Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol Evidence-based medicine and the challenge of low back pain: where are we now? Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761] Cost-effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for nonspecific low back pain: design of a stepped-wedge cluster randomised controlled trial The Effectiveness of a Posted Information Package on the Beliefs and Behavior of Musculoskeletal Practitioners: The UK Chiropractors, Osteopaths, and Musculoskeletal Physiotherapists Low Back Pain ManagemENT (COMPLeMENT) Randomized Trial How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Adherence of Irish general practitioners to European guidelines for acute low back pain: a prospective pilot study. Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers’ perspectives and experiences Evaluation of a Theory-Informed Implementation Intervention for the Management of Acute Low Back Pain in General Medical Practice: The IMPLEMENT Cluster Randomised Trial Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain What Comparative Effectiveness Research Is Needed? A Framework for Using Guidelines and Systematic Reviews to Identify Evidence Gaps and Research Priorities Effectiveness of implementation strategies in improving physician adherence to guideline recommendations in heart failure: a systematic review protocol The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT): Cluster randomised controlled trial study protocol Key Steps in Conducting Systematic Reviews for Underpinning Clinical Practice Guidelines: Methodology of the European Association of Urology. EAU guidelines on renal cell carcinoma: the 2010 update. Understanding diagnosis and management of dementia and guideline implementation in general practice: a qualitative study using the theoretical domains framework Effectiveness of Peer Assessment for Implementing a Dutch Physical Therapy Low Back Pain Guideline: Cluster Randomized Controlled Trial Changing the use of electronic fetal monitoring and labor support: a case study of barriers and facilitators. Reporting of prognostic markers: current problems and development of guidelines for evidence-based practice in the future Nurses' perceived knowledge, beliefs, skills, and needs regarding evidence-based practice: implications for accelerating the paradigm shift.
Background Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care . A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines . Further , the review recommended the use of theory in the development of implementation interventions . A clinical practice guideline for the management of acute low-back pain has been developed in Australia ( 2003 ) . Acute low-back pain is a common condition , has a high burden , and there is some indication of an evidence - practice gap in the allied health setting . This provides an opportunity to develop and test a theory-based implementation intervention which , if effective , may provide benefits for patients with this condition . Aims This study aims to estimate the effectiveness of a theory-based intervention  to increase allied health practitioners ' ( physiotherapists and chiropractors in Victoria , Australia ) compliance with a clinical practice guideline for acute non-specific low back pain ( LBP ) , compared with providing practitioners with a printed copy of the guideline . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray  , and improving mean level of disability for patients three months post-onset of acute LBP . Methods The design of the study is a cluster r and omised trial . Restricted r and omisation was used to r and omise 210 practice s ( clusters ) to an intervention or control group . Practitioners in the control group received a printed copy of the guideline . Practitioners in the intervention group received a theory-based intervention developed to address prospect ively identified barriers to practitioner compliance with the guideline . The intervention primarily consisted of an educational symposium .  Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period , three months post the intervention symposia , are eligible for inclusion . Sample size calculations are based on recruiting between 15 to 40 patients per practice . Outcome assessors will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN12609001022257 ( date registered 25th November 2009 Low  back pain  has long been described as a challenge for both primary care physicians and specialists . Management of  low back pain  has also been criticized as frequently arbitrary , inappropriate , or ineffective . Contributing factors have been an inadequate evidence base and a need for more rigorous appraisal s of the available literature . Evidence -based medicine , an approach to clinical problem solving , is predicated on the premise that high- quality health care will result from practice s consistent with the best evidence . In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion , authority , and un systematic clinical observations , evidence -based medicine emphasizes the need for rigorous critical appraisal s of the scientific literature to inform medical decision making . Evidence -based medicine places strong weight on the requirement for valid studies , particularly r and omized controlled trials , to appropriately evaluate the effectiveness of health care interventions . Because of the rapidly increasing volume of medical literature , however , most clinicians are unable to keep up-to- date with all the new data . Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic review s and evidence -based clinical practice guidelines . Like primary studies , systematic review s and clinical practice guidelines must adhere to high method ologic st and ards to reduce error and bias . As in other areas of medicine , the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings . In addition to more rigorous primary studies , an increasing number of high- quality systematic review s and evidence -based clinical practice guidelines for low back pain are also available . Although some research gaps and method ologic shortcomings persist , the richer evidence base has greatly improved our underst and ing of what does and does not work for low back pain . Despite these advances , the best available evidence often does not inform everyday clinical decisions for low back pain . Nonetheless , there is widespread agreement that adherence to evidence -based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care . This article review s basic principles of evidence -based medicine , discusses evidence -based medicine in the context of low back pain management , and summarizes some useful evidence -based medicine re sources Background Low back pain ( LBP ) is a common and costly problem . Initiatives design ed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence -based clinical guidelines . The three professional groups of chiropractic , osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines . Even so , many seem unaware that such guidelines exist . Furthermore , the behaviour of at least some of these practitioners differs from that recommended in these guidelines .Few r and omised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control . All these trials have used a cluster design and most have method ological flaws . None specifically focus upon practitioner behaviour towards LBP patients . Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results . Although numerous LBP guidelines have been developed worldwide , there is a paucity of data on whether their dissemination actually changes practitioner behaviour . Primarily because of its low unit cost , sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy . The effect size of such a strategy , at an individual practitioner level , is likely to be small . However , if large numbers of practitioners are targeted , this strategy might achieve meaningful changes at a population level . Methods The primary aim of this prospect i ve , pragmatic r and omised controlled trial is to test the short-term effectiveness ( six-months following intervention ) of a directly-posted information package on the reported clinical behaviour ( primary outcome ) , attitudes and beliefs of UK chiropractors , osteopaths and musculoskeletal physiotherapists . We sought to r and omly allocate a combined sample of 1,800 consenting practitioners to receive either the information package ( intervention arm ) or no information above that gained during normal practice ( control arm ) . We collected question naire data at baseline and six-months post-intervention . The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity , work and bed-rest , that fall within categories previously defined by an expert consensus exercise as either ' guideline -consistent ' and ' guideline -inconsistent ' Background Low back pain ( LBP ) is one of the most prevalent and expensive health care problems in industrialised countries . LBP leads to high health care utility and productivity losses ; leaving the individual , the employer , and society with substantial costs . To improve the care for LBP patients and reduce the high societal and financial burden of LBP , in 2010 the ‘ Multidisciplinary care guideline for nonspecific low back pain ’ was developed in the Netherl and s. The current paper describes the design of a study aim ing to evaluate the ( cost- ) effectiveness of a multifaceted strategy to implement this guideline . Methods In a cluster-r and omised controlled trial , the ( cost- ) effectiveness of a multifaceted implementation strategy will be compared to passive guideline dissemination . Using a stepped-wedge approach , participating general practitioners , physiotherapists , and occupational physicians are allocated into clusters and will attend a multidisciplinary continuing medical education training session . The timing these clusters receive the training is the unit of r and omisation . LBP patients visiting the participating health care providers are invited to participate in the trial and will receive access to a multimedia intervention aim ed at improving beliefs , cognitions , and self-management . The primary outcome measure of this study is patient back beliefs . Secondary outcome measures on patient level include pain , functional status , quality of life , health care utility , and productivity losses . Outcome measures on professional level include knowledge and attitude towards the guideline , and guideline adherence . A process evaluation for the implementation strategy will be performed among the health care providers and the patients . Furthermore , a qualitative subgroup analysis among patients with various ethnic background s will be performed . Discussion This study will give insight into the ( cost- ) effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for non-specific back pain to improve outcomes on patient and professional level . The valuable information gained with this study may prove useful for policy-makers , health care providers , and research ers who are in the process of reducing the burden of back pain on individuals and society . Trial Registration Netherl and s Trial Register ( NTR ) : NTR4329 . Registered December 20th , 2013 Study Design . R and omized controlled trial . Objective . To investigate the effect of a printed information package on the low back pain (LBP)-related beliefs and reported behavior of musculoskeletal practitioners ( chiropractors , osteopaths , and musculoskeletal physiotherapists ) across the United Kingdom . Summary of Background Data . A substantial proportion of