Low Back Pain Guidelines

This section was compiled by Frank M. Painter, D.C.
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Best Practices for Chiropractic Management of Adult
Patients With Mechanical Low Back Pain:
A Clinical Practice Guideline for
Chiropractors in the United States

J Manipulative Physiol Ther 2023 (Jun 20); S0161-4754 ~ FULL TEXT

This paper updates the best-practice guideline on chiropractic management of mechanical LBP in adults in the US from the prior iterations. [4, 82] This guideline provides evidence-informed guidance to DCs related to both initial care management and the progression of care throughout an episode of the condition to reduce practice variability among providers while improving outcomes. We identified benchmarks and decision points in care management and provided information related to each issue. Providers can use this document as a reference point for the care they provide their patients. This updated Clinical Practice Guideline (CPG) condensed the number of recommendations from 51 to 38 while providing more evidence-informed insight into the diagnostic considerations for LBP, including the history and examination and diagnostic imaging. This document provides a more comprehensive description of the conservative management approaches to LBP, including chiropractic approaches and co-management considerations for multidisciplinary care.

A Systematic Review of Clinical Practice Guidelines
for Persons With Non-specific Low Back Pain
With and Without Radiculopathy

Arch Phys Med Rehabil 2023 (Mar 23) [EPUB] ~ FULL TEXT

We developed evidence-based recommendations from high-quality clinical practice guidelines (CPGs) to inform the WHO PIR for people with LBP with and without radiculopathy. These recommendations emphasize the potential benefits of education, exercise, manual therapy, and cognitive/behavioral interventions.

Non-Invasive and Minimally Invasive Management
of Low Back Disorders

J Occupational and Environmental Medicine 2020 (Mar); 62 (3): e111–e138 ~ FULL TEXT

Quality evidence to guide the treatment of LBP is available. Detailed algorithms have been developed using the quality evidence where available, with supplementation with the Panel’s expert opinions (ie, consensus guidance). Acute LBP is best initially treated with directional stretching, progressive aerobic exercise, management of kinesiophobia, and NSAIDs. Work limitations may be needed especially for those with occupational demands exceeding the patient’s abilities; limitations should be gradually eliminated. Adjunctive use of other treatments (eg, muscle relaxants, manipulation) may be added particularly for those with worse and/or persistent pain. There may be some patients for whom initial treatment with manipulation may be effective, however, if there is not rapid improvement with manipulation, it is recommended that the primary focus should change to progressive exercises.

Diagnosis and Treatment of Low Back Pain   PDF
North American Spine Society (Jan 30, 2020) ~ FULL TEXT

The North American Spine Society announced the release of evidence-based clinical guidelines for multidisciplinary spine care for the diagnosis and treatment of low back pain. The guidelines can help practitioners treat adult patients with non-specific low back pain above the knee, according to a press release issued by the North American Spine Society.

Clinical Decision Guides for Chiropractic Management
A Unique Series of 3 Articles

Current Evidence for Diagnosis of Common Conditions Causing
Low Back Pain: Systematic Review and Standardized
Terminology Recommendations

J Manipulative Physiol Ther. 2019 (Nov); 42 (9): 651–664   ~ FULL TEXT

This review describes evidence-based diagnostic criteria for common conditions contributing to neuromusculoskeletal low back pain. Understanding the accuracy of tests and the evidence basis from which diagnostic criteria are derived can inform management decisions and the amount of confidence placed in a working diagnosis. Adopting IASP-applicable terminology is recommended to improve communication among health professionals, patients, and researchers, and to improve the quality of diagnosis-related research.

Development of an Evidence-Based Practical Diagnostic
Checklist and Corresponding Clinical Exam
for Low Back Pain

J Manipulative Physiol Ther. 2019 (Nov); 42 (9): 665–676   ~ FULL TEXT

Based on a systematic review of the literature, this article describes an office-based examination leading to working diagnoses for common conditions causing or contributing to LBP. A practical diagnostic checklist for clinical evaluation at a primary spine care level may help to efficiently demonstrate evidence for or against working diagnoses.

