Implementing clinical guidelines for low back pain remains a challenge

Koes BW. Eur Spine J. Published online: July 3, 2010.

A comparison of international clinical guidelines for low back pain management found that diagnostic and therapeutic recommendations are similar.

This study, by Bart W. Koes, MD, and colleagues at Erasmus MC, Rotterdam, the Netherlands, updates a previous review that included clinical guidelines published up to the year 2000. The researchers included guidelines that met the following criteria: the target group consisted mainly of primary health care professionals and the guideline was published in English, German, Finnish, Spanish, Norwegian or Dutch. This review included the most recently published guidelines from 13 countries and 2 international clinical guidelines from Europe between 2000 and 2008.

Guideline content was similar with regard to diagnostic classification and the use of diagnostic and therapeutic interventions. For acute low back pain, there were several consistent features: early and gradual patient activity, discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity. The consistent features for low back pain included supervised exercises, cognitive behavioral therapy and multidisciplinary treatment.

For both acute and chronic low back pain, the guidelines differed with regard to spinal manipulation and drug treatment. Some of these differences may be due to a lack of strong evidence or due to differences in local health care systems. Implementing these clinical guidelines remains a challenge for clinical practice and research, they wrote.

This manuscript essentially reviews clinical guidelines from various countries; some of them happen to be fairly old. Further, the most important aspect is that this overview addresses only non-specific low back pain management in primary care and that management is greatly limited to acute pain.

The recommendations for low back pain diagnosis are appropriate, and they are also widely practiced. Therapeutic recommendations such as avoiding bed rest and staying active are also appropriate; however, a supervised exercise program is not recommended in the reviewed guidelines for acute or subacute pain. That is somewhat surprising as it is common practice for patients to go through an exercise program, with or without supervision. In general, supervised programs are more effective than non-supervised programs.

Finally, the overview has multiple differences of opinions on what drugs should be used, including opioids, but the panel has not provided a recommendation on whether opioids should be used or not.

In summary, the guidelines are in line with the practice patterns of most physicians in the United States and across the world. These guidelines will not alter practice patterns or change clinical practice patterns.

– Laxmaiah Manchikanti, MD
Chairman of the Board and Chief Executive Officer, ASIPP and SIPMS
Medical Director, Pain Management Center of Paducah
Associate Clinical Professor
Anesthesiology and Perioperative Medicine
University of Louisville, Kentucky
Paducah, Ky.