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GRADE: An Emerging Consensus on Rating Quality of Evidence and Strength of Recommendations

By |January 23, 2017|Guidelines|

GRADE: An Emerging Consensus on Rating Quality of Evidence and Strength of Recommendations

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Brit Med J 2008 (Apr 26); 336 (7650): 924–926 ~ FULL TEXT

Gordon H Guyatt, Andrew D Oxman, Gunn E Vist,
Regina Kunz, Yngve Falck-Ytter

G H Guyatt
CLARITY Research Group,
Department of Clinical Epidemiology and Biostatistics,
Room 2C12, 1200 Main Street,
West Hamilton, ON, Canada L8N 3Z5


Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide.


From the FULL TEXT Article

Summary points

  • Failure to consider the quality of evidence can lead to misguided recommendations; hormone replacement therapy for post-menopausal women provides an instructive example
  • High quality evidence that an intervention’s desirable effects are clearly greater than its undesirable effects, or are clearly not, warrants a strong recommendation
  • Uncertainty about the trade-offs (because of low quality evidence or because the desirable and undesirable effects are closely balanced) warrants a weak recommendation
  • Guidelines should inform clinicians what the quality of the underlying evidence is and whether recommendations are strong or weak
  • The Grading of Recommendations Assessment, Development and Evaluation (GRADE ) approach provides a system for rating quality of evidence and strength of recommendations that is explicit, comprehensive, transparent, and pragmatic and is increasingly being adopted by organisations worldwide

Introduction:

Guideline developers around the world are inconsistent in how they rate quality of evidence and grade strength of recommendations. As a result, guideline users face challenges in understanding the messages that grading systems try to communicate. Since 2006 the BMJ has requested in its “Instructions to Authors” on bmj.com that authors should preferably use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for grading evidence when submitting a clinical guidelines article. What was behind this decision?

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Clinical Practice Guidelines for the Noninvasive Management
of Low Back Pain

By |December 2, 2016|Chiropractic Care, Guidelines, Low Back Pain|

Clinical Practice Guidelines for the Noninvasive Management of Low Back Pain: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

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Eur J Pain. 2016 (Oct 6).   doi: 10.1002/ejp.931 ~ FULL TEXT

J.J. Wong, P. Côté, D.A. Sutton, K. Randhawa, H.
Yu, S. Varatharajan, R. Goldgrub, M. Nordin, D.P.

UOIT-CMCC Centre for the Study of
Disability Prevention and Rehabilitation,
University of Ontario Institute of Technology (UOIT)
Canadian Memorial Chiropractic College (CMCC),
Oshawa, ON, Canada.


BACKGROUND: &nbsp Low back pain (LBP) is a major health problem, having a substantial effect on peoples’ quality of life and placing a significant economic burden on healthcare systems and, more broadly, societies. Many interventions to alleviate LBP are available but their cost effectiveness is unclear.

We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias.

According to high-quality guidelines:

(1)   all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options;

(2)   patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation;

(3)   the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and

(4)   patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation.

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Low Back Pain Guidelines Section

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Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

By |November 2, 2016|Guidelines, Low Back Pain|

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

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SOURCE:   Ann Int Medicine 2007 (Oct 2);   147 (7):   478–491

Roger Chou, MD; Amir Qaseem, MD, PhD, MHA;
Vincenza Snow, MD; Donald Casey, MD, MPH, MBA;
J. Thomas Cross, Jr, MD, MPH; Paul Shekelle, MD, PhD;
Douglas K. Owens, MD, MS

Clinical Efficacy Assessment Subcommittee
of the American College of Physicians
and the American College of Physicians/
American Pain Society Low Back Pain Guidelines Panel*


Review the complete Guideline for the Evaluation and Management of Low Back Pain: Evidence Review
(482 page Adobe Acrobat file)

From the FULL TEXT Article:

The Abstract

Recommendation 1:   Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).

Recommendation 2:   Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).

Recommendation 3:   Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).

Recommendation 4:   Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate–quality evidence).

Recommendation 5:   Clinicians should provide patients with evidence–based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self–care options (strong recommendation, moderate–quality evidence).

WARNING:   Before following Recommendation #6,
please review the
Contra-indications to NSAIDS use

.