musculoskeletal practitioners in United Kingdom does not follow current LBP guideline recommendations . Methods . In total , 1758 practitioners were r and omly allocated to either of the 2 study arms . One arm was posted a printed information package containing guideline recommendations for the management of LBP ( n = 876 ) and the other received no intervention ( n = 882 ) . The primary outcome measure consisted of 3 “ quality indicators ” ( activity , work , and bed-rest ) relating to a vignette of a patient with LBP , in which responses were dichotomized into either “ guideline -inconsistent ” or “ guideline -consistent . ” The secondary outcome was the practitioners ' LBP-related beliefs , measured using the Health Care Providers Pain and Impairment Relationship Scale . Outcomes were measured at baseline and at 6 months . Results . Follow-up at 6 months was 89 % . The changes in reported behavior on the quality indicators were as follows : activity , odds ratio ( OR ) 1.29 ( 95 % confidence interval , 1.03–1.61 ) and number needed to be treated ( NNT ) , 19 ( 15–28 ) ; work , OR 1.35 ( 1.07–1.70 ) and NNT 19 ( 14–29 ) ; and bed-rest , OR 1.31 ( 0.97–1.76 ) and NNT 47 ( 33–103 ) . The composite NNT for a change from guideline -inconsistent to guideline -consistent behavior on at least 1 of the 3 quality indicators was 10 ( 9–14 ) . LBP-related beliefs were significantly improved in those who were sent the information package ( P = 0.002 ) , but only to a small degree ( mean difference , 0.884 scale points ; 95 % confidence interval , 0.319–1.448 ) . Conclusion . Printed educational material can shift LBP-related beliefs and reported behaviors of musculoskeletal practitioners , toward practice that is more in line with guideline recommendations & NA ; Guidelines for the management of low back pain ( LBP ) have existed for many years , but adherence to these by health care practitioners ( HCPs ) remains suboptimal . The aim of this study was to measure the attitudes , beliefs and reported clinical behaviour of UK physiotherapists ( PTs ) and general practitioners ( GPs ) about LBP and to explore the associations between these . A cross‐sectional postal survey of GPs ( n = 2000 ) and PTs ( n = 2000 ) was conducted that included the  Pain Attitudes and Beliefs Scale ( PABT.PT )  , and a vignette of a  patient with non‐specific LBP ( NSLBP )  with questions asking about recommendations for work , activity and bedrest . Data from 1022 respondents ( 442 GPs and 580 PTs ) who had recently treated patients with LBP were analysed . Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations , 28 % reported they would advise this patient to remain off work . Work advice was significantly related to the PABS.PT scores with higher biomedical ( F1,986 = 77.5 , p < 0.0001 ) and lower behavioural ( F1,981 = 31.9 , p < 0.001 ) scores associated with advice to remain off work . We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse . Many HCPs held the belief that LBP necessitates some avoidance of activities and work . The attitudes and beliefs of these HCPs were associated with their self‐reported clinical behaviour regarding advice about work . Future studies need to investigate whether approaches aim ed at modifying these HCP factors can lead to improved patient outcomes Abstract Purpose To evaluate the effectiveness of non-steroidal anti-inflammatory drugs ( NSAIDs ) for the management of neck pain and associated disorders ( NAD ) , whiplash-associated disorders , and non-specific low back pain ( LBP ) with or without radiculopathy . Methods We systematic ally search ed six data bases from 2000 to 2014 . R and om pairs of independent review ers critically appraised eligible systematic review s using the Scottish Intercollegiate Guidelines Network criteria . We included systematic review s with a low risk of bias in our best evidence synthesis . Results We screened 706 citations and 14 systematic review s were eligible for critical appraisal . Eight systematic review s had a low risk of bias . For recent-onset NAD , evidence suggests that intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy . For NAD ( duration not specified ) , oral NSAIDs may be more effective than placebo . For recent-onset LBP , evidence suggests that : ( 1 ) oral NSAIDs lead to similar outcomes to placebo or a muscle relaxant ; and ( 2 ) oral NSAIDs with bed rest lead to similar outcomes as placebo with bed rest . For persistent LBP , evidence suggests that : ( 1 ) oral NSAIDs are more effective than placebo ; and ( 2 ) oral NSAIDs may be more effective than acetaminophen . For recent-onset LBP with radiculopathy , there is inconsistent evidence on the effectiveness of oral NSAIDs versus placebo . Finally , different oral NSAIDs lead to similar outcomes for neck and LBP with or without radiculopathy . Conclusions For NAD , oral NSAIDs may be more effective than placebo . Oral NSAIDs are more effective than placebo for persistent LBP , but not for recent-onset LBP . Different oral NSAIDs lead to similar outcomes for neck pain and LBP There are no national low back pain ( LBP ) clinical guidelines in Irel and , and neither the level of adherence of General Practitioners ( GPs ) to the European guidelines , nor the cost of LBP to the patient and the state , have been investigated . A prospect i ve pilot study was conducted on 54 consenting patients ( 18 M , 36F : mean age ( SD ) : 40.5 ( 14.3 ) years ) with a new episode of acute LBP ( <3 months ) attending one of nine participating GPs . Baseline demographic , LBP classification [ i.e. simple back ache ( SBA ) , nerve root pain ( NRP ) , serious spinal pathology ( SSP ) ] and primary care management data were recorded over a three month period . Adherence and costs were estimated based on : medication prescription , referral for