Development of a Clinical Decision Aid for Chiropractic
Management of Common Conditions Causing Low Back Pain
in Veterans: Results of a Consensus Process

J Manipulative Physiol Ther. 2019 (Nov); 42 (9): 677–693   ~ FULL TEXT

This article offers an evidence-based clinical decision aid for multimodal chiropractic care for veterans with LBP. A 4ñpage document outlines the management process, evidence-based treatments for specific conditions, intervention descriptions, and definitions for 6 essential components of chiropractic care. The decision aid was validated through a web-based consensus process including DCs practicing in VA health care facilities.

Guideline Recommendations on the Pharmacological Management
of Non-specific Low Back Pain in Primary Care
– Is There a Need to Change?

Expert Rev Clin Pharmacol. 2019 (Feb); 12 (2): 145–157 ~ FULL TEXT

Upcoming guideline updates should explicitly shift their focus from pain to function and from pharmacotherapy to non-pharmacological treatments; patient education is important to make sure NSLBP patients accept these changes. To improve the quality of NSLBP care, the evidence-practice gap should be closed through guideline implementation strategies.

The Global Spine Care Initiative: Applying Evidence-based
Guidelines on the Non-invasive Management of Back and
Neck Pain to Low- and Middle-income Communities

European Spine Journal 2018 (Sep); 27 (Suppl 6): 851–860 ~ FULL TEXT

Guidelines developed for high-income settings were adapted to inform a care pathway and model of care for medically underserved areas and low- and middle-income countries by considering factors such as costs and feasibility, in addition to benefits, harms, and the quality of underlying evidence. The selection of recommended conservative treatments must be finalized through discussion with the involved community and based on a biopsychosocial approach. Decision determinants for selecting recommended treatments include costs, availability of interventions, and cultural and patient preferences. This information can be used to inform the GSCI care pathway and model of care in medically underserved areas and low- and middle-income countries.

Spinal Manipulative Therapy and Other Conservative Treatments
for Low Back Pain: A Guideline From the Canadian
Chiropractic Guideline Initiative

J Manipulative Physiol Ther. 2018 (May); 41 (4): 265–293 ~ FULL TEXT

For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises).   A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.

Evidence-Based Nonpharmacologic Strategies for Comprehensive
Pain Care: The Consortium Pain Task Force White Paper

Explore (NY). 2018 (May); 14 (3): 177–211 ~ FULL TEXT

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain.

National Clinical Guidelines for Non-surgical Treatment of Patients
with Recent Onset Low Back Pain or Lumbar Radiculopathy

European Spine Journal 2018 (Jan); 27 (1): 60–75 ~ FULL TEXT

Two multidisciplinary working groups developed two national clinical guidelines for non-surgical treatment in adult patients with non-specific low back pain (LBP) and lumbar radiculopathy (LR) of less than 12 weeks’ duration under the Danish Health Authority. The recommendations are based on limited evidence or on consensus, but are well aligned with recommendations from similar international guidelines. The guideline working groups strongly recommend that research efforts in relation to all aspects of the management of LBP and, in particular, LR be intensified.

The Non-pharmacologic Therapies Low Back Pain Guidelines
A Unique Series of Articles

All 6 of the following guidelines reviewed the medical literature on low back pain and strongly advise medical doctors to first recommend non-pharmacologic therapies, including chiropractic, BEFORE resorting to offering NSAIDs, opiates or other more invasive treatments, for low back (spinal) pain patients.

These recommendations will:

  1.   save money,
  2.   will increase patient satisfaction,
  3.   will improve patient outcomes and
  4.   will reduce chronicity and potential addiction.

Guideline for Opioid Therapy and Chronic Noncancer Pain
CMAJ. 2017 (May 8); 189 (18): E659–E666 ~ FULL TEXT

This new Canadian guideline published today (May 8, 2017) in the Canadian Medical Association Journal (CMAJ) strongly recommends doctors to consider non-pharmacologic therapy, including chiropractic, in preference to opioid therapy for chronic non-cancer pain.   The guideline is the product of an extensive review of evidence involving input from medical, non-medical, regulatory, and patient stakeholders.

