After diagnostic testing, your patient was diagnosed with low back pain without any specific injury. One of the most important aspects of the care at this point is to create a comprehensive teaching plan. What are the important teaching points you need to consider for the acute care of this individual? And what would you suggest for prevention of potential future injuries? Please use references; listed below and the uploaded article. You don’t have to use all, but the article seem useful. Rihn JA et al. Duration of symptoms resulting from lumbar disc herniation: effect on treatment outcomes: analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am. 2011 Oct 19;93(20):1906–14. [PMID: 22012528]Suri P et al. Recurrence of radicular pain or back pain after nonsurgical treatment of symptomatic lumbar disk herniation. Arch Phys Med Rehabil. 2012 Apr;93(4):690–5. [PMID: 22464091]Eur Spine J (2010) 19:2075–2094
DOI 10.1007/s00586-010-1502-y
An updated overview of clinical guidelines for the management
of non-specific low back pain in primary care
Bart W. Koes • Maurits van Tulder •
Chung-Wei Christine Lin • Luciana G. Macedo
James McAuley • Chris Maher

Received: 30 October 2009 / Revised: 15 June 2010 / Accepted: 16 June 2010 / Published online: 3 July 2010
Ó The Author(s) 2010. This article is published with open access at
Abstract The aim of this study was to present and compare the content of (inter)national clinical guidelines for the
management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines
have been issued in many countries. Given that the available
scientific evidence is the same, irrespective of the country,
one would expect these guidelines to include more or less
similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical
guidelines published up to and including the year 2000.
Guidelines were included that met the following criteria: the
target group consisted mainly of primary health care professionals, and the guideline was published in English,
German, Finnish, Spanish, Norwegian, or Dutch. Only one
guideline per country was included: the one most recently
published. This updated review includes national clinical
guidelines from 13 countries and 2 international clinical
guidelines from Europe published from 2000 until 2008. The
content of the guidelines appeared to be quite similar
regarding the diagnostic classification (diagnostic triage)
and the use of diagnostic and therapeutic interventions.
Consistent features for acute low back pain were the early
and gradual activation of patients, the discouragement of
prescribed bed rest and the recognition of psychosocial
factors as risk factors for chronicity. For chronic low back
pain, consistent features included supervised exercises,
cognitive behavioural therapy and multidisciplinary treatment. However, there are some discrepancies for recommendations regarding spinal manipulation and drug
treatment for acute and chronic low back pain. The comparison of international clinical guidelines for the management of low back pain showed that diagnostic and
therapeutic recommendations are generally similar. There
are also some differences which may be due to a lack of
strong evidence regarding these topics or due to differences
in local health care systems. The implementation of these
clinical guidelines remains a challenge for clinical practice
and research.
Keywords Low back pain Clinical guidelines
Review Diagnosis Treatment
B. W. Koes (&)
Department of General Practice, Erasmus MC,
P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
M. van Tulder
Department of Health Sciences and the EMGO Institute
for Health and Care Research, VU University Amsterdam,
Amsterdam, The Netherlands
C.-W. C. Lin L. G. Macedo J. McAuley C. Maher
George Institute, Sydney, Australia
Low back pain remains a condition with a relatively high
incidence and prevalence. Following a new episode, the
pain typically improves substantially but does not resolve
completely during the first 4–6 weeks. In most people the
pain and associated disability persist for months; however,
only a small proportion remains severely disabled [1]. For
those whose pain does resolve completely, recurrence
during the next 12 months is not uncommon [2, 3].
There is a wide acceptance that the management of low
back pain should begin in primary care. The challenge for
primary care clinicians is that back pain is but one of many
conditions that they manage. For example while back pain,
in absolute numbers, is the eighth most common condition
managed by Australian GPs, it only accounts for 1.8% of
their case load [4]. To assist primary care practitioners to
provide care that is aligned with the best evidence, clinical
practice guidelines have been produced in many countries
around the world.
The first low back pain guideline was published in
1987 by the Quebec Task Force with authors pointing to
the absence of high-quality evidence to guide decision
making [5]. Since that time there has been a strong
growth in research addressing diagnosis and prognosis but
especially research on therapy. As an example of this
growth, at the time of the Spitzer guideline [5] there were
only 108 randomised controlled trials evaluating physiotherapy treatments for low back pain but as at April 2009
there were 958.1 The Cochrane database (Central) currently lists more than 2500 controlled trials evaluating
treatment for back and neck pain. The evidence from
these trials for most interventions is summarised in systematic reviews and meta-analysis. The Cochrane Back
Review Group, for example, has now published 32 systematic reviews of randomised controlled trials evaluating
interventions for low back pain. In the near future, systematic reviews of studies evaluating diagnostic intervention for low back pain will also be included in the
Cochrane Library.
This dramatic growth in research would be a comfort to
those who were members of the original Quebec Task
Force but perhaps a challenge to those who served on
committees for later guidelines. With a large and ever
increasing research base to inform guidelines two potential
problems arise. The first and most obvious is that the recommendations in the guidelines may become out of date.
The second is that with a wealth of information to consider,
the various committees producing guidelines may produce
quite different treatment recommendations. At the same
time one can argue that if more precise and valid information becomes available recommendations will become
more similar. A previous systematic review of clinical
practice guidelines was conducted in 2001 [6]. In that
review we assessed the available clinical guidelines from
11 countries and concluded that the guidelines provided
generally similar recommendations regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features
were the early and gradual activation of patients, the discouragement of prescribed bed rest, and the recognition of
psychosocial factors as risk factors for chronicity. However, there were discrepancies for recommendations
Based upon search of PEDro database April 29, 2009.
Eur Spine J (2010) 19:2075–2094
regarding exercise therapy, spinal manipulation, muscle
relaxants, and patient information.
Bouwmeester et al. [7] concluded recently that the
quality of mono- and multidisciplinary clinical guidelines
for the management of low back pain, as measured with the
AGREE instrument has improved over time. The present
article focuses on the actual content of national clinical
guidelines on low back pain which have been issued since
2001. These guidelines are compared regarding the content
of their recommendations, the target group, the guideline
committee and its procedures, and the extent to which the
recommendations were based on the available literature
(the scientific evidence). We also highlight any changes in
recommendations that have occurred over time in comparison with our previous review [6].
Clinical guidelines were searched using electronic databases
covering the period 2000–2008: Medline (key words: low
back pain, clinical guidelines), PEDro (key words: low back
pain, practice guidelines, combined with AND), National
Guideline Clearinghouse (; key word:
low back pain), and National Institute for Health and Clinical
Excellence (NICE) (; key word: low back
pain). Guidelines used in the previous review were checked
for updates. We also checked the content and reference list of
relevant reviews on guidelines, included a search on the Web
of Science citation index for articles citing the previous
review and asked experts in the field. To be included in this
review, the guidelines had to meet the following criteria: (1)
the guideline concerned the diagnosis and clinical management of low back pain, (2) the guideline was targeted at a
multidisciplinary audience in the primary care setting, and
(3) the guideline was available in English, German, Finnish,
Spanish, Norwegian or Dutch because documents in these
languages could be read by the reviewers. Only one guideline
was included per country unless there were separate guidelines for acute and chronic low back pain. Where more than
one eligible guideline was available for a country, we
included the most recent guideline issued by a national body.