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An Updated Overview of Clinical Guidelines for the Management of Non-specific Low Back Pain in Primary Care

By |October 28, 2016|Guidelines, Low Back Pain|

An Updated Overview of Clinical Guidelines for the Management of Non-specific Low Back Pain in Primary Care

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SOURCE:   Eur Spine J. 2010 (Dec); 19 (12): 2075–2094

Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C.

Department of General Practice,
Erasmus MC, P.O. Box 2040, 3000 CA,
Rotterdam, The Netherlands


This review of national and international guidelines conducted by Koes et. al. points out the disparities between guidelines with respect to spinal manipulation and the use of drugs for both chronic and acute low back pain.

Another review of guidelines published in June 2010 also noted a great degree of similarity between guidelines and that

“Recommendations for management of acute LBP emphasized patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy.”

Although there is always a need for more evidence, the evidence over the last few years is providing much stronger support for SMT and that evidence is slowly finding its way into major clinical guidelines both in the United States and internationally.

The Abstract

The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000.

Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity.

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Low Back Pain and Chiropractic Page

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Management of Neck Pain and Associated Disorders

By |March 23, 2016|Guidelines, Neck Pain, Whiplash|

Management of Neck Pain and Associated Disorders: A Clinical Practice Guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

The Chiro.Org Blog


SOURCE:   Eur Spine J. 2016 (Mar 16) [Epub]

Côté P, Wong JJ, Sutton D, Shearer HM, Mior S et. al.

Canada Research Chair in
Disability Prevention and Rehabilitation,
University of Ontario Institute of Technology (UOIT),
2000 Simcoe Street North,
Oshawa, ON, L1H 7L7, Canada.


PURPOSE:   To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD).

METHODS:   This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration.

RECOMMENDATION 1:   Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III.

RECOMMENDATION 2:   Clinicians should assess prognostic factors for delayed recovery from NAD.

RECOMMENDATION 3:   Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care.

RECOMMENDATION 4:   For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat.

RECOMMENDATION 5:   For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections.

RECOMMENDATION 6:   For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction.

RECOMMENDATION 7:   For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management.

RECOMMENDATION 8:   Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

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Adherence to Clinical Practice Guidelines Among Three Primary Contact Professions

By |September 5, 2014|Chiropractic Care, Clinical Decision-making, Evidence-based Medicine, Guidelines|

Adherence to Clinical Practice Guidelines Among Three Primary Contact Professions: A Best Evidence Synthesis of the Literature for the Management of Acute and Subacute Low Back Pain

The Chiro.Org Blog


SOURCE:   J Can Chiropr Assoc 2014 (Sept);   58(3):   220–237

Lyndon G. Amorin-Woods, B.App.Sci (Chiropractic)
Randy W. Beck, BSc (Hons), DC, PhD, DACNB, FAAFN, FACFN, Gregory F. Parkin-Smith, MTech(Chiro), MBBS, MSc, DrHC, James Lougheed, BA (Hons), Alexandra P. Bremner, BSc (Hons), DipEd, GradDipAppStats, PhD

Senior Clinical Supervisor, School of Health Professions
Murdoch University
Enrolled student, Master of Public Health
School of Population Health Faculty of Medicine, Dentistry and Health Sciences
The University of Western Australia


Aim:   To determine adherence to clinical practice guidelines in the medical, physiotherapy and chiropractic professions for acute and subacute mechanical low back pain through best-evidence synthesis of the healthcare literature.

Methods:   A structured best-evidence synthesis of the relevant literature through a literature search of relevant databases for peer-reviewed papers on adherence to clinical practice guidelines from 1995 to 2013. Inclusion of papers was based on selection criteria and appraisal by two reviewers who independently applied a modified Downs & Black appraisal tool. The appraised papers were summarized in tabular form and analysed by the authors.

Results:   The literature search retrieved 23 potentially relevant papers that were evaluated for methodological quality, of which 11 studies met the inclusion criteria. The main finding was that no profession in the study consistently attained an overall high concordance rating. Of the three professions examined, 73% of chiropractors adhered to current clinical practice guidelines, followed by physiotherapists (62%) and then medical practitioners (52%).

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