Critical Appraisal of Clinical Practice Guidelines for Pain Management

Running head: CRITICAL APPRAISAL
Assignment 3- Critique of clinical practice guidelines using the AGREE 11
tool
Name of the Student
Name of the University
Author Note

CRITICAL APPRAISAL1
Introduction- Pain management, also referred to as algiatry or pain control refers to
the branch of medicine that employs multidisciplinary approach for improving and easing the
quality of life of individuals who are suffering from chronic pain. Common treatment
approaches to chronic pain encompasses interventional procedures, physical exercise,
pharmacological techniques, such as, antidepressants analgesics, and anticonvulsants,
physical therapy, application of heat or ice, and a range of psychological measures, such as
cognitive behavioural therapy and biofeedback (Rice, Smith & Blyth, 2016). This assignment
will contain a critical appraisal of two clinical practice guidelines that focus on non-specific
low back pain management, and vaccine injection based pain management, respectively.
Critique- The scope of the CPG by Oliveira et al. (2018) was well-defined since the
researchers identified LBP as a major contributor to disability on a global basis and also
highlighted the high prevalence of non-specific LBP in the USA, Germany, Switzerland, and
the Netherlands. Hence, the CPG addressed the target population that comprised of people
who have been diagnosed with non-specific LBP. The guidelines were issued by
interdisciplinary group comprising of primary care physicians, chiropractors, physical and
manual therapists, orthopaedic surgeons, rheumatologists, physical and manual therapists,
and radiologists. Employment of systematic methods helps in inclusion of prospective articles
in a secondary research. The researchers used a combination of key search phrases related to
clinical guidelines and LBP for extracting articles from the OVID and MEDLINE electronic
databases, published from 2008-17. Clear information was provided on the criteria for article
selection. Though they clearly elucidated the benefits of the recommendations for different
strategies that help in diagnosis and treatment of LBP, they failed to elaborate on the risks
and side effects while formulating the recommendations. The recommendations were
unambiguous, identifiable, and specific, and the facilitators and barriers for implementation
were also highlighted. The research was funded by the Capes Foundation, NHMRC, Early

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Career Fellowship, and Career Development Fellowship. In addition, there was no conflict of
interest, apart from obtaining lecture fees from Pfzer. They also elaborated on
recommendation 9 for updating the guidelines.
In contrast the guideline by Taddio et al. (2015) recognised the pervasiveness of pain
from vaccine injections and also highlighted that demonstrating noncompliance with
vaccination compromises the immunisation benefits, and lead to outbreak of several diseases.
The researchers stated that healthcare providers who were responsible for vaccine
administration were the intended audience and the 25 stakeholders had diverse expertise in
pain, medicine, fear, pharmacy, nursing, vaccinology, epidemiology, and other disciplines.
They used systematic methods for retrieving evidence and also used the AGREE II tool for
developing the guideline. Adequate and detailed information was provided on the benefits of
different recommendations such as, procedural interventions, physical intervention,
pharmacologic interventions, and process interventions. However, they failed to discuss the
risks or adverse impacts associated with each intervention type. They planned to update the
CPG in the next 5–10 years, and mentioned Canadian Institutes of Health Research as the
funding organisation. The recommendations are precise and explicit and the competing
interests regarding consultation fees, government relation, and grants from different
pharmaceutical agencies. However, in both the CPG, the audit and monitoring criteria were
not fulfilled by the researchers.
Evidence for clinical guideline- The CPG that was based on non-specific LBP
management in primary care is more effective, when compared to the CPG that focused on
vaccine injection for pain management (Oliveira et al., 2018). LBP is a common disorder that
affects the nerves, muscles, and bones of the back and is generally classified as acute, sub-
chronic or chronic, depending on the duration (Maher, Underwood & Buchbinder, 2017). The
health question that had been covered by the guideline was accurately formulated owing to

