Guidelines For Acute Low Back Pain Research Articles

Economic Evaluation of Active Implementation versus Guideline Dissemination for Evidence-Based Care of Acute Low-Back Pain in a General Practice Setting

IntroductionThe development and publication of clinical practice guidelines for acute low-back pain has resulted in evidence-based recommendations that have the potential to improve the quality and safety of care for acute low-back pain. Development and dissemination of guidelines may not, however, be sufficient to produce improvements in clinical practice; further investment in active implementation of guideline recommendations may be required. Further research is required to quantify the trade-off between the additional upfront cost of active implementation of guideline recommendations for low-back pain and any resulting improvements in clinical practice.MethodsCost-effectiveness analysis alongside the IMPLEMENT trial from a health sector perspective to compare active implementation of guideline recommendations via the IMPLEMENT intervention (plus standard dissemination) against standard dissemination alone.ResultsThe base-case analysis suggests that delivery of the IMPLEMENT intervention dominates standard dissemination (less costly and more effective), yielding savings of $135 per x-ray referral avoided (-$462.93/3.43). However, confidence intervals around point estimates for the primary outcome suggest that – irrespective of willingness to pay (WTP) – we cannot be at least 95% confident that the IMPLEMENT intervention differs in value from standard dissemination.ConclusionsOur findings demonstrate that moving beyond development and dissemination to active implementation entails a significant additional upfront investment that may not be offset by health gains and/or reductions in health service utilization of sufficient magnitude to render active implementation cost-effective.

Quality of Low Back Pain Guidelines Improved

Systematic review of clinical guidelines. To assess the methodological quality of clinical guidelines for the management of acute and chronic low back pain (LBP) in primary care and compare their recommendations. A guideline evaluation performed in 2004 concluded that the quality and transparency of the development process and consistency in the reporting of primary care guidelines for LBP need to be improved. At present, several guidelines have been revised and new guidelines are published. We evaluated if the quality of guidelines has improved. Guidelines published since 2004 were selected by electronically searching in MEDLINE, Cochrane Back Review Group database, Guideline Clearing House, Google, and contacting experts. The methodological quality of the guidelines was assessed by 2 authors independently, using the Appraisal of Guidelines, Research, and Evaluation in Europe instrument. Also, the diagnostic and therapeutic recommendations were compared. Fourteen guidelines were included. In general, the quality was satisfactory. The guidelines had best scores on clarity and presentation. The domain scores of scope and purpose were often moderate due to the absence of description of the clinical questions. The domain of stakeholder involvement scored moderate, mostly because guidelines were not tested among target users. Domains that had generally low scores were applicability and editorial independence. Four guidelines scored low on the rigor of development, but the other guidelines scored high on this domain.The diagnostic and therapeutic recommendations in the guidelines for acute LBP were mainly comparable while the recommendations for the management of chronic LBP varied widely. Compared to the quality assessment performed in 2004, the average quality of guidelines has improved. However, guideline developers should still improve the quality transparency of the development process. Especially the applicability of guidelines and the editorial independence need to be ensured in future guidelines.

Survey of Acute Low Back Pain Management by Specialty Group and Practice Experience

The objective of this study was to explore concurrence with evidence-based management of acute back pain by primary care specialty and years in practice groups. Participants randomly selected from five American Medical Association physician groups were surveyed asking their initial care recommendations for case scenarios with and without sciatica. Response differences were compared among groups and with the Agency for Health Research Quality's guideline. Response rate was 25%. Emergency physicians were least likely to order diagnostic studies for both cases but more often made recommendations likely to promote inactivity. Occupational physicians were less likely to order diagnostic studies and more likely choose treatments conducive to increasing activity. The longer physicians were in practice, the less likely they were to follow recommendations. All specialty groups selected more nonevidence-based interventions for the patient with sciatica. General practitioners were least likely to follow the guidelines in either case. Despite widespread dissemination of acute low back pain guidelines, the study suggests a lack of adherence by certain primary care groups, physicians with more practice experience, and in specific areas of management.

Overcoming Barriers to Evidence Based Practice: An example using the acute low back pain guidelines

N E Foster Department of Physiotherapy Studies, Keele University Although considerable effort has gone into developing clinical guidelines, such as the acute low back pain guidelines (RCGP, 1999), little is known about the effectiveness of communicating them to individuals. Physiotherapists play a key role in the treatment of low back pain, yet research exploring their perspectives of evidencebased practice and the use of guidelines is lacking. This study explored potentially useful strategies to help musculoskeletal physiotherapists use research evidence and clinical guidelines in practice. An exploratory interview study was undertaken, using purposive sampling and data source triangulation. Following a pilot study, semi-structured interviews were undertaken with ten identified experts in the field of clinical guidelines. Focus group interviews were then completed with 40 musculoskeletal physiotherapists across nine different sites. All interviews were transcribed and analysed using content analysis on the QSR NUD*IST computer package. Key themes included those of dissemination and implementation. Although aware of the guidelines, many physiotherapists had not seen them, or expressed difficulty in obtaining copies. A consistent theme across the focus groups was that the Chartered Society of Physiotherapy should be more proactive and raise awareness of the various publications and valuable pieces of research. It was also felt that some form of quality assurance should be set up to ensure that physiotherapy courses, across all levels, are evidence-based or accredited. Findings highlighted a lack of experience in guidelines implementation. Suggested strategies included use of educational support networks or outreach visits at a local level. This study has highlighted that guidelines are still largely failing to impact on clinical practice and specific solutions are needed for the physiotherapy profession. The last phase of the study will explore the clinical usefulness of the suggested strategies.

Evidence for Interferential Therapy for Acute Low Back Pain

A P Moore Clinical Research Unit for Healthcare Professions, University of Brighton, Eastbourne Clinical investigations of the efficacy of interferential therapy (IFT) are warranted, as despite being the most frequently used modality by UK physiotherapists for low back pain (LBP) (Foster et al, 1999), there is no evidence base. A single blind randomised controlled trial was conducted to investigate the efficacy of IFT for LBP disability and to compare two IFT electrode placement methods. Clinical guidelines for acute LBP recommend early active management (Back Book, 1996). Ethical approval was obtained from the Research Ethical Committee of the University of Ulster. Sixty consenting subjects with LBP who met the inclusion criteria were randomly assigned to one of three groups: