Guest guest Posted March 9, 2010 Report Share Posted March 9, 2010 Docs: Here is a Medscape article on current LBP Guidelines. Lyndon McGill, D.C. Salem, Oregon www.SalemSpineClinic.com www.lyndon.myevolv.com From Spine Quality of Low Back Pain Guidelines Improved Walter Bouwmeester, PT; Annefloor van Enst, BSc; Maurits van Tulder, PhD Posted: 03/01/2010; Spine. 2009;34(23):2562-7. © 2009 Lippincott & Wilkins Abstract and Introduction Abstract Study Design. Systematic review of clinical guidelines. Objective. 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. Summary of Background Data. 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. Methods. 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. Results. 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. Conclusion. 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. Introduction Evidence-based medicine has become increasingly more important over the past decade. The management of low back pain (LBP) has been positively affected by the availability of more clinical quality trials and better use of critical appraisal techniques to evaluate and apply research findings.[1] A large number of systematic reviews are available within and outside the framework of the Cochrane Back Review Group that have evaluated the diagnostic and therapeutic interventions or LBP.[2] This large body of evidence has greatly improved our understanding of what does and does not work for LBP. However, in clinical practice this evidence should be integrated with clinical expertise of the care provider and patient's preferences and expectations.[3] In 2001, a comparison of the content of back pain guidelines was published that showed that diagnostic and therapeutic recommendations were generally similar, although some discrepancies were identified.[4] Subsequently, a quality assessment of guidelines published before 2001 was performed.[5] At that time an instrument regarding the quality of clinical guidelines had just been developed, namely, the AGREE (Appraisal of Guidelines, Research, and Evaluation in Europe) instrument (http://www.agreecollaboration.org; April 2002).[6] Although originally developed as a set of criteria for developing guidelines, the instrument was useful for assessing the quality of guidelines in a systematic review as well. The authors concluded that on average the quality of the guidelines was low. The aim of the present study was to assess if the quality of guidelines on LBP in primary care has improved since 2001. Furthermore, the main recommendations for diagnosis and treatment of available guidelines were compared. Materials and Methods Selection of Guidelines Guidelines where identified through searching in the electronic databases of MEDLINE ("Guideline" [Publication Type] or "Guidelines" [Mesh] or "Practice Guideline" [Publication Type] or "Health Planning Guidelines"[Mesh] and low back pain; Clinical guideline and low back pain; and "Guideline" [Publication Type] and low back pain and primary care) Cochrane Back Review Group, Guideline Clearing House (NGC) (http://www.guideline.gov), and the personal files of the principal investigator (M.v.T.). The database of the NGC was only used to track guidelines. Furthermore, personal communication was initiated to check if some of the guidelines (Finland and England) had been revised or not. Only guidelines published after 2001 were included in this review, because guidelines published before 2001 were already included and assessed in the previous guideline evaluation.[5] Since guidelines are infrequently published in medical journals, the search engine Google was also perused using the keywords "guideline," "low back pain," and "primary care" (http://www.google.com; we checked the first 100 of a total of 208,000 links identified). Guidelines included in this review had to meet the following criteria: (1) the guideline addressed the clinical management of acute or chronic LBP, (2) the target group consisted of primary health care providers, (3) the guideline must be published by a professional group, and (4) the guideline was available in English, German, or Dutch (including authorized English translations of foreign-language guidelines). Guidelines were excluded if they addressed the management of specific LBP (including lumbosacral radicular syndrome), occupational-related LBP, secondary care of LBP provided by medical specialists, prevention of LBP, or if they were developed by one individual or one health care center/hospital. Additional information (other publication or website) was only taken into account when the guideline explicitly referred to it. Quality Assessment The quality of the guidelines was assessed by 2 authors, independently. The guidelines were reviewed using the Dutch version of the AGREE instrument (http://www.cbo.nl; April 2006).