National Clinical Guidelines for Non-surgical Treatment of Patients
with Recent Onset Low Back Pain or Lumbar Radiculopathy

European Spine Journal 2017 (Apr 20): 1451–1460 ~ FULL TEXT

In 2012, the Danish Finance Act appropriated a total of €10.8 mio for the preparation of clinical guidelines. The Danish Health Authority (DHA) was subsequently commissioned to formulate 47 national clinical guidelines to support evidence-based decision making within health areas with a high burden of disease, a perceived large variation in practice, or uncertainty about which care was appropriate. [1] Two of these areas were low back pain (LBP) and lumbar radiculopathy (LR). Consequently in 2014, two working groups were formed with the aim of developing national clinical guidelines for non-surgical interventions for recent onset (<12 weeks) LBP and for recent onset (<12 weeks) LR. The primary target groups for these guidelines were primary sector healthcare providers, i.e., general practitioners, chiropractors, and physiotherapists, but also medical specialists or others in the primary or secondary healthcare sector handling patients with LBP or LR.

Association of Spinal Manipulative Therapy with Clinical Benefit
and Harm for Acute Low Back Pain: Systematic Review
and Meta-analysis

JAMA. 2017 (Apr 11); 317 (14): 1451–1460 ~ FULL TEXT

For the second time in as many months, a prominent medical journal has endorsed spinal manipulation for the management of low back pain. [1] On April 11th 2017, JAMA published a systematic review of 26 randomized clinical trials in order to evaluate the safety and effectiveness of spinal manipulation for low back pain.   The authors concluded:   “Among patients with acute low back pain, spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.”

Systemic Pharmacologic Therapies for Low Back Pain:
A Systematic Review for an American College of
Physicians Clinical Practice Guideline

Annals of Internal Medicine 2017 (Apr 4); 166 (7): 480–492

The American College of Physicians (ACP) released updated guidelines this week that recommend the use of noninvasive, non-drug treatments for low back pain before resorting to drug therapies, which were found to have limited benefits. One of the non-drug options cited by ACP is spinal manipulation.

Nonpharmacologic Therapies for Low Back Pain: A Systematic
Review for an American College of Physicians
Clinical Practice Guideline

Annals of Internal Medicine 2017 (Apr 4); 166 (7): 493–505 ~ FULL TEXT

This report updates and expands on the earlier ACP/APS review [105] with additional interventions and newer evidence. We found evidence that mind–body interventions not previously addressed — tai chi (SOE, low) and mindfulness-based stress reduction (SOE, moderate) [45–47] — are effective for chronic low back pain; the new evidence also strengthens previous conclusions regarding yoga effectiveness (SOE, moderate). For interventions recommended as treatment options in the 2007 ACP/APS guideline [2], our findings were generally consistent with the prior review. Specifically, exercise therapy, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture are supported with some evidence of effectiveness for chronic low back pain (SOE, low to moderate). Unlike our previous report, which stated that higher-intensity multidisciplinary rehabilitation seemed to be more effective than lower-intensity programs, a stratified analysis based on currently available evidence [54] did not find a clear intensity effect. Our findings generally are consistent with recent systematic reviews not included in our evidence synthesis [106–117]. Although harms were not well-reported, serious adverse events were not described.
You will also enjoy the introductory Editorial, titled:
Management of Low Back Pain: Getting From
Evidence-Based Recommendations to High-Value Care

Annals of Internal Medicine 2017 (Apr 4); 166 (7): 533-534

Noninvasive Treatments for Acute, Subacute, and Chronic
Low Back Pain: A Clinical Practice Guideline From
the American College of Physicians

Annals of Internal Medicine 2017 (Apr 4); 166 (7): 514–530 ~ FULL TEXT

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).