investigations , treatment or consultations , and wage replacement costs ( time signed off work ) . For both SBA and NRP , medication prescriptions were consistent with European guideline recommendations , but not for referral for further treatment ( 39 % of SBA patients were referred on first visit ) , secondary care ( 54 % of NRP patients were referred on first visit ) , or discontinuation of work ( 50 % NRP patients on first GP visit ) . The average total cost ( direct and wage replacement ) for a single episode of LBP over 12 weeks was 20,531 Euros ( 20,300 - 20,762 ) . Direct costs accounted for 43 % [ 8874.36 Euros , ( 8643.37 - 9105.37 Euros ) ] and wage replacement costs 57 % ( 11,657 Euros ) . In conclusion , management of acute LBP in a cohort of GPs in Irel and was not consistent with European clinical guideline recommendations , and warrants higher levels of postgraduate education among GPs , as well as restructuring of primary care services , which should improve patient outcome and reduce costs Background Hypertension and diabetes , key risk factors for cardiovascular disease , are significant health problems globally . As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000 , clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011 . This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting . Methods A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level , as well as to gain insight into how practitioners view the usability and practicality of the guidelines . Ten family health centres were r and omly chosen from a list of all the family health centres ( n = 136 ) located in Ulaanbaatar City . In each centre , a focus group discussion with nurses ( n = 20 ) and individual interviews with practice doctors ( n = 10 ) and practice managers ( n = 10 ) were conducted . Data was analysed using a thematic approach utilising the Theoretical Domains Framework . Results The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice . They also reported having attended guideline training sessions which were focused on practice skill development . The majority of participants expressed satisfaction with the wide range of re sources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines . The re sources , supplied from 2011 onwards , included screening devices , equipment for blood tests , medications and educational material s. Other enablers were the participants ’ commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines . Primary care providers reported a number of challenges in implementing the guidelines , including frustration caused by increased workload and long waiting times , time constraints , difficulties with conflicting tasks and low patient health literacy . Conclusions This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low re source primary care setting s. It also offers some key lessons that might be carefully considered when other evidence -based clinical guidelines are to be put into effect in low re source setting s and elsewhere Introduction This cluster r and omised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain ( LBP ) in general practice . Methods General practice s were r and omised to either  access to a guideline for acute LBP ( control ) or facilitated interactive workshops ( intervention ) . We measured behavioural predictors ( e.g. knowledge , attitudes and intentions ) and fear avoidance beliefs . We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner ( GP ) level : behavioural simulation ( clinical decision about vignettes ) and rates of x-ray and CT-scan ( medical administrative data ) . All those not involved in the delivery of the intervention were blinded to allocation . Results 47 practice s ( 53 GPs ) were r and omised to the control and 45 practice s ( 59 GPs ) to the intervention . The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information ; a minimum of 38 GPs were available from the intervention group , and a minimum of 40 GPs from the control group . For the behavioural constructs , although effect estimates were small , the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral . For behavioural simulation , intervention group GPs were more likely to adhere to guideline recommendations about x-ray ( OR 1.76 , 95%CI 1.01 , 3.05 ) and more likely to give advice to stay active ( OR 4.49 , 95%CI 1.90 to 10.60 ) . Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear ; rate ratio 0.87 ( 95%CI 0.68 , 1.10 ) for x-ray or CT-scan . Conclusions The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence -based guideline , but it did not result in statistically significant changes in actual behaviour . Trial Registration Australian New Zeal and Clinical Trials Registry Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain 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 ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied OBJECTIVE : The effect of clinical guidelines on re source utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied . We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain . DESIGN : Physician groups were r and omized to receive guideline education and individual feedback , supporting patient education material s , both , or neither . The impact on guideline adherence and re source utilization was evaluated during the 12-month period before and after implementation . PARTICIPANTS : Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practice s. INTERVENTIONS : Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders . The patient education component included written and videotaped material s on the care of low back pain . MAIN RESULTS : The clinician intervention was associated with an absolute increase in guideline -consistent behavior of 5.4 % in the intervention group versus a decline of 2.7 % in the control group ( P=.04 ) . The patient education intervention produced no significant change in guideline -consistent behavior , but was poorly adopted . Patient characteristics including duration of pain , prior history of low back pain , and number of visits during the illness episode were strong predictors of service utilization and guideline -consistent behavior . CONCLUSIONS : Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline -consistent behavior . Patient education material s did not enhance guideline effectiveness . Implementation barriers could limit the utility of this approach in usual care setting The authors developed and tested a framework for identifying evidence gaps and prioritizing comparative effectiveness research by using a combination of clinical practice guidelines and systematic review s. In phase 1 of the project , reported elsewhere , 45 clinical questions on the management of primary open-angle glaucoma were derived from practice guidelines and prioritized by using a 2-round Delphi survey of clinicians . On the basis of the clinicians ' responses , 9 questions were classified as high-priority . In phase 2 , reported here , systematic review s that addressed the 45 clinical questions were identified . The review s were classified as at low , high , or unclear risk of bias , and evidence gaps ( in which no systematic review was at low risk of bias ) were identified . The following comparative effectiveness research agenda is proposed : Two of the 9 high-priority questions require new primary research ( such as a r and omized , controlled trial ) and 4 require a new systematic review . The utility and limitations of the framework and future adaptations are discussed Introduction The uptake of Clinical Practice Guideline ( CPG ) recommendations that improve outcomes in heart failure ( HF ) remains suboptimal . We will conduct a systematic review to identify implementation strategies that improve physician adherence to class I recommendations , those with clear evidence that benefits outweigh the risks . We will use American , Canadian and European HF guidelines as our reference . Methods and analysis We will conduct a literature search in the data bases of MEDLINE , EMBASE , HEALTHSTAR , CINAHL , Cochrane Library , Campbell Collaboration , Joanna Briggs Institute Evidence Based Practice , Centre for Review s and Dissemination and Evidence Based Practice Centres . We will include prospect i ve studies evaluating implementation interventions aim ed at improving uptake of class I CPG recommendations in HF . We will extract data in duplicate . We will classify interventions according to their level of application ( ie , provider , organisation , systems level ) and common underlying characteristics ( eg , education , decision-support , financial incentives ) using the Cochrane Effective Practice and Organisation of Care Taxonomy . We will assess the impact of the intervention on adherence to the CPGs . Outcomes will include proportion of eligible patients who were : prescribed a CPG-recommended pharmacological treatment ; referred for device consideration ; provided self-care education at discharge ; and provided left ventricular function assessment . We will include clinical outcomes such as hospitalisations , readmissions and mortality , if data is available . We will identify the common elements of successful and failing interventions , and examine the context in which they were applied , using the Process Re design context ual framework . We will synthesis e the results narratively and , if appropriate , will pool results for meta- analysis . Discussion and dissemination In this review , we will assess the impact of implementation strategies and context ual factors on physician adherence to HF CPGs . We will explore why some interventions may succeed in one setting and fail in another . We will disseminate our findings through briefing reports , publications and presentations . Trial registration number CRD42015017155 Abstract Objective : to review and up date the evidence for different forms of manual therapy ( MT ) for patients with different stages of non-specific low back pain ( LBP ) . Data sources : MEDLINE , Cochrane-Register-of-Controlled-Trials , PEDro , EMBASE . Method : A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent review ers according to Cochrane and PRISMA guidelines . A total of 360 studies were evaluated using qualitative criteria . Two stages of LBP were categorized ; combined acute – subacute and chronic . Further sub-classification was made according to MT intervention : MT1 ( manipulation ) ; MT2 ( mobilization and soft-tissue-techniques ) ; and MT3 ( MT1 combined with MT2 ) . In each sub-category , MT could be combined or not with exercise or usual medical care ( UMC ) . Consequently , quantitative evaluation criteria were applied to 56 eligible r and omized controlled trials ( RCTs ) , and hence 23 low-risk of bias RCTs were identified for review . Only studies providing new up date d information ( 11/23 RCTs ) are presented here . Results : Acute – subacute LBP : STRONG- evidence in favour of MT1 when compared to sham for pain , function and health improvements in the short-term ( 1–3 months ) . MODERATE- evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain , function and health improvements in the short-term . Chronic LBP : MODERATE to STRONG- evidence in favour of MT1 in comparison to sham for pain , function and overall-health in the short-term . MODERATE- evidence in favour of MT3 combined with exercise or UMC in comparison to  exercise  and back-school was established for pain , function and quality -of-life in the short and long-term . LIMITED- evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term . LIMITED- evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term . Conclusion : This