Guidelines from the following countries/regions and agencies (year of publication) were included:
Australia, National Health and Medical Research
Council (2003) [8];
Austria, Center for Excellence for Orthopaedic Pain
Management Speising (2007) [9];
Canada, Clinic on Low back Pain in Interdisciplinary
Practice (2007) [10];
Europe, COST B13 Working Group on Guidelines for
the Management of Acute Low Back Pain in Primary Care
(2004) [11];
Eur Spine J (2010) 19:2075–2094
Europe, COST B13 Working Group on Guidelines for
the Management of Chronic Low Back Pain in Primary
Care (2004) [12];
Finland, Working group by the Finnish Medical Society
Duodecim and the Societas Medicinae Physicalis et
Rehabilitationis Fenniae. Duodecim (2008) [13];
France, Agence Nationale d’Accreditation et d’Evaluation en Sante (2000) [14];
Germany, Drug Committee of the German Medical
Society (2007) [15];
Italy, Italian Scientific Spine Institute (2006) [16];
New Zealand, New Zealand Guidelines Group
(2004) [17];
Norway, Formi & Sosial- og helsedirectorated
(2007) [18];
Spain, the Spanish Back Pain Research Network
(2005) [19];
The Netherlands, The Dutch Institute for Healthcare
Improvement (CBO) (2003) [20];
United Kingdom, National Health Service (2008) [21];
United States, American College of Physicians and the
American Pain Society (2007) [22].
Data regarding the diagnostic and therapeutic recommendations as well as background information of the
guideline process were extracted from the guidelines by
four of the authors, each assessing 3–4 guidelines. The
Finnish and Norwegian guidelines were assessed by colleagues with relevant language skills from The Netherlands
and Finland. The focus was on the process of guideline
development and the recommendations for diagnosis and
treatment. We used the same data categories as in the previous review to facilitate comparisons (see Tables 1, 2, 3).
Patient population
Each of the guidelines considered the duration of symptoms but they vary in their scope and definitions. For
example, the guidelines from Australia and New Zealand
focus on acute low back pain whereas the guidelines from
Austria and Germany consider acute, subacute, chronic and
recurrent low back pain. The cut-off for chronic is not
always specified but when it was, 12 weeks was used.
Sometimes the word persistent rather than chronic was
used. Two guidelines (Austrian and German) provide recommendations for recurrent low back pain but do not
explicitly define ‘recurrent’.
Diagnostic recommendations
Table 1 compares the diagnostic classification and the
recommendations on diagnostic procedures in the various
guidelines. All guidelines recommend a diagnostic triage
where patients are classified as having (2) non-specific low
back pain, (2) suspected or confirmed serious pathology
(‘red flag’ conditions such as tumour, infection or fracture)
and (3) radicular syndrome. Some guidelines, e.g. the
Australian and New Zealand guidelines, do not distinguish
between non-specific low back pain and radicular syndrome. The German guideline also classifies a group of
patients who are at risk for chronicity, based on ‘yellow
All guidelines are consistent in their recommendations
that diagnostic procedures should focus on the identification of red flags and the exclusion of specific diseases
(sometimes including radicular syndrome). Red flags
include, for example, age at onset (20 or [55 years),
significant trauma, unexplained weight loss and widespread neurologic changes. The types of physical examination and physical tests that are recommended show
some variation. Some, such as the European guideline,
limit the examination to a neurological screen whereas
others advocate a more comprehensive musculoskeletal
(including inspection, range of motion/spinal mobility,
palpation, and functional limitation) and neurological
examination. The components of the neurologic screening
are not always explicit but where they are, comprise
testing of strength, reflexes, sensation and straight leg
None of the guidelines recommend routine use of
imaging, with imaging recommended at the initial visit
only for cases of suspected serious pathology (e.g. Australian, European) or where the proposed treatment (e.g.
manipulation) requires the exclusion of a specific cause of
low back pain (French). Imaging is sometimes recommended where sufficient progress is not being made but the
time cut-off varies from 4 to 7 weeks. Guidelines often
recommend MRI in cases with red flags (e.g. European,
Finland, Germany).
All guidelines mention psychosocial factors associated
with poor prognosis with some describing them as ‘yellow flags’. There is, however, considerable variation in
the amount of details given about how to assess ‘yellow
flags’ or the optimal timing of the assessment. The
Canadian and the New Zealand guidelines provide specific tools for identifying yellow flags and clear guidelines for what should be done once yellow flags are
Patient population
Acute (3 months)
Acute (0–6 week),
subacute (6–12 week)
chronic ([12 week),
and recurrent
Acute, subacute and
Acute (6 weeks) and
subacute (6–
12 weeks) LBP
Chronic LBP
([12 weeks)
Australia (2003)
Austria (2007)
Canada (2007)
Europe (2006)
Europe (2006)
Non-specific low back pain
Nerve root pain/radicular
Specific spinal pathology
Non-specific low back pain
Nerve root pain/radicular
Serious spinal pathology
All divided into acute,
subacute and persistent
Back Pain with suspected
serious pathologies
Back pain with
neurological involvement
Simple back pain
Including high-grade
spondylolisthesis, facet
arthrosis, severe
degenerative disc disease
Specific LBP (based on list
of red flags)
‘We cannot recommend spinal
palpatory and range of
motion tests in the diagnosis
of chronic low back pain’
Diagnostic triage, neuroscreening
Physical assessment including
neurological screening when
Physical examination in
patients with back pain and
neurological involvement
includes SLR, motor,
sensitivity, reflex signs
Inspection, palpation, range of
motion testing of lumbar
spine, neurological screening
(strength, reflexes,
sensibility, SLR)
Neurological examination in
case it is suspected. (Physical
examination such as
inspection, range of motion
and posture may have low
reliability and validity and
should be used with caution)
Specific low back pain
Non-specific LBP
Conduct physical examination
to assess for the presence of
serious conditions
Physical examination
Non-specific low back pain
(divided into acute,
subacute and chronic)
Diagnostic classification
Table 1 Clinical guidelines recommendations regarding diagnosis of low back pain
X-ray in case of suspected
structural deformities
MRI in case of red flags
No radiographic imaging
Diagnostic imaging tests
(including X-rays, CT and
MRI) are not routinely
indicated for non-specific
low back pain
Not recommended for
simple low back pain but
recommended for pain
with neurological
involvement and
suspected serious
pathology. MRI and CT
scans recommended if
surgery is in question
After 4–6 weeks may be
indicated in search for a
specific cause
Not useful in the first
4 weeks of an episode
Not recommended unless