Low Back Pain And Radicular Pain:
Assessment And Management
Belgian Health Care Knowledge Centre, (2017). ~ FULL TEXT

Low back pain (LBP) is a considerable public health problem which combines high frequency, healthcare consumption and societal cost. In Belgium, according to the 2013 Health interview survey, 21% of the 15 years old and plus declared to have suffered from low back disorder or other chronic back defect in the past 12 months. [1] Low back pain is a common cause for seeking health care. In 2004, in Belgium, one-fourth of patients between 18 and 75 years had visited a GP in the preceding 10 years because of LBP and 40.000 multiple-day and 46.000 one-day hospitalizations were reported for patients with LBP problems. [2]

Clinical Practice Guidelines for the Noninvasive Management
of Low Back Pain: A Systematic Review by the Ontario
Protocol for Traffic Injury Management (OPTIMa) Collaboration

European J Pain 2017 (Feb); 21 (2): 201–216 ~ FULL TEXT

We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high-quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed.

A Narrative Review of Lumbar Fusion Surgery With
Relevance to Chiropractic Practice

J Chiropractic Medicine 2016 (Dec); 15 (4): 259–271 ~ FULL TEXT

This article describes the indications for fusion, common surgical practice, potential complications, and relevant published chiropractic literature. This review includes 10 cases that showed positive benefits from chiropractic manipulation, flexion-distraction, and/or manipulation under anesthesia for postfusion lumbar pain. Chiropractic care may have a role in helping patients in pain who have undergone lumbar fusion surgery.

Low Back Pain and Sciatica in Over 16s:
Assessment and Management

NICE Guideline, NG 59   (Nov 2016)
National Guideline Centre (UK)   ~ FULL TEXT

This guideline covers the assessment and management of low back pain and sciatica in adults over the age of 16 years.
You may also enjoy this PDF version (1067 pages).

Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis:
Results of an International Delphi Study

Spine (Phila Pa 1976). 2016 (Aug 1); 41 (15): 1239–1246   ~ FULL TEXT

A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated.

The six top items were

"leg or buttock pain while walking,"
"flex forward to relieve symptoms,"
"feel relief when using a shopping cart or bicycle,"
"motor or sensory disturbance while walking,"
"normal and symmetric foot pulses,"
"lower extremity weakness,"
"low back pain."

Significant change in certainty ceased after six questions at 80% (P < .05).

Noninvasive Treatments for Low Back Pain   PDF
Agency for Healthcare Research and Quality (AHRQ)   (Feb 2016)
Comparative Effectiveness Review Number 169   ~ FULL TEXT

The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based Practice Centers (EPCs), sponsors the development of systematic reviews to assist public- and privatesector organizations in their efforts to improve the quality of health care in the United States. These reviews provide comprehensive, science-based information on common, costly medical conditions, and new health care technologies and strategies.

Low Back Pain: Guidelines for the Clinical Classification of
Predominant Neuropathic, Nociceptive, or Central Sensitization Pain

Pain Physician. 2015 (May); 18 (3): E333–346   ~ FULL TEXT

Modern pain neuroscience has advanced our understanding about pain, including the role of central sensitization (CS) in amplifying pain experiences. CS is defined as “an amplification of neural signaling within the central nervous system that elicits pain hypersensitivity” [11], “increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input” [3], or “an augmentation of responsiveness of central neurons to input from unimodal and polymodal receptors”. [12] Although one might say that these definitions differ substantially, they all point to the same underlying neurophysiological mechanism of increased neuronal response to stimuli in the central nervous system (i.e., central hyperexcitability). The definitions originate from laboratory research, but the awareness that the concept of CS should be translated to the clinic is growing. [13, 14]

Chronic Low Back Pain: Chiropractic Quality Standard   PDF
Royal College of Chiropractors   (2014)

Quality Standards are tools designed to help deliver the best possible outcomes for patients. They are a series of specific, concise quality statements with associated measures that provide aspirational, but achievable, markers of high-quality patient care covering the treatment of different conditions. They also form an important part in addressing the increasing priority being placed on improving quality and patient outcomes.

Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy   PDF
North American Spine Society   (2014) ~ FULL TEXT

The objective of the North American Spine Society (NASS) Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum, efficacious treatment and functional recovery from this spinal disorder

Worsening Trends in the Management and Treatment of Back Pain
JAMA Internal Medicine 2013 (Sep 23); 173 (17): 1573–1581 ~ FULL TEXT

We identified 23,918 visits for spine problems, representing an estimated 440 million visits. Approximately 58% of patients were female. Mean age increased from 49 to 53 years (P< .001) during the study period. Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010 (unadjusted P< .001). In contrast, narcotic use increased from 19.3% to 29.1% (P< .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8% to 14.0% (P< .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3% during the study period (P< .001). These trends were similar after stratifying by short-term vs long-term presentations, visits to PCPs vs non-PCPs, and adjustment for age, sex, race/ethnicity, PCP status, symptom duration, region, and metropolitan location.   Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care.