systematic review up date s the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies Background Evidence generated from reliable research is not frequently implemented into clinical practice . Evidence -based clinical practice guidelines are a potential vehicle to achieve this . A recent systematic review of implementation strategies of guideline dissemination concluded that there was a lack of evidence regarding effective strategies to promote the uptake of guidelines . Recommendations from this review , and other studies , have suggested the use of interventions that are theoretically based because these may be more effective than those that are not . An evidence -based clinical practice guideline for the management of acute low back pain was recently developed in Australia . This provides an opportunity to develop and test a theory-based implementation intervention for a condition which is common , has a high burden , and for which there is an evidence - practice gap in the primary care setting . Aim This study aims to test the effectiveness of a theory-based intervention for implementing a clinical practice guideline for acute low back pain in general practice in Victoria , Australia . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of patients who are referred for a plain x-ray  , and improving mean level of disability for patients three months post-consultation . Methods / Design This study protocol describes the details of a cluster r and omised controlled trial . Ninety-two general practice s ( clusters ) , which include at least one consenting general practitioner , will be r and omised to an intervention or control arm using restricted r and omisation . Patients aged 18 years or older who visit a participating practitioner for acute non-specific low back pain of less than three months duration will be eligible for inclusion . An average of twenty-five patients per general practice will be recruited , providing a total of 2,300 patient participants . General practitioners in the control arm will receive access to the guideline using the existing dissemination strategy . Practitioners in the intervention arm will be invited to participate in facilitated face-to-face workshops that have been underpinned by behavioural theory . Investigators ( not involved in the delivery of the intervention ) , patients , outcome assessors and the study statistician will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN012606000098538 ( date registered 14/03/2006 ) CONTEXT The findings of systematic review s ( SRs ) and meta-analyses ( MAs ) are used for clinical decision making . The European Association of Urology has committed increasing re sources into the development of high quality clinical guidelines based on such SRs and MAs . OBJECTIVE In this paper , we have summarised the process of conducting SRs for underpinning clinical practice guidelines under the auspices of the European Association of Urology Guidelines Office . EVIDENCE ACQUISITION The process involves explicit methods and the findings should be reproducible . When conducting a SR , the essential first step is to formulate a clear and answerable research question . An extensive literature search lays the foundation for evidence synthesis . Data are extracted independently by two review ers and any disagreements are resolved by discussion or arbitration by a third review er . EVIDENCE SYNTHESIS In SRs , data for particular outcomes in individual r and omised controlled trials may be combined statistically in a meta- analysis to increase power when the studies are similar enough . Biases in studies included in a SR/MA can lead to either an over estimation or an under estimation of true intervention effect size , result ing in heterogeneity in outcome between studies . A number of different tools are available such as Cochrane Risk of Bias assessment tool for r and omised controlled trials . In circumstances where there is too much heterogeneity , or when a review has included nonr and omised comparative studies , it is more appropriate to conduct a narrative synthesis . The GRADE tool for assessing quality of evidence strives to be a structured and transparent system , which can be applied to all evidence , regardless of quality . A SR not only identifies , evaluates , and summarises the best available evidence , but also the gaps to be targeted by future studies . CONCLUSIONS SRs and MAs are integral in developing sound clinical practice guidelines and recommendations . PATIENT SUMMARY Clinical practice guidelines should be evidence based , and systematic review s and meta-analyses are essential in their production . We have discussed the key steps of conducting systematic review s and meta-analyses in this paper CONTEXT AND OBJECTIVES The European Association of Urology Guideline Group for renal cell carcinoma ( RCC ) has prepared these guidelines to help clinicians assess the current evidence -based management of RCC and to incorporate the present recommendations into daily clinical practice . EVIDENCE ACQUISITION The recommendations provided in the current up date d guidelines are based on a thorough review of available RCC guidelines and review articles combined with a systematic literature search using Medline and the Cochrane Central Register of Controlled Trials . EVIDENCE SYNTHESIS A number of recent prospect i ve r and omised studies concerning RCC are now available with a high level of evidence , whereas earlier publications were based on retrospective analyses , including some larger multicentre validation studies , meta-analyses , and well- design ed controlled studies . CONCLUSIONS These guidelines contain information for the treatment of an individual patient according to a current st and ardised general approach . Up date d recommendations concerning diagnosis , treatment , and follow-up can improve the clinical h and ling of patients with RCC Background Dementia is a growing problem , causing substantial burden for patients , their families , and society . General practitioners ( GPs ) play an important role in diagnosing and managing dementia ; however , there are gaps between recommended and current practice . The aim of this study was to explore GPs ’ reported practice in diagnosing and managing dementia and to describe , in theoretical terms , the proposed explanations for practice that was and was not consistent with evidence -based guidelines . Methods Semi-structured interviews were conducted with GPs in Victoria , Australia . The Theoretical Domains Framework ( TDF ) guided data collection and analysis . Interviews explored the factors hindering and enabling achievement of 13 recommended behaviours . Data were analysed using content and thematic analysis . This paper presents an in-depth description of the factors influencing two behaviours , assessing co-morbid depression using a vali date d tool , and conducting a formal cognitive assessment using a vali date d scale . Results A total of 30 GPs were interviewed . Most GPs reported that they did not assess for co-morbid depression using a vali date d tool as per recommended guidance . Barriers included the belief that depression can be adequately assessed using general clinical indicators and that vali date d tools provide little additional information ( theoretical domain of ‘ Beliefs about consequences ’ ) ; discomfort in using vali date d tools ( ‘ Emotion ’ ) , possibly due to limited training and confidence ( ‘ Skills ’ ; ‘ Beliefs about capabilities ’ ) ; limited awareness of the need for , and forgetting to conduct , a depression assessment ( ‘ Knowledge ’ ; ‘ Memory , attention and decision processes ’ ) . Most reported practising in a manner consistent with the recommendation that a formal cognitive assessment using a vali date d scale be undertaken . Key factors enabling this were having an awareness of the need to conduct a cognitive assessment ( ‘ Knowledge ’ ) ; possessing the necessary skills and confidence ( ‘ Skills ’ ; ‘ Beliefs about capabilities ’ ) ; and having adequate time and re sources ( ‘ Environmental context and re sources ’ ) . Conclusions This is the first study to our knowledge to use a theoretical approach to investigate the barriers and enablers to guideline -recommended diagnosis and management of dementia in general practice . It has identified key factors likely to explain GPs ’ uptake of the guidelines . The results have informed the design of an intervention aim ed at supporting practice change in line with dementia guidelines , which is currently being evaluated in a cluster r and omised trial Background Clinical practice guidelines are considered important instruments to improve quality of care . However , success is dependent on adherence , which may be improved using peer assessment , a strategy in which professionals assess performance of their peers in a simulated setting . Objective The aim of this study was to determine whether peer assessment is more effective than case-based discussion s to improve knowledge and guideline -consistent clinical reasoning in the Dutch physical therapy guideline for low back pain ( LBP ) . Design A cluster r and omized controlled trial was conducted . Setting and Participants Ten communities of practice ( CoPs ) of physical therapists were cluster r and omized ( N=90 ) : 6 CoPs in the peer- assessment group ( n=49 ) and 4 CoPs in the case-based discussion group ( control group ) ( n=41 ) . Intervention Both groups participated in 4 educational sessions and used clinical patient cases . The peer- assessment group reflected on performed LBP management in different roles . The control group used structured discussion s. Measurements Outcomes were assessed at baseline and at 6 months . The primary outcome measure was knowledge and guideline -consistent reasoning , measured with 12 performance indicators using 4 vignettes with specific guideline -related patient profiles . For each participant , the total score was calculated by adding up the percentage scores ( 0–100 ) per vignette , divided by 4 . The secondary outcome measure was reflective practice , as measured by the Self-Reflection and Insight Scale ( 20–100 ) . Results Vignettes were completed by 78 participants ( 87 % ) . Multilevel analysis showed an increase in guideline -consistent clinical reasoning of 8.4 % in the  peer- assessment group , whereas the control group showed a decline of 0.1 % ( estimated group difference=8.7 % , 95 % confidence interval=3.9 to 13.4 ) . No group differences were found on self-reflection . Limitations The small sample size , a short-term follow-up , and the use of vignettes as a proxy for behavior were limitations of the study . Conclusions Peer assessment leads to an increase in knowledge and guideline -consistent clinical reasoning BACKGROUND Decreasing the use of continuous electronic fetal monitoring and increasing professional labor support for low-risk pregnancies are recommended by the Society of Obstetricians and Gynecologists of Canada . This study explored factors influencing the successful ( and unsuccessful ) introduction of an evidence -based fetal health surveillance guideline . METHODS This qualitative case study was conducted at two tertiary and one community hospital . Data were collected in 14 clinician focus groups ( 51 nurses ) , followed by 8 interviews with nurse administrators and educators . Analysis of verbatim transcripts and unit records included coding and categorizing data to form profiles that were compared across hospitals . RESULTS Implementation of the guideline recommendations in the hospital setting s was affected by many different factors originating