National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy
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To summarise recommendations about 20 non-surgical interventions for recent onset (<12 weeks) non-specific low back pain (LBP) and lumbar radiculopathy (LR) based on two guidelines from the Danish Health Authority.
Two multidisciplinary working groups formulated recommendations based on the GRADE approach.
Sixteen recommendations were based on evidence, and four on consensus. Management of LBP and LR should include information about prognosis, warning signs, and advise to remain active. If treatment is needed, the guidelines suggest using patient education, different types of supervised exercise, and manual therapy. The guidelines recommend against acupuncture, routine use of imaging, targeted treatment, extraforaminal glucocorticoid injection, paracetamol, NSAIDs, and opioids.
Recommendations are based on low to moderate quality evidence or on consensus, but are well aligned with recommendations from international guidelines. The guideline working groups recommend that research efforts in relation to all aspects of management of LBP and LR be intensified.
KeywordsClinical guideline Low back pain Lumbar radiculopathy Non-surgical intervention Recommendations Conservative treatment
We would like to acknowledge the contributions of Kirsten Birkefoss, Marina T. Axelsen, and Hanne Caspersen, research librarians at the Danish Health Authority; Christine Marie Bækø Halling, project manager at the Danish Health Authority; Helle Ulrichsen, chairman of the LBP working group, and Karsten Junker, chairman of LR working group.
Compliance with ethical standards
Funding was provided by The Danish Finance Act (2012), and the DHA was commissioned to formulate the national clinical guidelines. Funding was provided to members of the project groups, i.e. lead reviewers (MJS and PK), project manager (BH), methodologists (JA and ST), search specialists, and chairmen. No funding was provided to the working or reference group members. The funders had no role in the design, collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
- 1.Danish Health Authority. Mandate for Development of National Clinical Guidelines [In Danish]. 4-1013-10/1/SBRO. Denmark: Danish Health and Medicines Authority, 2012. https://www.sst.dk/da/sundhed/kvalitet-og-retningslinjer/~/media/EA5CFD60216C4DAA9102C21DF6C121D1.ashx
- 2.Flachs EM, Eriksen L, Koch MB, Ryd JT, Dibba E, Skov-Ettrup L, Juel K. The burden of disease in Denmark—Diseases [In Danish]. National Institute of Public Health, University of Southern Denmark. Copenhagen: Danish Health Authority, 2015. https://www.sst.dk/da/sygdom-og-behandling/~/media/00C6825B11BD46F9B064536C6E7DFBA0.ashx
- 3.Danish Health Authority. Health of the Danish people—The national health profile 2013[In Danish]. Danish Health Authority, Copenhagen, 2014. https://www.sst.dk/~/media/1529A4BCF9C64905BAC650B6C45B72A5.ashx
- 5.GBD 2015 Disease and Injury Incidence and Prevalence Collaborators (2016) Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388(10053):1545–1602CrossRefGoogle Scholar
- 10.Danish Health Authority. National Clinical Guideline: interventions for recent onset low back pain [in Danish]. 2016. https://www.sst.dk/da/udgivelser/2016/nkr-laenderygsmerter
- 11.Danish Health Authority. National Clinical Guideline: interventions for recent onset lumbar radiculopathy [in Danish]. 2016. https://www.sst.dk/da/udgivelser/2016/lumbal-nerverodspaavirkning-ikke-kirurgisk-behandling
- 13.Danish Health Authority. Handbook of methodology: a model for conducting clinical guidelines [in Danish]. 2015. https://www.sst.dk/da/nkr/metode/metodehaandbog, 2017
- 19.http://www.covidence.org. Accessed 18 Apr 2017
- 20.http://community.cochrane.org/tools/review-production-tools/revman-5. Accessed 18 Apr 2017
- 21.https://gradepro.org. Accessed 18 Apr 2017
- 22.https://www.magicapp.org. Accessed 18 Apr 2017
- 29.Luijsterburg PA, Verhagen AP, Ostelo RW, van den Hoogen HJ, Peul WC, Avezaat CJ et al (2008) Physical therapy plus general practitioners’ care versus general practitioners’ care alone for sciatica: a randomised clinical trial with a 12-month follow-up. Eur Spine J 17(4):509–517CrossRefPubMedPubMedCentralGoogle Scholar
