A critical review of guidelines for low back pain treatment.
OBJECTIVE
Little is known about the methodological quality of guidelines for low back pain treatment. We evaluated the methods used by the developers according to established standards.


METHODS
PubMed, guideline databases, and the World Wide Web were used to identify guidelines. Seventeen guidelines met the inclusion criteria: interventions for low back pain stated, recommendations based on or explicitly linked to evidence, and English version available. Guidelines were evaluated independently by two appraisers using a practical tool for this purpose, Users' Guides to the Medical Literature, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument.


RESULTS
Thirteen guidelines (76%) specified the most important therapies applied, but only nine (53%) included a complete description of the target population. Explicit processes to identify, select, and combine evidence were described in only six guidelines (35%). Few guidelines (3; 18%) explicitly considered all main outcomes when formulating therapeutic recommendations, and none contained a process to determine the relative value of different outcomes. Methodological criteria for grading the strength of the recommendations varied, and were often insufficiently specified. None of the guidelines assessed the impact of uncertainty associated with the evidence and values used. According to AGREE the quality score was highest for the scope and purpose, and clarity and presentation domains, and lowest for editorial independence and applicability. With regard to the recommendations, there was consensus for some of the interventions for acute pain (analgesics and NSAIDs, maintaining physical activity, and avoiding excessive bed rest), but explicit recommendations were lacking or ambiguous for 41% of the interventions. Most of the guidelines did not contemplate specific recommendations for chronic pain.


CONCLUSIONS
A small number of the available guidelines for low back pain treatment achieved acceptable results for specific quality criteria. In general, the methods to develop the guidelines' therapeutic recommendations need to be more rigorous, more explicit and better explained. In addition, greater importance should be placed on the recommendations for chronic pain.
Arnau
Josep M
JM
Fundació Institut Català de Farmacologia, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain. jma@icf.uab.es
Vallano
Antoni
A
Lopez
Anna
A
Pellisé
Ferran
F
Delgado
Maria J
MJ
Prat
Nuria
N
D000203:Activities of Daily Living; D000700:Analgesics / Q000627:therapeutic use; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D016206:Databases, Bibliographic; D005081:Exercise Therapy / Q000592:standards; D006801:Humans; D017116:Low Back Pain / Q000628:therapy*; D015588:Observer Variation; D017410:Practice Guidelines as Topic / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000592:standards* / Q000639:trends; D012106:Research
D000700:Analgesics; D000894:Anti-Inflammatory Agents, Non-Steroidal