REVIEW ARTICLE

An updated overview of clinical guidelines for the managementof 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

� The Author(s) 2010. This article is published with open access at Springerlink.com

Abstract The aim of this study was to present and com-

pare the content of (inter)national clinical guidelines for the

management of low back pain. To rationalise the manage-

ment 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 treat-

ment. 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 pro-

fessionals, 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 treat-

ment. However, there are some discrepancies for recom-

mendations regarding spinal manipulation and drug

treatment for acute and chronic low back pain. The com-

parison of international clinical guidelines for the manage-

ment 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

Introduction

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

B. W. Koes (&)

Department of General Practice, Erasmus MC,

P.O. Box 2040, 3000 CA Rotterdam, The Netherlands

e-mail: b.koes@erasmusmc.nl

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

123

Eur Spine J (2010) 19:2075–2094

DOI 10.1007/s00586-010-1502-y

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 physio-

therapy treatments for low back pain but as at April 2009

there were 958.1 The Cochrane database (Central) cur-

rently lists more than 2500 controlled trials evaluating

treatment for back and neck pain. The evidence from

these trials for most interventions is summarised in sys-

tematic reviews and meta-analysis. The Cochrane Back

Review Group, for example, has now published 32 sys-

tematic reviews of randomised controlled trials evaluating

interventions for low back pain. In the near future, sys-

tematic reviews of studies evaluating diagnostic inter-

vention 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 rec-

ommendations 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 infor-

mation 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 diagnos-

tic classification (diagnostic triage) and the use of diag-

nostic and therapeutic interventions. Consistent features

were the early and gradual activation of patients, the dis-

couragement of prescribed bed rest, and the recognition of

psychosocial factors as risk factors for chronicity. How-

ever, there were discrepancies for recommendations

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 com-

parison with our previous review [6].

Methods

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 (www.guideline.gov; key word:

low back pain), and National Institute for Health and Clinical

Excellence (NICE) (www.nice.org.uk; 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 manage-

ment 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 guide-

lines 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 agen-

cies (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];1 Based upon search of PEDro database April 29, 2009.

2076 Eur Spine J (2010) 19:2075–2094

123

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’Evalua-

tion 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];

and

United States, American College of Physicians and the

American Pain Society (2007) [22].

Data regarding the diagnostic and therapeutic recom-

mendations 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 col-

leagues 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 pre-

vious review to facilitate comparisons (see Tables 1, 2, 3).

Results

Patient population

Each of the guidelines considered the duration of symp-

toms 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 rec-

ommendations 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 syn-

drome. The German guideline also classifies a group of

patients who are at risk for chronicity, based on ‘yellow

flags’.

All guidelines are consistent in their recommendations

that diagnostic procedures should focus on the identifi-

cation 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 wide-

spread neurologic changes. The types of physical exami-

nation 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

raising.

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. Aus-

tralian, European) or where the proposed treatment (e.g.

manipulation) requires the exclusion of a specific cause of

low back pain (French). Imaging is sometimes recom-

mended 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 ‘yel-

low 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 spe-

cific tools for identifying yellow flags and clear guide-

lines for what should be done once yellow flags are

identified.

Eur Spine J (2010) 19:2075–2094 2077

123

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2078 Eur Spine J (2010) 19:2075–2094

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ecti

on

,p

alp

atio

n,

neu

rolo

gic

alsc

reen

ing

;

refl

exes

,S

LR

/Las

egu

e,

sen

sib

ilit

y,

stre

ng

th

Fu

rth

erin

ves

tig

atio

n(e

.g.

lab

test

ing

)is

bas

edo

nre

dfl

ags

X-r

ayn

ot

use

ful

inac

ute

no

n-s

pec

ific

LB

P

CT

,M

RI

on

lyin

case

sw

ith

susp

ecte

dra

dic

ula

rp

ain

,

or

sten

osi

s,o

rsp

ecifi

c

pat

ho

log

ysu

chas

tum

ou

rs

Aft

er6

wee

ks

per

sist

ent

pai

nX

-ray

may

be

ind

icat

edo

raf

ter

6–

8w

eek

san

MR

I

Ev

alu

ate

risk

fact

ors

for

chro

nic

ity

(yel

low

flag

s);

incl

ud

ing

bio

log

ical

,p

sych

olo

gic

al,

occ

up

atio

nal

,li

fest

yle

,an

d

iatr

og

enic

fact

ors

Ital

y(2

00

6)

Acu

te,

sub

acu

tean

d

chro

nic

LB

P

No

n-s

pec

ific

LB

P

Sp

ecifi

cL

BP

Sci

atic

a

Pai

n/f

un

ctio

nal

lim

itat

ion

on

tru

nk

mo

vem

ent

Pal

pat

ion

Po

stu

ral

eval

uat

ion

Neu

rolo

gic

alex

amis

reco

mm

end

ed(S

LR

,

sen

sib

ilit

y)

Use

less

for

no

n-s

pec

ific

acu

teL

BP

Op

tio

naf

ter

4–

6w

eek

sif

surg

ery

isin

dic

ated

(sci

atic

a)

Scr

een

ing

afte

r2

wee

ks:

yel

low

flag

s,W

add

ell

test

(fo

rp

ain

beh

avio

ur)

Eur Spine J (2010) 19:2075–2094 2079

123

Ta

ble

1co

nti

nu

ed

Co

un

try

Pat

ien

tp

op

ula

tio

nD

iag

no

stic

clas

sifi

cati

on

Ph

ysi

cal

exam

inat

ion

Imag

ing

Psy

cho

soci

alfa

cto

rs

New

Zea

lan

d(2

00

4)

Acu

teL

BP

(\3

mo

nth

s)N

on

-sp

ecifi

cL

BP

Sp

ecifi

cp

ath

olo

gic

chan

ge

Neu

rolo

gic

alsc

reen

ing

Est

abli

shd

egre

eo

ffu

nct

ion

al

lim

itat

ion

cau

sed

by

the

pai

n

Inv

esti

gat

ion

sin

firs

t

4–

6w

eek

sd

on

ot

pro

vid

e

clin

ical

ben

efit

un

less

Red

Fla

gs

pre

sen

t

Th

ere

are

risk

sas

soci

ated

wit

hu

nn

eces

sary

rad

iolo

gy

Scr

een

for

yel

low

flag

sw

ith

the

Acu

teL

ow

Bac

kP

ain

Scr

een

ing

Qu

esti

on

nai

re,

and

ifat

risk

,

clin

ical

asse

ssm

ent

No

rway

(20

07

)A

cute

and

sub

acu

te

(\3

mo

nth

s)

Ch

ron

ic([

3m

on

ths)

No

n-s

pec

ific

LB

P

Rad

icu

lar

pai

n

Ser

iou

sp

ath

olo

gie

s/ac

ute

neu

rolo

gic

alco

nd

itio

ns

(Cau

da

equ

ina

syn

dro

me)