- 30.World Health Organization. Regional Office for Europe (1998) Therapeutic patient education: continuing education programmes for health care providers in the field of prevention of chronic diseases: report of a WHO working group. CopenhagenGoogle Scholar
- 37.Karjalainen K, Malmivaara A, Pohjolainen T, Hurri H, Mutanen P, Rissanen P et al (2003) Mini-intervention for subacute low back pain: a randomized controlled trial. Spine (Phila Pa 1976) 28(6):533–540 (discussion 40-1) Google Scholar
- 44.Rabin A, Shashua A, Pizem K, Dickstein R, Dar G (2014) A clinical prediction rule to identify patients with low back pain who are likely to experience short-term success following lumbar stabilization exercises: a randomized controlled validation study. J Orthop Sports Phys Ther 44(1):6-B13CrossRefPubMedGoogle Scholar
- 47.Gilbert FJ, Grant AM, Gillan MG, Vale L, Scott NW, Campbell MK et al (2004) Does early imaging influence management and improve outcome in patients with low back pain? A pragmatic randomised controlled trial. Health Technol Assess 8(17):iii, 1–131Google Scholar
- 53.Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO et al (2007) Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. Lancet 370(9599):1638–1643CrossRefPubMedGoogle Scholar
- 68.Huber J, Lisinski P, Samborski W, Wytrazek M (2011) The effect of early isometric exercises on clinical and neurophysiological parameters in patients with sciatica: An interventional randomized single-blinded study. Isokinet Exerc Sci 19(3):207–214Google Scholar
- 74.Petersen T, Larsen K, Nordsteen J, Olsen S, Fournier G, Jacobsen S (2011) The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization: A randomized controlled trial. Spine 36(24):1999–2010CrossRefPubMedGoogle Scholar
- 75.Furlan AD, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L et al (2012) A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med 2012:953139CrossRefPubMedGoogle Scholar
- 76.Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW et al (2005) Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev 1:CD001351Google Scholar
- 79.Chou R, Hashimoto R, Friedly J, Fu R, Dana T, Sullivan S et al (2015) Pain management injection therapies for low back pain. US: Rockville, Maryland: Agency for Healthcare Research and Quality. Contract No.: ReportGoogle Scholar
- 85.Cohen SP, Gupta A, Strassels SA, Christo PJ, Erdek MA, Griffith SR et al (2012) Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections: a multicenter, randomized controlled trial. Arch Intern Med 172(2):134–142CrossRefPubMedGoogle Scholar
- 89.el Zahaar MS (1991) The value of caudal epidural steroids in the treatment of lumbar neural compression syndromes. J Neurol Orthop Med Surg 12:181–184Google Scholar
- 91.Helliwell M, Robertson JC, Ellis RM (1985) Outpatient treatment of low-back pain and sciatica by a single extradural corticosteroid injection. Brit J Clin Pract. 39(6):228–231Google Scholar
- 95.Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV (2012) Effect of fluoroscopically guided caudal epidural steroid or local anesthetic injections in the treatment of lumbar disc herniation and radiculitis: a randomized, controlled, double blind trial with a two-year follow-up. Pain Physician 15(4):273–286PubMedGoogle Scholar
- 99.Rogers P, Nash T, Schiller D, Norman J (1992) Epidural steroids for sciatica. Pain Clin 5:67–72Google Scholar
- 106.Peul WC, van den Hout WB, Brand R, Thomeer RT, Koes BW, Leiden-The Hague Spine Intervention Prognostic Study G (2008) Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ 336(7657):1355–1358CrossRefPubMedPubMedCentralGoogle Scholar
- 108.Wong JJ, Cote P, Sutton DA, Randhawa K, Yu H, Varatharajan S et al (2016) Clinical practice guidelines for the noninvasive management of low back pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain 21(2):201–216Google Scholar
- 109.National Institute for Health Care Excellence (2016) Low back pain and sciatica: management of non-specific low back pain and sciatica. National Institute for health Care Excellence, LondonGoogle Scholar