Skip to main content

National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy

Abstract

Purpose

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.

Methods

Two multidisciplinary working groups formulated recommendations based on the GRADE approach.

Results

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.

Conclusion

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.

This is a preview of subscription content, access via your institution.

References

  1. 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. 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. 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

  4. 4.

    Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F et al (2012) A systematic review of the global prevalence of low back pain. Arthritis Rheum 64(6):2028–2037

    Article  PubMed  Google Scholar 

  5. 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):1545–1602

    Article  Google Scholar 

  6. 6.

    Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C et al (2014) The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 73(6):968–974

    Article  PubMed  Google Scholar 

  7. 7.

    Dunn KM, Hestbaek L, Cassidy JD (2013) Low back pain across the life course. Best Pract Res Clin Rheumatol 27(5):591–600

    Article  PubMed  Google Scholar 

  8. 8.

    Kongsted A, Kent P, Hestbaek L, Vach W (2015) Patients with low back pain had distinct clinical course patterns that were typically neither complete recovery nor constant pain. A latent class analysis of longitudinal data. Spine J 15(5):885–894

    Article  PubMed  Google Scholar 

  9. 9.

    Konstantinou K, Hider SL, Jordan JL, Lewis M, Dunn KM, Hay EM (2013) The impact of low back-related leg pain on outcomes as compared with low back pain alone: a systematic review of the literature. Clin J Pain 29(7):644–654

    Article  PubMed  Google Scholar 

  10. 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. 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

  12. 12.

    Qaseem A, Forland F, Macbeth F, Ollenschlager G, Phillips S, van der Wees P et al (2012) Guidelines International Network: toward international standards for clinical practice guidelines. Ann Intern Med 156(7):525–531

    Article  PubMed  Google Scholar 

  13. 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

  14. 14.

    Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G et al (2011) GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol 64(4):395–400

    Article  PubMed  Google Scholar 

  15. 15.

    Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M et al (2008) Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine (Phila Pa 1976) 33(1):90–94

    Article  Google Scholar 

  16. 16.

    Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G et al (2010) AGREE II: advancing guideline development, reporting and evaluation in health care. J Clin Epidemiol 63(12):1308–1311

    Article  PubMed  Google Scholar 

  17. 17.

    Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C et al (2007) Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 7:10

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Furlan AD, Pennick V, Bombardier C, vanTulder M, Editorial Board CBRG (2009) 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine (Phila Pa 1976) 34(18):1929–1941

    Article  Google Scholar 

  19. 19.

    http://www.covidence.org. Accessed 18 Apr 2017

  20. 20.

    http://community.cochrane.org/tools/review-production-tools/revman-5. Accessed 18 Apr 2017

  21. 21.

    https://gradepro.org. Accessed 18 Apr 2017

  22. 22.

    https://www.magicapp.org. Accessed 18 Apr 2017

  23. 23.

    Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D et al (2011) GRADE guidelines 6. Rating the quality of evidence-imprecision. J Clin Epidemiol 64(12):1283–1293

    Article  PubMed  Google Scholar 

  24. 24.

    Balshem H, Helfand M, Schunemann HJ, Oxman AD, Kunz R, Brozek J et al (2011) GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 64(4):401–406

    Article  PubMed  Google Scholar 

  25. 25.

    Pengel LH, Refshauge KM, Maher CG, Nicholas MK, Herbert RD, McNair P (2007) Physiotherapist-directed exercise, advice, or both for subacute low back pain: a randomized trial. Ann Intern Med 146(11):787–796

    Article  PubMed  Google Scholar 

  26. 26.

    Rozenberg S, Delval C, Rezvani Y, Olivieri-Apicella N, Kuntz JL, Legrand E et al (2002) Bed rest or normal activity for patients with acute low back pain: a randomized controlled trial. Spine (Phila Pa 1976) 27(14):1487–1493

    Article  Google Scholar 

  27. 27.

    Malmivaara A, Hakkinen U, Aro T, Heinrichs ML, Koskenniemi L, Kuosma E et al (1995) The treatment of acute low back pain–bed rest, exercises, or ordinary activity? N Engl J Med 332(6):351–355

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Olaya-Contreras P, Styf J, Arvidsson D, Frennered K, Hansson T (2015) The effect of the stay active advice on physical activity and on the course of acute severe low back pain. BMC Sports Sci Med Rehabil 7:19

    Article  PubMed  PubMed Central  Google Scholar 

  29. 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):509–517

    Article  PubMed  PubMed Central  Google Scholar 

  30. 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. Copenhagen

  31. 31.

