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 flags’.
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 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. 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 identified.
Summary of Common Recommendations for Diagnosis of Low back pain
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* Diagnostic triage (non-specific low back pain, radicular syndrome, serious pathology).
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* Screen for serious pathology using red flags.
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* Physical examination for neurologic screening (including straight leg raising test).
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* Consider psychosocial factors (yellow flags) if there is no improvement.
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* Routine imaging not indicated for non-specific low back pain.
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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.
Table 2 Clinical guidelines recommendations regarding treatment of low back pain
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 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 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 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
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Acute or Subacute Pain
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* Reassure patients (favourable prognosis).
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* Advise to stay active.
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* 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).
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* Discourage bed rest.
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* Do not advise a supervised exercise programme.
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Chronic Pain
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* Discourage use of modalities (such as ultrasound, electrotherapy)
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* Short-term use of medication/manipulation
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* Supervised exercise therapy
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* Cognitive behavioural therapy
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* Multidisciplinary treatment
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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.
Table 3 Target group, authors, evidence base, consensus, and implementation of clinical guidelines in 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).
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.