Acute Low Back Pain: Chiropractic Quality Standard   PDF
Royal College of Chiropractors   (2012) ~ FULL TEXT

By providing a clear description of what a high-quality service looks like, clinics can improve quality and achieve excellence. The quality standards encompass statutory requirements, best practice and existing clinical guidelines, but they are not a new set of targets or mandatory indicators for performance management. They are, however, a useful source to form the basis of clinical audit and to identify priorities for future improvement.

An Updated Overview of Clinical Guidelines for Chronic Low
Back Pain Management in Primary Care

Joint Bone Spine. 2012 (Mar); 79 (2): 176–185 ~ FULL TEXT

Compared to previous assessments, the average quality of the guidelines dealing with chronic low back pain has improved. Furthermore, all guidelines are increasingly aligning in providing therapeutic recommendations that are clearly differentiated from those formulated for acute pain. However, there is still a need for improving quality and generating new evidence for this particular condition.

Low Back Pain Clinical Practice Guidelines Linked to the
International Classification of Functioning, Disability,
and Health from the Orthopaedic Section of the
American Physical Therapy Association
Orthop Sports Phys Ther. 2012; 42 (4): A1–A57

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF).

An Updated Overview of Clinical Guidelines for the Management
of Non-specific Low Back Pain in Primary Care

European Spine Journal 2010 (Dec); 19 (12): 2075–2094 ~ FULL TEXT

This review of national and international guidelines conducted by Koes et. al. points out the disparities between guidelines with respect to spinal manipulation and the use of drugs for both chronic and acute low back pain.

Guidelines for the Evidence-Informed Primary Care
Management of Low Back Pain
Institute of Health Economics
Toward Optimized Practice (TOP) Alberta, Canada   (2009)   ~ FULL TEXT

The Evidence Source provides information on the “seed” guideline(s) that were used to develop the Alberta guideline recommendations. The Evidence Source also provides information on the design of the study that was referenced in the “seed” guideline in support of the recommendation.

Low Back Pain: Early Management of Persistent
Non-specific Low Back Pain
NICE Clinical Guidelines, No. 88 (240 pages)   (May 2009)
National Institute for Health and Clinical Excellence

It is perhaps fitting that the last guideline produced by the National Collaborating Centre for Primary Care prior to its merger with related NICE guidelines groups, should cover the same disorder that the RCGP published as its first comprehensive evidence based guideline over a decade ago: the early management of non-specific low back pain.
You may also enjoy this glossy patient version (25 pages)   PDF

Diagnostic Imaging Practice Guidelines for Musculoskeletal
Complaints in Adults — An Evidence-Based Approach: Parts 1–3

J Manipulative Physiol Ther 2007 and 2008: 684–717, 2–32, 33-88 ~ FULL TEXT

Recommendations for diagnostic imaging guidelines of adult spine disorders are provided, supported by more than 385 primary and secondary citations. The overall quality of available literature is low, however. On average, 45 Delphi panelists completed 1 of 2 rounds, reaching more than 85% agreement on all 55 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility. Dissemination and implementation strategies are discussed.

Nonpharmacologic Therapies for Acute and Chronic Low Back Pain:
A Review of the Evidence for American Pain Society/
American College of Physicians Clinical Practice Guideline

Annals of Internal Medicine 2007 (Oct 2); 147 (7): 492–504 ~ FULL TEXT

Researchers sought to determine the benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain). Researchers conducted MEDLINE searchers and the Cochrane Database of Systematic Reviews and graded the methodologies of the studies. Researchers concluded that there was good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation were moderately effective for chronic or subacute low back pain.