alerting features of
serious conditions are
‘We recommend the assessment of
prognostic factors (yellow flags)
in patients with chronic low back
Assess for psychosocial factors
and review them in detail if there
is no improvement
Assess patients’ perceived
disability and probability to
return to usual activity after
4 weeks of disability or at first
consultation if patient has a
history of long-lasting backrelated disability (Symptom
Check List Back Pain Prediction
Evaluate psychosocial factors in
patients who do not show
improvement over time (with
recommended treatment) and in
patients with recurrent LBP
Yellow flags associated with the
progression from acute to
chronic should be assessed early
to facilitate intervention
Psychosocial factors
Eur Spine J (2010) 19:2075–2094
Acute, subacute and
chronic LBP
Acute low back pain
3 months
Finland (2008)
France (2000)
Acute, subacute,
chronic/recurrent LBP
Acute, subacute and
chronic LBP
Germany (2007)
Italy (2006)
‘‘uncomplicated’’ low
back pain [3 months
Patient population
Table 1 continued
Specific LBP
Non-specific LBP
Patients at risk for
chronicity (based on
yellow flags)
Specific LBP (based on red
Radicular pain
Non-specific LBP
Diagnostic and therapeutic
(hyperalgesic sciatica,
paralysing sciatica, cauda
equina syndrome)
Option after 4–6 weeks if
surgery is indicated
Neurological exam is
recommended (SLR,
Postural evaluation
Useless for non-specific
acute LBP
After 6 weeks persistent
pain X-ray may be
indicated or after
6–8 weeks an MRI
CT, MRI only in cases with
suspected radicular pain,
or stenosis, or specific
pathology such as
X-ray not useful in acute
non-specific LBP
X-rays not repeated. CT/
MRI only in exceptional
Not to be ordered in the first
7 weeks except when the
treatment selected
infiltration) requires
formal elimination of
specific form of low back
MRI is first-line imaging
investigation if special
examinations are needed
Plain lumbar X-ray is basic
investigation before other
imaging studies
No imaging in first 6 weeks
Pain/functional limitation on
trunk movement
Further investigation (e.g. lab
testing) is based on red flags
Inspection, palpation,
neurological screening;
reflexes, SLR/Lasegue,
sensibility, strength
Assessment of function,
anxiety and/or depression
using validated measure
Musculoskeletal and
neurological examination to
identify specific cause
Rating of muscle strength
To rule out ‘‘so-called
symptomatic acute low back
pain’’ or emergencies
So-called symptomatic
acute low back pain with
or without sciatica
(fracture, neoplasm,
infection, inflammatory
Non-specific low back pain
Inspection, palpation, spinal
mobility (flexion), SLR-test,
strength, reflexes
Physical examination
Acute & Chronic:
Possible serious or specific
Nerve root dysfunction
(sciatic syndrome,
intermittent claudication)
Non-specific LBP
Diagnostic classification
Screening after 2 weeks: yellow
flags, Waddell test (for pain
Evaluate risk factors for chronicity
(yellow flags); including
biological, psychological,
occupational, lifestyle, and
iatrogenic factors
Recommended to assess
psychosocial factors
Acute and Chronic:
Assess illness behaviour,
depression in subacute LBP
A list of psychosocial factors
(yellow flags) is included in the
Psychosocial factors
Eur Spine J (2010) 19:2075–2094
Acute LBP (3 months)
Acute and subacute
(3 months)
New Zealand (2004)
Norway (2007)
Non-specific acute,
subacute and chronic
Acute (0–12 week) and
chronic ([12 week)
Acute 6 weeks, sub
acute 6–12 weeks,
chronic [3 months
Acute and chronic LBP
Spain (2005)
The Netherlands (2003)
United Kingdom (2008)
United States (2007)
Chronic ([3 months)
Patient population
Table 1 continued
LBP due to specific causes
Neurological screening
(including SLR, strength,
reflexes, sensory symptoms)
Confirm pain is in the lower
back, is mechanical, not
Inflammatory low back pain
and stiffness
Serious pathology
Non-specific LBP
Rule out serious pathology
(identify red flags)
SLR-test, neurological
inspection; loss of motor
control, sensibility, miction.
Palpation of spine, Inspection
of lumbar kyphosis or
flattened lumbar lordosis
Clinical history, red flags. Do
not recommend palpation and
tests of intervertebral
Non-specific low back pain:
Mechanical low back pain
Specific LBP (based on a
list of red flags)
Non-specific LBP
Non-specific low back pain
Nerve root pain/radicular
Specific spinal pathology
Serious pathologies/acute
neurological conditions
(Cauda equina syndrome)
Inspection, posture, deformity,
Spinal mobility, including
finger-to-floor distance,
Neurological screening
(SLR/Lasegue) if radicular
pain is suspected
Establish degree of functional
limitation caused by the pain
Non-specific LBP
Radicular pain
Neurological screening
Non-specific LBP
Physical examination
Specific pathologic change
Diagnostic classification
Discouraged for nonspecific LBP
Recommended for
radiculopathy or spinal
stenosis only if patients
are potential candidates
for further intervention
Only where progressive
neurological or serious
pathology is suspected
Does not inform
management of nonspecific low back pain but
may be indicated to rule
in/out serious pathologies
Not useful in non-specific
acute LBP
Not useful in non-specific
LBP; X-rays, CT and
MRI use only in case of
red flags
First choice is MRI
Not recommended in acute,
subacute chronic LBP and
radicular pain in the
absence of red flags,
Recommended in case of
red flag
There are risks associated
with unnecessary
Investigations in first
4–6 weeks do not provide
clinical benefit unless Red
Flags present
Assessment of psychosocial risk
factors strongly recommended
Recognise and manage
psychosocial barriers (yellow
flags) to recovery
Assessment of psychosocial
factors (yellow flags) is
recommended. These include
emotional reaction, cognitions
and behaviour
Assess psychological factors in 2–
6 weeks after treatment if not
improving. Assess physiological
factors as prognostic factor only
A list of yellow flags is presented
as risk factors for chronicity, sick
Screen for yellow flags with the
Acute Low Back Pain Screening
Questionnaire, and if at risk,
clinical assessment
Psychosocial factors
Eur Spine J (2010) 19:2075–2094
In a few guidelines (Netherlands,
US) the measurement of yellow
flags are now more strongly
recommended. In Germany the
assessments is now
recommended at a much earlier
In some guidelines
(Finland, Germany) now
more explicit statements
regarding the use of CT
and MRI
More countries (UK,
US) now include
recommendations for
chronic LBP in
addition to acute LBP.
Germany now
includes subacute and
recurrent LBP
Addition of guidelines
from countries such as
Austria, Canada,
France, Italy, Norway,
Spain and a unified
one from Europe
Most apparent changes since 2001
Table 1 continued
Patient population
Diagnostic classification
Almost no change in
diagnostic classifications
used in the guidelines
Physical examination
Almost no change in
recommended types of
physical examination
Psychosocial factors
Eur Spine J (2010) 19:2075–2094
Summary of Common Recommendations for Diagnosis of Low back
* Diagnostic triage (non-specific low back pain, radicular
syndrome, serious pathology).