[6] The AGREE instrument consists of 23 items in 6 domains (Table 1). Each item is rated on a 4-point scale: 1, strongly disagree; 2, disagree; 3, agree; and 4, strongly agree. We used the additional information on the operationalization of the items, provided in the user guide of the AGREE instrument, to determine clear definitions of each. Domain scores were calculated by dividing the difference between the obtained score and the minimum possible score by the difference between the maximum possible and minimum possible score. The AGREE group stated that it is not yet possible to set a threshold score for the domain scores to make a distinction between "good" and "bad" guidelines. Table 1. Domains and Items of the AGREE Instrument AGREE Domain AGREE Item Scope and purpose The overall objective of the guideline is specifically described The clinical question covered by the guideline is specifically described The patients to whom the guideline is meant to apply are specifically described Stakeholder involvement The guideline development group includes individuals from all the relevant professional groups The patients' views and preferences have been sought The target users of the guideline are clearly defined The guideline has been piloted among target users Rigor of development Systematic methods were used to search for evidence The criteria for selecting the evidence are clearly described The methods used for formulating the recommendations are clearly described The health benefits, side effects and risks have been considered in formulating the recommendations There is an explicit link between the recommendations and the supporting evidence The guideline has been externally reviewed by experts prior to its publication A procedure for updating the guideline is provided Clarity and presentation The recommendations are specific and unambiguous The different options for the management of the condition are clearly presented Key recommendations are easily identifiable The guideline is supported with tools for application Applicability The potential organizational barriers in applying the recommendations have been discussed The potential cost implications of applying the recommendations have been considered The guideline presents key review criteria for monitoring and/or audit purposes Editorial independence The guideline is editorially independent from the funding body Conflicts of interest of guideline development members have been recorded Discrepancies between the scores of the 2 reviewers were resolved in a consensus meeting only when there was a difference in positive and negative assessment (e.g., scoring 1 or 2 vs. 3 or 4). If discrepancies remained, they were discussed with the principal investigator (M.v.T.). Selection of Guidelines We identified 9 references to guidelines in Medline;[7–15] 4 in the Cochrane Back Review Group database;[16–18] 2 on the Guideline Clearing House website;[19–20] and 4 in Google.[21–24] Guidelines were excluded for different reasons. The guideline of the North American Spine Society[15] and the guideline of Veterans Health Administration, Department of Defense[20] were both officially withdrawn. The Norwegian and Israeli guidelines were excluded because they were only available in Norwegian and Hebrew.[11,14] At the end, 14 guidelines for the primary care management of LBP were included: COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care, European, 2004,[13] Drug Committee of the German Medical Society, Germany, 2007,[8] American College of Physicians; American Pain Society Low Back Pain Guidelines Panel, United States, 2007,[9] Center of Excellence for Orthopedic Pain Management Speising, Austria, 2007,[10] The Care and Research Institute (IRCCS), Italy, 2006,[12] COST B13 Working Group on Guidelines for Chronic Low Back Pain in Primary Care, European, 2004,[7] National Health and Medical Research Council, 2003, Australia,[16] National Health Committee. National Advisory Committee on Health and Disability, Accident Rehabilitation and Compensation Insurance Corporation; New Zealand, 2004,[17] Clinic on Low-Back Pain in Interdisciplinary Practice (Clip) Guidelines; Canada, 2007,[18] Institute for Clinical Systems Improvement (ICSI); United States, 2005,[19] Royal Dutch Association for Physiotherapy; physiotherapy guidelines; the Netherlands, 2003,[21] Royal Dutch Association for Physiotherapy; Manual Therapy Guidelines; the Netherlands, 2003,[22] Dutch College for General Practice; the Netherlands, 2005,[23] Dutch Quality Institute for Healthcare; the Netherlands, 2003.