018 clinical practice guidelines for pain, agitation (sedation), delirium, immobility (rehabilitation/mobility), and sleep (disruption) in critically ill adults. We involved critical illness survivors from start to finish, used and expanded upon Grading of Recommendations, Assessment, Development and Evaluation methodology for making recommendations, identified evidence gaps, and developed communication strategies to mitigate challenges. Thirty-two experts from five countries, across five topic-specific sections; four methodologists, two medical librarians, four critical illness survivors, and two Society of Critical Care Medicine support staff. Unique approaches included the following: 1) critical illness survivor involvement to help ensure patient-centered questions and recommendations; 2) qualitative and semiquantitative approaches for developing descriptive statements; 3) operationalizing a three-step approach to generating final recommendations; and 4) systematic identification of evidence gaps. Critical illness survivors contributed to prioritizing topics, questions, and outcomes, evidence interpretation, recommendation formulation, and article review to ensure that their values and preferences were considered in the guidelines. Qualitative and semiquantitative approaches supported formulating descriptive statements using comprehensive literature reviews, summaries, and large-group discussion. Experts (including the methodologists and guideline chairs) developed and refined guideline recommendations through monthly topic-specific section conference calls. Recommendations were precirculated to all members, presented to, and vetted by, most members at a live meeting. Final electronic voting provided links to all forest plots, evidence summaries, and "evidence to decision" frameworks. Written comments during voting captured dissenting views and were integrated into evidence to decision frameworks and the guideline article. Evidence gaps, reflecting clinical uncertainty in the literature, were identified during the evidence to decision process, live meeting, and voting and formally incorporated into all written recommendation rationales. Frequent scheduled "check-ins" mitigated communication gaps. Our multifaceted, interdisciplinary approach and novel methodologic strategies can help inform the development of future critical care clinical practice guidelines.

The impact of choosing words carefully: an online investigation into imaging reporting strategies and best practice care for low back pain.

BackgroundLow back pain clinical practice guidelines consistently recommend against the routine ordering of spinal imaging; however, imaging is frequently requested in primary care, without evidence of benefit. Imaging reports frequently identify degenerative features which are likely to be interpreted as ‘abnormal’, despite their high prevalence in symptom-free individuals. The aim of this study was to investigate whether post-imaging back-related perceptions are influenced by providing prior information about normal findings, and to compare the effect of receiving imaging results with best practice care (without imaging). The impact of introducing novel, ‘enhanced’ reporting strategies was also explored.MethodsThis study was a simulated-patient, randomised, multiple-arm experiment. Patient scenarios were presented to volunteer healthy adult participants via an online survey. In the scenarios, ‘virtual’ patients with low back pain were randomised to one of three groups. Group 1 received imaging and was pre-informed about normal findings. Group 2 received imaging (without pre-information). Group 3 received best practice care: quality information without imaging. Group 1 was further divided to receive either a standard report, or an ‘enhanced’ report (containing altered terminology and epidemiological information). The primary outcome was back-related perceptions (BRP), a composite score derived from three numeric rating scale scores exploring perceptions of spinal condition, recovery concerns and planned activity. The secondary outcomes were satisfaction and kinesiophobia.ResultsFull data were available from 660 participants (68% female). Analysis of covariance revealed a significant effect of group after controlling for baseline BRP scores n}{}(F(2,74)=10.4,plt 0.001,{eta }_{p}^{2}=.04). Pairwise comparisons indicated that receiving best practice care resulted in more positive BRPs than receiving imaging results, and receiving prior information about normal findings had no impact. Enhanced reporting strategies also positively impacted BRPs n}{}(F(1,275)=13.06,plt 0.001,{eta }_{p}^{2}=.05). Significant relationships between group allocation and both satisfaction n}{}(F(2,553)=7.5,p=0.001,{eta }_{p}^{2}=.03) and kinaesiophobia n}{}(F(2,553)=3.0,p=0.050,{eta }_{p}^{2}=.01) were found, with statistically significant pairwise comparisions again in favour of best-practice care.ConclusionIntervention strategies such as enhanced reporting methods and the provision of quality information (without imaging) have the potential to improve the outcome of patients with recent-onset LBP and should be further considered by primary care providers.

Adherence to Back Pain Clinical Practice Guidelines by Brazilian Physical Therapists: A Cross-sectional Study.