* Screen for serious pathology using red flags.
* Physical examination for neurologic screening (including straight
leg raising test).
* Consider psychosocial factors (yellow flags) if there is no
* Routine imaging not indicated for non-specific low back pain.
Therapeutic recommendations
Table 2 compares therapeutic recommendations given in
the various guidelines. Patient advice and information is
recommended in all guidelines. The common message is
that patients should be reassured that they do not have a
serious disease, that they should stay as active as possible
and progressively increase their activity levels. Compared
with the previous review, the current guidelines increasingly mention early return to work (despite having low
back pain) in their list of recommendations.
Recommendations for the prescription of medication
are generally consistent. Paracetamol/acetaminophen is
usually recommended as a first choice because of the
lower incidence of gastrointestinal side effects. Nonsteroidal anti-inflammatory drugs are the second choice in
cases where paracetamol is not sufficient. There is some
variation between guidelines with regard to recommendations for opioids, muscle relaxants, steroids, antidepressant and anticonvulsive medication as co-medication
for pain relief. Where the mode of consumption of analgesics is described, time-contingent rather than paincontingent use, is advocated.
There is now broad consensus that bed rest should be
discouraged as a treatment for low back pain. Some
guidelines state that if bed rest is indicated because of
severity of pain, then it should not be advised for more than
2 days (e.g., Germany, New Zealand, Spain, Norway). The
Italian guideline advises 2–4 days of bed rest for major
sciatica but does clearly describe how major sciatica differs
from sciatica where bed rest is contraindicated.
There is also consensus that a supervised exercise programme (as distinct from encouraging resumption of normal activity) is not indicated for acute low back pain.
Those guidelines that consider subacute and chronic low
back pain recommend exercise but note that there is no
evidence that one form of exercise is superior to another.
The European guideline advises against exercise that
requires expensive training and machines. The one area of
Provide information,
assurance and advice
to resume normal
activity (stay active)
Acute LBP: expect a
favourable course;
maintain normal daily
Reassurance and advice
to return to work and
usual activities
Reassure and advise
patients to stay active
and continue normal
daily activities
including work if
Australia (2003) [8]
Austria (2007) [9]
Canada (2007) [10]
Europe (2006)
(acute) [11]
Preferably to be taken at
regular intervals; first
choice paracetamol,
second choice NSAIDs.
Third choice consider
short course of muscle
relaxants on its own or
added to NSAIDs
Prescribe medication, if
necessary for pain relief;
NSAIDs, muscle relaxants
and analgesics for acute.
Low evidence for
NSAIDs and analgesics
for subacute pain
Only for short periods: (1)
paracetamol, (2) tramadol
or NSAID, (3) opioids
Chronic LBP: Options:
NSAIDs/Coxibs; Opioids;
Antidepressant; muscle
relaxants; Anticonvulsion medication
(for radicular pain),
3) muscle relaxants or weak
opioids as last option
Do not advise specific
exercises (for example
stretching, flexion, and
extension exercises)
for acute low back
Strengthening exercises,
extension exercises
and specific exercises
are not recommended
for acute but
recommended for
subacute and chronic
with no superior form
of exercise
Exercise therapy
recommended as
monotherapy or in
combination with back
school, massage
Not recommended
Do not prescribe bed
rest as a treatment
Consider (referral for)
spinal manipulation
for patients who are
failing to return to
normal activities
(but if necessary,
only for a short
Avoid bedrest
Acute LBP:
Not advisable
Bed rest
Recommended for
short- term pain
reduction for acute.
Recommended with
low evidence for
subacute and chronic
Chronic LBP:
Optional for patients
with persistent
problems with
performing daily
Optional for patients
who do not return to
normal level of
activity within the first
Not specifically
mentioned in the
Chronic LBP:
Acute LBP:
Acute LBP:
Acute LBP: (1)
Paracetamol; (2) NSAIDs
Not recommended:
antidepressants, muscle
Conflicting evidence of
spinal manipulation
versus placebo in first
2–4 weeks
There is conflicting
evidence of the effect
of exercises but
evidence shows that it
is no better than usual
First choice paracetamol,
second choice NSAIDs,
third choice oral opioids
Table 2 Clinical guidelines recommendations regarding treatment of low back pain
Refer patients with
neurological symptoms
such as cauda equina
Refer patients with
neurological signs or
symptoms if functional
deficits are persistent or
deteriorating after
4 weeks
In case of suspected specific
LBP; Surgery is optional
only after 2 years of
conservative treatment,
persisting complaints and
with a surgical indication
When alerting features (red
flags) or serious
conditions are present
Referral to specialist
Eur Spine J (2010) 19:2075–2094
Advice and reassurance
to return to normal
Benign nature of
condition; prognosis is
good; continue
ordinary daily
activities. Back pain
may recur but even
then recovery is
usually good
Short-term education
about the back, in
groups, is not
Europe (2006)
Finland (2008) [13]
France (2000) [14]
(chronic) [12]
Table 2 continued
Physical exercise is
recommended, no
particular type is
Provides short-term
benefit. No
recommendation for
one form of manual
therapy over another
Flexion exercises have
been not been shown
to be of benefit. No
recommendation on
extension exercises
Chronic: Additional
recommendations for:
acetylsalicylic acid, Level
II following failure to
respond to Level I and
Level III (strong opioids)
on a case by case basis.
Tetrazepam, Tricyclic
Acute & Chronic:
Chronic LBP: similar
effectiveness as GP,
physiotherapy, etc.
Similar effectiveness as
GP in subacute LBP
Acute LBP: some
Recommend short
course of spinal
Regular simple analgesics,
non-steroidal antiinflammatory drugs and
muscle relaxants. No
evidence for systemic
Chronic: Intensive
training effective for
pain and function
Subacute: gradually
increasing exercises
Light exercises (e.g.
walking) can be
Active exercises not
effective in early
Acute LBP:
Supervised exercise
therapy is advisable
approaches that don’t
require expensive
training and machines.
Cognitive behavioural
approach including
graded activity and
group therapy are
Acute & Chronic:
Chronic LBP Analgesics
used periodically, be
aware of side effect of
NSAIDs (gastrointestinal,
Antidepressant only if clear
Benzodiazepines not
Acute/Subacute LBP: (1)
paracetamol, (2) NSAIDs,
(3) adding a weak opiate
to paracetamol/NSAID.
