Structure of the Guideline
The American College of Occupational and Environmental Medicine (ACOEM) Guideline on Low Back Disorders is impressive. In its over 800 pages, it covers a myriad of assessment procedures and interventions and aims to inform a multitude of health care providers about evidence-based practice for low back pain in the adult working population. Recommendations are based on no less than 2391 references and range from the type of mattress to the type of surgery. Despite its respectable size, the guideline is extremely user-friendly and easy to follow. It is structured in a logical way starting with assessment procedures and progressing through conservative interventions to surgery and delayed rehabilitation. Recommendations, level of evidence and level of confidence are provided for each section.

Inclusion of Directional Preference in the Guideline
Directional preference, or the absence thereof, is considered in various sections of the Guideline. Testing for DP is recommended as a critical component of Exercise Prescription for patients with acute, subacute, chronic LBP, post-operative LBP and radiculopathy. For patients with an identified DP, directional exercises are recommended for the management of acute, subacute, chronic LBP and radiculopathy. It is noteworthy that the absence of a DP is also considered for several recommendations. For example, it is listed in the criteria for recommending magnetic resonance imaging. Slump stretching is recommended in patients with acute, subacute or chronic LBP but without a DP. Similarly, work rehabilitation programs are recommended for patients with subacute or chronic LBP who have failed an active treatment approach including directional exercises. Interestingly, directional exercises are also one of the treatments that should have been attempted prior to prescribing opioid medication. Finally, DP exercises may be combined with other interventions including aerobic exercises, massage therapy, biofeedback (select sub-group of patients) and mobilizations/ manipulations.

Conclusion
Considering that the testing of DP is recommended for all patients with LBP (excluding those with serious pathology) and that the absence of DP is included in many recommendations for other interventions, it is obvious that this guideline considers DP an important component of informed LBP management.

Guidelines