Insp

ecti

on

,p

ost

ure

,d

efo

rmit

y,

Sp

inal

mo

bil

ity

,in

clu

din

g

fin

ger

-to

-flo

or

dis

tan

ce,

Neu

rolo

gic

alsc

reen

ing

(SL

R/L

aseg

ue)

ifra

dic

ula

r

pai

nis

susp

ecte

d

No

tre

com

men

ded

inac

ute

,

sub

acu

tech

ron

icL

BP

and

rad

icu

lar

pai

nin

the

abse

nce

of

red

flag

s,

Rec

om

men

ded

inca

seo

f

red

flag

Fir

stch

oic

eis

MR

I

Ali

sto

fy

ello

wfl

ags

isp

rese

nte

d

asri

skfa

cto

rsfo

rch

ron

icit

y,

sick

leav

e

Sp

ain

(20

05

)N

on

-sp

ecifi

cac

ute

,

sub

acu

tean

dch

ron

ic

Sp

ecifi

csp

inal

pat

ho

log

y

Ner

ve

roo

tp

ain

/rad

icu

lar

pai

n

No

n-s

pec

ific

low

bac

kp

ain

Cli

nic

alh

isto

ry,

red

flag

s.D

o

no

tre

com

men

dp

alp

atio

nan

d

test

so

fin

terv

erte

bra

l

mo

bil

ity

No

tu

sefu

lin

no

n-s

pec

ific

LB

P;

X-r

ays,

CT

and

MR

Iu

seo

nly

inca

seo

f

red

flag

s

Ass

ess

psy

cho

log

ical

fact

ors

in2

–

6w

eek

saf

ter

trea

tmen

tif

no

t

imp

rov

ing

.A

sses

sp

hy

sio

log

ical

fact

ors

asp

rog

no

stic

fact

or

on

ly

Th

eN

eth

erla

nd

s(2

00

3)

Acu

te(0

–1

2w

eek

)an

d

chro

nic

([1

2w

eek

)

LB

P

No

n-s

pec

ific

LB

P

Sp

ecifi

cL

BP

(bas

edo

na

list

of

red

flag

s)

SL

R-t

est,

neu

rolo

gic

al

insp

ecti

on

;lo

sso

fm

oto

r

con

tro

l,se

nsi

bil

ity

,m

icti

on

.

Pal

pat

ion

of

spin

e,In

spec

tio

n

of

lum

bar

ky

ph

osi

so

r

flat

ten

edlu

mb

arlo

rdo

sis

No

tu

sefu

lin

no

n-s

pec

ific

acu

teL

BP

Ass

essm

ent

of

psy

cho

soci

al

fact

ors

(yel

low

flag

s)is

reco

mm

end

ed.

Th

ese

incl

ud

e

emo

tio

nal

reac

tio

n,

cog

nit

ion

s

and

beh

avio

ur

Un

ited

Kin

gd

om

(20

08

)A

cute

\6

wee

ks,

sub

acu

te6

–1

2w

eek

s,

chro

nic

[3

mo

nth

s

No

n-s

pec

ific

low

bac

kp

ain

:

Mec

han

ical

low

bac

kp

ain

Infl

amm

ato

rylo

wb

ack

pai

n

and

stif

fnes

s

Ser

iou

sp

ath

olo

gy

Ru

leo

ut

seri

ou

sp

ath

olo

gy

(id

enti

fyre

dfl

ags)

Co

nfi

rmp

ain

isin

the

low

er

bac

k,

ism

ech

anic

al,

no

t

infl

amm

ato

ry

Do

esn

ot

info

rm

man

agem

ent

of

no

n-

spec

ific

low

bac

kp

ain

bu

t

may

be

ind

icat

edto

rule

in/o

ut

seri

ou

sp

ath

olo

gie

s

Rec

og

nis

ean

dm

anag

e

psy

cho

soci

alb

arri

ers

(yel

low

flag

s)to

reco

ver

y

Un

ited

Sta

tes

(20

07

)A

cute

and

chro

nic

LB

PN

on

-sp

ecifi

cL

BP

LB

Pd

ue

tosp

ecifi

cca

use

s

LB

P-R

adic

ulo

pat

hy

/Sp

inal

Ste

no

sis

Neu

rolo

gic

alsc

reen

ing

(in

clu

din

gS

LR

,st

ren

gth

,

refl

exes

,se

nso

rysy

mp

tom

s)

On

lyw

her

ep

rog

ress

ive

neu

rolo

gic

alo

rse

rio

us

pat

ho

log

yis

susp

ecte

d

Dis

cou

rag

edfo

rn

on

-

spec

ific

LB

P

Rec

om

men

ded

for

rad

icu

lop

ath

yo

rsp

inal

sten

osi

so

nly

ifp

atie

nts

are

po

ten

tial

can

did

ates

for

furt

her

inte

rven

tio

n

Ass

essm

ent

of

psy

cho

soci

alri

sk

fact

ors

stro

ng

lyre

com

men

ded

2080 Eur Spine J (2010) 19:2075–2094

123

Summary of Common Recommendations for Diagnosis of Low backpain

* 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

improvement.

* 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 increas-

ingly 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. Nonste-

roidal anti-inflammatory drugs are the second choice in

cases where paracetamol is not sufficient. There is some

variation between guidelines with regard to recommen-

dations for opioids, muscle relaxants, steroids, antide-

pressant and anticonvulsive medication as co-medication

for pain relief. Where the mode of consumption of anal-

gesics is described, time-contingent rather than pain-

contingent 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 pro-

gramme (as distinct from encouraging resumption of nor-

mal 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 ofTa

ble

1co

nti

nu

ed

Co

un

try

Pat

ien

tp

op

ula

tio

nD

iag

no

stic

clas

sifi

cati

on

Ph

ysi

cal

exam

inat

ion

Imag

ing

Psy

cho

soci

alfa

cto

rs

Mo

sta

pp

are

nt

cha

ng

essi

nce

20

01

Ad

dit

ion

of

gu

idel

ines

fro

mco

un

trie

ssu

chas

Au

stri

a,C

anad

a,

Fra

nce

,It

aly

,N

orw

ay,

Sp

ain

and

au

nifi

ed

on

efr

om

Eu

rop

e

Mo

reco

un

trie

s(U

K,

US

)n

ow

incl

ud

e

reco

mm

end

atio

ns

for

chro

nic

LB

Pin

add

itio

nto

acu

teL

BP

.

Ger

man

yn

ow

incl

ud

essu

bac

ute

and

recu

rren

tL

BP

Alm

ost

no

chan

ge

in

dia

gn

ost

iccl

assi

fica

tio

ns

use

din

the

gu

idel

ines

Alm

ost

no

chan

ge

in

reco

mm

end

edty

pes

of

ph

ysi

cal

exam

inat

ion

Inso

me

gu

idel

ines

(Fin

lan

d,

Ger

man

y)

no

w

mo

reex

pli

cit

stat

emen

ts

reg

ard

ing

the

use

of

CT

and

MR

I

Ina

few

gu

idel

ines

(Net

her

lan

ds,

US

)th

em

easu

rem

ent

of

yel

low

flag

sar

en

ow

mo

rest

ron

gly

reco

mm

end

ed.

