Content and quality appraising of clinical practice guidelines for the non-pharmacological management of spine pain: A systematic review

Introduction. Spine pain is a highly prevalent condition globally, leading to enormous burden on the healthcare providers. Clinical practice guidelines provide guidance on how to effectively manage patients with spine pain. This review aimed to summarize and critically appraise the content and quality of recent guidelines for the non-pharmacological management of spine pain.
Methods. Six electronic databases (MEDLINE, EMBASE, CINAHL, PEDro, Scopus, Epistemonikos), seven guideline clearinghouse websites, and grey literature were searched from January 1st, 2012 to March 16th, 2022. Two reviewers independently screened titles and abstracts, and full-texts to identify eligible guidelines, and extracted the characteristics and recommendations of admissible guidelines. Five reviewers critically appraised the quality using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE II) and AGREE-Recommendation Excellence (AGREE REX). Inter-rater agreement was calculated for each domain and total score of these tools, using the intraclass correlation coefficient (ICC (2,1)) with absolute agreement.
Results. We screened 18,997 citations from electronic databases and 82 from guideline clearinghouse websites, yielding 30 admissible guidelines (11 lumbago, 9 lumbago with radiculopathy, 3 cervicalgia, 3 cervicalgia with radiculopathy, 3 Whiplash, 1 spondylolisthesis) from 12 countries. For lumbago, guidelines had consistent recommendations for (exercise, heat, cognitive behavioral therapy, self-management, education, and remaining active), against (traction and bed rest), and inconsistent (mobilization/manipulation, massage, therapeutic ultrasound, and TENS). For lumbago with radiculopathy, guidelines had consistent recommendations for (exercises, cognitive behavioral therapy, self-management, education, advices to remaining active, advices to return-to-work), against (traction, therapeutic ultrasound), and inconsistent (acupuncture). For cervicalgia, guidelines had consistent recommendations for (exercises, mobilization/manipulation, and cognitive behavioral therapy), against (traction), and inconsistent (education, therapeutic ultrasound). For cervicalgia with radiculopathy, guidelines had consistent recommendations for (mobilization/manipulation, traction, exercises, acupuncture, education, and reassurance). For Whiplash, guidelines had consistent recommendations for (education and reassurance), against (collar), and inconsistent (mobilization/manipulation, laser therapy, and heat). For spondylolisthesis, there were no recommendations provided. The AGREE II tool revealed that 13 guidelines were rated as high quality. The mean total score for the AGREE II tool was 75% (SD=11), the average domain across included guidelines (highest to lowest) were: scope and purpose (91%), clarity of presentation (81%), editorial independence (80%), stakeholder involvement (74%), rigor of development (72%), and applicability (41%). AGREE REX tool revealed that 11 guidelines were classified as high quality while 19 as moderate quality. The mean total score for the AGREE REX tool was 65% (SD=12), and the average domain across included guidelines (highest to lowest) were: clinical applicability (75%), implementability (72%), values and preferences (55%). The ICC (2,1) values were excellent for both tools among the five raters.
Conclusions. The majority of the guidelines recommend multimodal interventions, which may include exercises, education, and cognitive behavioural therapies.
Major methodological limitations included the domain of applicability for AGREE-II and Values and preferences for AGREE-REX. Future development of evidence-based guidelines should minimize the methodological flaws found in the current guidelines.