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Table 3

Target group, authors, evidence base, consensus, and implementation of clinical guidelines in low back pain

CountryTarget groupGuideline committeeEvidence baseConsensusPresentation/Implementation
Australia (2003)Primary and secondary careMultidisciplinary: Osteopathic, Rheumatology, Physiotherapy, Chiropractic, GP, Epidemiology, consumer representative (n = 9)Update of the previous Australian guideline using the AGREE. Comprehensive literature search (up to 2002) pubmed, cinhal embase and Cochrane for clinical evidence. All recommendations are linked to evidence levelUse of consensus method not clearFree online version, Included in book ‘evidence-based management of acute musculoskeletal pain: a guide for clinicians’

Austria (2007)Primary and secondary care (all who are involved with diagnosis and treatment of LBP)Multidisciplinary (psychiatry, orthopaedics, general practice, physiotherapy, radiology, psychology, neurology, rehabilitation, osteology?, pain medicine, ergotherapy, rheumatology, neurosurgery (n = 17)Based on European guidelines (2004) + updated evidence regarding massage and acupuncture. Grading of evidence was used using an explicit weighting system
No direct linking between recommendations and underlying evidence
Draft guideline presented and approved at two consensus meetingsPublished in national journal in Austria

Canada (2007)Primary careMultidisciplinary with primary health care professionalsBased on an extensive literature review of the best available evidence and assessment of knowledge in all areas of back pain management it also combines with participant’s clinical experienceUse of consensus method not clearAvailable on website

Europe (2006)
Primary careMultidisciplinary: experts in the field of low back pain research in primary care (n = 14)Literature search from 1966 to 2003 on the Cochrane Library,
Medline, Embase for searches of Cochrane reviews (and on other systematic reviews if a Cochrane review was not available), additional trials published after the Cochrane reviews, and existing national guidelines. Strength of evidence was assessed based on the original
ratings of the AHCPR Guidelines (1994) and levels of evidence recommended in the method guidelines of the
Cochrane Back Review group
Use of consensus method not clear; “use of group discussions”Publication in a journal with planned update after 3 years

Europe (2006)
Primary care and secondary careMultidisciplinary: experts in the field of low back pain research in primary care (n = 11)Literature search up to 2002. Based on systematic review of systematic reviews and randomised clinical trials on CLBP. Systematic reviews were rated using the Oxman & Guyatt index and RCTs rated using the van Tulder et al. 1997 criteriaUse of consensus method not clear. Use of group discussions, no formal grading scheme usedPublished on a website and in a journal. Professional associations will disseminate and implement these guidelines

Finland (2008)Primary and secondary carePhysiatrist, radiologist, general practitioner and occupational health physician, neurosurgeon, physiotherapist, orthopaedic surgeon (n = 8)Based on explicit weighing of evidence. Important decision points are backed up by level of evidence statementsConsensus on evidence synthesis and text during Committee meetingsA summary of the guidelines has been published in the Finnish journal (Duodecim 2008). The whole text is published on the website of the Finnish Current Care Guidelines

France (2000)Acute and Chronic:
Non stated
Acute LBP: Multidisciplinary; Rheumatologist (2), Physiotherapist, Psychiatrist, Neuro radiologist, GP (2), Radiologist, Occupational Medicine Specialist, Orthopaedic surgeon, Specialist in Physical Medicine and Rehabilitation (11).
Chronic LBP: Multidisciplinary;Rheumatologist (2), Physiotherapist, Psychiatrist, Neuro-radiologist, GP (4), Radiologist, Occupational Medicine Specialist, Orthopaedic surgeon, Specialist in Physical Medicine and Rehabilitation (13)
Acute & Chronic:
Review of the literature—no further detail provided
Acute & Chronic:
Use of consensus in the absence of evidence
Acute & Chronic:
Guidelines commissioned from the Agence Nationale d’Accreditation d’Evaluation en Sante by CNAMTS, the French national health insurance fund. Reports published in English and French and available online

Germany (2007)Primary and secondary careMultidisciplinary: Drug committee of the German medical association, including general practice, pharmacology (n = ?)Based on European guidelines (2006). Recommendations are all supported with referencesDraft guidelines are presented and discussed with various medical disciplinesComplete guidelines and summaries for practitioners are available on a website

