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.
"Similar to prior reviews of guidelines, applicability and editorial independence domains scored the lowest [31,32]. In the case of editorial independence, low scores were mostly assigned due to authors failing to adequately report their methodology. "
[Show abstract][Hide abstract] ABSTRACT: While many women and infants have an uneventful course during the postpartum period, others experience significant morbidity. Effective postpartum care in the community can prevent short, medium and long-term consequences of unrecognised and poorly managed problems. The use of rigorously developed, evidence-based guidelines has the potential to improve patient care, impact on policy and ensure consistency of care across health sectors. This study aims to compare the scope and content, and assess the quality of clinical guidelines about routine postpartum care in primary care.
PubMed, the National Guideline Clearing House, Google, Google Scholar and relevant college websites were searched for relevant guidelines. All guidelines regarding routine postpartum care published in English between 2002 and 2012 were considered and screened using explicit selection criteria. The scope and recommendations contained in the guidelines were compared and the quality of the guidelines was independently assessed by two authors using the AGREE II instrument.
Six guidelines from Australia (2), the United Kingdom (UK) (3) and the United States of America (USA) (1), were included. The scope of the guidelines varied greatly. However, guideline recommendations were generally consistent except for the use of the Edinburgh Postnatal Depression Scale for mood disorder screening and the suggested time of routine visits. Some recommendations lacked evidence to support them, and levels or grades of evidence varied between guidelines. The quality of most guidelines was adequate. Of the six AGREE II domains, applicability and editorial independence scored the lowest, and scope, purpose and clarity of presentation scored the highest.
Only one guideline provided comprehensive recommendations for the care of postpartum women and their infants. As well as considering the need for region specific guidelines, further research is needed to strengthen the evidence supporting recommendations made within guidelines. Further improvement in the editorial independence and applicability domains of the AGREE ll criteria would strengthen the quality of the guidelines.
"A recurring conclusion of high quality systematic reviews and randomised controlled trials (RCTs) in the field of back pain is that most treatments show modest effects compared to natural course, and small or no differences between the effectiveness of different interventions    . This leads to equivocal and sometimes contradictory messages in clinical practice guidelines  , and frustration in clinicians attempting to provide evidence-based care for their patients. In part, the underwhelming results reported by these studies are likely due to incomplete understanding of what factors might be necessary to include in interventions to help influence outcome. "
[Show abstract][Hide abstract] ABSTRACT: Mediation analysis is a useful research method that potentially allows identification of the mechanisms through which treatments affect patient outcomes. This chapter reviews the theoretical framework, research designs and statistical approaches used in mediation analysis. It describes what can be learnt from previous mediation research, much of which has investigated mediating factors of psychosocial interventions in other health conditions. It also summarises the few treatment-mediation studies of psychosocial interventions conducted in back pain. This chapter shows that there is emerging evidence about the role of some psychological factors as potential treatment mediators, such as self-efficacy and catastrophising. Mediation analysis can equally be applied to non-psychological factors. Pre-planned and appropriately conducted mediation analysis in adequately powered clinical trials would be a step forward in understanding treatment effects in back pain and improving patient management.
Best practice & research. Clinical rheumatology 10/2013; 27(5):685-97. DOI:10.1016/j.berh.2013.10.001 · 2.60 Impact Factor
"Historically, studies have suggested a weak association between body weight and low back pain , and guidelines for the treatment of low back pain have not included diet and weight loss as recommendations [4,5]. Updating this view appears to be in order as an elevated body mass index is considered a risk factor for low back pain chronicity [6,7], and recent studies have indicated that overweight and obese patients are at a higher risk for musculoskeletal pain expression, as are patients with the metabolic syndrome and type 2 diabetes. "
[Show abstract][Hide abstract] ABSTRACT: Background
Back pain is one of the most common complaints that patients report to physicians and two-thirds of the population has an elevated body mass index (BMI), indicating they are either overweight or obese. It was once assumed that extra body weight would stress the low back and lead to pain, however, researchers have reported inconsistencies association between body weight and back pain. In contrast, more recent studies do indicate that an elevated BMI is associated with back pain and other musculoskeletal pain syndromes due to the presence of a chronic systemic inflammatory state, suggesting that the relationship between BMI and musculoskeletal pains be considered in more detail.
To describe how an elevated BMI can be associated with chronic systemic inflammation and pain expression. To outline measurable risk factors for chronic inflammation that can be used in clinical practice and discuss basic treatment considerations.
Adiposopathy, or “sick fat” syndrome, is a term that refers to an elevated BMI that is associated with a chronic systemic inflammatory state most commonly referred to as the metabolic syndrome. The best available evidence suggests that the presence of adiposopathy determines if an elevated BMI will contribute to musculoskeletal pain expression. It is not uncommon for physicians to fail to identify the presence of adiposopathy/metabolic syndrome.
Patients with an elevated BMI should be further examined to identify inflammatory factors associated with adiposopathy, such as the metabolic syndrome, which may be promoting back pain and other musculoskeletal pain syndromes.
Chiropractic and Manual Therapies 05/2013; 21(1):15. DOI:10.1186/2045-709X-21-15
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