InG

erm

any

the

asse

ssm

ents

isn

ow

reco

mm

end

edat

am

uch

earl

ier

stag

e

Eur Spine J (2010) 19:2075–2094 2081

123

Ta

ble

2C

lin

ical

gu

idel

ines

reco

mm

end

atio

ns

reg

ard

ing

trea

tmen

to

flo

wb

ack

pai

n

Co

un

try

Ed

uca

tio

nM

edic

atio

nE

xer

cise

sM

anip

ula

tio

nB

edre

stR

efer

ral

tosp

ecia

list

Au

stra

lia

(20

03

)[8

]P

rov

ide

info

rmat

ion

,

assu

ran

cean

dad

vic

e

tore

sum

en

orm

al

acti

vit

y(s

tay

acti

ve)

Fir

stch

oic

ep

arac

etam

ol,

seco

nd

cho

ice

NS

AID

s,

thir

dch

oic

eo

ral

op

ioid

s

No

tre

com

men

ded

:

anti

con

vu

lsan

ts,

anti

dep

ress

ants

,m

usc

le

rela

xan

ts

Th

ere

isco

nfl

icti

ng

evid

ence

of

the

effe

ct

of

exer

cise

sb

ut

evid

ence

sho

ws

that

it

isn

ob

ette

rth

anu

sual

care

Co

nfl

icti

ng

evid

ence

of

spin

alm

anip

ula

tio

n

ver

sus

pla

ceb

oin

firs

t

2–

4w

eek

s

No

tad

vis

able

Wh

enal

erti

ng

feat

ure

s(r

ed

flag

s)o

rse

rio

us

con

dit

ion

sar

ep

rese

nt

Au

stri

a(2

00

7)

[9]

Acu

teL

BP

:ex

pec

ta

fav

ou

rab

leco

urs

e;

mai

nta

inn

orm

ald

aily

acti

vit

ies

Acu

teL

BP

:(1

)

Par

acet

amo

l;(2

)N

SA

IDs

3)

mu

scle

rela

xan

tso

rw

eak

op

ioid

sas

last

op

tio

n

Ch

ron

icL

BP

:O

pti

on

s:

NS

AID

s/C

ox

ibs;

Op

ioid

s;

An

tid

epre

ssan

t;m

usc

le

rela

xan

ts;

An

ti-

con

vu

lsio

nm

edic

atio

n

(fo

rra

dic

ula

rp

ain

),

Cap

saic

in

On

lyfo

rsh

ort

per

iod

s:(1

)

par

acet

amo

l,(2

)tr

amad

ol

or

NS

AID

,(3

)o

pio

ids

Acu

teL

BP

:

No

tsp

ecifi

call

y

men

tio

ned

inth

e

gu

idel

ine

Ch

ron

icL

BP

:

Ex

erci

seth

erap

y

reco

mm

end

edas

mo

no

ther

apy

or

in

com

bin

atio

nw

ith

bac

k

sch

oo

l,m

assa

ge

Acu

teL

BP

:

Op

tio

nal

for

pat

ien

ts

wh

od

on

ot

retu

rnto

no

rmal

lev

elo

f

acti

vit

yw

ith

inth

efi

rst

wee

ks

Ch

ron

icL

BP

:

Op

tio

nal

for

pat

ien

ts

wit

hp

ersi

sten

t

pro

ble

ms

wit

h

per

form

ing

dai

ly

acti

vit

ies

Acu

teL

BP

:

Av

oid

bed

rest

(bu

tif

nec

essa

ry,

on

lyfo

ra

sho

rt

per

iod

)

Inca

seo

fsu

spec

ted

spec

ific

LB

P;

Su

rger

yis

op

tio

nal

on

lyaf

ter

2y

ears

of

reco

mm

end

ed

con

serv

ativ

etr

eatm

ent,

per

sist

ing

com

pla

ints

and

wit

ha

surg

ical

ind

icat

ion

Can

ada

(20

07

)[1

0]

Rea

ssu

ran

cean

dad

vic

e

tore

turn

tow

ork

and

usu

alac

tiv

itie

s

NS

AID

s,m

usc

lere

lax

ants

and

anal

ges

ics

for

acu

te.

Lo

wev

iden

cefo

r

NS

AID

san

dan

alg

esic

s

for

sub

acu

tep

ain

Str

eng

then

ing

exer

cise

s,

exte

nsi

on

exer

cise

s

and

spec

ific

exer

cise

s

are

no

tre

com

men

ded

for

acu

teb

ut

reco

mm

end

edfo

r

sub

acu

tean

dch

ron

ic

wit

hn

osu

per

ior

form

of

exer

cise

Rec

om

men

ded

for

sho

rt-

term

pai

n

red

uct

ion

for

acu

te.

Rec

om

men

ded

wit

h

low

evid

ence

for

sub

acu

tean

dch

ron

ic

No

tre

com

men

ded

Ref

erp

atie

nts

wit

h

neu

rolo

gic

alsi

gn

so

r

sym

pto

ms

iffu

nct

ion

al

defi

cits

are

per

sist

ent

or

det

erio

rati

ng

afte

r

4w

eek

s

Eu

rop

e(2

00

6)

(acu

te)

[11]

Rea

ssu

rean

dad

vis

e

pat

ien

tsto

stay

acti

ve

and

con

tin

ue

no

rmal

dai

lyac

tiv

itie

s

incl

ud

ing

wo

rkif

po

ssib

le

Pre

scri

be

med

icat

ion

,if

nec

essa

ryfo

rp

ain

reli

ef;

Pre

fera

bly

tob

eta

ken

at

reg

ula

rin

terv

als;

firs

t

cho

ice

par

acet

amo

l,

seco

nd

cho

ice

NS

AID

s.

Th

ird

cho

ice

con

sid

er

sho

rtco

urs

eo

fm

usc

le

rela

xan

tso

nit

so

wn

or

add

edto

NS

AID

s

Do

no

tad

vis

esp

ecifi

cex

erci

ses

(fo

rex

amp

le

stre

ng

then

ing

,

stre

tch

ing

,fl

exio

n,an

d

exte

nsi

on

exer

cise

s)

for

acu

telo

wb

ack

pai

n

Co

nsi

der

(ref

erra

lfo

r)

spin

alm

anip

ula

tio

n

for

pat

ien

tsw

ho

are

fail

ing

tore

turn

to

no

rmal

acti

vit

ies

Do

no

tp

resc

rib

eb

ed

rest

asa

trea

tmen

t

Ref

erp

atie

nts

wit

h

neu

rolo

gic

alsy

mp

tom

s

such

asca

ud

aeq

uin

a

syn

dro

me

2082 Eur Spine J (2010) 19:2075–2094

123

Ta

ble

2co

nti

nu

ed

Co

un

try

Ed

uca

tio

nM

edic

atio

nE

xer

cise

sM

anip

ula

tio

nB

edre

stR

efer

ral

tosp

ecia

list

Eu

rop

e(2

00

6)

(ch

ron

ic)

[12]

Ad

vic

ean

dre

assu

ran

ce

tore

turn

ton

orm

al

acti

vit

ies

Rec

om

men

du

seo

fN

SA

ID

for

sho

rtte

rmp

ain

reli

ef

and

op

ioid

sin

case

pat

ien

t

isn

ot

resp

on

din

gto

oth

er

trea

tmen

t.C

on

sid

erth

e

use

of

no

rad

ren

erg

ico

r

no

rad

ren

erg

ic-

sero

ton

erg

ic

anti

dep

ress

ants

asco

-

med

icat

ion

for

pai

nre

lief

Su

per

vis

edex

erci

se

ther

apy

isad

vis

able

spec

ifica

lly

app

roac

hes

that

do

n’t

req

uir

eex

pen

siv

e

trai

nin

gan

dm

ach

ines

.

