Acute Lower Back Problems in Adults - Methodology

Methodology for Guideline Development

The general theory and principles underlying development of clinical practice guidelines are presented in an Institute of Medicine report; [17] <http://text.nlm.nih.gov> other reports published by AHCPR provide specific information on the clinical guideline development process. [18] <http://text.nlm.nih.gov> These materials provided a starting point for developing the Clinical Practice Guideline on low back problems. AHCPR provided the general parameters for guideline development. The panel, aided by the methodologists and consultants, then independently determined the specific methodology for the project, directed the literature review, and developed the guideline findings and recommendations.

Formation of the Panel and Staff

AHCPR initiated formation of the panel and appointed its chairperson and members. Important considerations in the choice of panel members were: (1) demonstrated knowledge about low back problems, (2) representation of major clinical disciplines involved in back care, and (3) geographic diversity. Nominations were solicited through a Federal Register announcement and from professional and consumer organizations and persons interested in the care of patients with low back problems.

More than 200 individuals were nominated. AHCPR selected 23 representing the fields of biomechanical and spine research, chiropractic care, emergency medicine, family medicine, internal medicine, neurology, neurosurgery, occupational health nursing, occupational medicine, occupational therapy, orthopedics, osteopathic medicine, physical and rehabilitation medicine, physical therapy, psychology, rheumatology, and radiology.

The panel also included a consumer representative who had experienced low back problems, but did not work in the health care field. Several consultants with expertise in spine research, clinical care of low back problems, clinical epidemiology, and health economics were appointed to the panel. Two methodologists with experience in developing clinical practice guidelines were assigned to the panel by AHCPR. Both methodologists were physicians with MPH degrees, one an emergency medicine physician and one an internist. The methodologists aided the panel in determining the scope of the literature search and the criteria to be used for selecting articles for panel review.

The panel chair formed a research and support staff that included two physicians: a spine–fellowship–trained orthopedic surgeon and an occupational–medicine–trained physician with an MPH degree. National Library of Medicine representatives aided the staff in retrieving literature. The staff screened articles and constructed evidence tables for articles according to panel review criteria. These evidence tables and the original articles were presented to the panel for review and interpretation. The panel used this information as the basis for its guideline findings and recommendations.

Public Comment and Peer Review

An open forum was held early in the guideline development process to give interested individuals, organizations, and agencies the opportunity to present written or verbal testimony. Later in the process, drafts of the guideline were sent out for peer and pilot review. AHCPR selected peer and pilot reviewers from those who had expressed interest in the guideline, participated in the open forum, or were nominated by professional organizations or panel members.

Over 100 peer reviewers were selected based on their expertise in the care of low back problems. They were asked to evaluate the comprehensiveness of the literature review as well as the panel's findings and recommendations. The pilot reviewers who were selected represented a cross–section of primary care settings including private and group practices, health maintenance organizations, and occupational medicine clinics. They were asked to evaluate the practical applicability of the guideline in their own practice settings by using examples published in the Quick Reference Guide for Clinicians and by soliciting feedback from patients given the Consumer Version. The panel used comments from peer and pilot reviewers to guide final revisions of the guideline.

Literature Search

The panel initiated a comprehensive literature search of topics deemed applicable to low back problems. The Quebec Task Force on Spinal Disorders had previously published an evidence–based guideline on low back problems, based upon an exhaustive literature search through 1984. [19] <http://text.nlm.nih.gov/tempfiles/is/tempDl48741.html> The bibliography from their report was the starting point in the literature search for this AHCPR guideline.

The literature search of articles published after 1984 was performed through the National Library of Medicine. Abstracts of 10,317 articles which met the search criteria were each independently evaluated by the orthopaedic surgeon and occupational medicine physician on the research staff. If either reviewer thought an article might be useful, the entire article was retrieved. A total of 3,918 articles (38 percent of all abstracts evaluated) was obtained for further evaluation.

Additional articles came from panel members, from the open forum process, and from unsolicited sources. All articles were entered in a comprehensive bibliography, classified by topic, and screened methodologically to determine if they contained information that might be useful to the panel.

Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults.
Clinical Practice Guideline No. 14. AHCPR Publication No. 95–0642.
Rockville, MD: Agency for Health Care Policy and Research, Public Health
Service, U.S. Department of Health and Human Services. December 1994.