Twenty-one CPGs[28-48] met the inclusion and exclusion criteria, of which seven (33.3%) were devoted to neck pain[28, 30-34, 49] (i.e., Canada, KNGF, APTA, DHA, OPTIMa, Scottish and SIMFER CPGs), fourteen (66.6%) CPGs were devoted to back pain[33, 35-47] (i.e., ACP, ACI, Belgium, Canada, DHA, German, Globe et al., NDMG, KNGF, Scottish, Colorado, TOP, VA/DoD and NICE CPGs), and 3 (14.3%) CPGs were devoted to sciatica[38, 47, 48] (i.e., DHA, NASS and NICE CPGs). Some guidelines contained more than one site. The study flow diagram is shown in Figure 1.
Characteristics of included CPGs
Table 1 shows the characteristics of the included CPGs. The included CPGs were from 11 individual countries, most of which are developed countries. Most were from the USA (n=6) and Canada (n=4). The Netherlands, Denmark and Germany each contributed two CPGs. The American CPGs mostly focused on low back pain (LBP) (n=4), and half of the CPGs from Canada were for neck pain (n=2). Most CPGs were developed by medical specialty societies (n=13, 61.9%), followed by governmental bodies (n=6, 26.1%) and guideline developer organizations (n=3, 13.0%).
ICCs
The interrater agreement was ‘very good’ for scope and purpose (domain 1), editorial independence (domain 6) and overall rating, ‘substantial’ for stakeholder involvement (domain 2), clarity of presentation (domain 4), and applicability (domain 5) and ‘moderate’ for the rigor of development (domain 3) (Table 2).
Quality
The highest mean score was 78.39 ± 13.34 for scope and purpose, and the lowest mean score was 40.67 ± 22.61 for applicability. Generally, nine CPGs had overall scores higher than 60%; these CPGs were deemed as strongly recommended for clinical care[31-33, 35, 36, 38, 39, 46, 47], ten CPGs were defined as recommended with modifications[28-30, 37, 41-45, 48], and three CPGs were deemed as not recommended[34, 40, 44]. The mean and SD of AGREE II scores for each domain and overall scores of various guidelines are shown in Table S1 and Figure 2A. The brief overall scores of CPGs are shown in Table 3.
The RIGHT checklist contains 22 requirements organized into 7 sections, with a total of 35 items. According to the RIGHT checklist, the CPGs with the largest number of reported items was NICE, DHA and SIGN (RIGHT score = 34), followed by OPTIMa (RIGHT score = 31) and Canada Guideline (RIGHT score = 30). Among the seven domains of the RIGHT checklist, field one (basic information) had the highest reporting rate (86.16%), and field six (funding, declaration and management of interest) obtained the lowest reporting rate (53.00%). The numbers of reported items are shown in Table 4. The mean compliance rates of each item are shown in Figure 2B. AGREE II and RIGHT were combined to calculate the quality of the CPGs (Figure 3).
Summarizing recommendations for spinal pain
Figure 4 summarizes the various strengths of recommendations of CPGs for neck pain and low back pain patients. Table 5 summarizes the various recommendations of assessment, diagnosis, and management of spinal pain CPGs. We classified recommendations into four groups: ‘recommended to do’, ‘could be considered to do’, ‘do not recommend to do’ or ‘uncertain/unclear’.
Neck pain
Patient-centered care
Most CPGs suggested that clinicians should provide patient-centered care that can lead to better outcomes. Patient-centered care included care methods such as providing individualized care[28-30], providing information for patients in a reassuring manner,[31] and shared decision-making[32].
Exclude serious pathology/red flag conditions and classify the stage of neck pain
Five CPGs offered recommendations regarding screening patients for potentially serious or structural pathology or for ‘red flag’ conditions at the initial assessment.[29, 30, 32-34] For example, clinicians should determine if there is a fracture, malignancy, infection, inflammatory cause of pain or another pathology reason.
Two CPGs mentioned that classification of neck pain grades should be conducted at the initial assessment.[29, 32] Three CPGs stated that one should classify neck pain as acute, subacute or chronic.[28, 30, 33] Then, management should be provided based on the stage of neck pain.