Co

gn

itiv

eb

ehav

iou

ral

app

roac

hin

clu

din

g

gra

ded

acti

vit

yan

d

gro

up

ther

apy

are

adv

isab

le

Rec

om

men

dsh

ort

cou

rse

of

spin

al

man

ipu

lati

on

/

mo

bil

isat

ion

Dis

cou

rag

edM

ost

inv

asiv

etr

eatm

ents

no

tre

com

men

ded

Su

rger

yn

ot

reco

mm

end

ed

un

less

inca

refu

lly

sele

cted

pat

ien

ts,

2y

ears

of

all

reco

mm

end

ed

con

serv

ativ

etr

eatm

ents

incl

ud

ing

mu

ltid

isci

pli

nar

y

app

roac

hes

wit

h

com

bin

edp

rog

ram

mes

of

cog

nit

ive

inte

rven

tio

nan

d

exer

cise

sh

ave

fail

ed

Fin

lan

d(2

00

8)

[13

]B

enig

nn

atu

reo

f

con

dit

ion

;p

rog

no

sis

is

go

od

;co

nti

nu

e

ord

inar

yd

aily

acti

vit

ies.

Bac

kp

ain

may

recu

rb

ut

even

then

reco

ver

yis

usu

ally

go

od

Acu

te/S

ub

acu

teL

BP

:(1

)

par

acet

amo

l,(2

)N

SA

IDs,

(3)

add

ing

aw

eak

op

iate

top

arac

etam

ol/

NS

AID

.

(4)

mu

scle

rela

xan

ts

An

tid

epre

ssan

to

nly

ifcl

ear

dep

ress

ion

.

Ben

zod

iaze

pin

esn

ot

reco

mm

end

ed

Ch

ron

icL

BP

An

alg

esic

s

use

dp

erio

dic

ally

,b

e

awar

eo

fsi

de

effe

cto

f

NS

AID

s(g

astr

oin

test

inal

,

card

iov

ascu

lar)

Acu

teL

BP

:

Act

ive

exer

cise

sn

ot

effe

ctiv

ein

earl

y

stag

es

Lig

ht

exer

cise

s(e

.g.

wal

kin

g)

can

be

reco

mm

end

ed

Su

bac

ute

:g

rad

ual

ly

incr

easi

ng

exer

cise

s

Ch

ron

ic:

Inte

nsi

ve

trai

nin

gef

fect

ive

for

pai

nan

dfu

nct

ion

Acu

teL

BP

:so

me

effe

ctiv

enes

s

Sim

ilar

effe

ctiv

enes

sas

GP

insu

bac

ute

LB

P

Ch

ron

icL

BP

:si

mil

ar

effe

ctiv

enes

sas

GP

,

anal

ges

ics,

ph

ysi

oth

erap

y,

etc.

Av

oid

bed

rest

;

ash

ort

per

iod

of

bed

rest

may

be

nec

essa

ryd

ue

to

inte

nse

bac

kp

ain

,

bu

tb

edre

stm

ust

no

tb

eco

nsi

der

ed

asa

trea

tmen

to

f

bac

kp

rob

lem

s

Imm

edia

tere

ferr

al:

Cau

da

equ

ina

syn

dro

me,

sud

den

mas

siv

ep

ares

is,

excr

uci

atin

gp

ain

Ref

erra

l:se

rio

us,

no

n

urg

ent

con

dit

ion

s

Mu

ltid

isci

pli

nar

y(b

io-

psy

cho

-so

cial

)

reh

abil

itat

ion

focu

sed

on

imp

rov

ing

fun

ctio

nal

cap

acit

y

Fra

nce

(20

00

)[1

4]

Sh

ort

-ter

med

uca

tio

n

abo

ut

the

bac

k,

in

gro

up

s,is

no

t

ben

efici

al

Acu

te&

Ch

ron

ic:

Reg

ula

rsi

mp

lean

alg

esic

s,

no

n-s

tero

idal

anti

-

infl

amm

ato

ryd

rug

san

d

mu

scle

rela

xan

ts.

No

evid

ence

for

syst

emic

cort

ico

ster

oid

s

Ch

ron

ic:

Ad

dit

ion

al

reco

mm

end

atio

ns

for:

acet

yls

alic

yli

cac

id,

Lev

el

IIfo

llo

win

gfa

ilu

reto

resp

on

dto

Lev

elI

and

Lev

elII

I(s

tro

ng

op

ioid

s)

on

aca

seb

yca

seb

asis

.

Tet

raze

pam

,T

ricy

clic

anti

dep

ress

ants

Acu

te:

Fle

xio

nex

erci

ses

hav

e

bee

nn

ot

bee

nsh

ow

n

tob

eo

fb

enefi

t.N

o

reco

mm

end

atio

no

n

exte

nsi

on

exer

cise

s

Ch

ron

ic:

Ph

ysi

cal

exer

cise

is

reco

mm

end

ed,

no

par

ticu

lar

typ

eis

adv

oca

ted

Acu

te&

Ch

ron

ic:

Pro

vid

essh

ort

-ter

m

ben

efit.

No

reco

mm

end

atio

nfo

r

on

efo

rmo

fm

anu

al

ther

apy

ov

eran

oth

er

Acu

tean

dC

hro

nic

:

No

tre

com

men

ded

Acu

te:

No

reco

mm

end

atio

n

Ch

ron

ic:

Rec

om

men

ded

ph

ysi

oth

erap

y/

beh

avio

ura

lth

erap

y/

mu

ltid

isci

pli

nar

y

pro

gra

mm

eif

no

n-

resp

on

seto

firs

t-li

ne

care

Eur Spine J (2010) 19:2075–2094 2083

123

Ta

ble

2co

nti

nu

ed

Co

un

try

Ed

uca

tio

nM

edic

atio

nE

xer

cise

sM

anip

ula

tio

nB

edre

stR

efer

ral

tosp

ecia

list

Ger

man

y(2

00

7)

[15]

Acu

teL

BP

:st

imu

late

dai

lyac

tiv

itie

s,

exp

lain

mo

vin

gis

no

t

dan

ger

ou

s,

Ch

ron

icL

BP

mo

re

inte

nse

psy

cho

ther

apy

ind

icat

edin

case

of

psy

cho

log

ical

co-

mo

rbid

ity

Acu

tean

dC

hro

nic

LB

P:

(1)

par

acet

amo

l,(2

)

NS

AID

s(o

ral

or

top

ical

),

(3)

Mu

scle

rela

xan

ts(i

n

case

sw

ith

mu

scle

spas

ms,

(4)

Op

ioid

s

Acu

teL

BP

:

exer

cise

ther

apy

no

t

effe

ctiv

e

Su

bac

ute

and

Ch

ron

ic

LB

P:

Ex

erci

seth

erap

y

wel

lsu

pp

ort

edb

y

evid

ence

Acu

teL

BP

:

Op

tio

nal

wit

hin

the

firs

t

4–

6w

eek

s

Ch

ron

icL

BP

:o

pti

on

if

sho

rtla

stin

g

Max

imu

mo

f2

day

s

bed

rest

Imm

edia

tesu

rger

y

ind

icat

edfo

rca

ud

aeq

uin

a

syn

dro

me

Op

tio

nal

refe

rral

for

surg

ery

:th

erap

yre

sist

ant

([6

wee

ks)

?si

gn

so

f

ner

ve

roo

tco

mp

ress

ion

Su

rger

ym

ayb

ean

op

tio

nif

afte

r2

yea

rsco

nse

rvat

ive

trea

tmen

t,in

clu

din

g

bio

psy

cho

soci

altr

eatm

ent

pro

gra

mm

ew

as

un

succ

essf

ul

Ital

y(2

00

6)

