Clinical guidelines in the management of low back pain

With the emergent concept of evidence-based practice, various countries have produced clinical guidelines for the management of acute low back pain since 1993-94. By and large the evidence-base for these proposals is consistent, though over the last 4 years it has increased considerably, and there has been a slight change of emphasis in several aspects. As all the guidelines are based on the same evidence, the similarity between them is not surprising. The common features are diagnostic triage along with periodic assessment to guide management strategies. There has been progressive reduction in the recommendation of rest as a treatment option, and early activation is increasingly recognized as a potent intervention. There has been a progressive recognition that psychosocial factors are important determinants for the risk of chronicity, and that such factors need to be addressed clinically. Specific therapeutic recommendations vary, but these are probably less important than the overall strategy. It is obviously hoped that clinical management should improve as a result of these initiatives, but effective dissemination and implementation are persisting concerns, and the effectiveness of clinical guidelines in changing clinical practice is still unproven.