(4) muscle relaxants
Recommend use of NSAID
for short term pain relief
and opioids in case patient
is not responding to other
treatment. Consider the
use of noradrenergic or
antidepressants as comedication for pain relief
Not recommended
Acute and Chronic:
a short period of
bedrest may be
necessary due to
intense back pain,
but bedrest must
not be considered
as a treatment of
back problems
Avoid bedrest;
Bed rest
behavioural therapy/
programme if nonresponse to first-line care
No recommendation
Multidisciplinary (biopsycho-social)
rehabilitation focused on
improving functional
Referral: serious, non
urgent conditions
Immediate referral: Cauda
equina syndrome, sudden
massive paresis,
excruciating pain
Surgery not recommended
unless in carefully
selected patients, 2 years
of all recommended
conservative treatments
approaches with
combined programmes of
cognitive intervention and
exercises have failed
Most invasive treatments
not recommended
Referral to specialist
Eur Spine J (2010) 19:2075–2094
Acute LBP: stimulate
daily activities,
explain moving is not
Germany (2007) [15]
Norway (2007) [18]
Advise to stay active
and working, or early
return to work,
New Zealand (2004)
Stay active, return to
normal activity
including work asap,
Education pamphlets
not helpful
Give information and
reassurance about
possible cause,
provoking factors, risk
factors, and structural
or postural alterations,
reassurance about
good prognosis, keep
active and if possible,
stay at work
Italy (2006) [16]
Chronic LBP more
intense psychotherapy
indicated in case of
psychological comorbidity
Table 2 continued
Subacute and Chronic
LBP: Exercise therapy
well supported by
(4) Antidepressants in cases
with depression
(3) Paracetamol ? opioid
or Tramadol
(1) Paracetamol
Opiates or diazepam may
be harmful
Paracetamol and NSAIDs
Tramadol and adding light
opioid to paracetamol
may be useful for sciatica
Steroids not recommended
in acute LBP, but can be
useful for a short time in
Muscle relaxants no
additional effect
NSAIDs recommended
Individual specific
In chronic LBP
exercises are
No specific exercises in
the first weeks
Specific back exercises
not helpful
After 1-2 weeks for pain
reduction and
improvement of
function (for small to
moderate effects)
May provide short-term
symptom control
First 4–6 weeks only
Consider for pain relief
Chronic LBP:
No specific exercises
Chronic LBP
After 2–3 weeks and
before 6 weeks,
prescribed by
physicians, done by
trained therapists
Acute LBP
Chronic LBP: option if
exercise therapy not
Paracetamol as preferred
Optional within the first
4–6 weeks
Acute LBP:
Acute LBP:
(1) paracetamol, (2)
NSAIDs (oral or topical),
(3) Muscle relaxants (in
cases with muscle spasms,
(4) Opioids
Acute and Chronic LBP:
In rare cases, not
longer than 2–
3 days
Not recommended
Bed rest [2 days
No recommended in
Chronic LBP
Contraindicated for
Discouraged for
acute LBP, except
2–4 days for major
Maximum of 2 days
Bed rest
Referral for surgical
intervention after 2 years’
Referral within primary
care for cognitive
behavioural treatment is
Suspicion of specific causes
(red flags), cauda equina
syndrome, or after
4–8 weeks
Multidisciplinary psychosocial intervention for
patients at high risk of
chronicity and chronic
Radiculopathy and
suspicion of specific
Surgery may be an option if
after 2 years conservative
treatment, including
biopsychosocial treatment
programme was
Optional referral for
surgery: therapy resistant
([6 weeks) ? signs of
nerve root compression
Immediate surgery
indicated for cauda equina
Referral to specialist
Eur Spine J (2010) 19:2075–2094
Acute and Chronic
The Netherlands (2003)
United Kingdom (2008)
Reassurance and advice
to stay active
Spain (2005) [19]
Provide information and
advice to foster
positive attitude and
pain is not serious,
temporary, tends to
recur, physical not
mechanical. Stay
active as possible
Stay active as much as
possible (despite the
pain), increase activity
level on a time
contingent basis
Table 2 continued
Not recommended: Topical
NSAIDs, antiepileptic
drugs (other than
gabapentin), herbal
Regular paracetamol
(preferred) or NSAID as
first line care. For
additional analgesia
combine paracetamol and
NSAID or add a weak
opioid (codeine or
tramadol). For nonresponders consider
benzodiazepine, tricyclic
(3) Opioids
(2) Tramadol or NSAID,
(1) Paracetamol,
Chronic LBP: Only for
short periods:
(3) muscle relaxants or
weak opioids or
combinations with
paracetamol/NSAIDS as
last option due to side
Advise patient to stay as
active as possible. No
regarding exercise
Chronic LBP:
Recommended are
varying and
supervised exercises
focused at improving
Consider after 4–
6 weeks for patients
who do not improve
their functioning
(1) Paracetamol
(2) NSAIDs,
Acute LBP:
Exercise as far as pain
allows including work
activities. As there is
no evidence for any
specific type of
exercise, choose the
one that patients
prefer. Not indicated
for patients with pain
for less than 6 weeks
Acute LBP:
Opioids are indicated for
patients with high levels
of pain who did not
improve with usual care
Paracetamol every 6 h, can
also be associated with
opioids and NSAID
although the last one
should not be prescribed
for longer than 3 months
No recommendations
Option as part of an
activating strategy for
patients who do not
show a favourable
Acute and Chronic
Not recommended
Rest in bed is less
effective than
staying active
Acute LBP:
Acute and Chronic
LBP: Avoid
Discouraged unless
patient can not
adopt another
posture. Then bed
rest for the
maximum of 48 h
Bed rest
If pain/disability continue
to be a problem despite
pharmacotherapy and
physical therapy consider
referral to
multidisciplinary back
pain service or chronic
pain clinic
If pain or disability remain
problematic for more than
a week or two consider
referral for physio/
physical therapy
If progressive neurological
Chronic LBP: Refer
patients with severe
disability who do not
respond to recommended
conservative treatments
for multidisciplinary
treatment focused on
functional recovery
Refer patient in case of red
Referral to specialist
Eur Spine J (2010) 19:2075–2094
Provide information on
prognosis, staying
active, self
United States (2007)
Most apparent changes since 2001
The advice to stay
active remains similar.
Now some guidelines
(european, NZ,
Canada, Italy,
Norway) explicitly
mention continuation/
early RTW
Self-care education
books recommended
Table 2 continued
Now more often explicit
recommendations (for or
against) anti-depressants,
opioids, benzodiazepines
and combinations of
No change regarding
recommendation of
paracetamol and NSAIDs
as first-line treatments and
regarding muscle
For subacute or chronic
([4 weeks)—
tramadol, opioids
For acute (4 weeks)—
muscle relaxants,
tramadol, opioids
Paracetamol, NSAIDs
recommended as first-line
Now more explicit
recommendations in
favour of exercise
therapy in subacute
and chronic LBP
The advice that exercise
therapy is not useful in
acute LBP has not
Recommended for
subacute or chronic
Not effective for acute
Recommendations for
spinal manipulation,
the timing of
application and target
group continue to vary
For acute LBP if not
against bedrest is
fairly consistent
between 2001 and
Even if required for
severe symptoms,
patients should be
encouraged to
return to normal
activities as soon
as possible
Bed rest
The recommendations for
referral appear more
explicit regarding : (1)
immediate referral (cauda
equina syndrome), (2)
medical specialist in case
of red flags, (3) referral
within primary care
behavioural therapy, (4)
treatments and (5)
consider surgery if
2 years of recommended
conservative care has
If suspicion of significant
nerve root impingement
or spinal stenosis
For interdisciplinary
intervention if chronic
Referral to specialist
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Eur Spine J (2010) 19:2075–2094
therapy that is contentious is the use of spinal manipulation. Some guidelines do not recommend the treatment
(e.g. Spanish, Australian), some advise that it is optional
(e.g. Austrian, Italian) and some suggest a short course for
those who do not respond to the first line of treatment (e.g.