    Traeger AC, Hubscher M, Henschke N, Moseley GL, Lee H, McAuley JH (2015) Effect of primary care-based education on reassurance in patients with acute low back pain: systematic review and meta-analysis. JAMA Intern Med 175(5):733–743

    Article  PubMed  Google Scholar 

  32. 32.

    Hasenbring MI, Pincus T (2015) Effective reassurance in primary care of low back pain: what messages from clinicians are most beneficial at early stages? Clin J Pain 31(2):133–136

    Article  PubMed  Google Scholar 

  33. 33.

    Damush TM, Weinberger M, Perkins SM, Rao JK, Tierney WM, Qi R et al (2003) The long-term effects of a self-management program for inner-city primary care patients with acute low back pain. Arch Intern Med 163(21):2632–2638

    Article  PubMed  Google Scholar 

  34. 34.

    Jellema P, van der Windt DA, van der Horst HE, Twisk JW, Stalman WA, Bouter LM (2005) Should treatment of (sub)acute low back pain be aimed at psychosocial prognostic factors? Cluster randomised clinical trial in general practice. BMJ 331(7508):84

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Indahl A, Velund L, Reikeraas O (1995) Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine (Phila Pa 1976) 20(4):473–477

    CAS  Article  Google Scholar 

  36. 36.

    Storheim K, Brox JI, Holm I, Koller AK, Bo K (2003) Intensive group training versus cognitive intervention in sub-acute low back pain: short-term results of a single-blind randomized controlled trial. J Rehabil Med 35(3):132–140

    Article  PubMed  Google Scholar 

  37. 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 

  38. 38.

    Hay EM, Mullis R, Lewis M, Vohora K, Main CJ, Watson P et al (2005) Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice. Lancet 365(9476):2024–2030

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Gohner W, Schlicht W (2006) Preventing chronic back pain: evaluation of a theory-based cognitive-behavioural training programme for patients with subacute back pain. Patient Educ Couns 64(1–3):87–95

    Article  PubMed  Google Scholar 

  40. 40.

    Hagen EM, Grasdal A, Eriksen HR (2003) Does early intervention with a light mobilization program reduce long-term sick leave for low back pain: a 3-year follow-up study. Spine (Phila Pa 1976) 28(20):2309–2315 (discussion 16)

    Article  Google Scholar 

  41. 41.

    Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR et al (2004) A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 141(12):920–928

    Article  PubMed  Google Scholar 

  42. 42.

    Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE (2006) Identifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a randomized clinical trial. Spine (Phila Pa 1976) 31(6):623–631

    Article  Google Scholar 

  43. 43.

    Hancock MJ, Maher CG, Latimer J, Herbert RD, McAuley JH (2008) Independent evaluation of a clinical prediction rule for spinal manipulative therapy: a randomised controlled trial. Eur Spine J 17(7):936–943

    Article  PubMed  PubMed Central  Google Scholar 

  44. 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-B13

    Article  PubMed  Google Scholar 

  45. 45.

    Klaber Moffett JA, Carr J, Howarth E (2004) High fear-avoiders of physical activity benefit from an exercise program for patients with back pain. Spine (Phila Pa 1976) 29(11):1167–1172

    Article  Google Scholar 

  46. 46.

    Ash LM, Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN (2008) Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol 29(6):1098–1103

    CAS  Article  PubMed  Google Scholar 

  47. 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, 1–131

  48. 48.

    Kendrick D, Fielding K, Bentley E, Miller P, Kerslake R, Pringle M (2001) The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial. Health Technol Assess 5(30):1–69

    CAS  Article  PubMed  Google Scholar 

  49. 49.

    Kerry S, Hilton S, Dundas D, Rink E, Oakeshott P (2002) Radiography for low back pain: a randomised controlled trial and observational study in primary care. Br J Gen Pract 52(479):469–474

    PubMed  PubMed Central  Google Scholar 

  50. 50.

    Cruser A, Maurer D, Hensel K, Brown SK, White K, Stoll ST (2012) A randomized, controlled trial of osteopathic manipulative treatment for acute low back pain in active duty military personnel. J Man Manip Ther. 20(1):5–15

    Article  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Hsieh CY, Adams AH, Tobis J, Hong CZ, Danielson C, Platt K et al (2002) Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial. Spine (Phila Pa 1976) 27(11):1142–1148

    Article  Google Scholar 

  52. 52.