Conduct physical examination and assess psychosocial factors
Four CPGs recommended that clinicians or physical therapist conduct comprehensive physical examinations to determine patients’ baseline status.[29, 30, 33, 34] The aim of the physical examination is to help diagnose and classify neck pain disorders. Three CPGs advised assessment of psychosocial factors, which are important factors for prognosis.[29, 32, 33]
Evaluate patient progress
Three CPGs recommended evaluating patient progress and using validated outcome measures.[29, 30, 32] Outcome measures included numeric pain rating scale and the patient-specific functional scale,[29] utilizing easily reproducible activity limitation and participation restriction measures[30] and self-rated recovery questions.[32]
Provide education or information
Six CPGs strongly recommended providing education or information for patient about their condition and management methods.[28-33] Education is a part of first-line, essential treatment. Common education consisted of providing structured and individualized education[31-33] such as advice, training, supervision, instruction, prognosis, encouragement, reassurance and pain management.[28-30] However, one CPG indicated that there was insufficient evidence to prove the effect of educational interventions for patients with neck pain.[34]
Patients should do physical activity or exercise
All CPGs recommended that patients to perform physical activity or exercise.[28-34] Exercise (e.g., strengthening, endurance and flexibility exercises) was recommended for the treatment of acute and chronic neck pain for both short- and long-term benefits.[28, 29, 33, 34] One CPG showed that clinicians could use exercise therapy for management of neck pain.[32] Two CPGs mentioned that exercise should/could combined with manual therapy.[31, 34]
Manual Therapy
All CPGs recommended that patients receive manual therapy to relieve pain. Manual therapy (manipulation and/or mobilization) combined with other modalities was recommended for treating both acute and chronic neck pain.[28-34] One CPG recommended manipulation alone for patients with acute neck pain and combination therapy for chronic neck pain.[34] However, for massage, the recommendations of different CPGs differed. Two CPGs recommended massage combined with other treatments to treat chronic neck pain.[28, 34] One CPG stated that clinicians could consider massage to be a potential treatment method.[29] Two CPGs did not recommend massage to treat neck pain.[31, 32]
Electrotherapy (including Transcutaneous Electrical Nervous Stimulation (TENS))
Two CPGs did not recommend electrotherapy for patients with neck pain,[29, 32] while one CPG recommended electrotherapy[34] and one recommended considering electrotherapy.[33] One other CPG indicated that there was insufficient evidence to show the effect of electrotherapy.[28]
Traction
Two CPGs did not recommend traction for neck pain patients,[29, 32] while one recommended it[30] and one recommended consideration.[31] Three CPGs gave unclear opinions regarding traction.[28, 33, 34]
Psychological therapy
One CPG recommended psychological therapy[33] and one CPG recommended that clinicians consider it.[29] One CPG did not recommend psychological therapy.[32]
Acupuncture and Ultrasound
There were three CPGs against acupuncture for treating neck pain,[29, 31, 32] while one CPG recommended using acupuncture for short-term relief of subacute and chronic neck pain[34]
One CPG recommended ultrasound therapy combined with physical therapy for chronic neck pain. [34] One CPG did not recommend ultrasound therapy.[29]
Cervical collar
One CPG suggested that a cervical collar could be considered only if primarily advised treatments are ineffective.[29] Another CPG stated that short-term use of cervical collar can be considered for patients with acute neck pain with radiating pain.[30] One CPG did not recommend the use of cervical collar,[32] and one CPG indicated that there was insufficient evidence to give a recommendation.[34]
Pharmacotherapy
Some CPGs recommended nonsteroidal anti-inflammatory drugs (NSAIDs),[31, 33] paracetamol,[34] tramadol[31] or muscle relaxants[33] after careful consideration of adverse events, contraindications, and patient preference. Furthermore, the duration should be short. However, one CPG did not recommend the use of paracetamol and recommended that clinicians consider the use of muscle relaxants.[32] For opioids, clinicians must carefully consider before using and only use these drugs in the short to medium term when other therapies have been insufficient.[31, 33]
Low back pain
Assessment
Clinicians were recommended to systematically collect formal histories[33, 35, 36, 38, 41-47] and physical examinations,[33, 36, 38, 41-44, 46, 47] identifying serious pathology (i.e., red flags),[33, 36-38, 41-47] and classifying acute, subacute and chronic pain,[33, 35, 38, 45-47] initially. Some CPGs also recommended that clinicians assess psychosocial factors[33, 36-47] such as STarT Back and Örebro questionnaires.[33, 36-38, 42, 45, 47]
Routine use of radiological imaging
Nine CPGs were against routine use of radiological imaging for LBP.[36-39, 41, 42, 45-47] Imaging should be considered only if the results influence the management method,[37, 44, 47] if there are clinical reasons to suspect serious underlying pathology (i.e., red flags)[36, 38, 39, 41, 44-46] or if symptoms worsen after a period of formal treatment according to the guideline.[40, 42, 46]
Provide education and exercise therapy
Most CPGs recommended patient education[33, 36-43, 45-47] (e.g., explaining the expected course, advising to remain active and providing information about self-management options) and exercise therapy[33, 35-43, 45-47] as the first-line choice for the management of acute, subacute and chronic low back pain.