US, the Netherlands). For some it is optional only in the
first weeks of an episode in acute low back pain (e.g.
Canada, Finland, Norway, Germany, New Zealand). The
French guideline advises that there is no evidence to recommend one form of manual therapy over another.
Summary of Common Recommendations for Treatment of Low
back pain
Acute or Subacute Pain
* Reassure patients (favourable prognosis).
* Advise to stay active.
* Prescribe medication if necessary (preferably time-contingent):
first line is paracetamol; second line is nonsteroidal
antiinflammatory drugs, consider muscle relaxants, opioids or
antidepressant and anticonvulsive medication (as co-medication
for pain relief).
* Discourage bed rest.
* Do not advise a supervised exercise programme.
Chronic Pain
* Discourage use of modalities (such as ultrasound, electrotherapy)
* Short-term use of medication/manipulation
* Supervised exercise therapy
* Cognitive behavioural therapy
* Multidisciplinary treatment
Evidence-based review
All guidelines are more or less based on a comprehensive
literature search, including Cochrane Library, Medline,
Embase. Some committees (Austria, Germany, Spain)
based their recommendations, entirely or in part, on the
European guidelines. Most guidelines use an explicit
weighting of the strength of the evidence.
The Dutch, UK, European, Finnish, German, Norwegian
and Australian guidelines give direct links between the
actual recommendations and the evidence (via specific
references) on which the recommendations are based.
Other guidelines do not present a direct link but state that
for recommendation there is at least moderate or fair evidence (New Zealand, US). Most committees use consensus
methods, mostly by group discussions when the evidence
was not convincing or not available.
Presentation and implementation
The activities related to the publication and dissemination
of the various guidelines show some differences and some
similarities. In most cases, the guidelines are accompanied
by easily accessible summaries for practitioners and
booklets for patients. Systematic implementation activities
are rare. In most cases, the printed versions of the guidelines are published in national journals and/or disseminated
through professional organisations to the target practitioners. Most guidelines are available on the websites of
participating organisation. In many countries, regular
updates of the guidelines are planned with time horizons of
3–5 years.
Table 3 shows some background variables related to the
development of the guidelines in the various countries.
Most of the guidelines focus on primary care though some
also include secondary care. The Spanish guideline is
written for health professions that treat low back pain.
Guideline committee
The various committees responsible for the development
and publication of guidelines appear to be different in size
and in the professional disciplines involved. Most committees are characterised by their multidisciplinary membership. These usually included primary care physicians,
physical and manual therapists, orthopaedic surgeons,
rheumatologists, radiologists, occupational and rehabilitation physicians. The number of members varied from 7 to
31. Only three committees included consumer representation (Australia, New Zealand, the Netherlands).
In the past decade many countries have issued (updated)
clinical guidelines for the management of low back pain. In
general these guidelines provide similar advice on the
management of low back pain. Common recommendations
are the diagnostic triage of patients with low back pain,
restricted use of radiographs, advice on early and progressive activation of patients, and the related discouragement of bed rest. The recognition of psychosocial
factors as a risk factor for chronicity is also consistent
across all guidelines, though with varying emphasis and
detail. There are also differences in the recommendations
provided by the guidelines, but these are few and probably
less than could expected for different health care systems
and cultures. One of the reasons for the similarity of the
guidelines might be that guideline committees are usually
aware of the content of other guidelines and are motivated
to produce similar recommendations that are deemed
Europe (2006) Primary care and
secondary care
Europe (2006) Primary care
Primary care
Available on website
Published in national journal in
Free online version, Included in
book ‘evidence-based
management of acute
musculoskeletal pain: a guide
for clinicians’
Multidisciplinary: experts in the field of Literature search up to 2002. Based on Use of consensus method not clear. Published on a website and in a
low back pain research in primary care systematic review of systematic
Use of group discussions, no
journal. Professional
(n = 11)
reviews and randomised clinical trials formal grading scheme used
associations will disseminate
on CLBP. Systematic reviews were
and implement these
rated using the Oxman & Guyatt index
and RCTs rated using the van Tulder
et al. 1997 criteria
Cochrane Back Review group
ratings of the AHCPR Guidelines (1994)
and levels of evidence recommended
in the method guidelines of the
Multidisciplinary: experts in the field of Literature search from 1966 to 2003 on Use of consensus method not clear; Publication in a journal with
low back pain research in primary care the Cochrane Library,
‘‘use of group discussions’’
planned update after 3 years
(n = 14)
Medline, Embase for searches of
Cochrane reviews (and on other
systematic reviews if a Cochrane
review was not available), additional
trials published after the Cochrane
reviews, and existing national
guidelines. Strength of evidence was
assessed based on the original
Based on an extensive literature review Use of consensus
of the best available evidence and
method not clear
assessment of knowledge in all areas
of back pain management it also
combines with participant’s clinical
Multidisciplinary with primary health
care professionals
Update of the previous Australian
Use of consensus
guideline using the AGREE.
method not clear
Comprehensive literature search (up to
2002) pubmed, cinhal embase and
Cochrane for clinical evidence. All
recommendations are linked to
evidence level
Multidisciplinary: Osteopathic,
Rheumatology, Physiotherapy,
Chiropractic, GP, Epidemiology,
consumer representative (n = 9)
Evidence base
Multidisciplinary (psychiatry,
Based on European guidelines
Draft guideline presented and
orthopaedics, general practice,
(2004) ? updated evidence regarding
approved at two consensus
physiotherapy, radiology, psychology, massage and acupuncture. Grading of
neurology, rehabilitation, osteology?,
evidence was used using an explicit
pain medicine, ergotherapy,
weighting system
rheumatology, neurosurgery (n = 17) No direct linking between
recommendations and underlying
Primary and secondary
Guideline committee
Austria (2007) Primary and secondary
care (all who are
involved with
diagnosis and
treatment of LBP)
Target group
Table 3 Target group, authors, evidence base, consensus, and implementation of clinical guidelines in low back pain
Eur Spine J (2010) 19:2075–2094
Primary and secondary
Primary and secondary
Primary and secondary
care, particularly
Primary care
Primary and secondary
Italy (2006)
New Zealand
Non stated
France (2000) Acute and Chronic:
Target group
Table 3 continued
Based on European guidelines (2006).