[16

]G

ive

info

rmat

ion

and

reas

sura

nce

abo

ut

po

ssib

leca

use

,

pro

vo

kin

gfa

cto

rs,

risk

fact

ors

,an

dst

ruct

ura

l

or

po

stu

ral

alte

rati

on

s,

reas

sura

nce

abo

ut

go

od

pro

gn

osi

s,k

eep

acti

ve

and

ifp

oss

ible

,

stay

atw

ork

Par

acet

amo

las

pre

ferr

ed

dru

g

NS

AID

sre

com

men

ded

Mu

scle

rela

xan

tsn

o

add

itio

nal

effe

ct

Ste

roid

sn

ot

reco

mm

end

ed

inac

ute

LB

P,

bu

tca

nb

e

use

ful

for

ash

ort

tim

ein

scia

tica

Tra

mad

ol

and

add

ing

lig

ht

op

ioid

top

arac

etam

ol

may

be

use

ful

for

scia

tica

Acu

teL

BP

No

spec

ific

exer

cise

s

reco

mm

end

ed

Ch

ron

icL

BP

Ind

ivid

ual

spec

ific

exer

cise

s

Aft

er2

–3

wee

ks

and

bef

ore

6w

eek

s,

pre

scri

bed

by

ph

ysi

cian

s,d

on

eb

y

trai

ned

ther

apis

ts

Ch

ron

icL

BP

:

Co

nsi

der

for

pai

nre

lief

Dis

cou

rag

edfo

r

acu

teL

BP

,ex

cep

t

2–

4d

ays

for

maj

or

scia

tica

Co

ntr

ain

dic

ated

for

scia

tica

No

reco

mm

end

edin

Ch

ron

icL

BP

Rad

icu

lop

ath

yan

d

susp

icio

no

fsp

ecifi

c

cau

ses

Mu

ltid

isci

pli

nar

yp

sych

o-

soci

alin

terv

enti

on

for

pat

ien

tsat

hig

hri

sko

f

chro

nic

ity

and

chro

nic

pai

n

New

Zea

lan

d(2

00

4)

[17

]

Ad

vis

eto

stay

acti

ve

and

wo

rkin

g,

or

earl

y

retu

rnto

wo

rk,

reas

sura

nce

Ed

uca

tio

np

amp

hle

ts

no

th

elp

ful

Par

acet

amo

lan

dN

SA

IDs

reco

mm

end

ed

Op

iate

so

rd

iaze

pam

may

be

har

mfu

l

Sp

ecifi

cb

ack

exer

cise

s

no

th

elp

ful

Fir

st4

–6

wee

ks

on

ly

May

pro

vid

esh

ort

-ter

m

sym

pto

mco

ntr

ol

Bed

rest

[2

day

s

har

mfu

l

Su

spic

ion

of

spec

ific

cau

ses

(red

flag

s),

cau

da

equ

ina

syn

dro

me,

or

afte

r

4–

8w

eek

s

No

rway

(20

07

)[1

8]

Sta

yac

tiv

e,re

turn

to

no

rmal

acti

vit

y

incl

ud

ing

wo

rkas

ap,

(1)

Par

acet

amo

l

(2)

NS

AID

(3)

Par

acet

amo

l?

op

ioid

or

Tra

mad

ol

(4)

An

tid

epre

ssan

tsin

case

s

wit

hd

epre

ssio

n

No

spec

ific

exer

cise

sin

the

firs

tw

eek

s

Inch

ron

icL

BP

exer

cise

sar

e

reco

mm

end

ed

Aft

er1

-2w

eek

sfo

rp

ain

red

uct

ion

and

imp

rov

emen

to

f

fun

ctio

n(f

or

smal

lto

mo

der

ate

effe

cts)

No

tre

com

men

ded

Inra

reca

ses,

no

t

lon

ger

than

2–

3d

ays

Ref

erra

lw

ith

inp

rim

ary

care

for

cog

nit

ive

beh

avio

ura

ltr

eatm

ent

is

op

tio

nal

Ref

erra

lfo

rsu

rgic

al

inte

rven

tio

naf

ter

2y

ears

’

LB

P

2084 Eur Spine J (2010) 19:2075–2094

123

Ta

ble

2co

nti

nu

ed

Co

un

try

Ed

uca

tio

nM

edic

atio

nE

xer

cise

sM

anip

ula

tio

nB

edre

stR

efer

ral

tosp

ecia

list

Sp

ain

(20

05

)[1

9]

Rea

ssu

ran

cean

dad

vic

e

tost

ayac

tiv

e

Par

acet

amo

lev

ery

6h

,ca

n

also

be

asso

ciat

edw

ith

op

ioid

san

dN

SA

ID

alth

ou

gh

the

last

on

e

sho

uld

no

tb

ep

resc

rib

ed

for

lon

ger

than

3m

on

ths

Op

ioid

sar

ein

dic

ated

for

pat

ien

tsw

ith

hig

hle

vel

s

of

pai

nw

ho

did

no

t

imp

rov

ew

ith

usu

alca

re

Ex

erci

seas

far

asp

ain

allo

ws

incl

ud

ing

wo

rk

acti

vit

ies.

As

ther

eis

no

evid

ence

for

any

spec

ific

typ

eo

f

exer

cise

,ch

oo

seth

e

on

eth

atp

atie

nts

pre

fer.

No

tin

dic

ated

for

pat

ien

tsw

ith

pai

n

for

less

than

6w

eek

s

No

tre

com

men

ded

Dis

cou

rag

edu

nle

ss

pat

ien

tca

nn

ot

ado

pt

ano

ther

po

stu

re.

Th

enb

ed

rest

for

the

max

imu

mo

f4

8h

Ref

erp

atie

nt

inca

seo

fre

d

flag

s

Th

eN

eth

erla

nd

s(2

00

3)

[20

]

Acu

tean

dC

hro

nic

LB

P:

Sta

yac

tiv

eas

mu

chas

po

ssib

le(d

esp

ite

the

pai

n),

incr

ease

acti

vit

y

lev

elo

na

tim

e

con

tin

gen

tb

asis

Acu

teL

BP

:

(1)

Par

acet

amo

l

(2)

NS

AID

s,

(3)

mu

scle

rela

xan

tso

r

wea

ko

pio

ids

or

com

bin

atio

ns

wit

h

par

acet

amo

l/N

SA

IDS

as

last

op

tio

nd

ue

tosi

de

effe

cts

Ch

ron

icL

BP

:O

nly

for

sho

rtp

erio

ds:

(1)

Par

acet

amo

l,

(2)

Tra

mad

ol

or

NS

AID

,

(3)

Op

ioid

s

Acu

teL

BP

:

Co

nsi

der

afte

r4

–

6w

eek

sfo

rp

atie

nts

wh

od

on

ot

imp

rov

e

thei

rfu

nct

ion

ing

Ch

ron

icL

BP

:

Rec

om

men

ded

are

tim

e-co

nti

ng

ent,

var

yin

gan

d

sup

erv

ised

exer

cise

s

focu

sed

atim

pro

vin

g

fun

ctio

n

Acu

tean

dC

hro

nic

LB

P:

Op

tio

nas

par

to

fan

acti

vat

ing

stra

teg

yfo

r

pat

ien

tsw

ho

do

no

t

sho

wa

fav

ou

rab

le

cou

rse

Acu

tean

dC

hro

nic

LB

P:

Av

oid

bed

rest

Ch

ron

icL

BP

:R

efer

pat

ien

tsw

ith

sev

ere

dis

abil

ity

wh

od

on

ot

resp

on

dto

reco

mm

end

ed

con

serv

ativ

etr

eatm

ents

for

mu

ltid

isci

pli

nar

y

trea

tmen

tfo

cuse

do

n

fun

ctio

nal

reco

ver

y

Un

ited

Kin

gd

om

(20

08

)

[21

]

Pro

vid

ein

form

atio

nan

d

adv

ice

tofo

ster

po

siti

ve

atti

tud

ean

d

real

isti

c

exp

ecta

tio

ns—

bac

k

pai

nis

no

tse

rio

us,

tem

po

rary

,te

nd

sto

recu

r,p

hy

sica

ln

ot

psy

cho

log

ical

,

mec

han

ical

.S

tay

acti

ve

asp

oss

ible

Reg

ula

rp

arac

etam

ol

(pre

ferr

ed)

or

NS

AID

as

firs

tli

ne

care

.F

or

add

itio

nal

anal

ges

ia

com

bin

ep

arac

etam

ol

and

NS

AID

or

add

aw

eak

op

ioid

(co

dei

ne

or

tram

ado

l).