[24] Quality Assessment In general, the quality of most guidelines was satisfactory (Table 2). The domains that had low scores (50% or less of the maximum possible score) were, like in the previous review, stakeholder involvement, applicability, and editorial independence. On average, the score for editorial independence was better compared to 2004, but the range was wide. The applicability has improved as well. The score of the domain scope and purpose has decreased, however, the rigor of development improved adequately. The assessors had a difference in AGREE score per article of 3.5 of 23. After a consensus meeting this was reduced to a score difference of 2.4. Table 2. Domain Scores of the Guidelines (Percentages) AGREE Domain A B C D E F G H I J K L M N Scope and purpose 61 56 89 67 39 61 61 61 22 56 89 89 56 61 Stakeholder involvement 50 38 46 54 46 46 79 58 25 50 71 50 83 75 Rigor of development 81 88 95 48 62 74 98 88 43 50 95 93 48 76 Clarity and presentation 67 96 92 46 88 75 92 100 92 88 96 100 96 100 Applicability 72 56 56 11 44 44 56 44 22 89 39 28 33 61 Editorial independence 92 83 83 8 17 83 50 42 25 42 100 58 0 33 A, Guidelines: COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care, European, 2004.[13] B, Drug Committee of the German Medical Society, Germany, 2007.[8] C, American College of Physicians; American Pain Society Low Back Pain Guidelines Panel, United States, 2007.[9] D, Centre of Excellence for Orthopaedic Pain management Speising, Austria, 2007.[10] E, The Care and Research Institute (IRCCS), Italy, 2006.[12] F, COST B13 Working Group on Guidelines for Chronic Low Back Pain in Primary Care, European, 2004.[7] G, National Health and Medical Research Council, 2003, Australia.[16] H, National Health Committee. National Advisory Committee on Health and Disability, Accident Rehabilitation and Compensation Insurance Corporation, New Zealand, 2004.[17] I, Clinic on Low-Back Pain in Interdisciplinary Practice (Clip) Guidelines, Canada, 2007.[18] J, Institute for Clinical Systems Improvement (ICSI), United States, 2005.[19] K, Royal Dutch Association for Physiotherapy, the Netherlands, 2005.[21] L, Royal Dutch Association for Physiotherapy; manual therapy the Netherlands, 2003.[22] M, Dutch College for General Practice, the Netherlands, 2005.[23] N, Dutch Orthopedic Society of Quality institute for Healthcare, the Netherlands, 2003.[24] The guidelines scored best on the domain clarity and presentation. Many presented unambiguous recommendations, different options for management and key recommendations were easily identifiable. Furthermore, almost every guideline had good scores on the domain of rigour of development. The average score was 74.2% of the maximum possible score. Only 4 of the 14 guidelines had a moderate score around 50% of the maximum possible score in this domain.[10,18,19,23] This was mainly because no information was reported about search strategies and selection of the literature in these 4 guidelines. The Dutch college of general practice[23] gave additional information about search strategy on their website, but did not refer to it. When guidelines are compiled using all current available evidence, the quality of the guideline will not be influenced by selection bias. A description of the review process by an expert, before publication, was frequently missing.[7,12,13,17,18,24] In contrast, the health benefits, side effects, and risk were mostly well described. The recommendations for diagnosis and treatment were mostly explicitly linked to the available evidence, except for the Italian guideline.[12] All but one[18] of the guidelines clearly described their scope and purpose. However, many guidelines still did not get the maximum score for this item due to poor description of expected health gain. The target patient population was well described in most guidelines. Nevertheless, the clinical questions were missing in almost every guideline; only the Royal Dutch Association of Physiotherapy and the US guideline paid attention to this aspect.[9,21,22] The involvement of stakeholders in the development of guidelines was moderate. In almost every guideline the working group covered all relevant disciplines. The target users of the guidelines are often especially mentioned, except for the guideline of the Clinic on Low-Back Pain in Interdisciplinary Practice (CLIP).[19] Many guidelines lack a description of how they include the views and preferences of patients or had not performed a test among target users. Editorial independence was mostly not completely described. Only 5 of the 14 guidelines gave satisfying information on the editorial independence and described possible conflicts of interests.[7–9,13,21] Scores were lowest on the domain of applicability. Especially the item of presentation of key criteria for monitoring and/or audit got low scores. The reviewers scored 17 times "strongly disagree" and 7 times "disagree." The ICSI guideline gave a full description on the method of monitor guideline adherence, and the European guidelines on acute and chronic back pain[7,13] gave some options. All the other guidelines lacked a description of this subject. Guideline developers also need to consider the possible costs and barriers, but few have taken this into account.