Recommendations are all supported
with references
Review of the literature—no further
detail provided
Acute & Chronic:
Multidisciplinary: occupational,
rehabilitation, physiotherapy,
chiropractic, manual therapy,
neurology, orthopaedics, radiology,
general practice (n = 11)
Multidisciplinary: consumer
representative, pain medicine,
occupation medicine, chiropractor,
psychologist, osteopath, occupational
medicine, physiotherapy,
rheumatology, GP, musculoskeletal
medicine (n = 16)
Contributed by relevant
professional groups
Comprehensive search of the literature Recommendations based on
(Cochrane, Medline, Embase), quality evidence and discussion in the
assessment, weighing of evidence
attached to the recommendations
Comprehensive literature search;
weighing of evidence using a rating
system based on strength of the
studies; for all recommendations, at
least moderate evidence available
Guidelines commissioned from
the Agence Nationale
d’Accreditation d’Evaluation
en Sante by CNAMTS, the
French national health
insurance fund. Reports
published in English and
French and available online
Acute & Chronic:
A summary of the guidelines
has been published in the
Finnish journal (Duodecim
2008). The whole text is
published on the website of
the Finnish Current Care
Publication in Norwegian
report, including a summary
and a patient brochure
Publication of report,
incorporating the guide to
assessing yellow flags,
endorsed by NZ Guidelines
Group and relevant
professional groups
Journal publication, complete
version available on website,
presentation at national
conferences of relevant
professional groups, local
workshop and training days,
outreach visits
Draft guidelines are presented and Complete guidelines and
discussed with various medical
summaries for practitioners
are available on a website
Use of consensus
in the absence of evidence
Acute & Chronic:
Based on explicit weighing of evidence. Consensus on evidence synthesis
Important decision points are backed
and text during Committee
up by level of evidence statements
Evidence base
Multidisciplinary: general medicine,
Literature search of international
Recommendations based on level
neurology, neurosurgery,
guidelines, systematic reviews in
of evidence, practicality issues
orthopaedics, rheumatology, physical
Medline and the Cochrane Library,
and own experience
medicine and rehabilitation,
weighing of evidence using a rating
occupational medicine, physiotherapy, system based on strength of the studies
epidemiology (n = 14)
Multidisciplinary: Drug committee of
the German medical association,
including general practice,
pharmacology (n = ?)
Chronic LBP:
Multidisciplinary;Rheumatologist (2),
Physiotherapist, Psychiatrist, Neuroradiologist, GP (4), Radiologist,
Occupational Medicine Specialist,
Orthopaedic surgeon, Specialist in
Physical Medicine and Rehabilitation
Acute LBP: Multidisciplinary;
Rheumatologist (2), Physiotherapist,
Psychiatrist, Neuro radiologist, GP
(2), Radiologist, Occupational
Medicine Specialist, Orthopaedic
surgeon, Specialist in Physical
Medicine and Rehabilitation (11).
Physiatrist, radiologist, general
practitioner and occupational health
physician, neurosurgeon,
physiotherapist, orthopaedic surgeon
(n = 8)
Guideline committee
Eur Spine J (2010) 19:2075–2094
Healthcare professionals Unspecified multidisciplinary team
working within the
NHS in England
providing primary
health care
Primary care
United States
7 authors for a large multidisciplinary
committee Clinical Efficacy
Assessment Subcommittee of the ACP
Comprehensive literature search of
English-language articles weighing of and consensus-based
evidence using a rating system; for all
recommendations, at least fair
evidence available
Update of previous guidelines
Not reported
(PRODIGY, RCGP): incorporates
new evidence from electronic database
search of guidelines, systematic
reviews and randomised controlled
trials on primary care management of
low back pain
Multidisciplinary; general practice,
All recommendations are supported as Recommendations were based on
orthopaedics, radiology, neurosurgery, possible by scientific evidence up to
the scientific
rehabilitation, physiotherapy,
Jan 2001. All evidence was weighted
evidence ? considerations such
psychology, patient representation,
using an explicit weighting system.
as patient preferences, costs,
chiropractic, manual therapy,
All recommendations are presented
availability of health services,
neurology, rheumatology, exercise
with their level of evidence
and/or organisational aspects
therapy (Cesar, Mensendieck),
anaesthesiology, occupational
(n = 31)
Primary and secondary
Health care professionals Spanish members of the COST B13 and Adapted from the European guidelines All members of the group
that treat low back pain a multidisciplinary team composed of with addition of new evidence and
approved the final version but
GP, rural medicine, rheumatology,
evidence in Spanish (systematically
consensus method is not clearly
rehabilitation, neurosurgery,
reviewed). Also recommendations
orthopaedics, radiology, work
were performed using the AGREE
medicine, public health, anxiety and
tool to better define the
stress, physical therapist, Evidencerecommendation using a standardised
based experts and anaesthesiologists
methodology. Studies were sent to the
Web de la Espalda for analysis of
methodological quality
Evidence base
Spain (2005)
Guideline committee
Target group
Table 3 continued
Valid for 5 years after
publication or until next
Journal publication, audio
summary and patient
CKS provides quick answers to
real-life clinical questions that
arise in the consultation,
linking to detailed answers
that clearly outline the
evidence on which they are
Part of the NHS Clinical
Knowledge Summaries
(CKS), a freely available,
online source of evidencebased information and
practical ‘know how’ about
the common conditions
managed in primary and firstcontact care
Published on website,
distributed among hospitals
and medical societies,
summary published in the
Dutch Medical Journal,
presented in Finnish journal
(Duodecim 1999)
Summary spreadsheet with
recommendations, an
algorithm for diagnosis and
treatment and an extensive
report published online.
Frequent updates are predicted
Eur Spine J (2010) 19:2075–2094
The current guidelines
appear more often
focused on primary
care as well as
secondary care
compared to 2001
when the focus was
more exclusively on
primary care
Most apparent change, if any, since 2001
Target group
Table 3 continued
Guideline committee
The guideline committees in 2001 as
well as currently consist of a
multidisciplinary panel (which of
course is not surprisingly since
multidisciplinary guidelines were
included in the current and the 2001
Evidence base
More guidelines now explicitly state
In 2001 and at present consensus In most cases the guideline is
that they are based on a previous
methods were used, Usually
published and disseminated
guideline (i.e. the European
group discussion take place, but
without an active
guidelines), furthermore almost all
the exact method is often not
implementation programme.
guidelines now explicitly state that
clear. This has not changed since This has not changed since
they applied a weighting system to the 2001
evidence. In 2001 a weighting system
The main change is that
was less often used
currently almost all guidelines
are available on a website
whereas in 2001 more often
paper versions were
Eur Spine J (2010) 19:2075–2094
sensible and relevant. In some instances the guidelines are
a national adaptation (e.g. in Spain) of the European
We do not present an exhaustive overview of all clinical
guidelines available, but focused on national multidisciplinary guidelines. This enables a reasonable comparison
of recommended approaches across countries. A limitation
is thus that not all available guidelines, including monodisciplinary guidelines, are included.
