European Spine Journal

, Volume 15, Issue 5, pp 641–647 | Cite as

Mono-disciplinary or multidisciplinary back pain guidelines? How can we achieve a common message in primary care?

  • Alan C. BreenEmail author
  • Maurits W. van Tulder
  • Bart W. Koes
  • Irene Jensen
  • Rhoda Reardon
  • Gert Bronfort
Original Article


Description of a workshop entitled “Sharing Guidelines for Low Back Pain Between Primary Health Care Providers: Toward a Common Message in Primary Care” that was held at the Fifth International Forum on Low Back Pain in Primary Care in Canada in May 2002. Despite a considerable degree of acceptance of current evidence-based guidelines, in practice, primary health care providers still do not share a common message. The objective of the workshop was to describe the outcomes of a workshop on the sharing of guidelines in primary care. The Fifth International Forum on Low Back Pain Research in Primary Care focused on relations between stakeholders in the primary care management of back pain. Participants in this workshop contributed to an open discussion on “how and why” evidence-based guidelines about back pain do or do not work in practice. Ways to minimise the factors that inhibit implementation were discussed in the light of whether guidelines are mono-disciplinary or multidisciplinary. Examples of potential issues for debate were contained in introductory presentations. The prospects for improving implementation and reducing barriers, and the priorities for future research, were then considered by an international group of researchers. This paper summarises the conclusions of three researcher subgroups that focused on the sharing of guidelines under the headings of: (1) the content, (2) the development process, and (3) implementation. How to share the evidence and make it meaningful to practice stakeholders is the main challenge of guideline implementation. There is a need to consider the balance between the strength of evidence in multidisciplinary guidelines and the utility/feasibility of mono-disciplinary guidelines. The usefulness of both mono-disciplinary and multidisciplinary guidelines was agreed on. However, in order to achieve consistent messages, mono-disciplinary guidelines should have a multidisciplinary parent. In other words, guidelines should be developed and monitored by a multidisciplinary team, but may be transferred to practice by mono-disciplinary messengers. Despite general agreement that multi-faceted interventions are most effective for implementing guidelines, the feasibility of doing this in busy clinical settings is questioned. Research is needed from local implementation pilots and quality monitoring studies to understand how to develop and deliver the contextual understanding required. This relates to processes of care as well as outcomes, and to social factors and policymaking as well as health care interventions. We commend these considerations to all who are interested in the challenges of achieving better-integrated, evidence-based care for people with back pain.


