Arnau Josep M, Vallano Antoni, Lopez Anna, Pellisé Ferran, Delgado Maria J, Prat Nuria
Fundació Institut Català de Farmacologia, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain.
Eur Spine J. 2006 May;15(5):543-53. doi: 10.1007/s00586-005-1027-y. Epub 2005 Oct 11.
Little is known about the methodological quality of guidelines for low back pain treatment. We evaluated the methods used by the developers according to established standards.
PubMed, guideline databases, and the World Wide Web were used to identify guidelines. Seventeen guidelines met the inclusion criteria: interventions for low back pain stated, recommendations based on or explicitly linked to evidence, and English version available. Guidelines were evaluated independently by two appraisers using a practical tool for this purpose, Users' Guides to the Medical Literature, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument.
Thirteen guidelines (76%) specified the most important therapies applied, but only nine (53%) included a complete description of the target population. Explicit processes to identify, select, and combine evidence were described in only six guidelines (35%). Few guidelines (3; 18%) explicitly considered all main outcomes when formulating therapeutic recommendations, and none contained a process to determine the relative value of different outcomes. Methodological criteria for grading the strength of the recommendations varied, and were often insufficiently specified. None of the guidelines assessed the impact of uncertainty associated with the evidence and values used. According to AGREE the quality score was highest for the scope and purpose, and clarity and presentation domains, and lowest for editorial independence and applicability. With regard to the recommendations, there was consensus for some of the interventions for acute pain (analgesics and NSAIDs, maintaining physical activity, and avoiding excessive bed rest), but explicit recommendations were lacking or ambiguous for 41% of the interventions. Most of the guidelines did not contemplate specific recommendations for chronic pain.
A small number of the available guidelines for low back pain treatment achieved acceptable results for specific quality criteria. In general, the methods to develop the guidelines' therapeutic recommendations need to be more rigorous, more explicit and better explained. In addition, greater importance should be placed on the recommendations for chronic pain.
对于腰痛治疗指南的方法学质量了解甚少。我们根据既定标准评估了指南制定者所采用的方法。
利用PubMed、指南数据库和万维网来识别指南。17项指南符合纳入标准：阐述了腰痛的干预措施、基于证据或与证据明确相关的建议，且有英文版本。两位评估者使用为此目的设计的实用工具《医学文献用户指南》以及《研究与评价指南评估》（AGREE）工具对指南进行独立评估。
13项指南（76%）明确了所应用的最重要治疗方法，但只有9项（53%）对目标人群进行了完整描述。仅有6项指南（35%）描述了识别、选择和整合证据的明确过程。很少有指南（3项；18%）在制定治疗建议时明确考虑了所有主要结局，且没有一项指南包含确定不同结局相对价值的过程。推荐强度分级的方法学标准各不相同，且往往规定不充分。没有一项指南评估了与所使用的证据和价值观相关的不确定性的影响。根据AGREE评估，范围和目的、清晰度和呈现领域的质量得分最高，编辑独立性和适用性领域的得分最低。关于建议，对于一些急性疼痛的干预措施（镇痛药和非甾体抗炎药、保持身体活动以及避免过度卧床休息）存在共识，但41%的干预措施缺乏明确建议或建议含糊不清。大多数指南没有考虑针对慢性疼痛的具体建议。
少数现有的腰痛治疗指南在特定质量标准方面取得了可接受的结果。总体而言，制定指南治疗建议的方法需要更加严谨、明确且解释得更好。此外，应更加重视针对慢性疼痛的建议。