[6] Organizational or financial aspects, such as the availability of multidisciplinary centers for treatment of LBP, may also limit the implementation of guidelines. Since implementation of scientific evidence is a major target of guideline development, these items should be taken in account. Diagnostic and Therapeutic Recommendations Most guidelines had similar recommendations for the diagnosis of acute and chronic LBP: Assess red flags to exclude specific pathology.[7–10,12,13,16–19,21–24] History taking and examination were recommended in most guidelines. Many guidelines recommended to assess red flags if patients do not improve. Only in case of red flags additional investigation, such as diagnostic imaging or laboratory tests, should be considered.[7–10,12,13,16–19,22–24] Make a distinction between nonspecific LBP, radicular syndrome, and specific pathology; the so-called diagnostic triage.[7–10,12,13,18,19,21,22] Assess psychosocial factors directly or in case of no improvement, to assess the risk of chronic LBP.[7–10,12,13,16–19,21–24] These factors are know as "yellow flags." Perform a physical examination that includes, for example, the straight leg raise test, palpation for tenderness, and neuromuscular testing.[8–10,12,13,16–19,21–24] Physical examination is part of triage diagnostics to exclude radicular syndrome.[7–10,12,13,18,19,21,22] Specific pathoanatomic diagnosis must not be used in communication with the patient.[7,16,24] Most guidelines did not describe a timescale for further investigation, with the exception of the New Zealand and ICSI guidelines.[17,20] There were also a number of recommendations for treatment of acute LBP that were rather consistent among the various international guidelines: Reassure patients on the favorable prognosis,[8–10,12,13,16–19,21–24] if available provide printed patient information.[16,19] Advise patients to stay active.[8–10,12,13,16–19,21–24] Discourage bed rest.[8–10,12,13,16–19,21–24] Prescribe medication if necessary (preferably time contingent).[8–10,12,13,16–19,23,24] paracetamol/acetaminophen, nonsteroidal anti-inflammatory drugs, muscle relaxants or opioids on an individual basis. If patients do not improve, spinal manipulation could be considered.[9,12,13,24] Spinal manipulation could be considered in the first month.[8,10,17–19,22] Advise nonspecific exercises if patients did not improve.[8,9,12,13,16–19,21,22,24] The recommendations for the treatment of chronic LBP varied widely. The following recommendations were rather consistent among the various international guidelines: Advise patients to stay active.[7–10,12,16–19,21–24] Discourage bed rest.[7–10,12,16–19,21–24] Advise time-contingent nonspecific exercises.[7,8,10,12,18,21,22,23,24] Consider back-schooling.[7,8,10,12,18,19,24] Refer to a multidisciplinary program if other options fail.[7,8,9,10,13,18,19,23,24] Analgesics can be used supportively only for short-term, because of potential for addiction.[7,8,10,12,18,19,24] The guidelines recommended different analgesics, probably because of a difference between countries. The following treatment options were less consistently recommended, but were recommended in 3 or more guidelines. The strength of recommendation was mostly moderate or weak: Behavioral therapy;[8,10,18,24] cognitive-behavioral therapy,[7,9,22] Spinal manipulation,[7,8,9,10,12,18,22,24] Massage,[8,9,10,12,18] Prescription of antidepressants,[7,10,12,18] Prescription of muscle relaxants,[7,8,10,12,18] Surgery was recommended if all abovementioned options failed.[7,8,10,12] Infiltration of trigger points, acupuncture, and epidural steroids had conflicting recommendations. Discussion This article is an update of the previous published quality assessment of guidelines on LBP in primary care.[5] Compared to the quality assessment performed in 2004, the quality of guidelines seems to have improved. However, several AGREE items (views and preferences of patients, test among target users, clinical questions, editorial independence, and applicability) still need to improve. Not all guidelines previously assessed in 2004 were updated and new guidelines were included in the present review. Eight of the 17 guidelines included in the previous 2004 review were updated, although more guidelines had stated plans for revision. Consequently, some of the available guidelines may not be based on current best evidence and recommendations may be out of date. We identified possible updates of guidelines by searching the Internet and initiating personal communication with experts in this field. This Internet search may have introduced a bias, because large, established institutes are more likely to be found on the Internet than smaller, less