Back pain Guidelines Primary Care Implementation 


  1. 1.
    Appraisal of Guidelines for Research and Evaluation (AGREE) Collaborative Group (2000) Guideline Development in Europe. Int J Technol Assess Health Care 16(4):1039–1049Google Scholar
  2. 2.
    Barnett AG, Underwood MR, Vickers MR (1999) Effect of UK national guidelines on services to treat patients with acute low back pain: follow-up questionnaire survey. BMJ 318:919–920PubMedGoogle Scholar
  3. 3.
    Bird C (2000) Commissioned R & D Programmes: implementation of low back pain guidelines in North Thames. NHS Executive, LondonGoogle Scholar
  4. 4.
    Clinical Standards Advisory Group (CSAG) (1994) Epidemiology review: the epidemiology and cost of back pain. Department of Health, LondonGoogle Scholar
  5. 5.
    Eccles M, Grimshaw J (1995) Ensuring that guidelines change clinical practice. In: The development and implementation of clinical guidelines. Report of the Clinical Guidelines Working Group. Royal College of General Practitioners, Exeter, pp 12–15Google Scholar
  6. 6.
    Emslie CJ, Grimshaw J, Templeton A (1993) Do clinical guidelines improve general practice management and referral of infertile couples? BMJ 306:1728–1731PubMedGoogle Scholar
  7. 7.
    Evans DW, Foster NE, Vogel S, Breen AC, Pincus T (2003) Implementing evidence-based practice in the UK physical therapy professions: do they want it and do they feel they need it? In: Proceedings of the 5th international forum on low back pain research in primary care. Montreal, CanadaGoogle Scholar
  8. 8.
    Grimshaw J, Freemantle N, Wallace S, Russell I, Hurwitz B, Watt I, Long A, Sheldon T (1995) Developing and implementing clinical practice guidelines. Quality Health Care 4:55–64Google Scholar
  9. 9.
    Grol R, Dalhuijsen J, Thomas S, in’t Veld C, Rutten G, Mokkink H (1998) Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 317:858–861PubMedGoogle Scholar
  10. 10.
    Jamison RN, Gintner L, Rogers JF, Fairchild DG (2002) Disease management for chronic pain: barriers of program implementation with primary care physicians. Pain Med 3(2):92–101CrossRefPubMedGoogle Scholar
  11. 11.
    Kitson A, Harvey G, McCormack B (1998) Enabling the implementation of evidence based practice: a conceptual framework. Quality Health Care 7:149–58Google Scholar
  12. 12.
    Langworthy J, Breen A (2003) Auditing the management of acute back pain in primary care: too late to preserve the momentum? In: Proceedings of the 32nd annual scientific meeting of the society for academic primary care, ManchesterGoogle Scholar
  13. 13.
    Little P, Smith L, Cantrell T, Chapman J, Langridge J, Pickering R (1996) General practitioners’ management of acute back pain: a survey of reported practice compared with clinical guidelines. BMJ 312:485–488PubMedGoogle Scholar
  14. 14.
    McDonald CJ, Hui SL, Smith DM, Tierney WM, Cohen SJ, Weinberger M, McCabe GP (1984) Reminders to physicians from an introspective computer trial. Ann Intern Med 100:130–138PubMedGoogle Scholar
  15. 15.
    McIntosh A, Shaw C (2003) Barriers to patient information provision in primary care: patients’ and general practitioners’ experiences and expectations of information for low back pain. Health Expect 6:19–29CrossRefPubMedGoogle Scholar
  16. 16.
    National Institute for Clinical Excellence (2002) Principles for best practice in clinical audit. Radcliffe Medical Press Ltd, OxfordGoogle Scholar
  17. 17.
    NHS Centre for Reviews and Dissemination (1999) Effective Health Care 2: getting evidence into practice. University of New YorkGoogle Scholar
  18. 18.
    Oxman AD, Thomson MA, Davis DA, Haynes RB (1995) No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 153:1423–1431PubMedGoogle Scholar
  19. 19.
    Pagliari H, Kahan JP (2003) Biomed II Concerted action on changing professional practice: a catalogue of survey items assessing attitudes towards guidelines and perceived barriers and facilitators to implementation. The CPP Perceptions LibraryGoogle Scholar
  20. 20.
    Royal College of General Practitioners, Clinical Guidelines Working Group (1995) The development and implementation of clinical guidelines. Royal College of General Practitioners, ExeterGoogle Scholar
  21. 21.
    Scheel IB, Hagen KB, Oxman AD (2002) Active sick leave for patients with back pain: all the players onside but still no action. Spine 27(6):654–659CrossRefPubMedGoogle Scholar
  22. 22.
    Schers H, Braspenning J, Drijver R (2000) Low back pain in general practice: reported management and reasons for not adhering to the guidelines in the Netherlands. Br J Gen Pract 50:640–644PubMedGoogle Scholar
  23. 23.
    Sweeney G, Stead J, Sweeney K, Greco M (2000) Exploring the implementation and development of clinical governance in primary care within the South West Region: views from PCG Clinical Governance Leads. NHS Executive South West Region-Research & Development Support Unit, ExeterGoogle Scholar
  24. 24.
    Thorsen T, Makela M (1999) Changing professional practice: theory and practice of clinical guidelines implementation. Danish Institute for Health Services Research and DevelopmentGoogle Scholar
  25. 25.
    van Tulder MW, Croft PR, van Splunteren P, Miedema HS, Underwood MR, Hendricks HJM, Wyatt ME, Borkan JM (2002) Disseminating and implementing the results of back pain research. Spine 27(5):E121–E127CrossRefPubMedGoogle Scholar
  26. 26.
    Watkins C, Harvey I, Langley C, Gray S, Faulkner A (1999) General practitioners’ use of guidelines in the consultation and their attitudes to them. Br J Gen Pract 49:11–15PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Alan C. Breen
    • 1
    Email author
  • Maurits W. van Tulder
    • 2
    • 3
  • Bart W. Koes
    • 4
  • Irene Jensen
    • 5
  • Rhoda Reardon
    • 3
  • Gert Bronfort
    • 6
  1. 1.The Institute for Musculoskeletal Research and Clinical ImplementationAnglo-European College of ChiropracticBournemouth, DorsetUK
  2. 2.Institute for Research in Extramural MedicineVU University Medical CenterAmsterdamThe Netherlands
  3. 3.Institute for Work & HealthTorontoCanada
  4. 4.Department of General PracticeErasmus UniversityRotterdam
  5. 5.Department of Personal Injury PreventionKarolinska InstituteStockholmSweden
  6. 6.Northwestern Health Sciences UniversityBloomingtonUSA

Personalised recommendations