NURS2007 Assignment 3: Critique of Pain Management Guidelines

This assignment presents a critical appraisal of two clinical practice guidelines (CPGs) related to pain management. The first CPG focuses on the management of non-specific low back pain, while the second addresses pain management associated with vaccine injections. The student utilizes the AGREE II tool to evaluate the guidelines across various domains, including scope and purpose, stakeholder involvement, rigor of development, and clarity of presentation. The report analyzes the strengths and weaknesses of each guideline, providing evidence-based rationales for the assessment. The student identifies the low back pain guideline as superior, citing factors such as a multidisciplinary approach, clear eligibility criteria, and comprehensive data extraction methods. The report also highlights the importance of considering cultural and religious differences when evaluating the guidelines. The analysis includes a detailed comparison of the recommendations, benefits, and limitations of each guideline, ultimately concluding with a comparative assessment of their effectiveness in pain management strategies. The report emphasizes the importance of considering the target audience and the potential impact of the guidelines on patient outcomes.

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

1CRITICAL APPRAISAL
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

2CRITICAL APPRAISAL
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

3CRITICAL APPRAISAL
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

4CRITICAL APPRAISAL
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

5CRITICAL APPRAISAL
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

6CRITICAL APPRAISAL
suggested some kinds of physical activity and approaches of delivery for chronic LBP
patients, in comparison to the earlier guidelines that only noted the predilection for
implementation of intensive training. In contrast, Taddio et al. (2015) recommended the
application of topical anaesthetics prior to injecting vaccines for reducing pain. However, it
has often been found that topical anaesthesia often results in swelling, burning sensation,
redness and lightening of the skin. Furthermore, the procedure must also be avoided in young
patients, and those with nystagmus and strong blink reflex (Phillips, McEnery-Stonelake &
Huang, 2019).
Differences- One major reason for not considering the CPG by Oliveira et al. (2018)
can be accredited to cultural and religious differences. Time and again it has been found that
vaccination workers who belong to a particular ethnic group. Have been attacked and killed
by militant groups and preachers. In addition, several people hold the belief that natural
infection offers an enhanced immune protection contrary to contracting infection or disease in
the future, in comparison to vaccination. Furthermore, the multidisciplinary team involved in
CPG formulation for non-specific LBP were from several countries and worked in different
domains, thus increasing reliability of the recommendations. This was in contrast to the fact
that CPG recommended by Taddio et al. (2015) was formulated by a team that comprised of
specialists from Canada. Thus, lack of diverse members in the multidisciplinary team reduced
representativeness of the findings, since it did not take into consideration the perception and
approach of culturally diverse patients towards vaccination.
The number of organisations involved in the research also resulted in differences
since recommendations obtained from members working in Denmark, Brazil. Australia, and
Switzerland could be better generalised to the global population. This is further confirmed by
the fact that the publications used in CPG for non-specific LBP management had been cited
more than 300 times, thus suggesting that the target audience was large enough (Oliveira et

7CRITICAL APPRAISAL
al., 2018). The European Spine Journal is particularly devoted to orthopaedics as it is
associated to different aspects of the human spine. Taking into consideration the fact that the
spinal cord is most affected in LBP, the CPG had a wider audience. In contrast, CMAJ has
been associated with dispute related to editorial independence.
Conclusion- On analysing both the CPGs discussed in the previous sections, it can be
concluded that they focused on the concept of pain management that has been identified as a
multifaceted domain of healthcare. Pain management is typically significant for control of
ongoing pain, particularly if the patients suffer from chronic or long-term pain. Following the
conduction of a comprehensive pain assessment, the healthcare provider generally prescribes
pain medications or other types of pain treatment such as, psychotherapy in order to provide
relief to the patients. Hence, the primary objective of both the articles was to increase
familiarity and understanding on the different pharmaceutical and non-pharmaceutical
interventions that can be applied for reducing pain. While the CPG that was considered better
focused on management of LBP that occurs due to joint or muscle strain, the other CPG
focused on all types of pain and vaccine injection for treating the same. Taking into
consideration the high prevalence of vaccine hesitancy and anti-vaccine myth, it can be
suggested that the former CPG for LBP management is most effective and can be easily
implemented in real-time healthcare settings. Hence, healthcare providers can administer
interventional procedures, psychological counselling, medication management, exercise
therapy, or refer to other medical specialists for ensuring that the severity and duration of
LBP among the patients get reduced.