established ones. Furthermore, English language guidelines will probably be overrepresented when searching the Internet and the authors were unable to read languages other than Dutch, German, and English. However, we believe that the guidelines we included reflect the current state-of-the-art of guidelines developed for the management of nonspecific LBP in primary care. This quality assessment was performed by other reviewers than in the previous article, which may have lead to different results in rating the items. MacDermid et al [25] showed that the AGREE instrument is reliable and valid for assessing the quality of clinical guidelines relevant to physical therapy practice. Pairs of appraisers out of 69 physical therapists showed good reliability, although there was variation across AGREE domains. Adding more than 3 appraisers did not consistently improve reliability.[25] Therefore, we do not expect that having different reviewers in this review compared with the 2004 review has led to a substantial bias. We have also attempted to minimize this potential bias by using a consensus meeting in which we critically reviewed our quality assessment and by discussing the quality assessment with the principal investigator who was also involved in an earlier article. This review showed that there still is room for improvement of the quality of guidelines and identified which AGREE items needs especially attention in future guidelines or updates of existing guidelines. At present, the AGREE instrument is probably more known among guideline developers than in 2004 when it was just published. Probably this has led to an improvement of the quality of guidelines as predicted in the previous article.[5] In some guidelines, the use of the AGREE instrument was specifically mentioned.[10,16,24] However, these guideline did not get higher scores than those that had no specific reference to the AGREE instrument. Compared to the previous assessment there was an improvement in applicability, but this improvement should continue since the absence of good applicability tools could lead to insufficient implementation, an important target of guidelines.[26] Also, authors should pay more attention to the editorial independence as there is evidence that the pharmaceutical industry has influence on guideline development and guideline recommendations.[27] Patient involvement and tests among target users were mostly not explicitly described in the guidelines. Especially the latter is an important item for further validation of guidelines.[6] In the previous review,[5] many guidelines did not explicitly describe how they had identified, selected, and summarized the available evidence. This item has improved, and search strategies and selection criteria were overall clearly described. Although the quality of underlying literature is high, good guidelines also take into consideration other aspects of treatment such as side effects, risks, costs, and ethical considerations. Future updates or future guidelines should spent more attention to these aspects. The diagnostic tools recommended were similar for acute and chronic LBP. Recommendations for acute LBP were quite consistent. Instead, there is little consensus among guidelines on the treatment of chronic LBP and more disciplines seem to be involved in treating chronic patients with LBP. Breen et al recommended developing multidisciplinary guidelines, which may be important especially in case of chronic LBP.[26] There is still room for generating evidence on management of chronic LBP, overcoming the flaws of currently published trials.[28] It is important to disseminate and implement this evidence and clinical guidelines seem useful tools for this purpose.[26] Successful implementation should lead to better adherence to guidelines of care providers and patients and consequently to better patient outcomes.[29] Concluding, the quality of guidelines for the management of acute and chronic LBP in primary care has improved during the last decade. Still, guideline developers should try to further improve guidelines using the AGREE instrument. Key Points We conducted a systematic review to assess the methodological quality of clinical guidelines for the management of acute and chronic LBP in primary care and compare their recommendations. Fourteen clinical guidelines were included. The 23 items of the AGREE instrument were used to assess the quality. Clarity and presentation of guidelines, scope and purpose, stakeholder involvement were domains which were met by the majority of guidelines. Applicability and editorial independence were domains where most guidelines scored low. The quality of recent guidelines is good, but there is still room for improvement. References Chou R. Evidence-based medicine and the challenge of low back pain: where are we now? Pain Pract 2005;5:153–78. Bombardier C, Esmail R, Nachemson AL. The Cochrane collaboration backreview group for spinal disorders. Spine 1997;22:837–40. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71–2. Koes BW, Van Tulder MW, Ostelo R, et al. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001;26:2504–13. Van Tulder MW, Tuut M, Pennick V, et al. Quality of primary care guidelines for acute low back pain. Spine 2004;29:E357–62. AGREE (Appraisal of Guidelines, Research, and Evaluation in Europe) Collaborative Group. Guideline development in Europe: an international comparison. Int J Technol Assess Health Care 2000;16:1039–49. Airaksinen O, Brox JI, Cedraschi C, et al. European guidelines for the management of chronic non-specific low back pain. Eur Spine J 2006;15:S192–300. Drug Committee of the German Medical Society, Recommendations for treatment of low back pain [in German]. Köln, Germany; 2007. Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. 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;147:478–91. Friedrich M, Likar R. Evidenz- und konsensusbasierte österreichische Leitlinien für das Management akuter und chronischer unspezifischer Kreuzschmerzen. Wien Klin Wochenschr 2007;119:189–97. Laerum E, Storheim K, Brox JL. New clinical guidelines for low back pain. Tidsskr Nor Laegeforen 2007;127:2706. Negrini S, Giovannoni S, Minozzi S, et al. Diagnostic therapeutic flow-charts for low back pain patients: the Italian clinical guidelines. Euro Medicophys 2006;42:151–70. Van Tulder MW, Becker A, Bekkering T, et al. European guidelines for the management of acute low back pain in primary care. Eur Spine J 2006;15(suppl 2):S169–91. Reis S, Lahad A. Clinical guidelines for diagnosis and treatment of acute low back pain. Harefuah 2007;146:631–5, 644. Wong DA, Mayer T, Watters W, et al. Unremitting Low Back Pain: North American Spine Society Phase III Clinical Guidelines for Multidisciplinary Spine Care Specialists. La Grange, IL: North American Spine Society; 2000:96. Australian Acute Musculoskeletal Pain Guidelines Group. Management of Acute Musculoskeletal Pain (National Library of Australia Cataloguing-in-Publication). Brisbane, Australia: Australian Academic Press; 2003. National Health Committee. New Zealand Acute Low Back Pain Guide. Wellington, New Zealand: National Advisory Committee on Health and Disability, Accident Rehabilitation and Compensation Insurance Corporation; 2004. Rossignol M, Arsenault B, Dionne C, et al. Clinic on Low-Back Pain in Interdisciplinary Practice (CLIP) Guidelines, 2007. Available at: http://www.santpub-mtl.qc.ca/clip. Institute for Clinical Systems Improvement (ICSI). Adult Low Back Pain. Bloomington, MN: ICSI; 2005. Department of Defense. Veterans Health Administration. Clinical Practice Guideline for the Management of Low Back Pain or Sciatica in the Primary Care Setting. Washington, DC: Department of Veterans Affairs (US); 1999. Bekkering GE, Hendriks HJM, Koes BW, et al. National Practice Guideline for the physiotherapeutic management of patients with low back pain. Physiotherapy 2003;89:82–96. Heijmans M, Hendriks HJM, Koes BW, et al. National Practice Guideline for manual therapy for patients with low back pain [in Dutch]. Ned Tijdschr Fys 2003;113(suppl 3):1–24. Chavannes AW, Mens JMA, Koes BW, et al. Dutch general practice guideline for non-specific low back pain [in Dutch]. Huisarts Wet 2005;48:113–23. The Dutch Institute for Healthcare Improvement (CBO). Clinical guideline for non-specific low back pain, 2003 [in Dutch]. MacDermid JC, D, Solway S, et al. Reliability and validity of the AGREE instrument used by physical therapists in assessment of clinical practice guidelines. BMC Health Serv Res 2005;5:18. Breen A, Van Tulder MW, Koes BW, et al. Mono-disciplinary or multidisciplinary back pain guidelines? How can we achieve a common message in primary care? Eur Spine J 2006;15:641–7. Choudhry NK, Stelfox HT, Detsky AS. Relationship between authors of clinical practice guidelines and the pharmaceutical industry. JAMA 2002;287:612–7. Van Tulder MW, Koes BW, Malmivaara A. Outcome of non-invasive treatment modalities on back pain: an evidence-based review. Eur Spine J 2006;15:S64–81. Fritz JM, Cleland JA, Brennan GP. Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists? Med Care 2007;45:973–80. Authors and Disclosures Walter Bouwmeester, PT, Annefloor van Enst, BSc, and Maurits van Tulder, PhD Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands. Address correspondence and reprint requests to Maurits van Tulder, PhD, Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands; E-mail: maurits.van.tulder@... The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Spine. 2009;34(23):2562-7. © 2009 Lippincott & Wilkins Quote Link to comment Share on other sites More sharing options...
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