    Hurley DA, McDonough SM, Dempster M, Moore AP, Baxter GD (2004) A randomized clinical trial of manipulative therapy and interferential therapy for acute low back pain. Spine (Phila Pa 1976) 29(20):2207–2216

    Article  Google Scholar 

  53. 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):1638–1643

    CAS  Article  PubMed  Google Scholar 

  54. 54.

    Faas A, Chavannes AW, van Eijk JT, Gubbels JW (1993) A randomized, placebo-controlled trial of exercise therapy in patients with acute low back pain. Spine (Phila Pa 1976) 18(11):1388–1395

    CAS  Article  Google Scholar 

  55. 55.

    Faas A, van Eijk JT, Chavannes AW, Gubbels JW (1995) A randomized trial of exercise therapy in patients with acute low back pain. Efficacy on sickness absence. Spine (Phila Pa 1976) 20(8):941–947

    CAS  Article  Google Scholar 

  56. 56.

    Seferlis T, Nemeth G, Carlsson AM, Gillstrom P (1998) Conservative treatment in patients sick-listed for acute low-back pain: a prospective randomised study with 12 months’ follow-up. Eur Spine J 7(6):461–470

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  57. 57.

    Cherkin DC, Deyo RA, Battie M, Street J, Barlow W (1998) A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 339(15):1021–1029

    CAS  Article  PubMed  Google Scholar 

  58. 58.

    Chok B, Lee R, Latimer J, Tan SB (1999) Endurance training of the trunk extensor muscles in people with subacute low back pain. Phys Ther 79(11):1032–1042

    CAS  PubMed  Google Scholar 

  59. 59.

    Machado LA, Maher CG, Herbert RD, Clare H, McAuley JH (2010) The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Med. 8:10

    Article  PubMed  PubMed Central  Google Scholar 

  60. 60.

    Liu JL, Li N (2010) Clinical observation of a combination of acupuncture and drug administration for non-specific acute lumbar sprain. J Acupunct Tuina Sci 8(1):47–49

    Article  Google Scholar 

  61. 61.

    Kennedy S, Baxter GD, Kerr DP, Bradbury I, Park J, McDonough SM (2008) Acupuncture for acute non-specific low back pain: a pilot randomised non-penetrating sham controlled trial. Complement Ther Med 16(3):139–146

    CAS  Article  PubMed  Google Scholar 

  62. 62.

    Williams CM, Maher CG, Latimer J, McLachlan AJ, Hancock MJ, Day RO et al (2014) Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet 384(9954):1586–1596

    CAS  Article  PubMed  Google Scholar 

  63. 63.

    Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D et al (2015) Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA 314(15):1572–1580

    CAS  Article  PubMed  Google Scholar 

  64. 64.

    Hofstee DJ, Gijtenbeek JM, Hoogland PH, van Houwelingen HC, Kloet A, Lotters F et al (2002) Westeinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica. J Neurosurg 96(1 Suppl):45–49

    PubMed  Google Scholar 

  65. 65.

    Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA (1999) Lack of effectiveness of bed rest for sciatica. N Engl J Med 340(6):418–423

    CAS  Article  PubMed  Google Scholar 

  66. 66.

    Bakhtiary AH, Safavi-Farokhi Z, Rezasoltani A (2005) Lumbar stabilizing exercises improve activities of daily living in patients with lumbar disc herniation. J Back Musculoskelet Rehabil 18(3–4):55–60

    Article  Google Scholar 

  67. 67.

    Paatelma M, Kilpikoski S, Simonen R, Heinonen A, Alen M, Videman T (2008) Orthopaedic manual therapy, McKenzie method or advice only for low back pain in working adults: a randomized controlled trial with one year follow-up. J Rehabil Med 40(10):858–863

    Article  PubMed  Google Scholar 

  68. 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):207–214

    Google Scholar 

  69. 69.

    Albert HB, Manniche C (2012) The efficacy of systematic active conservative treatment for patients with severe sciatica: a single-blind, randomized, clinical, controlled trial. Spine (Phila Pa 1976) 37(7):531–542

    Article  Google Scholar 

  70. 70.

    Ye C, Ren J, Zhang J, Wang C, Liu Z, Li F et al (2015) Comparison of lumbar spine stabilization exercise versus general exercise in young male patients with lumbar disc herniation after 1 year of follow-up. Int J Clin Exp Med 8(6):9869–9875

    PubMed  PubMed Central  Google Scholar 

  71. 71.

    Machado LA, de Souza M, Ferreira PH, Ferreira ML (2006) The McKenzie method for low back pain: a systematic review of the literature with a meta-analysis approach. Spine (Phila Pa 1976) 31(9):E254–E262

    Article  Google Scholar 

  72. 72.

    Santilli V, Beghi E, Finucci S (2006) Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J 6(2):131–137

    Article  PubMed  Google Scholar 

  73. 73.

    Bronfort G, Hondras MA, Schulz CA, Evans RL, Long CR, Grimm R (2014) Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation. Ann Intern Med 161(6):381–391

    Article  PubMed  Google Scholar 

  74. 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):1999–2010

    Article  PubMed  Google Scholar 

  75. 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 2012:953139

    Article  PubMed  Google Scholar 

  76. 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:CD001351

    Google Scholar 

  77. 77.

    Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS (2013) Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine (Phila Pa 1976) 38(22):1939–1946

    Article  Google Scholar 

  78. 78.

    Chou R, Hashimoto R, Friedly J, Fu R, Bougatsos C, Dana T et al (2015) Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med 163(5):373–381

    Article  PubMed  Google Scholar 

  79. 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.: Report

  80. 80.

    Kolsi I, Delecrin J, Berthelot JM, Thomas L, Prost A, Maugars Y (2000) Efficacy of nerve root versus interspinous injections of glucocorticoids in the treatment of disk-related sciatica. A pilot, prospective, randomized, double-blind study. Joint Bone Spine. 67(2):113–118

    CAS  PubMed  Google Scholar 

  81. 81.

    Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C et al (2005) A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology (Oxford) 44(11):1399–1406

    CAS  Article  Google Scholar 

  82. 82.

    Buchner M, Zeifang F, Brocai DR, Schiltenwolf M (2000) Epidural corticosteroid injection in the conservative management of sciatica. Clin Orthop Relat Res. 375(375):149–156

    Article  Google Scholar 

  83. 83.

    Bush K, Hillier S (1991) A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica. Spine (Phila Pa 1976) 16(5):572–575

    CAS  Article  Google Scholar 

  84. 84.

    Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A et al (1997) Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med 336(23):1634–1640

    CAS  Article  PubMed  Google Scholar 

  85. 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):134–142

    Article  PubMed  Google Scholar 

  86. 86.

    Cohen SP, White RL, Kurihara C, Larkin TM, Chang A, Griffith SR et al (2012) Epidural steroids, etanercept, or saline in subacute sciatica: a multicenter, randomized trial. Ann Intern Med 156(8):551–559

    Article  PubMed  Google Scholar 

  87. 87.

    Cuckler JM, Bernini PA, Wiesel SW, Booth RE Jr, Rothman RH, Pickens GT (1985) The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. J Bone Joint Surg Am 67(1):63–66

    CAS  Article  PubMed  Google Scholar 

  88. 88.

    Datta R, Upadhyay KK (2011) A randomized clinical trial of three different steroid agents for treatment of low backache through the caudal route. Med J Armed Forces India 67(1):25–33

    Article  PubMed  PubMed Central  Google Scholar 

  89. 89.

    el Zahaar MS (1991) The value of caudal epidural steroids in the treatment of lumbar neural compression syndromes. J Neurol Orthop Med Surg 12:181–184

    Google Scholar 

  90. 90.

    Ghahreman A, Ferch R, Bogduk N (2010) The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med 11(8):1149–1168

    Article  PubMed  Google Scholar 

  91. 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):228–231

    Google Scholar 

  92. 92.

    Iversen T, Solberg TK, Romner B, Wilsgaard T, Twisk J, Anke A et al (2011) Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ 343:d5278

    Article  PubMed  PubMed Central  Google Scholar 

  93. 93.

    Karppinen J, Malmivaara A, Kurunlahti M, Kyllonen E, Pienimaki T, Nieminen P et al (2001) Periradicular infiltration for sciatica: a randomized controlled trial. Spine 26(9):1059–1067

    CAS  Article  PubMed  Google Scholar 

  94. 94.

