Royal College of General Practitioners Guidelines on bed rest in acute low back pain: A need for re-evaluation

Abstract

A critique, originally circulated 15 years ago, of the use of evidence in guidelines concerning rest in low-back pain, is reproduced. The conceptual background against which evidence was considered is discussed with the suggestion that attempts to reconcile data and concept resulted in advice on treatment which is now being questioned. It is necessary to be vigilant lest expectations of evidence unduly influence its assessment.

Keywords:

• Rest
• Low-back pain
• Systematic review
• Evidence-based guidelines
• Critique

Afterword

At the time it was written, publication of my critique was refused by the BMJ, Lancet, and the RCGP's own journal although reviewers' comments were that they had no criticism of the presentation or accuracy of the content; one even going so far as to say that the guideline's advice was already ignored by experienced general practitioners and therefore publication was unnecessary as it would not alter practice! It was circulated to members of the RCGP guideline committee and the main author of the evidence review on which the guidelines were based.ⁱⁱ None of those receiving it responded. More recently it was sent to a senior member of Cochrane systematic review committees on back pain management who has since responded publiclyⁱⁱⁱ to their latest review.^iv He concludes his personal commentary:

‘The findings of this review do not oppose the recommendations in the current clinical guidelines, which favour the advice to stay active above bed rest. At the same time, the review shows that the underlying scientific evidence for the recommendations is rather thin. Future high-quality trials will very likely have an important impact on the estimate of the effects and are likely to change our confidence in it’.

Meanwhile teaching internationally has been influenced by the guidelines: those prepared to advise short-term rest as beneficial to some patients, continue to be designated ‘guideline non-compliant’,^v indicating a failure of education, knowledge or respect for evidence: ‘Future research is needed to determine the factors influencing non-compliance before selecting effective interventions to change physicians’ practice behaviour'.

The author has spent most of his career concerned with gathering evidence on which to base better medical practice in back pain so that its mis-use, no matter how well-meaning, raises the serious concern that the more we claim that evidence is central to our judgments the more the incentives to manipulate it. Advice should be based on evidence but its evaluation should not be influenced by conformity to ideas that have become rigid dogma resistant to the consideration of contrary findings.