PERSISTANT LOW BACK PAIN FIGURE 2: SOME EXAMPLES OF THE RECOMMENDATIONS FOR PRACTICE FROM (2)

Note: All recommendations were given a grading (ie. A,C or D) - figure 4 explains what each grade means

PART 1. Focus on exercise The key recommendation is: People with persistent LBP should be given the opportunity to participate in an exercise programme, in a form appropriate and acceptable to each individual, after physiotherapy assessment

A

To improve function one or more of the following should be considered: ■ Organised aerobic exercises ■ General exercises

■ Hydrotherapy exercises ■ Mobilising exercises ■ Strengthening exercises ■ Core stability exercises ■ McKenzie exercises

A A A C C C C

To apply the above the Guidelines

PART 2. Focus on manual therapy The following key recommendation was made: Manual therapy, if used, should be part of a package of interventions that include exercise and self-management to reduce pain, improve function and improve psychological status for people with persistent LBP

A

To improve function ■ Combined manipulation and manual mobilisation should be considered as part of the package of interventionsA

■ Manipulation alone (as opposed to combined manipulation and manual mobilisation) is not recommended as a part of a package of intervention to improve function

A

Development Group (GDG) made a series of recommendations and some examples of these are given below. ■ Patient choice should affect the choice of exercise e.g. believing the benefits of aerobic exercise should suggest aerobic exercise as a first choice of exercise programme

D

■ Resources in the person’s community – should affect choice of exercise eg. a local swimming pool with a self-help hydrotherapy group may suggest hydrotherapy exercises as a first choice of treatment

D

■ The confidence and experience of the practitioner is important eg. experts teaching exercises with conviction are likely to achieve the best outcomes and this should be recognised

D

Examples of recommendations consider- ing the application of manual therapy ■ Individual expectations need to be elicited; unrealistic expectations such as expecting a ‘cure’ should not be reinforced, people should be encour- aged to take responsibility for manag- ing their pain using appropriate self- management strategies

D

■ Manipulative techniques should be considered where the aim is temporary pain relief as part of a strategy (agreed by the person with persistent LBP) to enable activity

D

■ The confidence and experience of the practitioner affects the outcomes e.g. an expert in manipulative techniques is likely to achieve the best outcomes and this should be recognised

D

PART 3. Focus on advice for people with persistent LBP Advice and education given by the practitioner should be appropriate and evidence based. Some main points drawn from sources outside the scope of these guidelines are: ■ Movement is beneficial for your back ■ There is unlikely to be any serious damage to your back ■ Your pain is likely to improve in the short-term but it is likely to recur ■ Simple painkillers are likely to help reduce the pain ■ Your back is strong ■ Staying at work/continuing with usual activity is normally helpful

The important point is that all practitioners give the same straightforward and clear messages. These recommendations were agreed by the GDG but came from literature outside the systematic review and hence they were not graded.

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references for the studies were imported into bibliographic software and titles and abstracts were scanned for RCTs relevant to this review. Full text paper copies of relevant RCTs were obtained for the reviewers.

The relevant RCTs (31 for exercise and 10 for manual therapy) were assessed for methodological quality by using a modification of the van Tulder Quality Scale (3) by two independent reviewers. Only those defined as high in methodolog- ical quality were used as the basis of recommendations and some examples are given.

Considering the effect of exercise in improving function, reliable evidence was that the following exercises improve function: ■ general exercises (4-6) ■ organised aerobic exercises - aerobic exercises and general exercises were similarly effective in improving function (7)

■ hydrotherapy exercises (8). See figure 2 for more specific recommen- dations.

Consensus methods The systematic review indicated uncertain- ty in whether the following types of exercise improved function for people with persistent LBP: ■ mobilising ■ strengthening ■ core stability ■ McKenzie. To address this uncertainty, and with a view to developing more complete and clinically useful guidelines, the GDG generated consensus evidence using a nominal group technique (figure 3) (9). To increase the credibility of this process nine additional experts in LBP joined the 14 GDG members to form the consensus expert group. Following previous CSP guideline development methods (10) 75% or more agreement of the expert group led to consensus evidence statements.

For both rounds of the questionnaire experts were asked to take into account all their knowledge and experience (clinical, research, service user) and the systematic review (containing results of some small and less methodologically sound papers). For the discussion experts were asked to explain the reasons for their vote.

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