Research Review By Dr. Brynne Stainsby©

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Date Posted:

January 2017

Study Title:

Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

Authors:

Wong JJ, Cote P, Sutton DA, Randhawa K et al.

Author's Affiliations:

UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology and Canadian Memorial Chiropractic College; Graduate Education and Research Programs, Canadian Memorial Chiropractic College; Canada Research Chair in Disability Prevention and Rehabilitation, UOIT; Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, USA; Physical Therapy, University of Alberta; Rehabilitation Research Centre, University of Alberta; Injury Prevention Centre and School of Public Health, University of Alberta, Edmonton, AB, Canada; Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal, QC, Canada; Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Toronto, ON, Canada; University of Saskatchewan, SK, Canada.

Publication Information:

European Journal of Pain 2017; 21(2): 201-216.

Background Information:

More than 80% of people experience low back pain (LBP) throughout their lives, and it remains a very common, costly cause of disability around the world (1-4). In fact, it is the most common reason patients present to healthcare providers for musculoskeletal complaints (5, 6).

Although many interventions are available to treat LBP, existing evidence suggests that most treatment effects are generally small and only short-term (7).

Clinical practice guidelines (CPGs) are systematically developed documents that synthesize research evidence, with a goal of optimizing patient care and improving health outcomes (8, 9). It is critical that these guidelines have strong methodology to prevent clinicians from considering interventions that are ineffective, expensive or harmful.

Given the importance of ensuring treatment recommendations are based on high-quality evidence, the purpose of this OPTIMa systematic review was to identify effective conservative interventions for the management of acute and chronic low back pain.

Pertinent Results:

Literature Search Results and Research Quality:
  • A total of 2504 titles and abstracts were screened for eligibility and 75 potentially relevant articles were identified for full-text screening. 14 were then deemed eligible for critical appraisal.
  • Ten guidelines were deemed to be of high quality (10-19).
  • Nine of the 10 high-quality guidelines addressed nonspecific LBP (10-18) and one targeted LBP with radiculopathy (19). Of these, one focused on acute (12), five on chronic (10, 11, 14, 15, 20) and three addressed both acute and chronic LBP (13, 16, 17).
Recommendations Derived from Included Guidelines:

For the management of ACUTE LBP, the following interventions were recommended by all guidelines:
  1. Provide advice, reassurance or education with evidence-based information regarding the expected course of recovery and effective self-care options
  2. Encourage early return to activity, staying active or avoiding prescribed bed rest
  3. Paracetamol or NSAIDs if indicated, with advice and consideration of risks and warning signs and symptoms
  4. A short course of muscle relaxants alone or in addition to NSAIDs if paracetamol or NSAIDs did not reduce pain
  5. Spinal manipulation for those not improving with self-care
For the management of ACUTE LBP, the following interventions were recommended by most guidelines:
  1. Short-term use of opioids on rare occasions to control refractory, severe pain. Long-term use may be associated with significant risks (13, 16, 17)
For the management of CHRONIC LBP, the following interventions were recommended by all guidelines:
  1. Provide education, advice and information promoting self-management, evidence-based information regarding the expected course of recovery and effective self-care options, brief education interventions
  2. Exercise or yoga. Three guidelines advocated considering patient preference, with up to eight sessions over up to 12 weeks
  3. Manual therapy, including spinal manipulation or mobilization, with a maximum of nine sessions over up to 12 weeks
  4. Paracetamol or NSAIDs if indicated, with advice and consideration of risks and warning signs and symptoms
  5. Short-term use of opioids if paracetamol or NSAIDs have not provided adequate pain relief, considering side-effects, risks and evidence of ongoing pain relief on re-assessment
  6. Multimodal rehabilitation including physical and psychological interventions in up to 100 hours over eight weeks
For the management of CHRONIC LBP, the following interventions were recommended by most guidelines:
  1. Massage (11, 13, 16, 17, 20)
  2. Acupuncture (11, 13, 15-17, 20)
  3. Antidepressants, although one guideline recommended against their use and another reported conflicting evidence (10, 13, 15-17)
For the management of CHRONIC LBP, the following interventions were NOT recommended by most guidelines:
  1. Muscle relaxants (13, 16, 17, 20)
  2. Gabapentin (10, 11, 16, 20)
  3. Passive modalities, including TENS, laser, IFC or ultrasound (10, 11, 13, 16)
For the management of lumbar disc herniation with radiculopathy, the one high-quality guideline (21) recommended:
  1. Spinal manipulation as an option for symptomatic relief (21)
  2. Limited course of structured exercise (based on consensus of the guideline development group)

Clinical Application & Conclusions:

This review identified the most effective conservative interventions for the management of acute and chronic LBP. Although it appears most interventions provide only short-lived, small benefits, the high-quality guidelines recommend that these patients should be provided with education and be encouraged to remain active.

The management of acute LBP may include spinal manipulation and/or medications as indicated. It should be noted, however, that the inclusion of paracetamol for the management of acute low back pain has recently been challenged by a high-quality randomized controlled trial (21). This is a pertinent reminder that clinical guidelines must continuously be updated. The management of chronic LBP may include medications, exercise, manual therapy, acupuncture and multimodal rehabilitation. The management of lumbar disc herniation with radiculopathy may include spinal manipulation for symptomatic relief, and possibly a short course of exercise.

Importantly, the reviewers noted that little information was provided regarding the optimal frequency and duration of these interventions. It highlights the need for high quality research regarding of effectiveness of individual and combined therapies, and the optimal dose for prescribing and implementing them.