Use of available evidence
Most reviews are based on extensive literature reviews.
Cochrane reviews are frequently used, comprehensive
searches in databases such as Medline, Embase and PEDro.
Increasingly the literature reviews of other and previous
guidelines are used as starting point for the (additional)
searches. Most committees also use some kind of weighting system and rating of the evidence. There is some variation in the way the recommendations are presented. In
some guidelines all the recommendations are directly
linked with references to the supporting evidence, and in
others a general remark is made that for all recommendations that there is at least moderate evidence available.
Differences in recommendations
Recommendations about the prescription of analgesic
medication remain fairly consistent. Most guidelines recommend paracetamol as the first option and nonsteroidal
anti-inflammatory preparations as the second option. Further recommendations about other drugs like opioids,
muscle relaxants and benzodiazepines and antidepressants
vary quite considerably. Part of these variations might
reflect the setting and custom in different countries. Since
all the guidelines were issued within a relative short time
frame, the availability of underlying evidence did not vary
The recommendations regarding spinal manipulation
continue to show some variation. In some guidelines
manipulation is recommended, or presented as a therapeutic option, usually for short-term benefit, but others do
not recommend it. This holds true for acute as well as
chronic low back pain. The reasons for these differences
remain speculative. Probably the underlying evidence is
not strong enough to result in similar recommendations
regarding manipulation across all guidelines, leaving the
committees some more room for interpretation, but also
local or political reasons may be involved.
There is now relatively large consensus across the various guidelines that specific back exercises (as opposed to
the advice to stay active, including for example walking,
cycling) are not recommended for patients with acute low
back pain. At the same time back exercises are recommended in chronic low back pain. Most guidelines do not
recommend a particular type of exercises for chronic low
back pain, but some state that they should be intense.
Recommendations in guidelines are based not only on
scientific evidence but also on consensus and discussion in
the guideline committees. Usually it is stated that consensus was based on group discussion, but the details of these
discussions are seldom reported. It is also generally unclear
which recommendations are based mainly on scientific
evidence and which are based on (mainly) consensus.
There is little information on whether cost-effectiveness
played an important role as a basis for the recommendation
in a guideline. Of course, there are not yet many costeffectiveness studies available [23], but it is not fully clear
to what extent the published studies were used.
Most guidelines state that the prognosis of an episode of
low back pain is good. This holds especially true for
patients with acute episodes of low back pain. For patients
presenting with a longer duration with low back pain or
with recurrent low back pain the prognosis may be less
favourable. More individualised and precise estimates of
the prognosis of an episode of low back pain may be
desirable in the future.
Few changes in management recommendations
over time
This update showed that overall the recommendations in
the current guidelines regarding diagnosis and treatment of
low back pain did not change substantially compared to the
guidelines issued about a decade ago. This may well
illustrate the lack of new evidence showing better results
with new diagnostic and therapeutic approaches and/or
new evidence showing the inefficacy of existing interventions. A less nihilistic view could be that already a decade
ago the most valid recommendations for the management
of low back pain were identified. Some may argue that this
is indeed the case, and that much more effort should now
be given to implementation of guidelines (see below).
Some recommendations did change over time. We now
see diagnostic recommendations appearing concerning the
value of MRI and CT scans (i.e. in relation to exclusion and
further diagnosis of red flags and serious spinal disorders).
However, these recommendations are not yet strong, possibly because there are not many diagnostic studies available evaluating the value of MRI in patients with low back
pain. Also, the recommendations regarding the assessment
of psychosocial risk factors for chronicity are more firm in
the current guidelines than that a decade ago. This reflects
the insight of the importance of these risk factors for the
development of chronicity and future disability. At the
same time we must conclude that we are not yet very
Eur Spine J (2010) 19:2075–2094
successful in effective screening of the patients at risk and
subsequent therapeutic management of them [24].
Most apparent changes regarding therapeutic interventions include the advice to continue work (despite having
low back pain) and or return to work as soon as possible.
There are now more recommendations of second line
medications such as antidepressants, opioids, benzodiazepines and compound medications. But these recommendations are not consistent across countries, potentially
because of weak underlying evidence. There are now also
more firm recommendations in favour of exercise therapy
in patients with subacute and chronic low back pain. The
latter is partly due to the fact that currently more guidelines
include recommendation for the management of chronic
low back pain as compared to a decade ago. Finally, the
reasons and options for referral within primary care and
secondary care are now more explicitly presented. It
appears that the global approach regarding the management
of low back pain remained largely unchanged in the past
decade, although some refinements have been suggested.
The extent to which currently available guidelines are used
and followed in the various countries remains largely
unknown. A few studies evaluating various implementation
strategies for low back pain guidelines show that changing
clinical practice is not an easy task [25, 26]. The publication and dissemination of guidelines alone is usually not
enough to change the behaviour of health care providers
[27]. The development of effective implementation strategies in this area remains a challenge.
Future developments in research and guideline
The present study was primary aimed at presenting an
update of the current clinical guidelines for the management of low back pain in primary care. Clinical guidelines
focused at secondary care settings, occupational care settings, or specific subgroups of patients with lumbosacral
radicular syndrome were not considered. Separate studies
need to be undertaken to present an overview for these
We assessed various aspects of the guideline development in Table 3. A formal assessment of the quality, e.g.
with the AGREE instrument was not included. This was the
topic of a separate paper which concluded that the quality
of the guidelines indeed has improved over time [7].
The development of future guidelines in this field may
benefit from previous experiences, evidence-based reviews,
and various (inter) national guidelines as presented in this
overview. The previous review of clinical guidelines listed
Eur Spine J (2010) 19:2075–2094
the following recommendations (slightly modified) for the
development of future guidelines in this field. Similar to a
recent review on the quality of guidelines [7], this review
shows that the quality of guidelines has improved over time
and some of the recommendations have been followed.
This includes recommendations 1, 3, and 4 (see below). For
others, there still is room for improvement Recommendation 2 is not consistently applied. Recommendations 5 and
6 have improved over time, but not all recommendations in
the guidelines are directly linked to the underlying evidence, and the process of the consensus methods used is
not well described. Finally, the implementation strategies
and the time frame of future updates are not well presented.
Recommendations for the development of future guidelines in the
field of low back pain
1. Make use of available evidence-based reviews and previous
clinical guidelines.
2. Include relevant non-English publications (if available).
3. Determine in advance the intended target groups (health care
professions, patient population, and policy makers).
4. Be aware that the makeup of the guideline committee may have a
direct impact on the content of the recommendations.
5. Specify exactly which recommendations are evidence-based and
supply the correct references to each of these recommendations.
6. Specify exactly which recommendations are consensus-based
and explain the process.
7. Determine in advance the implementation strategy, and set a
time frame for future updates of the guideline.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
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