Effects of Guideline-oriented Treatment for Low Back Pain and Ways to Implement Guidelines

Background: Development and implementation of evidence-based guidelines appear to be two of the most promising and effective tools for improving the quality of care. New multifaceted strategies have been developed to prove perceived barriers and discrepancies between current practice and the guidelines' recommendations.

Objective: This systematic review compared the effectiveness of guideline-oriented treatments for LBP with non-guideline oriented treatments and determined which implementation strategies for clinical practitioners had been used to ensure the acceptance and application of successful guidelines in clinical practice settings.

Method: A computer-aided sensitive search was performed in multiple databases. Randomised controlled trials were included if they dealt with the clinical management of LBP.

Results: There was limited evidence that both a guideline-oriented patient treatment using a "personal active implementation program" or an "early multifaceted implementation program" have better effect on pain (VAS) and functional disability in LBP. Effect sizes for pain outcome ranged between d = 0.14 and d = 0.36, for functional disability, assessed by questionnaires, ranged between d = 0.5 (CI 0.08 / 0.91) and d = 0.58 (CI 0.16 / 1.0). Reported findings showed at best a moderate effect of the "guideline" treatment in comparison to non-guideline treatments. There was no evidence that an education- and feedback-supported, multifaceted implementation program decreases the application of radiology and speciality services. There was conflicting evidence that a multifaceted implementation program changes the referral to physiotherapy.

Conclusion: Further research should address the underlying causes for these disturbing findings. It should particularly include cost-effectiveness, the same main outcomes and should be adapted to the Swiss health system.