    Klenerman L, Greenwood R, Davenport HT, White DC, Peskett S (1984) Lumbar epidural injections in the treatment of sciatica. Br J Rheumatol 23(1):35–38

    CAS  Article  PubMed  Google Scholar 

  95. 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):273–286

    PubMed  Google Scholar 

  96. 96.

    Manchikanti L, Singh V, Cash KA, Pampati V, Falco FJ (2014) A randomized, double-blind, active-control trial of the effectiveness of lumbar interlaminar epidural injections in disc herniation. Pain Physician 17(1):E61–E74

    PubMed  Google Scholar 

  97. 97.

    Mathews JA, Mills SB, Jenkins VM, Grimes SM, Morkel MJ, Mathews W et al (1987) Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections. Br J Rheumatol 26(6):416–423

    CAS  Article  PubMed  Google Scholar 

  98. 98.

    Riew KD, Park JB, Cho YS, Gilula L, Patel A, Lenke LG et al (2006) Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. J Bone Joint Surg Am 88(8):1722–1725

    Article  PubMed  Google Scholar 

  99. 99.

    Rogers P, Nash T, Schiller D, Norman J (1992) Epidural steroids for sciatica. Pain Clin 5:67–72

    Google Scholar 

  100. 100.

    Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA (2009) Efficacy of steroid and nonsteroid caudal epidural injections for low back pain and sciatica: a prospective, randomized, double-blind clinical trial. Spine (Phila Pa 1976) 34(14):1441–1447

    Article  Google Scholar 

  101. 101.

    Snoek W, Weber H, Jorgensen B (1977) Double blind evaluation of extradural methyl prednisolone for herniated lumbar discs. Acta Orthop Scand 48(6):635–641

    CAS  Article  PubMed  Google Scholar 

  102. 102.

    Tafazal S, Ng L, Chaudhary N, Sell P (2009) Corticosteroids in peri-radicular infiltration for radicular pain: a randomised double blind controlled trial. One year results and subgroup analysis. Eur Spine J 18(8):1220–1225

    Article  PubMed  PubMed Central  Google Scholar 

  103. 103.

    Valat JP, Giraudeau B, Rozenberg S, Goupille P, Bourgeois P, Micheau-Beaugendre V et al (2003) Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial. Ann Rheum Dis 62(7):639–643

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  104. 104.

    Wilson-MacDonald J, Burt G, Griffin D, Glynn C (2005) Epidural steroid injection for nerve root compression. A randomised, controlled trial. J Bone Joint Surg Br 87(3):352–355

    CAS  Article  PubMed  Google Scholar 

  105. 105.

    Sabnis AB, Diwan AD (2014) The timing of surgery in lumbar disc prolapse: A systematic review. Indian J Orthop 48(2):127–135

    Article  PubMed  PubMed Central  Google Scholar 

  106. 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):1355–1358

    Article  PubMed  PubMed Central  Google Scholar 

  107. 107.

    Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS et al (2006) Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 296(20):2441–2450

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  108. 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):201–216

  109. 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, London

    Google Scholar 

  110. 110.

    Preventive US (2009) Services Task Force. Screening for skin cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 150(3):188–193

    Article  Google Scholar 

  111. 111.

    Petitti DB, Teutsch SM, Barton MB, Sawaya GF, Ockene JK, DeWitt T et al (2009) Update on the methods of the U.S. Preventive Services Task Force: insufficient evidence. Ann Intern Med 150(3):199–205

    Article  PubMed  Google Scholar 

  112. 112.

    Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A et al (2008) Going from evidence to recommendations. BMJ 336(7652):1049–1051

    Article  PubMed  PubMed Central  Google Scholar 

  113. 113.

    Andrews J, Guyatt G, Oxman AD, Alderson P, Dahm P, Falck-Ytter Y et al (2013) GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol 66(7):719–725

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

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.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Mette Jensen Stochkendahl.

Ethics declarations

Funding

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.

Conflicts of interest

Potential conflicts of interest have been declared by all involved partners and made publicly available on the DHA webpage (in Danish) [10, 11].

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PDF 8135 kb)

Supplementary material 2 (PDF 5658 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Stochkendahl, M.J., Kjaer, P., Hartvigsen, J. et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 27, 60–75 (2018). https://doi.org/10.1007/s00586-017-5099-2

Download citation

Keywords

  • Clinical guideline
  • Low back pain
  • Lumbar radiculopathy
  • Non-surgical intervention
  • Recommendations
  • Conservative treatment