Fo

rn

on

-

resp

on

der

sco

nsi

der

ben

zod

iaze

pin

e,tr

icy

clic

anti

dep

ress

ant

No

tre

com

men

ded

:T

op

ical

NS

AID

s,an

tiep

ilep

tic

dru

gs

(oth

erth

an

gab

apen

tin

),h

erb

al

rem

edie

s

Ad

vis

ep

atie

nt

tost

ayas

acti

ve

asp

oss

ible

.N

o

spec

ific

reco

mm

end

atio

ns

reg

ard

ing

exer

cise

No

reco

mm

end

atio

ns

incl

ud

ed

Acu

teL

BP

:

Res

tin

bed

isle

ss

effe

ctiv

eth

an

stay

ing

acti

ve

Ifp

rog

ress

ive

neu

rolo

gic

al

defi

cit

Ifp

ain

or

dis

abil

ity

rem

ain

pro

ble

mat

icfo

rm

ore

than

aw

eek

or

two

con

sid

er

refe

rral

for

ph

ysi

o/

ph

ysi

cal

ther

apy

Ifp

ain

/dis

abil

ity

con

tin

ue

tob

ea

pro

ble

md

esp

ite

ph

arm

aco

ther

apy

and

ph

ysi

cal

ther

apy

con

sid

er

refe

rral

to

mu

ltid

isci

pli

nar

yb

ack

pai

nse

rvic

eo

rch

ron

ic

pai

ncl

inic

Eur Spine J (2010) 19:2075–2094 2085

123

Ta

ble

2co

nti

nu

ed

Co

un

try

Ed

uca

tio

nM

edic

atio

nE

xer

cise

sM

anip

ula

tio

nB

edre

stR

efer

ral

tosp

ecia

list

Un

ited

Sta

tes

(20

07

)

[22]

Pro

vid

ein

form

atio

no

n

pro

gn

osi

s,st

ayin

g

acti

ve,

self

man

agem

ent

Sel

f-ca

reed

uca

tio

n

bo

ok

sre

com

men

ded

Par

acet

amo

l,N

SA

IDs

reco

mm

end

edas

firs

t-li

ne

dru

gs

Fo

rac

ute

(\4

wee

ks)

—

mu

scle

rela

xan

ts,

ben

zod

iaze

pin

es,

tram

ado

l,o

pio

ids

Fo

rsu

bac

ute

or

chro

nic

([4

wee

ks)

—

anti

dep

ress

ants

,

ben

zod

iaze

pin

es,

tram

ado

l,o

pio

ids

No

tef

fect

ive

for

acu

te

LB

P

Rec

om

men

ded

for

sub

acu

teo

rch

ron

ic

LB

P

Fo

rac

ute

LB

Pif

no

t

imp

rov

ing

Ev

enif

req

uir

edfo

r

sev

ere

sym

pto

ms,

pat

ien

tssh

ou

ldb

e

enco

ura

ged

to

retu

rnto

no

rmal

acti

vit

ies

asso

on

asp

oss

ible

Fo

rin

terd

isci

pli

nar

y

inte

rven

tio

nif

chro

nic

Ifsu

spic

ion

of

sig

nifi

can

t

ner

ve

roo

tim

pin

gem

ent

or

spin

alst

eno

sis

Mo

sta

pp

are

nt

cha

ng

essi

nce

20

01

Th

ead

vic

eto

stay

acti

ve

rem

ain

ssi

mil

ar.

No

wso

me

gu

idel

ines

(eu

rop

ean

,N

Z,

Can

ada,

Ital

y,

No

rway

)ex

pli

citl

y

men

tio

nco

nti

nu

atio

n/

earl

yR

TW

No

chan

ge

reg

ard

ing

reco

mm

end

atio

no

f

par

acet

amo

lan

dN

SA

IDs

asfi

rst-

lin

etr

eatm

ents

and

reco

mm

end

atio

n

reg

ard

ing

mu

scle

rela

xan

ts

No

wm

ore

oft

enex

pli

cit

reco

mm

end

atio

ns

(fo

ro

r

agai

nst

)an

ti-d

epre

ssan

ts,

op

ioid

s,b

enzo

dia

zep

ines

and

com

bin

atio

ns

of

med

icat

ion

s

Th

ead

vic

eth

atex

erci

se

ther

apy

isn

ot

use

ful

in

acu

teL

BP

has

no

t

chan

ged

No

wm

ore

exp

lici

t

reco

mm

end

atio

ns

in

fav

ou

ro

fex

erci

se

ther

apy

insu

bac

ute

and

chro

nic

LB

P

Rec

om

men

dat

ion

sfo

r

spin

alm

anip

ula

tio

n,

the

tim

ing

of

app

lica

tio

nan

dta

rget

gro

up

con

tin

ue

tov

ary

Th

e reco

mm

end

atio

n

agai

nst

bed

rest

is

fair

lyco

nsi

sten

t

bet

wee

n2

00

1an

d

no

w

Th

ere

com

men

dat

ion

sfo

r

refe

rral

app

ear

mo

re

exp

lici

tre

gar

din

g:

(1)

imm

edia

tere

ferr

al(c

aud

a

equ

ina

syn

dro

me)

,(2

)

med

ical

spec

iali

stin

case

of

red

flag

s,(3

)re

ferr

al

wit

hin

pri

mar

yca

re

(ph

ysi

oth

erap

y/c

og

nit

ive

beh

avio

ura

lth

erap

y,

(4)

mu

ltid

isci

pli

nar

y

trea

tmen

tsan

d(5

)

con

sid

ersu

rger

yif

2y

ears

of

reco

mm

end

ed

con

serv

ativ

eca

reh

as

fail

ed

2086 Eur Spine J (2010) 19:2075–2094

123

therapy that is contentious is the use of spinal manipula-

tion. 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 rec-

ommend 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

Setting

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 com-

mittees are characterised by their multidisciplinary mem-

bership. These usually included primary care physicians,

physical and manual therapists, orthopaedic surgeons,

rheumatologists, radiologists, occupational and rehabilita-

tion physicians. The number of members varied from 7 to

31. Only three committees included consumer representa-

tion (Australia, New Zealand, the Netherlands).

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 evi-

dence (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 guide-

lines are published in national journals and/or disseminated

through professional organisations to the target practitio-

ners. 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.