This was a cross-sectional observational study. (i) to investigate whether Brazilian physical therapists make clinical decisions for patients with low back pain based upon clinical practice guidelines and (ii) to determine whether the physical therapists are able to recognize differential diagnoses of low back pain associated with red or yellow flags. Early adherence to clinical practice guidelines may accelerate recovery and reduce the costs associated with low back pain. It is unknown whether Brazilian physical therapists follow clinical practice guidelines to make their clinical decisions in the treatment of patients with low back pain. The sample consisted of physical therapists from two Brazilian physical therapy associations. The data were collected via electronic survey and face-to-face interviews. The survey was composed of six hypothetical clinical cases of low back pain, which served as a basis to evaluate clinical decisions and adherence to clinical practice guidelines for low back pain. The study participants had 27 possible answers for each clinical case and could choose up to five answers. The results were analyzed in three ways: full adherence, partial adherence, or no adherence to the recommendations from clinical practice guidelines. A total of 530 physical therapists were invited and 189 participated in the study (response rate = 35.6%). Full adherence to the guidelines was low for all six cases (rates ranging from 5%-24%). Partial adherence to the guidelines was higher when compared with full adherence (rates ranging from 32%-75%). The participants were more likely to identify differential diagnoses associated with yellow flags than with red flags. Brazilian physical therapists are not using the best available evidence in their clinical decision making for patients with low back pain. Wider dissemination of clinical practice guidelines should be urgently undertaken. 2.

Neck Pain: Clinical Practice Guidelines Help Ensure Quality Care.

In 2008, physical therapists published the first neck pain clinical practice guidelines. These guidelines have been updated and are now available in the July 2017 issue of JOSPT. To update these guidelines, physical therapists teamed with the International Collaboration on Neck Pain to identify leading practices. These revised guidelines provide direction to clinicians as they screen, evaluate, diagnose, and make treatment-based classifications of neck pain. They also outline the best nonsurgical treatment options based on the published literature. At the end of the day, the best care is a combination of the leading science, the clinical expertise of your health care provider, and your input as the patient. These guidelines help inform the first step in this process. J Orthop Sports Phys Ther 2017;47(7):513. doi:10.2519/jospt.2017.0508.

Relationship Between Using Clinical Practice Guidelines for Pain Treatment and Physicians' Training and Attitudes Toward Patients and the Effects on Patient Care.

To determine the use of clinical practice guidelines (CPGs) for chronic pain (CP) management; analyze the effects of training in pain and the attitudes of physicians toward pain and CP patients on the adherence to these CPGs; and assess the impact of adherence to CPGs on patient care. This was a cross-sectional study in a sample of physicians involved in CP patient management. Information on the use of CPGs for CP management, their training in pain, and their attitudes toward pain, patients, and patient care was collected. Descriptive and bivariate analyses were performed, and a multinomial logistic regression model was constructed to analyze factors associated with the use of CPGs. Of the 257 physicians surveyed, 46.6% were physiatrists, 26.7% were general practitioners, and 26.7% were medical oncologists. Although 96.5% claimed to have received training in pain, only 10.1% had received college training, and 76.3% expressed having gaps in their knowledge; 53.9% stated they applied CPGs often/always, and 12.5% rarely/never. Limited knowledge on pain, reduced involvement in training activities, more negative attitudes toward patients, and having experienced CP were the factors related to reduced adherence to CPGs, especially among the youngest respondents. The greater the use of CPGs, the better the patient care was. Access to scientific information and specialized training are factors related to the use of CPGs for pain treatment. Therefore, the inclusion of CP training in university and during medical specialty training will be essential measures to improve adherence to CPG, thereby improving patient care and pain control.

American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain.

Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement conventional management of musculoskeletal disorders, including those that cause low back pain (LBP). Osteopathic manipulative treatment is defined in the Glossary of Osteopathic Terminology as "The therapeutic application of manually guided forces by an osteopathic physician (U.S. Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. OMT employs a variety of techniques" (eAppendix). Somatic dysfunction is defined as "Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment." These guidelines update the AOA guidelines for osteopathic physicians to utilize OMT for patients with nonspecific acute or chronic LBP published in 2010 on the National Guideline Clearinghouse.1 METHODS: This update process commenced with literature searches that included electronic databases, personal contact with key researchers of OMT and low back pain, and Internet search engines. Early in the process, the Task Force on the Low Back Pain Clinical Practice Guidelines discovered the 2014 systematic literature review conducted by Franke et al2; this study serves as the basis for this updated guideline and further builds upon the literature used to support the previous guidelines. Findings from other eligible studies published after the search parameters of the Franke et al systematic review were also incorporated. The authors of the systematic review identified 307 studies. Thirty-one were evaluated and 16 were excluded. Of the 15 studies included in the review, 6 were retrieved from Germany, 5 from the United States, 2 from the United Kingdom, and 2 from Italy. Two additional studies published after the Franke et al review were also included. Osteopathic manipulative treatment significantly reduces pain and improves functional status in patients, including pregnant and postpartum women, with nonspecific acute and chronic LBP. Franke et al found that in acute and chronic nonspecific LBP, moderate-quality evidence suggested that OMT had a significant effect on pain relief (mean difference [MD], -12.91; 95% CI, -20.00 to -5.82) and functional status (standard mean difference [SMD], -0.36; 95% CI, -0.58 to -0.14). More specifically, in chronic nonspecific LBP, the evidence suggested a significant difference in favor of OMT regarding pain (MD, -14.93; 95% CI, -25.18 to -4.68) and functional status (SMD, -0.32; 95% CI, -0.58 to -0.07). When examining nonspecific LBP in pregnancy, low-quality evidence suggested a significant difference in favor of OMT for pain (MD, -23.01; 95% CI, -44.13 to -1.88) and functional status (SMD, -0.80; 95% CI, -1.36 to -0.23). Conversely for nonspecific LBP postpartum, Franke et al found that moderate-quality evidence suggested a significant difference in favor of OMT for pain (MD, -41.85; 95% CI, -49.43 to -34.27) and functional status (SMD, -1.78; 95% CI, -2.21 to -1.35).2 CONCLUSION: The conclusions of Franke et al further strengthen the findings that OMT reduces LBP. In a 2005 systematic review conducted by Licciardone et al3 and the basis of the LBP guidelines published in 2010, it was determined that OMT reduces pain more than expected from placebo effects alone, and these results had the potential to last beyond the first year of treatment. Franke et al specifically stated that clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women 3 months after treatment. Larger randomized controlled trials with robust comparison groups are needed to further validate the effects of OMT on LBP. In addition, more research is needed to understand the mechanics of OMT and its short- and long-term effects, as well as the cost-effectiveness of such treatment.

Using the RE-AIM framework to evaluate and guide a quality improvement program: Implementation of low back pain clinical practice guidelines

Using the RE-AIM framework to evaluate and guide a quality improvement program: Implementation of low back pain clinical practice guidelines

The Methodological Approach Used to Develop the 2013 Pain, Agitation, and Delirium Clinical Practice Guidelines for Adult ICU Patients

In 2006, the American College of Critical Care Medicine assembled a 20-member task force to revise the 2002 guidelines for sedation and analgesia in critically ill adults. This article describes the methodological approach used to develop the American College of Critical Care Medicine's 2013 ICU Pain, Agitation, and Delirium Clinical Practice Guidelines. Review article. Multispecialty critical care units. Adult ICU patients. The task force was divided into four subcommittees, focusing on pain, sedation, delirium, and related outcomes. Unique aspects of this approach included the use of: 1) the Grading of Recommendations Assessment, Development and Evaluation method to evaluate the literature; 2) a librarian to conduct literature searches and to create and maintain the pain, agitation, and delirium database; 3) creation of a single web-based database; 4) rigorous psychometric analyses of pain, sedation, and delirium assessment tools; 5) the use of anonymous electronic polling; and 6) creation of an ICU pain, agitation, and delirium care bundle. The pain, agitation, and delirium database includes over 19,000 references. With the help of psychometric experts, members developed a scoring system and analyzed the psychometric properties of 6 behavioral pain scales, 10 sedation/agitation scales, and 5 delirium monitoring tools. A meta-analysis was performed to assess the overall impact of benzodiazepine versus nonbenzodiazepine sedation on ICU outcomes. The pain, agitation, and delirium guidelines include 54 evidence-based statements and recommendations. The quality of evidence and strength for each statement and recommendation was ranked. In the absence of sufficient evidence or group consensus, no recommendations were made. An ICU pain, agitation, and delirium care bundle was created to facilitate adoption of the pain, agitation, and delirium guidelines. It focuses on taking an integrated approach to assessing, treating, and preventing pain, agitation/sedation, and delirium in critically ill patients, and it links pain, agitation, and delirium management to spontaneous awakening trials, spontaneous breathing trials, and ICU early mobility and sleep hygiene programs in order to achieve synergistic benefits to ICU patient outcomes. The 2013 ICU pain, agitation, and delirium guidelines provide critical care providers with an evidence-based, integrated, and interdisciplinary approach to managing pain, agitation/sedation, and delirium. The methodological approach used to develop the guidelines ensures that they are rigorous, evidence-based, and transparent. Implementation of the ICU pain, agitation, and delirium care bundle is expected to have a significant beneficial impact on ICU outcomes and costs.