Published 9/1/2010
Michael H. Heggeness, MD, PhD

AAOS endorses back pain guidelines

Critical analysis leads to formal endorsement

For the first time ever, the AAOS has endorsed clinical practice guidelines generated by another medical specialty society. At its meeting in June, the AAOS Board of Directors approved the endorsement of the American Pain Society’s Guideline on Management of Low Back Pain.

The need for guidelines
The modern practice of orthopaedic surgery requires orthopaedists to apply evidence-based medicine (EBM) to the decision-making process used in the care of patients. EBM involves the integration of the best available research evidence in deciding on clinical therapies. The creation of clinical practice guidelines to address specific clinical treatment issues has been one of the most useful and popular applications of EBM.

The AAOS and many other medical specialty societies have initiated formal processes for conducting detailed investigations of clinical issues, producing such guidelines, and distributing them widely. Guidelines produced by the AAOS, for example, are reported in AAOS Now and summarized in the Journal of the AAOS and The Journal of Bone and Joint Surgery. They also are made available on both the AAOS Web site and the National Guideline Clearinghouse Web site.

The evidence base
The creation of a valid clinical practice guideline involves an extensive review of the clinical research on the topic being investigated. Specific questions concerning that topic are evaluated with regard to the available published data, and data are stratified by reliability and rigor. The questions asked in the guideline are then answered with only the highest and most reliable data available from the clinical literature.

Answers to each of the questions become the guideline recommendations and each is assigned a level of strength based on the quality and reliability of the evidence available. Specific recommendations and conclusions are stated in the guidelines to help direct clinical decision making, but the guidelines are never intended to mandate or proscribe specific treatments.

As the wider medical community begins to recognize the importance of EBM, several medical societies and other groups are also generating clinical guidelines. To the credit of the entire medical community, the AAOS and many societies are asked to evaluate the clinical guidelines produced by other groups.

Testing the process
The AAOS was recently asked to evaluate guidelines generated by the American College of Physicians and the American Pain Society directed at the diagnosis and treatment of low back pain (
Tables 1 and 2). With the approval of the AAOS Guidelines and Technology Oversight Committee (GTOC) and the AAOS Evidence-Based Practice Committee (EBPC), it was agreed upon to review these guidelines—the first time that the AAOS has undertaken a critical analysis of guidelines generated by another society.

The committee first performed a review of the process followed in generating the guidelines. Attention was directed to the rigor of the literature search, the quality of the systematic review, clear delineation of inclusion and exclusion criteria for the evidence, the funding sources for the process, and possible conflict of interest from the authors of the guidelines. These were all judged to be satisfactory.

Next, a panel of five AAOS members, all trained and experienced in EBM, critically evaluated the content of the guideline. Members of this External Guideline Review Team (Michael H. Heggeness, MD, PhD; John S. Kirkpatrick, MD; Charles A. Reitman, MD; Sohail K. Mirza, MD, MPH; and William A. Abdu, MD) verified the cited clinical evidence and the appropriateness of the analysis. They then voted on the appropriateness of an AAOS endorsement of this clinical guideline; the vote for approval was unanimous.

The review team reported its findings and recommendation to the combined membership of the EBPC and the GTOC. Both committees—as well as the Council on Research, Quality Assessment and Technology—also voted in favor of an AAOS endorsement. The AAOS Board of Directors approved this formal endorsement on June 18, 2010.

Initial Evaluation and Management Guidelines

Interventional Therapies and Surgery Guidelines

Michael H. Heggeness, MD, PhD, is a member of the Evidence-Based Practice Committee and served as the leader of the External Guideline Review Team.

AAOS members interested in participating in evidence-based medicine–related activity with the Academy are encouraged to contact Fareeha Shuttari-Khan, MPH, AAOS evidence-based medicine coordinator, at shuttari@aaos.org