Diagnosis and Treatment of Low Back Pain: A Joint Clinical
Practice Guideline from the American College of
Physicians and the American Pain Society

Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491 ~ FULL TEXT

Low back pain is the fifth most common reason for all physician visits in the United States. [1, 2] Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months [2], and 7.6% reported at least 1 episode of severe acute low back pain (see Glossary) within a 1-year period. [3] Low back pain is also very costly: Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $26.3 billion in 1998. [4] In addition, indirect costs related to days lost from work are substantial, with approximately 2% of the U.S. work force compensated for back injuries each year. [5] You will enjoy these recommendations because their ONLY recommendation for active treatment of acute low back pain is spinal adjusting (manipulation).
You may also want to review their 482-page evidence review, titled:
Guideline for the Evaluation and Management of Low Back Pain   PDF

European Guidelines for Acute and Chronic LBP

Chronic Low Back Pain. Good Clinical Practice (GCP)   PDF
Belgian Health Care Knowledge Centre (KCE)   (Dec 2006) ~ FULL TEXT
Brussels, Belgium;

Report No.: 48 C (D/2006/10.273/71) ~ FULL TEXT
Like the proverbial bad penny that keeps turning up, chronic low back pain is a real curse that seems to keep coming back the more you try to get rid of it. But in addition to the pain and discomfort caused to individuals, the social cost of this disorder in terms of medical treatments and absenteeism is also a problem that clearly needs to be addressed. It was therefore inevitable that the KCE would one day be invited to tackle this problem in the hope that it would find, if not radical solutions, at least a number of clear and effective strategies.

European Guidelines for the Management of Acute Nonspecific
Low Back Pain in Primary Care

European Spine Journal 2006 (Mar); 15 Suppl 2: S169–191 ~ FULL TEXT

The primary objective of these European evidence-based guidelines is to provide a set of recommendations that can support existing and future national and international guidelines or future updates of existing guidelines.
Refer also to their 55-page document:   Amended version   PDF

European Guidelines for the Management of Chronic
Nonspecific Low Back Pain

European Spine Journal 2006 (Mar); 15 Suppl 2: S192–300 ~ FULL TEXT

This particular guideline intends to foster a realistic approach to improving the treatment of common (nonspecific) chronic low back pain (CLBP).
Refer also to their 206-page document:   Amended version June 14th 2005   PDF
You may also like their:   Backpain Europe website

Costs and Outcomes of Chiropractic Treatment
for Low Back Pain
Technology report no 56   (July 2005) ~ FULL TEXT
Canadian Coordinating Office for Health Technology Assessment (CCOHTA), Ottawa, Canada

This report is a review of existing public literature, studies, materials and other information and documentation (collectively the “source documentation”) which are available to CCOHTA. The accuracy of the contents of the source documentation on which this report is based is not warranted, assured or represented in any way by CCOHTA and CCOHTA does not assume responsibility for the quality, propriety, inaccuracies or reasonableness of any statements, information or conclusions contained in the source documentation.

Chapter 2. European Guidelines for Prevention
in Low Back Pain
COST B13 Working Group on Guidelines for Prevention in Low Back Pain   (November 2004) ~ FULL TEXT

These are based on systematic reviews, existing evidence-based guidelines, and scientific studies. The studies on which these recommendations are based were often variable and imprecise in specifying the interventions and outcomes investigated. Hence, it is not always possible to state exactly which outcomes will be influenced by a given intervention.

New Zealand Acute Low Back Pain Guide   PDF
New Zealand Guidelines Group   (Oct 2004)
Accident Compensation Corporation (ACC), Wellington, New Zealand   ~ FULL TEXT

This publication replaces the previous New Zealand Acute Low Back Pain Guide (1997) and incorporates the Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain. The New Zealand Acute Low Back Pain Guide provides a best practice approach, taking into account relevant evidence, for the effectiveness of treatment of acute low back pain for the prevention of chronic pain and disability. It follows an extensive review of the international literature and wide consultation with professional groups in New Zealand.