Italy (2006)Primary and secondary care, particularlyMultidisciplinary: general medicine, neurology, neurosurgery, orthopaedics, rheumatology, physical medicine and rehabilitation, occupational medicine, physiotherapy, epidemiology (n = 14)Literature search of international guidelines, systematic reviews in Medline and the Cochrane Library, weighing of evidence using a rating system based on strength of the studiesRecommendations based on level of evidence, practicality issues and own experienceJournal publication, complete version available on website, presentation at national conferences of relevant professional groups, local workshop and training days, outreach visits

New Zealand (2004)Primary careMultidisciplinary: consumer representative, pain medicine, occupation medicine, chiropractor, psychologist, osteopath, occupational medicine, physiotherapy, rheumatology, GP, musculoskeletal medicine (n = 16)Comprehensive literature search; weighing of evidence using a rating system based on strength of the studies; for all recommendations, at least moderate evidence availableContributed by relevant professional groupsPublication of report, incorporating the guide to assessing yellow flags, endorsed by NZ Guidelines Group and relevant professional groups

Norway (2007)Primary and secondary careMultidisciplinary: occupational, rehabilitation, physiotherapy, chiropractic, manual therapy, neurology, orthopaedics, radiology, general practice (n = 11)Comprehensive search of the literature (Cochrane, Medline, Embase), quality assessment, weighing of evidence attached to the recommendationsRecommendations based on evidence and discussion in the groupPublication in Norwegian report, including a summary and a patient brochure

Spain (2005)Health care professionals that treat low back painSpanish members of the COST B13 and a multidisciplinary team composed of GP, rural medicine, rheumatology, rehabilitation, neurosurgery, orthopaedics, radiology, work medicine, public health, anxiety and stress, physical therapist, Evidence-based experts and anaesthesiologistsAdapted from the European guidelines with addition of new evidence and evidence in Spanish (systematically reviewed). Also recommendations were performed using the AGREE tool to better define the recommendation using a standardised methodology. Studies were sent to the Web de la Espalda for analysis of methodological qualityAll members of the group approved the final version but consensus method is not clearly describedSummary spreadsheet with recommendations, an algorithm for diagnosis and treatment and an extensive report published online. Frequent updates are predicted

The Netherlands (2003)Primary and secondary careMultidisciplinary; general practice, orthopaedics, radiology, neurosurgery, rehabilitation, physiotherapy, psychology, patient representation, chiropractic, manual therapy, neurology, rheumatology, exercise therapy (Cesar, Mensendieck), anaesthesiology, occupational (n = 31)All recommendations are supported as possible by scientific evidence up to Jan 2001. All evidence was weighted using an explicit weighting system. All recommendations are presented with their level of evidenceRecommendations were based on the scientific evidence + considerations such as patient preferences, costs, availability of health services, and/or organisational aspectsPublished on website, distributed among hospitals and medical societies, summary published in the Dutch Medical Journal, presented in Finnish journal (Duodecim 1999)

United Kingdom (2008)Healthcare professionals working within the NHS in England providing primary health careUnspecified multidisciplinary teamUpdate of previous guidelines (PRODIGY, RCGP): incorporates new evidence from electronic database search of guidelines, systematic reviews and randomised controlled trials on primary care management of low back painNot reportedPart of the NHS Clinical Knowledge Summaries (CKS), a freely available, online source of evidence-based information and practical ‘know how’ about the common conditions managed in primary and first-contact care
CKS provides quick answers to real-life clinical questions that arise in the consultation, linking to detailed answers that clearly outline the evidence on which they are based

United States (2007)Primary careMultidisciplinary
7 authors for a large multidisciplinary committee Clinical Efficacy Assessment Subcommittee of the ACP
Comprehensive literature search of English-language articles weighing of evidence using a rating system; for all recommendations, at least fair evidence availableEvidence-based and consensus-basedJournal publication, audio summary and patient summary
Valid for 5 years after publication or until next update

Most apparent change, if any, since 2001
The current guidelines appear more often focused on primary care as well as secondary care compared to 2001 when the focus was more exclusively on primary careThe guideline committees in 2001 as well as currently consist of a multidisciplinary panel (which of course is not surprisingly since multidisciplinary guidelines were included in the current and the 2001 review)More guidelines now explicitly state that they are based on a previous guideline (i.e. the European guidelines), furthermore almost all guidelines now explicitly state that they applied a weighting system to the evidence. In 2001 a weighting system was less often usedIn 2001 and at present consensus methods were used, Usually group discussion take place, but the exact method is often not clear. This has not changed since 2001In most cases the guideline is published and disseminated without an active implementation programme. This has not changed since 2001
The main change is that currently almost all guidelines are available on a website whereas in 2001 more often paper versions were distributed