8CRITICAL APPRAISAL
References
Ayoub, S. S., & Flower, R. J. (2019). Loss of hypothermic and anti-pyretic action of
paracetamol in cyclooxygenase-1 knockout mice is indicative of inhibition of
cyclooxygenase-1 variant enzymes. European journal of pharmacology, 172609.
https://doi.org/10.1016/j.ejphar.2019.172609
Ciemins, E. L., Brant, J., Kersten, D., Mullette, E., & Dickerson, D. (2016). Why the
interdisciplinary team approach works: insights from complexity science. Journal of
palliative medicine, 19(7), 767-770. https://doi.org/10.1089/jpm.2015.0398
MacDonald, N. E. (2015). Vaccine hesitancy: Definition, scope and
determinants. Vaccine, 33(34), 4161-4164.
https://doi.org/10.1016/j.vaccine.2015.04.036
Maher, C., Underwood, M., & Buchbinder, R. (2017). Non-specific low back pain. The
Lancet, 389(10070), 736-747. https://doi.org/10.1016/S0140-6736(16)30970-9
McGowan, J., Sampson, M., Salzwedel, D. M., Cogo, E., Foerster, V., & Lefebvre, C.
(2016). PRESS peer review of electronic search strategies: 2015 guideline
statement. Journal of clinical epidemiology, 75, 40-46.
https://doi.org/10.1016/j.jclinepi.2016.01.021
Mirshafiey, A., Taeb, M., Mortazavi-Jahromi, S. S., Jafarnezhad-Ansariha, F., Rehm, B. H.,
Esposito, E., ... & Matsuo, H. (2017). Introduction of β-d-mannuronic acid (M2000)
as a novel NSAID with immunosuppressive property based on COX-1/COX-2
activity and gene expression. Pharmacological reports, 69(5), 1067-1072.
https://doi.org/10.1016/j.pharep.2017.04.015

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Oliveira, C. B., Maher, C. G., Pinto, R. Z., Traeger, A. C., Lin, C. W. C., Chenot, J. F., ... &
Koes, B. W. (2018). Clinical practice guidelines for the management of non-specific
low back pain in primary care: an updated overview. European Spine Journal, 27(11),
2791-2803. https://doi.org/10.1007/s00586-018-5673-2
Osborne, P. J., Jimenez-Torres, G. J., Landa, Y., Mahoney, J., & Madan, A. (2017). Chronic
pain management group psychotherapy for psychiatric inpatients: A pilot
study. Bulletin of the Menninger Clinic, 81(2), 123-149.
https://doi.org/10.1521/bumc.2017.81.2.123
Phillips, C. B., McEnery-Stonelake, M., & Huang, C. C. (2019). Topical Anesthesia.
In Evidence-Based Procedural Dermatology (pp. 541-554). Springer, Cham.
https://doi.org/10.1007/978-3-030-02023-1_33
Rice, A. S., Smith, B. H., & Blyth, F. M. (2016). Pain and the global burden of
disease. Pain, 157(4), 791-796. doi: 10.1097/j.pain.0000000000000454
Rojas, E., Munoz-Gama, J., Sepúlveda, M., & Capurro, D. (2016). Process mining in
healthcare: A literature review. Journal of biomedical informatics, 61, 224-236.
https://doi.org/10.1016/j.jbi.2016.04.007
Taddio, A., McMurtry, C. M., Shah, V., Riddell, R. P., Chambers, C. T., Noel, M., ... &
Lang, E. (2015). Reducing pain during vaccine injections: clinical practice guideline.
CMAJ: Canadian Medical Association Journal, 187(13), 975.
http://www.cmaj.ca/content/cmaj/187/13/975.full.pdf
World Health Organization. (2018). 6.24 Low back pain.
https://www.who.int/medicines/areas/priority_medicines/Ch6_24LBP.pdf

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World Health Organization. (2019). Ten threats to global health in 2019.
https://www.who.int/emergencies/ten-threats-to-global-health-in-2019

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Appendix 1- AGREE tool for LBP management CPG
Domain Item
AGREE II Rating
1
Strongly
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
Scope and
purpose
1. The overall
objective(s) of the
guideline is (are)
specifically
described.
Y
2. The health
question(s)
covered by the
guideline is (are)
specifically
described.
Y
3. The population
(patients, public,
etc.) to whom the
guideline is meant
to apply is
specifically
Y

12CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongly
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
described.
Comments:
Stakeholder
involvement
4. The guideline
development
group includes
individuals from
all the relevant
professional
groups.
Y
5. The views and
preferences of the
target population
(patients, public,
etc.) have been
sought.
Y
6. The target users of
the guideline are
Y

13CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongly
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
clearly defined.
Comments:
Rigor of
development
7. Systematic
methods were used
to search for
evidence.
Y
8. The criteria for
selecting the
evidence are
clearly described.
Y
9. The strengths and
limitations of the
body of evidence
are clearly
described.
Y
10. The methods for
formulating the
Y

14CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongly
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
recommendations
are clearly
described.
11. The health
benefits, side
effects and risks
have been
considered in
formulating the
recommendations.
Y
12. There is an explicit
link between the
recommendations
and the supporting
evidence.
Y
13. The guideline has
been externally
reviewed by
experts prior to its
Y

15CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongly
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
publication.
14. A procedure for
updating the
guideline is
provided.
Y
Comments:
Clarity of
presentation
15. The
recommendations
are specific and
unambiguous.
Y
16. The different
options for
management of the
condition or health
issue are clearly
presented.
Y
17. Key
recommendations
Y

16CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongly
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
are easily
identifiable.
Comments:
Applicability 18. The guideline
describes
facilitators and
barriers to its
application.
Y
19. The guideline
provides advice
and/or tools on
how the
recommendations
can be put into
practice.
Y
20. The potential
resource
Y

17CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongly
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
implications of
applying the
recommendations
have been
considered.
21. The guideline
presents
monitoring and/ or
auditing criteria.
Y
22. The views of the
funding body have
not influenced the
content of the
guideline.
Y
Comments:
Editorial
independence 23. Competing Y

18CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongly
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
interests of
guideline
development
group members
have been
recorded and
addressed.
Comments:
Overall
Guideline
Assessment
1. Rate the overall
quality of this
guideline.
1
Lowest
possible
quality
2 3 4 5 6
7
Highest
possible
quality
Overall
Guideline
Assessment
2. I would
recommend this
guideline for use.
Yes Yes, with modifications No
Information on limitations of the
recommendations with explanation
on audit and monitoring is needed
Notes:

19CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongly
Disagre
e
2 3 4 5 6
7
Strongl
y Agree

20CRITICAL APPRAISAL
Appendix 2- AGREE tool for vaccine injection
Domain Item
AGREE II Rating
1
Strongl
y
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
Scope and
purpose
24. The overall
objective(s) of
the guideline is
(are)
specifically
described.
Y
25. The health
question(s)
covered by the
guideline is
(are)
specifically
described.
Y
26. The population
(patients,
public, etc.) to
whom the
Y

21CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongl
y
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
guideline is
meant to apply
is specifically
described.
Comments:
Stakeholder
involvement
27. The guideline
development
group includes
individuals
from all the
relevant
professional
groups.
Y
28. The views and
preferences of
the target
population
Y

22CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongl
y
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
(patients,
public, etc.)
have been
sought.
29. The target users
of the guideline
are clearly
defined.
Y
Comments:
Rigor of
developmen
t
30. Systematic
methods were
used to search
for evidence.
Y
31. The criteria for
selecting the
evidence are
Y

23CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongl
y
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
clearly
described.
32. The strengths
and limitations
of the body of
evidence are
clearly
described.
Y
33. The methods
for formulating
the
recommendatio
ns are clearly
described.
Y
34. The health
benefits, side
effects and risks
have been
Y

24CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongl
y
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
considered in
formulating the
recommendatio
ns.
35. There is an
explicit link
between the
recommendatio
ns and the
supporting
evidence.
Y
36. The guideline
has been
externally
reviewed by
experts prior to
its publication.
Y

25CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongl
y
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
37. A procedure for
updating the
guideline is
provided.
Y
Comments:
Clarity of
presentation
38. The
recommendatio
ns are specific
and
unambiguous.
Y
39. The different
options for
management of
the condition or
health issue are
clearly
presented.
Y

26CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongl
y
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
40. Key
recommendatio
ns are easily
identifiable.
Y
Comments:
Applicabilit
y
41. The guideline
describes
facilitators and
barriers to its
application.
Y
42. The guideline
provides advice
and/or tools on
how the
recommendatio
ns can be put
Y

27CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongl
y
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
into practice.
43. The potential
resource
implications of
applying the
recommendatio
ns have been
considered.
Y
44. The guideline
presents
monitoring and/
or auditing
criteria.
Y
45. The views of
the funding
body have not
influenced the
content of the
Y

28CRITICAL APPRAISAL
Domain Item
AGREE II Rating
1
Strongl
y
Disagre
e
2 3 4 5 6
7
Strongl
y Agree
guideline.
Comments:
Editorial
independen
ce
46. Competing
interests of
guideline
development
group members
have been
recorded and
addressed.
Y
Comments:
Overall
Guideline
Assessment
3. Rate the overall
quality of this
guideline.
1
Lowest
possible
2 3 4 5 6 7
Highes
t