I recently finished my transitional Doctorate of Physical Therapy degree. There was long hours involved and lucky for you, I saved all (well…maybe most) of my work. Here is an oldie, but a goodie (voice of Kasey Kasem)
A Critical Appraisal of Clinical Practice Guidelines for Low Back Pain (LBP)
P: For patients with back and/or leg pain
I: what is the level of evidence regarding varying interventions, outcome measures, risk factors, and assessment processes
C: throughout the profession of physical therapy
O: that can be used in the course of care of individual patients
Reviewer:
Vincent Gutierrez, PT, MPT, cert. MDT
Search:
Ovidsp with title terms “low back pain” and “guidelines” with keyword of “physical therapy”. The results were limited to articles published in the previous two years. Seven citations were found.
Date of Search: March 1, 2014
Citation:
Delitto A, George S, Van Dillen L, et al. Low Back Pain: Clinical Practice Guidelines Linded to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. JOSPT 2012;42(4):A1-A57.
Summary:
The purpose of this guideline is to provide physical therapists with information, based on strength of the current evidence, regarding risk factors, clinical course, diagnosis/classification, differential diagnosis, examination, and interventions in the treatment of low back pain, with or without leg symptoms.
Content experts, appointed by the Orthpaedic Section of the American Physical Therapy Association (APTA), researched the above information. The authors independently searched the following databases: MEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews to initially acquire the content matter. The articles were limited to articles published prior to 2011 and the authors searched the reference list of each article in order to prevent the omission of a relevant article. The articles were leveled according to the criteria from the Centre for Evidence-based Medicine and were then were issued a grade of recommendation as previously described in the research.
The authors provided a comprehensive list of both International Statistical Classification of Diseases and Related Health Problems (ICD) Codes 10 and International Classification of Functioning, Disability and Health (ICF) codes.
The authors determined that based on lesser quality studies that data does not support a cause of LBP and risk factors are weakly associated with LBP.
Based on lesser quality studies, the data supports performing interventions that reduce the likelihood of transitioning from acute to chronic LBP and reducing the likelihood of recurrences.
Based on evidence from high quality studies, it is recommended to sub-classify patients based on signs and symptoms, such as the Treatment Based Classification System. Based on moderate evidence, the following signs and symptoms are useful in classifying patients based on the ICF and ICD-10: mobility impairment in the thoracic, lumbar or sacroiliac regions, referred or radiating pain into a lower extremity and generalize pain.
Based on evidence from high quality studies through expert opinion, it is recommended based on moderate evidence to consider performing a differential diagnosis to when serious medical conditions are suspected.
Based on high quality studies, there is strong evidence to recommend utilizing the Oswestry Disability Index (ODI or the Roland and Morris Disability Questionnaire (RMDQ) in order to monitor change pre-post intervention.
Based solely on case control studies, it is recommended based on opinion that clinicians should assess activity participation limitations.
Based on multiple high quality studies and few case studies, the authors provide strong evidence for recommending manipulative therapy in the treatment of LBP. These recommendations are only provided for patients with symptoms above the knee.
Based on high quality studies, the authors recommend performing trunk coordination, strengthening and endurance exercises to reduce pain and disability with patients ranging from subacute to chronic and also patients status post microdiscectomy. This recommendation is based on strong evidence.
Based on both high quality studies and case control studies, the authors recommend utilizing repeated movements or procedures, in a specific direction, to promote centralization. This is based on strong evidence.
Based on lesser quality evidence and case controlled studies, the authors recommend flexion exercises, combined with other interventions, for reducing pain in older patients with chronic symptoms. This is based on weak evidence.
Based on lesser quality studies and case series, the authors recommend lower quarter nerve mobilization procedures to reduce pain in patients with subacute and chronic LBP, with lower extremity symptoms. This is based on weak evidence.
Based on research ranging from high quality studies to expert opinion, it is recommended that clinicians avoid educational techniques based on pathoanatomy and extended bed rest. Recommended advice is centered on the inherent strength of the spine, the neuroscience explaining pain, the overall favorable prognosis of LBP, the use of active (as compared to passive) coping mechanisms, and early return to activity. This is based on strong evidence.
Conclusion:
Based on the Clinical Practice Guidelines above, the following is recommended based on strong evidence: utilizing an outcome measure such as the ODI or RMDQ, manual therapy, trunk coordination, strengthening and endurance exercises, promoting centralization, and performing patient education.