Discussion

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 pro-

gressive activation of patients, and the related discour-

agement 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

Eur Spine J (2010) 19:2075–2094 2087

123

Ta

ble

3T

arg

etg

rou

p,

auth

ors

,ev

iden

ceb

ase,

con

sen

sus,

and

imp

lem

enta

tio

no

fcl

inic

alg

uid

elin

esin

low

bac

kp

ain

Countr

yT

arget

gro

up

Guid

elin

eco

mm

itte

eE

vid

ence

bas

eC

onse

nsu

sP

rese

nta

tion/I

mple

men

tati

on

Au

stra

lia

(20

03

)

Pri

mar

yan

dse

con

dar

y

care

Mult

idis

cip

linar

y:

Ost

eop

ath

ic,

Rh

eum

ato

log

y,

Ph

ysi

oth

erap

y,

Ch

iro

pra

ctic

,G

P,

Ep

idem

iolo

gy

,

consu

mer

repre

senta

tive

(n=

9)

Up

dat

eo

fth

ep

rev

iou

sA

ust

rali

an

guid

elin

eusi

ng

the

AG

RE

E.

Co

mpre

hen

siv

eli

tera

ture

sear

ch(u

pto

20

02

)p

ub

med

,ci

nh

alem

bas

ean

d

Coch

rane

for

clin

ical

evid

ence

.A

ll

reco

mm

end

atio

ns

are

lin

ked

to

evid

ence

lev

el

Use

of

con

sen

sus

met

hod

not

clea

r

Fre

eo

nli

ne

ver

sio

n,

Incl

ud

edin

book

‘evid

ence

-bas

ed

man

agem

ent

of

acute

mu

scu

losk

elet

alp

ain

:a

gu

ide

for

clin

icia

ns’

Au

stri

a(2

00

7)

Pri

mar

yan

dse

con

dar

y

care

(all

wh

oar

e

inv

olv

edw

ith

dia

gno

sis

and

trea

tmen

to

fL

BP

)

Mult

idis

cip

linar

y(p

sych

iatr

y,

ort

hopae

dic

s,gen

eral

pra

ctic

e,

ph

ysi

oth

erap

y,

rad

iolo

gy,

psy

cho

log

y,

neu

rolo

gy,

reh

abil

itat

ion

,o

steo

log

y?,

pai

nm

edic

ine,

erg

oth

erap

y,

rheu

mat

olo

gy

,n

euro

surg

ery

(n=

17

)

Bas

edo

nE

uro

pea

nguid

elin

es

(20

04

)?

up

dat

edev

iden

cere

gar

din

g

mas

sage

and

acupunct

ure

.G

radin

gof

evid

ence

was

use

du

sin

gan

exp

lici

t

wei

ghti

ng

syst

em

No

dir

ect

lin

kin

gb

etw

een

reco

mm

end

atio

ns

and

un

der

lyin

g

evid

ence

Dra

ftg

uid

elin

ep

rese

nte

dan

d

app

rov

edat

two

con

sen

sus

mee

tin

gs

Pu

bli

shed

inn

atio

nal

jou

rnal

in

Au

stri

a

Can

ada

(20

07

)

Pri

mar

yca

reM

ult

idis

cip

linar

yw

ith

pri

mar

yh

ealt

h

care

pro

fess

ion

als

Bas

edo

nan

exte

nsi

ve

lite

ratu

rere

vie

w

of

the

bes

tav

aila

ble

evid

ence

and

asse

ssm

ent

of

kn

ow

led

ge

inal

lar

eas

of

bac

kp

ain

man

agem

ent

ital

so

com

bin

esw

ith

par

tici

pan

t’s

clin

ical

exp

erie

nce

Use

of

con

sen

sus

met

hod

not

clea

r

Av

aila

ble

on

web

site

Eu

rope

(20

06

)

(Acu

te)

Pri

mar

yca

reM

ult

idis

cip

linar

y:

exper

tsin

the

fiel

do

f

low

bac

kp

ain

rese

arch

inp

rim

ary

care

(n=

14

)

Lit

erat

ure

sear

chfr

om

1966

to2003

on

the

Coch

ran

eL

ibra

ry,

Med

line,

Em

bas

efo

rse

arch

eso

f

Coch

rane

revie

ws

(and

on

oth

er

syst

emat

icre

vie

ws

ifa

Coch

rane

revie

ww

asnot

avai

lable

),ad

dit

ional

tria

lsp

ub

lish

edaf

ter

the

Co

chra

ne

revie

ws,

and

exis

ting

nat

ional

gu

idel

ines

.S

tren

gth

of

evid

ence

was

asse

ssed

bas

edo

nth

eo

rig

inal

rati

ngs

of

the

AH

CP

RG

uid

elin

es(1

99

4)

and

level

sof

evid

ence

reco

mm

ended

inth

em

ethod

gu

idel

ines

of

the

Co

chra

ne

Bac

kR

evie

wg

roup

Use

of

conse

nsu

sm

ethod

not

clea

r;

‘‘u

seo

fg

rou

pd

iscu

ssio

ns’

’

Pu

bli

cati

on

ina

jou

rnal

wit

h

pla

nn

edu

pd

ate

afte

r3

yea

rs

Eu

rope

(20

06

)

(Ch

ron

ic)

Pri

mar

yca

rean

d

seco

nd

ary

care

Mult

idis

cip

linar

y:

exper

tsin

the

fiel

do

f

low

bac

kp

ain

rese

arch

inp

rim

ary

care

(n=

11

)

Lit

erat

ure

sear

chup

to2002.

Bas

edo

n

syst

emat

icre

vie

wof

syst

emat

ic

revie

ws

and

random

ised

clin

ical

tria

ls

on

CL

BP

.S

yst

emat

icre

vie

ws

wer

e

rate

du

sin

gth

eO

xm

an&

Gu

yat

tin

dex

and

RC

Ts

rate

du

sing

the

van

Tu

lder

etal

.1

99

7cr

iter

ia

Use

of

con

sen

sus

met

ho

dn

ot

clea

r.

Use

of

gro

up

dis

cuss

ion

s,n

o

form

alg

rad

ing

sch

eme

use

d

Pu

bli

shed

on

aw

ebsi

tean

din

a

jou

rnal

.P

rofe

ssio

nal

asso

ciat

ions

wil

ldis

sem

inat

e

and

imp

lem

ent

thes

e

gu

idel

ines

2088 Eur Spine J (2010) 19:2075–2094

123

Ta

ble

3co

nti

nu

ed

Countr

yT

arget

gro

up

Guid

elin

eco

mm

itte

eE

vid

ence

bas

eC

onse

nsu

sP

rese

nta

tion/I

mple

men

tati

on

Fin

lan

d

(20

08

)

Pri

mar

yan

dse

con

dar

y

care

Ph

ysi

atri

st,

rad

iolo

gis

t,g

ener

al

pra

ctit

ion

eran

do

ccu

pat

ion

alh

ealt

h

ph

ysi

cian

,n

euro

surg

eon,

ph

ysi

oth

erap

ist,

ort

ho

pae

dic

surg

eon

(n=

8)

Bas

edo

nex

pli

cit

wei

ghin

gof

evid

ence

.

