Elsevier

The Spine Journal

Volume 20, Issue 7, July 2020, Pages 998-1024
The Spine Journal

Systematic Review
Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

https://doi.org/10.1016/j.spinee.2020.04.006Get rights and content

Abstract

Background context

The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

Study design

This is a guideline summary review.

Methods

This guideline is the product of the Low Back Pain Work Group of NASS’ Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

Results

Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

Conclusions

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx

Introduction

To improve the knowledge base concerning the diagnosis and treatment of nonspecific low back pain in adult patients, the Low Back Pain Work Group of the North American Spine Society's (NASS) Evidence-Based Guideline Development Committee developed an evidence-based clinical guideline on this topic. When employing the principles of evidence-based medicine, the clinical literature is extensively searched to answer specific clinical questions about a disease state or medical condition. The literature, identified in the search, is rated according to its scientific merit using NASS evidence analysis criteria and the levels of evidence as determined by specific rule sets that apply to human, clinical investigations. The evidence with the highest possible levels of evidence obtained from the searches is utilized to answer the specific clinical questions. As a final step, the answers to clinical questions are reformulated as recommendations. Recommendations are then assigned a recommendation grade according to the level of evidence for the best clinical evidence available at the time of answering each question. The intent of the grade of recommendation is to indicate the strength of evidence used by the work group in answering the question asked.

Section snippets

Methods

The methods used to develop this guideline and guideline development disclosure policies are detailed in the complete guideline [1] and technical report [2]. In brief (Figure), a multidisciplinary work group of spine care specialists, including representatives from the fields of primary care, psychology, neurosurgery, orthopedic surgery, physical medicine and rehabilitation (PM&R), chiropractic care, physical therapy, anesthesiology, research, and radiology, convened to identify clinical

Results

Eighty-two clinical questions were addressed in this guideline. Work group members engaged in a two-step screening process to determine article eligibility, including title and abstract screening and evidentiary review. The total number of articles retrieved, eligible for critical appraisal, and meeting inclusion criteria for each individual clinical question can be accessed in the technical report [2]. A total of 119 recommendations and two work group consensus statements were issued.

Summary of recommendations

Recommendations were graded according to the NASS Grades of Recommendation [4]. In summary, these are Recommendation Grade A=Good evidence, Recommendation Grade B=Fair evidence, Recommendation Grade C=Poor quality evidence, and I=Insufficient or conflicting evidence. The recommendations are summarized below.

Discussion

This evidence-based clinical guideline for the diagnosis and treatment of low back pain has several functions. It is an educational tool for both clinicians and patients, and as such this particular guideline is intended to assist practitioners who treat adult patients with nonspecific low back pain. This guideline also serves to focus and rate the scientific data on this topic. An evidence-based guideline such as this allows a clinician access to the best and most current evidence and reduces

Acknowledgments

Development of this guideline was funded in its entirety by the North American Spine Society (NASS) with the exception that stakeholder societies provided representatives and paid for the travel and accommodation of their representatives to recommendation meetings. The NASS Evidence-Based Guideline Development Committee developed this guideline.

All participating authors have disclosed potential conflicts of interest consistent with NASS’ disclosure policy (http://www.spine.org/DisclosurePolicy

References (312)

  • M Teraguchi et al.

    The association of combination of disc degeneration, end plate signal change, and Schmorl node with low back pain in a large population study: the Wakayama Spine Study

    Spine J

    (2015)
  • JH Atkinson et al.

    Effects of noradrenergic and serotonergic antidepressants on chronic low back pain intensity

    Pain

    (1999)
  • C Dickens et al.

    The relationship between pain and depression in a trial using paroxetine in sufferers of chronic low back pain

    Psychosomatics

    (2000)
  • CA Birbara et al.

    Treatment of chronic low back pain with etoricoxib, a new cyclo-oxygenase-2 selective inhibitor: improvement in pain and disability–a randomized, placebo-controlled, 3-month trial

    J Pain

    (2003)
  • B Eskin et al.

    Prednisone for emergency department low back pain: a randomized controlled trial

    J Emerg Med

    (2014)
  • BW Friedman et al.

    Parenteral corticosteroids for Emergency Department patients with non-radicular low back pain

    J Emerg Med

    (2006)
  • GE Ruoff et al.

    Tramadol/acetaminophen combination tablets for the treatment of chronic lower back pain: a multicenter, randomized, double-blind, placebo-controlled outpatient study

    Clin Ther

    (2003)
  • H Frerick et al.

    Topical treatment of chronic low back pain with a capsicum plaster

    Pain

    (2003)
  • JA Turner et al.

    Efficacy of cognitive therapy for chronic low back pain

    Pain

    (1993)
  • HD Basler et al.

    TTM based counselling in physiotherapy does not contribute to an increase of adherence to activity recommendations in older adults with chronic low back pain - a randomised controlled trial

    Eur J Pain

    (2007)
  • R Leclaire et al.