Study Methods:

  • A systematic search strategy was developed in consultation with a health sciences librarian and reviewed by a second librarian.
  • Ten databases were searched from January 1st, 2005 to April 30th, 2014, using appropriate search terms for each database. Reference lists of relevant guidelines were screened for additional resources. Finally, grey literature was searched using 14 databases.
  • Two authors independently screened titles and abstracts for inclusion.
  • Only guidelines in the English language which targeted adults and/or children with low back pain with or without radiculopathy and included recommendations for management were included in this review.
  • Two authors then independently appraised each guideline using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument (22). Guidelines with poorly conducted systematic literature searches, or those with inadequate methods to critically appraise the evidence were deemed to have fatal flaws and were excluded from this systematic review.
  • One reviewer extracted data from high-quality guidelines and built evidence tables. A second reviewer then confirmed the data.
  • Recommendations were synthesized using evidence tables and summarized according to whether they were recommended, not recommended, or lacked evidence to support or refute use of the intervention. The recommendations were stratified by the duration of LBP and number of guidelines recommending the use of the particular intervention.

Study Strengths / Weaknesses:

Strengths:
  • The authors constructed a clearly defined research question and investigated via a thorough and systematic search of the literature.
  • Independent screening of titles, abstracts and full texts was conducted.
  • Only those trials assessed as being of high quality were included.
  • Assessment of risk of bias was performed with a validated set of criteria.
  • Two authors independently extracted the data from the included articles.
  • Only those studies assessed as high quality trials were included.
Weaknesses:
  • The primary limitation of this study relates more to the quality of the body of evidence than the methodology of the review itself. Most of the guidelines identified initially were excluded from this paper.
  • The main limitation of this study itself was the limitation to guidelines published in the English language. This may limit the external validity of the paper.
  • Finally, definitions used to classify acute and chronic low back pain varied across the guidelines and may have led to misclassification of recommendations.

Additional References:

  1. Cassidy JD, Carroll LJ, Cote P. The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine 1998; 23: 1860–1866; discussion 1867.
  2. Cassidy JD, Cote P, Carroll LJ, et al. Incidence and course of low back pain episodes in the general population. Spine 2005; 30: 2817–2823.
  3. Walker BF. The prevalence of low back pain: A systematic review of the literature from 1966 to 1998. J Spinal Disord 2000; 13: 205–217.
  4. Hincapie CA, Cassidy JD, Cote P, et al. Whiplash injury is more than neck pain: A population-based study of pain localization after traffic injury. J Occup Environ Med 2010; 52: 434–440.
  5. Cypress BK. Characteristics of physician visits for back symptoms: A national perspective. Am J Public Health 1983; 73: 389–395.
  6. Cote P, Cassidy JD, Carroll L. The treatment of neck and low back pain: Who seeks care? Who goes where? Med Care 2001; 39: 956–967.
  7. Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. Spine 2008; 8: 1–7.
  8. Shekelle P, Woolf S, Grimshaw JM et al. Developing clinical practice guidelines: Reviewing, reporting, and publishing guidelines; updating guidelines; and the emerging issues of enhancing guideline implementability and accounting for comorbid conditions in guideline development. Implement Sci 2012; 7: 62.
  9. Institute of Medicine Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical Practice Guidelines We Can Trust. R. Graham, M. Mancher, D. Miller Wolman, S. Greenfield, and E. Steinberg, eds (Washington, DC: National Academies Press (US)).
  10. Airaksinen O, Brox JI, Cedraschi C, et al. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006; 15 (Suppl 2): S192–S300.
  11. Nielens H, Van Zundert J, Mairiaux P, et al. Belgian Health Care Knowledge Centre. Chronic Low Back Pain (KCE Report) 2006.
  12. van Tulder M, Becker A, Bekkering T, et al. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006; 15 (Suppl 2): S169–S191.
  13. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society Ann Intern Med 2007; 147: 478–491.
  14. Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: An evidence-based clinical practice guideline from the American Pain Society. Spine 2009; 34: 1066–1077.
  15. National Institute of Health and Care Excellence Low back pain: early management of persistent non-specific low back pain. 2009.
  16. Cutforth G, Peter A, Taenzer P. The Alberta health technology assessment (HTA) ambassador program: The development of a contextually relevant, multidisciplinary clinical practice guideline for non-specific low back pain: A review. Physiother Can 2011; 63: 278–286.
  17. Livingston C, King V, Little A, et al. Evidence-based clinical guidelines project. Evaluation and management of low back pain: A clinical practice guideline based on the joint practice guideline of the American College of Physicians and the American Pain Society (Salem, Oregon: Office for Oregon Health Policy and Research). 2011.
  18. Delitto A, George SZ, Van Dillen LR, et al. Low back pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2012; 42: A1–A57.
  19. North American Spine Society. Evidence-based clinical guidelines for multidisciplinary spine care. Diagnosis and treatment of lumbar disc herniation with radiculopathy (Rockville MD: Agency for Healthcare Research and Quality). 2012.
  20. Scottish Intercollegiate Guidelines Network. Management of chronic pain. A national clinical guideline (Rockville MD: Agency for Healthcare Research and Quality). 2013.
  21. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J 2014; 14: 180–191.
  22. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: A double-blind, randomised controlled trial. Lancet 2014; 384: 1586–1596.
  23. Brouwers MC, Kho ME, Browman GP et al. AGREE II: Advancing guideline development, reporting and evaluation in health care. CMAJ 2010; 182: E839–E842.