Imp

ort

ant

dec

isio

np

oin

tsar

eb

ack

ed

up

by

level

of

evid

ence

stat

emen

ts

Con

sen

sus

on

evid

ence

syn

thes

is

and

tex

td

uri

ng

Co

mm

itte

e

mee

tin

gs

Asu

mm

ary

of

the

gu

idel

ines

has

bee

np

ub

lish

edin

the

Fin

nis

hjo

urn

al(D

uo

dec

im

20

08

).T

he

wh

ole

tex

tis

pu

bli

shed

on

the

web

site

of

the

Fin

nis

hC

urr

ent

Car

e

Gu

idel

ines

Fra

nce

(20

00

)A

cute

and

Ch

ron

ic:

No

nst

ated

Acu

teL

BP

:M

ult

idis

cip

lin

ary;

Rh

eum

ato

log

ist

(2),

Ph

ysi

oth

erap

ist,

Psy

chia

tris

t,N

euro

rad

iolo

gis

t,G

P

(2),

Rad

iolo

gis

t,O

ccu

pat

ion

al

Med

icin

eS

pec

iali

st,

Ort

ho

pae

dic

surg

eon

,S

pec

iali

stin

Ph

ysi

cal

Med

icin

ean

dR

ehab

ilit

atio

n(1

1).

Ch

ron

icL

BP

:

Mu

ltid

isci

pli

nar

y;R

heu

mat

olo

gis

t(2

),

Ph

ysi

oth

erap

ist,

Psy

chia

tris

t,N

euro

-

rad

iolo

gis

t,G

P(4

),R

adio

log

ist,

Occ

up

atio

nal

Med

icin

eS

pec

iali

st,

Ort

ho

pae

dic

surg

eon

,S

pec

iali

stin

Ph

ysi

cal

Med

icin

ean

dR

ehab

ilit

atio

n

(13

)

Acu

te&

Ch

ron

ic:

Rev

iew

of

the

lite

ratu

re—

no

furt

her

det

ail

pro

vid

ed

Acu

te&

Ch

ron

ic:

Use

of

con

sen

sus

inth

eab

sence

of

evid

ence

Acu

te&

Chro

nic

:

Gu

idel

ines

com

mis

sio

ned

fro

m

the

Ag

ence

Na

tion

ale

d’A

ccre

dit

ati

on

d’E

valu

ati

on

enS

an

teb

yC

NA

MT

S,

the

Fre

nch

nat

ion

alh

ealt

h

insu

ran

cefu

nd

.R

epo

rts

pu

bli

shed

inE

ng

lish

and

Fre

nch

and

avai

lab

leo

nli

ne

Ger

man

y

(20

07

)

Pri

mar

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cati

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ple

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ver

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aila

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sen

tati

on

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confe

rence

sof

rele

van

t

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fess

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l

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rksh

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mar

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edic

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chir

op

ract

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ist,

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mar

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dse

con

dar

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care

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idis

cipli

nar

y:

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upat

ional

,

reh

abil

itat

ion

,p

hy

sio

ther

apy

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chir

opra

ctic

,m

anual

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apy,

neu

rolo

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hopae

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logy,

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eral

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pre

hen

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lite

ratu

re

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chra

ne,

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lin

e,E

mb

ase)

,q

ual

ity

asse

ssm

ent,

wei

gh

ing

of

evid

ence

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ched

toth

ere

com

men

dat

ion

s

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om

men

dat

ions

bas

edo

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cuss

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inth

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mar

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atie

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bro

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Eur Spine J (2010) 19:2075–2094 2089

123

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ble

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2090 Eur Spine J (2010) 19:2075–2094

123

sensible and relevant. In some instances the guidelines are

a national adaptation (e.g. in Spain) of the European

guidelines.

We do not present an exhaustive overview of all clinical

guidelines available, but focused on national multidisci-

plinary guidelines. This enables a reasonable comparison

of recommended approaches across countries. A limitation

is thus that not all available guidelines, including mono-

disciplinary 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 weight-

ing system and rating of the evidence. There is some var-

iation 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 recommenda-

tions that there is at least moderate evidence available.

Differences in recommendations

Recommendations about the prescription of analgesic

medication remain fairly consistent. Most guidelines rec-

ommend paracetamol as the first option and nonsteroidal

anti-inflammatory preparations as the second option. Fur-

ther 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

much.

The recommendations regarding spinal manipulation

continue to show some variation. In some guidelines

manipulation is recommended, or presented as a thera-

peutic 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 var-

ious 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 lowTa

ble

3co

nti

nu

ed

Countr

yT

arget

gro

up

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elin

eco

mm

itte

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vid

ence

bas

eC

onse

nsu

sP

rese

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tion/I

mple

men

tati

on

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sta

pp

are

nt

cha

ng

e,if

an

y,si

nce

20

01

Th

ecu

rren

tg

uid

elin

es

app

ear

mo

reo

ften

focu

sed

on

pri

mar

y

care

asw

ell

as

seco

nd

ary

care

com

par

edto

20

01

wh

enth

efo

cus

was

mo

reex

clu

sivel

yo

n

pri

mar

yca

re

Th

eg

uid

elin

eco

mm

itte

esin

20

01

as

wel

las

curr

entl

yco

nsi

sto

fa

mu

ltid

isci

pli

nar

yp

anel

(wh

ich

of

cou

rse

isn

ot

surp

risi

ng

lysi

nce

mu

ltid

isci

pli

nar

yg

uid

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esw

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incl

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and

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ate

that

they

are

bas

edo

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pre

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us

gu

idel

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(i.e

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pea

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gu

idel

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),fu

rther

mo

real

most

all

gu

idel

ines

no

wex

pli

citl

yst

ate

that

they

app

lied

aw

eigh

tin

gsy

stem

toth

e

evid

ence

.In

2001

aw

eighti

ng

syst

em

was

less

oft

enu

sed

In2

00

1an

dat

pre

sen

tco

nse

nsu

s

met

hod

sw

ere

use

d,

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ally

gro

up

dis

cuss

ion

tak

ep

lace

,b

ut

the

exac

tm

eth

od

iso

ften

no

t

clea

r.T

his

has

no

tch

ang

edsi

nce

20

01

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ost

case

sth

eg

uid

elin

eis

publi

shed

and

dis

sem

inat

ed

wit

ho

ut

anac

tiv

e

imp

lem

enta

tio

np

rogra

mm

e.

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ish

asn

ot

chan

ged

sin

ce

20

01

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em

ain

chan

ge

isth

at

curr

entl

yal

mo

stal

lg

uid

elin

es

are

avai

lab

leo

na

web

site

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erea

sin

20

01

mo

reo

ften

pap

erv

ersi

on

sw

ere

dis

trib

ute

d

Eur Spine J (2010) 19:2075–2094 2091

123

back pain. At the same time back exercises are recom-

mended 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 consen-

sus 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 cost-

effectiveness 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 interven-

tions. 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, pos-

sibly because there are not many diagnostic studies avail-

able 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

successful in effective screening of the patients at risk and

subsequent therapeutic management of them [24].

Most apparent changes regarding therapeutic interven-

tions 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, benzodiaze-

pines and compound medications. But these recommen-

dations 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.

Implementation

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 publica-

tion and dissemination of guidelines alone is usually not

enough to change the behaviour of health care providers

[27]. The development of effective implementation strate-

gies in this area remains a challenge.

Future developments in research and guideline

development

The present study was primary aimed at presenting an

update of the current clinical guidelines for the manage-

ment of low back pain in primary care. Clinical guidelines

focused at secondary care settings, occupational care set-

tings, or specific subgroups of patients with lumbosacral

radicular syndrome were not considered. Separate studies

need to be undertaken to present an overview for these

settings.

We assessed various aspects of the guideline develop-

ment 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

2092 Eur Spine J (2010) 19:2075–2094

123

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 Recommenda-

tion 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 evi-

dence, 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 per-

mits any noncommercial use, distribution, and reproduction in any

medium, provided the original author(s) and source are credited.

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