Manual Therapy
Three CPGs recommended manual therapy for acute,[35] subacute,[35] and chronic low back pain. One guideline indicated manual therapy could be considered for short-term pain relief for chronic LBP.[33] In addition, some guidelines suggested that manual therapy could be applied if self-care and medication therapy did not provide significant improvements[36] or that it could be offered as a part of multimodal management.[37, 39, 46, 47]
One CPG recommended massage for treating acute and subacute low back pain,[35] while two guidelines indicated that massage was not recommended for acute low back pain but could be considered for chronic low back pain.[40, 41] One guideline stated that there was insufficient evidence to show the effect of manual therapy including massage.[45]
Electrotherapy (including Transcutaneous Electrical Nervous Stimulation (TENS))
For electrotherapy, one CPG recommended it for treating chronic low back pain,[35] and one indicated electrotherapy can be considered for chronic low back pain.[33] However, six CPGs did not recommend electrotherapy[36, 37, 40, 42, 44, 47] and two CPGs pointed out that there was not enough evidence to give the recommendation.[45, 46]
Traction
Most CPGs did not recommend traction for low back pain care,[37, 40, 42, 44, 45, 47] and two CPGs pointed out that there was insufficient evidence to show the effect of traction for treating low back pain.[35, 46]
Acupuncture and ultrasound
For acupuncture, the CPGs gave various opinions. The ACP recommended acupuncture for treating LBP.[35] One CPG recommended acupuncture for subacute or chronic pain patients and for subacute or acute low back pain patients who cannot tolerate (NSAIDs) or other medications.[44] In contrast, two CPGs did not recommend acupuncture for managing LBP.[39, 47] Most CPGs did not give specific recommendations based on recent evidence.[37, 40, 42, 45-47] In addition, ultrasound was not recommended for LBP management[37, 40, 42, 44, 45, 47].
Passive strategies
Most CPGs did not recommend passive strategies such as belts or corsets,[37, 47] foot orthotics,[37] rocker sole shoes[47] or bed rest.[40, 42, 43, 45] Only one CPG mentioned that bracing/orthoses can be included in the care plan for chronic LBP management.
Heat/cold therapy
Heat/cold therapy was recommended for the short-term relief of acute[35, 44-46] or subacute[35, 44] LBP. One CPG indicated heat therapy can be used to treat chronic LBP as a part of multimodal care.[42]
Pharmacotherapy
For the management of chronic low back pain, nonpharmacologic therapy should be the primary treatment. For those who have had an inadequate response to nonpharmacologic therapy, pharmacologic treatment should be considered. For pharmacologic treatment, NSAIDs should be treated as a first-line therapy[35, 36, 42, 46] and should be given in the lowest effective dose and for the shortest period.[42, 47] One CPG stated that NSAIDs should only be offered in addition to usual care for acute LBP.[39]
Two CPGs recommended paracetamol as the first choice and NSAIDs as the second choice of pharmacotherapy for LBP management.[36, 45] In contrast, many CPGs did not recommend paracetamol to treat LBP.[37, 39, 40, 42, 46, 47]
The recommendations for muscle relaxants were conflicting. One CPG recommended muscle relaxants,[35] and three CPGs stated that nonbenzodiazepine muscle relaxants can be considered.[44, 45] Three CPGs did not recommend muscle relaxants.[37, 40, 44]
Antidepressants could be considered to manage chronic LBP.[33, 35, 37, 40, 45, 46]
Most CPGs recommended the use of opioids only if NSAIDs were ineffective, not tolerated, or contraindicated[37, 47] or if common care failed and if the known risks and realistic benefits were discussed with patients.[33, 35, 38]
Epidural steroid injection
Most CPGs had a consensus opinion about epidural steroid injection. They were all against epidural steroid injection for patients without radiculopathy,[45-47] long-term reduction of radicular low back pain,[46] or spinal stenosis.[46] For patients with acute or subacute severe radicular pain[37, 47] or for very short-term reduction of radicular low back pain,[46] an epidural steroid injection can be considered.
Surgery
For patients with the following situations, surgery can be considered: 1. severe and disabling pain persisting after nonsurgical treatment;[39, 44, 45] 2. radicular symptoms, symptoms of neurogenic claudication, or severe stenosis;[44, 45] and 3. nerve root compression proved by MRI or CT.[44] In addition, NICE did not recommend disc replacement or spinal fusion for low back pain.[47]
Sciatica
Two CPGs did not recommend routine use of imaging for patients with sciatica,[39, 47] while one CPG recommended MRI for patients with history and physical examination findings consistent with sciatica.[48] Exercise and manual therapy can be considered to treat sciatica, but only as a part of multimodal treatment.[39, 47] NICE recommended antidepressants and gabapentin as initial treatment for neuropathic pain.[47] Epidural steroid injection was recommended to relieve severe radicular pain.[47, 48] For surgery, one guideline recommended discectomy, which can provide more effective pain relief than other care for patients with sciatica whose symptoms warrant surgery treatment.[48] However, another CPG suggested that clinicians consider spinal decompression for patients with sciatica when nonsurgical treatment is ineffective in improving pain or function and their radiological findings are consistent with sciatic symptoms.[47]