    Back school in a first episode of compensated acute low back pain: a clinical trial to assess efficacy and prevent relapse

    Arch Phys Med Rehabil

    (1996)
  • MO Magalhaes et al.

    The shortterm effects of graded activity versus physiotherapy in patients with chronic low back pain: a randomized controlled trial

    Manual Therapy

    (2015)
  • W Göhner et al.

    Preventing chronic back pain: evaluation of a theory-based cognitive-behavioural training programme for patients with subacute back pain

    Patient Educ Couns

    (2006)
  • North American Spine Society. Diagnosis and treatment of low back pain. Burr Ridge, IL: North American Spine Society;...
  • North American Spine Society. Diagnosis and treatment of low back pain technical report. Burr Ridge, IL: North American...
  • North American Spine Society. Levels of evidence for primary research question. 2015. Available...
  • North American Spine Society. Grades of recommendation. 2005. Available...
  • R Donelson et al.

    A prospective study of centralization of lumbar and referred pain: a predictor of symptomatic discs and anular competence

    Spine

    (1997)
  • I Heuch et al.

    Body mass index as a risk factor for developing chronic low back pain: a follow-up in the Nord-Trondelag Health Study

    Spine

    (2013)
  • S Kääriä et al.

    Low back pain, work absenteeism, chronic back disorders and clinical findings in the low back as predictors of hospitalization due to low back disorders: a 28-year follow-up of industrial employees

    Spine

    (2005)
  • K Matsudaira et al.

    Potential risk factors of persistent low back pain developing from mild low back pain in urban Japanese workers

    PLoS ONE

    (2014)
  • EWP Bakker et al.

    Spinal mechanical load: a predictor of persistent low back pain? A prospective cohort study

    Eur Spine J

    (2007)
  • SM Alsaadi et al.

    Poor sleep quality is strongly associated with subsequent pain intensity in patients with acute low back pain

    Arthritis Rheumatol

    (2014)
  • J Coste et al.

    Prognosis and quality of life in patients with acute low back pain: insights from a comprehensive inception cohort study

    Arthritis Care Res

    (2004)
  • JM Fritz et al.

    The use of nonorganic signs and symptoms as a screening tool for returnto-work in patients with acute low back pain

    Spine

    (2000)
  • WS Shaw et al.

    Early disability risk factors for low back pain assessed at outpatient occupational health clinics

    Spine

    (2005)
  • WS Shaw et al.

    The effect of body mass index on recovery and return to work after onset of work-related low back pain

    J Occup Environ Med

    (2012)
  • RJ Gatchel et al.

    Predicting outcome of chronic back pain using clinical predictors of psychopathology: a prospective analysis

    Health Psychol

    (1995)
  • RJ Gatchel et al.

    The dominant role of psychosocial risk factors in the development of chronic low back pain disability

    Spine

    (1995)
  • SE Reme et al.

    Distressed, immobilized, or lacking employer support? A sub-classification of acute work-related low back pain

    J Occup Rehabil

    (2012)
  • C Rolli Salathe et al.

    Resources for preventing sickness absence due to low back pain

    Occup Med

    (2012)
  • WS Shaw et al.

    Psychiatric disorders and risk of transition to chronicity in men with first onset low back pain

    Pain Med

    (2010)
  • JA Turner et al.

    Worker recovery expectations and fear-avoidance predict work disability in a population-based workers’ compensation back pain sample

    Spine

    (2006)
  • M Melloh et al.

    Predicting the transition from acute to persistent low back pain

    Occup Med

    (2011)
  • MJ Sewitch et al.

    First lifetime back pain and psychiatry treatment: psychological factors and recovery in compensated workers

    AAOHN J

    (2000)
  • C Costa Lda et al.

    Prognosis for patients with chronic low back pain: inception cohort study

    BMJ

    (2009)
  • J Coste et al.

    Classification of nonspecific low back pain. I. Psychological involvement in low back pain: a clinical, descriptive approach

    Spine

    (1992)
  • M Lundberg et al.

    The impact of fear-avoidance model variables on disability in patients with specific or nonspecific chronic low back pain

    Spine

    (2011)
  • AD Gupta

    Sacroiliac joint pathologies in low back pain

    J Back Musculoskel Rehabil

    (2009)
  • L Berg et al.

    Do more MRI findings imply worse disability or more intense low back pain? A cross-sectional study of candidates for lumbar disc prosthesis

    Skelet Radiol

    (2013)
  • Cited by (0)

    FDA device/drug status: Not applicable.

    Author Disclosures: All participating authors have disclosed potential conflicts of interest consistent with NASS' disclosure policy (http://www.spine.org/DisclosurePolicy). The Technical Report associated with this document includes the disclosures of all authors and contributors along with a description of participating and contributing societies. It is available at: https://www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/LowBackPainTechReport.pdf. AMY: Staff at the North American Spine Society. KAR: Staff at the North American Spine Society 2012-2017

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