in the practice environment , with the potential adopters , and related to the characteristics of the guideline . The influences of these diverse factors interacted sometimes to magnify or counteract each other 's effect . The physical setting , adopter concerns , and the medicolegal issues surrounding the guideline played critical roles in uptake . In addition , changes preceding the introduction of the recommendations , the institution 's agenda , and nursing and medical leadership influenced the uptake of guideline recommendations . The number and experience of nurses in each setting and availability of equipment also affected guideline acceptance and use . CONCLUSIONS When implementing best practice , it is important to identify organizational barriers to the change that will need managing by the appropriate level of administration in the organization . Careful tailoring of implementation interventions to the barriers originating with the potential adopters is also necessary . Be prepared for unanticipated effects Prognostic markers help to stratify patients for treatment by identifying patients with different risks of outcome ( e.g. recurrence of disease ) , and are important tools in the management of cancer and many other diseases . Systematic review and meta-analytical approaches to identifying the most valuable prognostic markers are needed because ( sometimes conflicting ) evidence relating to markers is often published across a number of studies . To investigate the practicality of this approach , an empirical investigation of a systematic review of  tumour markers for neuroblastoma was performed ; 260 studies of prognostic markers were identified , which considered 130 different markers . The reporting of these studies was often inadequate , in terms of both statistical analysis and presentation , and there was considerable heterogeneity for many important clinical /statistical factors . These problems restricted both the extraction of data and the meta- analysis of results from the primary studies , limiting feasibility of the evidence -based approach . Guidelines for reporting the results of primary prognostic marker studies in cancer , and other diseases , are given in order to facilitate both the interpretation of individual studies and the undertaking of systematic review s , meta- analysis and , ultimately , evidence -based practice . General availability of full individual patient data is a necessary step forward and would overcome the majority of problems encountered , including poorly reported summary statistics and variability in cutoff level , outcome assessed and adjustment factors used . It would also limit the problem of reporting bias , although publication bias will remain a concern until studies are prospect ively registered . Such changes in practice would help important evidence -based review s to be conducted in order to establish the most appropriate prognostic markers for clinical use , which should ultimately improve patient care BACKGROUND The paradigm shift to evidence -based nursing practice in the United States has been slow . Although multiple barriers to evidence -based practice ( EBP ) have been identified through prior studies , there is a gap in the literature specifically identifying key variables ( e.g. , belief that EBP produces quality outcomes ) that are correlated with the extent to which nurses engage in EBP . AIM The primary aims of this study were to ( 1 ) describe nurses ' knowledge , beliefs , skills , and needs regarding EBP ; ( 2 ) determine whether relationships exist among these variables ; and ( 3 ) describe major barriers and facilitators to EBP . METHODS A descriptive survey was conducted with a convenience sample of 160 nurses who were attending EBP conferences or workshops in four states located within the Eastern Region of the United States . RESULTS Although participant beliefs about the benefit of EBP were high , knowledge of EBP was relatively low . Significant relationships were found between the extent to which the nurses ' practice is evidence -based and ( 1 ) nurses ' knowledge of EBP , ( 2 ) nurses ' beliefs about the benefits of EBP , ( 3 ) having an EBP mentor , and ( 4 ) using the Cochrane Data base of Systematic Review s and the National Guideline Clearinghouse . CONCLUSION AND IMPLICATION S Health care systems need to implement interventions that not only increase nurses ' EBP knowledge and skills , but also strengthen their beliefs about the benefit of evidence -based care . EBP mentors may be key in accelerating a more rapid shift toward evidence -based nursing practice . Theoretically driven r and omized controlled trials are urgently needed to test the effectiveness of interventions on advancing evidence -based care
Clinicians believed that guidelines were categorical , prescriptive , and constrained professional practice ; however , popular clinical practice s superseded the guidelines .
Imaging referrals were used to manage consultations and to obtain definitive diagnoses .
Clinicians ' perceptions reflected a lack of content knowledge and underst and ing of how guidelines are developed .
DISCUSSION Addressing misconceptions and other barriers to uptake of evidence -based guidelines for managing LBP is needed to improve knowledge transfer and close the evidence - practice gap in the treatment of this common condition
INTRODUCTION Despite the availability of evidence -based guidelines for the management of low back pain ( LBP ) that contain consistent messages , large evidence - practice gaps in primary care remain .
OBJECTIVES To perform a systematic review and meta synthesis of qualitative studies that have explored primary care clinicians ' perceptions and beliefs about guidelines for LBP , including perceived enablers and barriers to guideline adherence .