Evidence-based Management of Acute Musculoskeletal Pain   PDF
Australian Acute Musculoskeletal Pain Guidelines Group   (Jun 2003)   ~ FULL TEXT

This document is the outcome of a multi-disciplinary review of the scientific evidence for the diagnosis, prognosis and treatment of acute musculoskeletal pain. The evidence is summarised in the form of a management plan and key messages that may be used to inform practice. The aim in conducting an evidence review is to facilitate the integration of the best available evidence with clinical expertise and the values and beliefs of patients.

Acute Low Back Pain Interdisciplinary Clinical Guidelines   PDF
The Norwegian Back Pain Network   (Oslo, 2002)   ~ FULL TEXT

”Guidelines are systematically developed statements to assist practitioners` decision about appropriate health care for specific circumstances”. [19]

Clinical Guidelines for the Management
of Acute Low Back Pain

Royal College of General Practitioners   (Dec 2001)   ~ FULL TEXT

This is Britian's follow-up to:   Bigos, Stanley J et al. “Acute Low Back Problems in Adults” released December 2001. Their comments on spinal manipulation were: “In acute and sub-acute back pain, manipulation provides better short-term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared.” AND “The risks of manipulation for low back pain are very low, provided patients are selected and assessed properly and it is carried out by a trained therapist or practitioner. Manipulation should not be used in patients with severe or progressive neurological deficit in view of the rare but serious risk of neurological complication.”

Musculoskeletal Disorders and the Workplace:
Low Back and Upper Extremities
National Research Council and Institute of Medicine   (2001)   ~ FULL TEXT

This report is the output of two years of dedicated labor on the part of a diverse, talented, and energetic panel of experts supported by an experienced, dedicated, and equally energetic staff. The effort was organized by the National Research Council (NRC) and the Institute of Medicine (IOM), in response to a charge from the National Institute for Occupational Safety and Health and the National Institutes of Health to conduct a comprehensive review of the scientific literature on the relationship of work and the workplace to musculoskeletal disorders of the low back and upper extremities. The impetus for the study was a set of questions posed by Congress. These questions and the panel’s responses, are presented in Appendix A.

Occupational Health Guidelines for the Management of
Low Back Pain at Work –– Principal Recommendations

Faculty of Occupational Medicine, London   (Mar 2000)   ~ FULL TEXT

Disability from back pain in people of working age is one of the most dramatic failures of health care in recent years. Its greatest impact is on the lives of those affected and their families. This review and the guidelines based on it aim to reduce the toll of harm by providing a new approach to back pain management at work which is based on the best available scientific evidence and uses this to make practical recommendations on how to tackle the occupational health aspects of the problem.

Low-Back Pain: Frequency, Management and Prevention
From an HTA Perspective

DIHTA - Danish Institute for Heath Technology Assessment   (Jan 1999)   ~ FULL TEXT
The Danish Institute for Health Technology Assessment (DIHTA) describes LBP, then labels treatments in 3 categories: Generally recommended, recommended in certain conditions, or not recommended. The FIRST recommended “treatment” is manual therapy (which includes chiropractic).

Guide to Assessing Psychosocial Yellow Flags in Acute
Low Back Pain: Risk Factors for Long–Term
Disability and Work Loss

New Zealand Guidelines Group   (1997)   ~ FULL TEXT

This guide is to be used in conjunction with the New Zealand Acute Low Back Pain Guide. It provides an overview of risk factors for long–term disability and work loss, and an outline of methods to assess these at risk. Identification should lead to appropriate early management targeted towards the prevention of chronic pain and disability.

Evaluation of the Low Back Industrial Injury
California Industrial Medical Council   (Apr 1997)   ~ FULL TEXT
Low back problems are common among workers. In the majority of injured workers with low back problems, recovery occurs within the first month of symptoms. Those who have not improved at the end of one month of treatment may need further diagnostic evaluation and consideration of other treatment options. Management of low back problems in injured workers includes consideration of environmental and personal factors which may be causing or aggravating the problem, as well as providing appropriate treatment that leads to a return to productive work.

Manga Guidelines (Aug 1993 & Feb 1998)
Pran Manga, Ph.D., Professor of Health Economics @ University of Ottawa
Includes the original 1993 and the updated 1998 recommendations to the Canadian Government about inclusion of chiropractic in their Health Care System.

