HOMOLOGATION OF THE CRITERIA FOR THE DIAGNOSIS AND TREATMENT
OF BACK DISORDERS IN EUROPE
Title.
Management of non-specific low back pain
based on scientific evidence.
Background.
Back disorders ("mechanical pathologies
of the spine") represent a major problem for industrialized
countries, both because of their frequency and because of
their health care and labor costs. Physicians tend not to
bear in mind the results of scientific studies when deciding
on the recommendations to make to their patients with back
pain. This means that a large number of patients are being
subjected to inappropriate diagnostic procedures or treatments,
or at least those not indicated in their case. Furthermore,
it means that the health care cost that these patients generate
is greater than necessary. This problem affects most European
countries alike.
Objective.
To prepare a Guideline for Clinical Practice
on Non-Specific Low Back Pain, based on scientific evidence
and in a Pan-European setting. With this end:
-
To analyze the available scientific evidence on the usefulness
and criteria for recommendation of each one of the available
diagnostic procedures and treatments for back pain.
-
To identify the procedures which have not been evaluated
with sufficient methodological quality, and thus to define
the priority areas of research.
-
To bring together procedures (diagnostic and therapeutic)
on whose utility scientific evidence exists, establishing
a Guideline for Clinical Practice that encourages performance
standards based on those recommended by the available
scientific evidence in order to ensure the greatest efficacy
(relation cost/outcome) of health resources.
-
To distribute and recommend the use of this protocol
among physicians, especially those in Primary Care.
Methodology.
With the goal of preparing the Guideline
for Clinical Practice, a Pan-European program was put into
effect through the COST organization of the European Commission.
A "Managing Committee" was constituted, made up
of the leading European researchers and clinics in the field
of back disorders. Due to COST's work system, the experts
forming part of the Committee had to be named by the national
governments of each one of the countries participating in
the program. And among them, the majority had participated
in the creation of the clinical guidelines based on scientific
evidence that already exist in the different European countries.
The Managing Committee formed three work groups centered,
respectively, on defining the recommendations referring to
the prevention of pain, acute pain and chronic pain. Each
one of these Work Groups was made up of members of the Managing
Committee and by other experts specialized in the specific
subject, who were selected for the importance of their scientific
work in the corresponding field.
Each Work Group was in Charge of:
-
Analyzing the available scientific evidence on each one
of the relevant procedures for its area (prevention or
diagnosis and treatment of acute or chronic low back pain).
However, as several clinical Guidelines on acute low back
pain already exist (based on existing scientific evidence),
the corresponding Work Group did not repeat the evaluation
of the scientific evidence already reviewed but rather
used the already existing Guidelines as a point of departure.
-
Approving a recommendation based on the available scientific
evidence on the use or avoidance of each procedure.
-
Combining the recommended diagnostic and therapeutic
procedures, defining a protocol for behavior that ensures
the greatest efficacy and efficiency (cost/outcome) possible
of the available resources.
Furthermore, a Spanish Work Group was formed, with specialists
named by the medical societies representing physicians involved
in handling patients with back disorders (primary care physicians,
radiologists, rehabilitation specialists, rheumatologists,
traumatologists, neurosurgeons, specialists in occupational
medicine, etc.). This Group's missions were: to transmit the
scientific studies published in Spanish which the Managing
Committee may have overlooked, to comment on the drafts of
the Guidelines and to collaborate in its distribution and
promoting its application.
In order to avoid needless repetition, the COST B13 program
bears in mind the previous work done by other groups, such
as the Cochrane Collaboration, the Agency for Health Care
Policy and Research (USA), the Royal College of General Practitioners
(United Kingdom) and the Swedish Agency for the Evaluation
of Health Care Technologies (Sweden- SBU).
However, most of these groups have formulated their recommendations
on the basis of scientific studies published in English only.
Furthermore, the political and economic pressures that certain
professional groups have exercised in some countries have
resulted in contradictory recommendations formulated by different
groups on the basis of the same evidence. Additionally, all
of these Guidelines have been centered on handling patients
with acute ailments, but nearly none has provided recommendations
on prevention or for the treatment of chronic patients, who
generate more than 80% of the global costs derived from back
problems.
For that reason, the B13 Management Committee brought the
scientific foundations on which these recommendations are
based up-to-date and incorporated the reliable scientific
studies published in other languages (the Spanish Work Group
helped to identify 16 studies published in Spanish that had
been ignored by previous Guidelines for Clinical Practice).
It included scientific evidence referring to chronic cases
and to mechanisms of prevention in order to provide more complete
information. Also, as a Pan-European venture, it was better
prepared to resist the pressures that some professional groups
might exercise on a local or national level.
Participants, along with the Foundation's
Science Department.
The main experts in mechanical pathologies
of the spine of the different European countries who participate
as members of the Managing Committee and/or the Work Groups.
In all, there are 49 experts from Austria, Belgium, Denmark,
Finland, France, Germany, Holland, Italy, Israel, Norway,
Spain, Sweden, Switzerland, and the United Kingdom.
Additionally, in the Spanish Work Group, there are 14 experts
from 10 Spanish Scientific societies representative of their
disciplines, relevant to the diagnosis and treatment of back
disorders.
The Spanish portion is funded entirely by the Kovacs Foundation.
The COST organization, under the European Commission's Secretariat
for Research is responsible for funding the international
coordination.
Status.
This project was begun in October 1999. The preparation of
the guidelines for clinical practice is in progress.
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