Guideline Warfare Over Interventional Therapies for Low Back Pain: Can We Raise the Level of Discourse? (original) (raw)
Related papers
Pain physician
Clinical guidelines are defined as systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. The clinical guideline industry has been erupting even faster than innovation in health care, constantly adding unhealthy perspectives with broad and complex mandates to health care interventions. Clinical guidelines are based on evidence-based medicine (EBM) and comparative effectiveness research (CER). Multiple issues related to the development of clinical guidelines are based on conflicts of interest, controversies, and limitations of the guideline process. Recently, the American Pain Society (APS) developed and published multiple guidelines in managing low back pain resulting in multiple publications. However, these guidelines have been questioned regarding their development process, their implementation, and their impact on various specialties. To reassess the APS guidelines' evidence synthesis...
Pain Physician, 2010
Background: Clinical guidelines are a constructive response to the reality that practicing physicians require assistance in assimilating and applying the exponentially expanding, often contradictory, body of medical knowledge. They attempt to define practices that meet the needs of most patients under most circumstances. Ideally, specific clinical recommendations contained within practice guidelines are systematically developed by expert panels who have access to all the available evidence, have an understanding of the clinical problem, and have clinical experience with the procedure being assessed, as well as knowledge of relevant research methods. The recent development of American Pain Society (APS) guidelines has created substantial controversy because of their perceived lack of objective analysis and recommendations perceived to be biased due to conflicts of interest. Objectives: To formally and carefully assess the APS guidelines’ evidence synthesis for low back pain for thera...
A critical review of guidelines for low back pain treatment
European Spine Journal, 2006
Main problem: 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.
Inconsistent Grading of Evidence Across Countries: a Review of Low Back Pain Guidelines
Journal of manipulative …, 2006
Objective: The aim of this study was to report clinical treatment recommendations for low back pain (LBP) based on 5 international guidelines and best evidence from the Cochrane database of systematic reviews. Methods: Five LBP guidelines available in English language were appraised, including 4 studies published since the seminal work by Koes et al (Spine 2001;26:2504-5213). The guidelines were examined for treatment recommendations concerning nonspecific LBP and guideline quality with application of the Appraisal of Guidelines for Research and Evaluation instrument. Secondly, a systematic literature search for reviews and randomized controlled trials was conducted using a modified version of the search strategy recommended by the Cochrane Back Review Group. Two systematic reviews were identified. Results: According to best evidence from review of the Cochrane database of systematic reviews, there remains a lack of consensus regarding reported efficacy of spinal manipulative therapy for the treatment of nonspecific LBP. Furthermore, the guidelines reviewed in the present study have not changed significantly with respect to treatment recommendations for nonspecific LBP since the original review, and there is inconsistency between the guidelines regarding optimal time to introduce spinal manipulation to treat nonspecific LBP. Conclusion: Treatment recommendations for nonspecific LBP, particularly spinal manipulation, remain inconclusive. Guideline developers need to consider guidelines in neighboring countries and reach consensus on how evidence is graded and incorporated into guidelines. Guidelines should continue to be regularly updated to incorporate new evidence and methods of grading the evidence. (J Manipulative Physiol Ther 2006;29:576-581.e2)
Effectiveness of clinical guidelines in interventional pain management
Pain physician, 2002
Many commissions and groups throughout the world have proposed clinical guidelines on the management of low back pain, spinal pain, and chronic pain. Practice guidelines are systematically developed statements to assist the practitioner and patient decisions about appropriate healthcare for specific clinical circumstances. The American Society of Interventional Pain Physicians developed practice guidelines for interventional techniques which are professional practice recommendations for practices for prevention, diagnosis and treatment of acute and chronic painful disorders, and in some cases, disability management. The effectiveness of so-called evidence-based guidelines has not proven. This study was designed to evaluate a total of 300 patients with 100 randomized patients seen in the month of January 1999, 2000 and 2001, in one private pain management practice in a non-university setting. The study was retrospective for 1999 and 2000, whereas it was prospective for 2001. The resu...