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the fact that LBP has been identified as one of the top diseases that accounts for the
maximum number of Disability-Adjusted Life Year (DALY) on a global basis. Furthermore,
the lifetime prevalence of non-specific LBP has been estimated to be 60-70% amid
industrialised nations, with 5% adult incidence each year (WHO, 2018). Hence, the CPG was
based on a well-addressed topic since identification of appropriate recommendations for LBP
management would act imperative in enhancing health outcomes of patients, and reducing the
prevalence and incidence rates, thus improving health-related quality of life. In contrast,
though the CPG by Taddio et al. (2015) was based on administration of vaccine injections for
pain management, refusal or reluctance to be vaccinated has been identified by the World
Health Organisation (2019) as one of the top most global threats to health and wellbeing in
2019. Therefore, there remains an uncertainty regarding the perception and attitude of
patients who have been diagnosed with pain, in relation to acceptance of the
recommendations.
Selection of this CPG over the other can also be accredited to the fact that the
guidelines incorporated by the researchers have been cited numerous times, thus increasing
relevance and reliability of the published findings (Oliveira et al., 2018). Presence of an
interdisciplinary approach to health and social care generally comprises of team members
who belong to diverse disciplines and work collaboratively, with a shared determination, to
set goal mouth, make pronouncements and share possessions and accountabilities (Ciemins,
Brant, Kersten, Mullette & Dickerson, 2016). Therefore, this CPG was more effective since a
team of clinicians who worked in different disciplines were involved during formulation of
the key recommendations that addressed management of LBP. Time and again it has been
established that presence of definite eligibility criteria for article selection set the boundaries
for a literature and/or systematic review (McGowan et al., 2016). This criteria is generally
determined, following development of the research question, usually prior to conducting a

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search of electronic databases. Thus, this CPG was considered better since the researchers
clearly elucidated on the key terms and databases that they selected for the guideline and the
limiters and filters that had been applied (Oliveira et al., 2018). Systematic methods that are
generally followed by researchers comprise of providing accurate definition for the concepts
used in research, the study design, setting, language, and exposure of interest. In this
guideline, the researchers clearly stated that only those guidelines that had been published in
English French, Portuguese, German, Chinese, Spanish, or Dutch language were included.
Data extraction process is imperative in research since it encompasses retrieval of necessary
information from a range of sources, followed by an analysis of the findings (Rojas, Munoz-
Gama, Sepúlveda & Capurro, 2016). However, Taddio et al. (2015) did not provide adequate
information on the search strategy that they followed while retrieving articles on pain
vaccination, which were incorporated in the guideline.
While developing the CPG on non-specific LBP, data extraction was performed by
two independent authors, with the use of a form and the researchers also compared the
findings from existing overviews, with that of the current CPG, followed by result
representation in tabular format (Oliveira et al., 2018). While the strength of the evidences
are clearly elucidated, there was lack of sufficient information on the limitations of the
recommended strategies. While elaborating on the treatment recommendations, the
researchers highlighted the importance of avoiding best rest, patient education in the form of
advice and reassurance, prescribing NSAID, administration of paracetamol, opioid
prescription, antidepressants, muscle relaxant, herbal medicines, and referral to specialists,
usage of radiofrequency, surgical methods, and multidisciplinary rehabilitation (Oliveira et
al., 2018).
The effectiveness of this CPG can be accredited to the fact that acetaminophen or
paracetamol has been found operative in treatment of pain by triggering the selective

CRITICAL APPRAISAL5
inhibition of COX activities located in the brain, thus contributing to pain management
(Ayoub & Flower, 2019). The fact that the researchers recommended administration of
NSAID was another correct approach since the drugs inhibit COX enzyme, thus preventing
formation of thromboxane and prostaglandin, thereby reducing inflammation during pain
(Mirshafiey et al., 2017). Reliability of this CPG can also be accredited to the fact that it was
based on already established evidences for the role of antidepressants in treatment of chronic
pain. This is in contrast to Taddio et al. (2015) elaborated on order of injection, no aspiration,
positioning, topical anaesthetic administration, clinician education, and patient education, for
vaccine injection administration. This cannot be cited as a better CPG owing to the fact that
presence of unverified reports about the side effects of vaccination such as, vaccine overload,
prenatal infection, autism risks, and other safety concerns will act as an impediment and
prevent healthcare workers from injecting vaccines to patients who report signs and
symptoms of pain (MacDonald, 2015).
Not only did the researchers elaborate on the key pharmacological interventions that
would help in effective LBP management, they also highlighted the importance of different
psychosocial therapy and exercise therapy. The guidelines were based on the fact that
psychosocial therapy helps the affected people to get a sound understanding of the
association between muscle tension and pain, with the related emotions, behaviour and
thoughts. In addition, the CPG was also based on existing evidences that subjecting LBP
patients to psychosocial therapy helps in cognitive restructuring, thus encouraging obliging
thought patterns, besides targeting a behavioural initiation of healthy accomplishments such
as, pacing and regular exercise (Osborne, Jimenez-Torres, Landa, Mahoney & Madan, 2017).
The researchers also highlighted the fact that most recommendations that they had elaborated
in the CPG were available in the web portals of the contributing organization, with the rest
being easily accessible in different scientific journals. In addition, the present CPG also