Chiropractic Care for Common Industrial Low Back Conditions
Chiropractic Technique 1993 (Aug); 5 (3): 119–125 ~ FULL TEXT

This is the first guideline I have seen which actually states the number of visits which may be appropriate for a variety of common low back conditions.   I have used these “Care Plans” for years, presenting them to third party's as a “working diagnosis” care plan, which need ongoing “fine tuning” during patient care. Check out this Chiropractic Technique article, and the attached care plans, which have been released exclusively to Chiro.Org by the National College of Chiropractic. Thanks, Dana! You will find other information like this in the GUIDELINES Section.

Guidelines for Chiropractic Quality Assurance and
Practice Parameters -- Major Recommendations
  (The Mercy Conference)
Aspen Publishers   (Apr 1993)   ~ FULL TEXT

This outline of the “Mercy Center” Consensus Statement covers history and exam, diagnostic imaging, instrumentation (including Questionnaires, Algometry, Inclinometers and Thermography), clinical laboratory recommendations, and a detailed section on record keeping and patient consent.
You can purchase a copy of it right here


Council on Chiropractic Guidelines and Practice Parameters   (CCGPP)
The Low Back Pain Guidelines

Clinical Practice Guideline:
Chiropractic Care for Low Back Pain

J Manipulative Physiol Ther. 2016 (Jan); 39 (1): 1–22 ~ FULL TEXT

To facilitate best practices specific to the chiropractic management of patients with common, primarily musculoskeletal disorders, the profession established the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) in 1995. [6] The organization sponsored and/or participated in the development of a number of “best practices” recommendations on various conditions. [21–32] With respect to chiropractic management of LBP, a CCGPP team produced a literature synthesis [8] which formed the basis of the first iteration of this guideline in 2008. [9] In 2010, a new guideline focused on chronic spine-related pain was published, [12] with a companion publication to both the 2008 and 2010 guidelines published in 2012, providing algorithms for chiropractic management of both acute and chronic pain. [10] Guidelines should be updated regularly. [33, 34] Therefore, this article provides the clinical practice guideline (CPG) based on an updated systematic literature review and extensive and robust consensus process. [9–12]

Algorithms for the Chiropractic Management of Acute
and Chronic Spine-Related Pain

Topics in Integrative Health Care 2012 (Dec 31); 3 (4) ~ FULL TEXT

The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain. [1-3]

Management of Chronic Spine-Related Conditions:
Consensus Recommendations of a Multidisciplinary Panel

J Manipulative Physiol Ther 2010 (Sep); 33 (7): 484–492 ~ FULL TEXT

A multidisciplinary panel of experienced practitioners was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for complex patients with chronic spine-related conditions, based on both the scientific evidence and their clinical experience.

Chiropractic Management of Low Back Disorders:
Report From a Consensus Process

J Manipulative Physiol Ther 2008 (Nov); 31 (9): 651–658 ~ FULL TEXT

A broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience.

Chiropractic Management of Low Back Pain and Low Back-Related
Leg Complaints: A Literature Synthesis

J Manipulative Physiol Ther 2008 (Nov); 31 (9): 659–674 ~ FULL TEXT

As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence.   There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.
You will also enjoy the Original CCGPP LBP Document   PDF


AHCPR's “Acute Low Back Problems in Adults” Series      

Acute Low Back Problems in Adults   (Clinical Guide)
Bigos, Stanley J et al.
December 1994 (AHCPR Publication No. 95–0642).
U.S. Agency for Health Care Policy and Research

Acute Low Back Problems in Adults   (Quick Reference Guide)
Bigos, Stanley J et al.
December 1994 (AHCPR Publication No. 95–0643).
U.S. Agency for Health Care Policy and Research

Acute Low Back Problems in Adults   (PDF Quick Reference Guide)
Bigos, Stanley J et al.
December 1994 (AHCPR Publication No. 95–0643).
U.S. Agency for Health Care Policy and Research
31 pages

Understanding Acute Low Back Problems   (Consumer/Patient Guideline)
Bigos, Stanley J et al.
December 1994 (AHCPR Publication No. 95-0644).
U.S. Agency for Health Care Policy and Research




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