European Spine Journal 2006 (Mar); 15 Suppl 2: S192–300 ~ FULL TEXT
O. Airaksinen, J. I. Brox, C. Cedraschi, J. Hildebrandt, J. Klaber-Moffett, F. Kovacs,
A. F. Mannion, S. Reis, J. B. Staal, H. Ursin, G. Zanoli, and On behalf of the
COST B13 Working Group on Guidelines for Chronic Low Back Pain
The primary objective of the 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 back pain guidelines.
This particular guideline intends to foster a realistic approach
to improving the treatment of common
(nonspecific) chronic low back pain (CLBP) in Europe by:
Providing recommendations on strategies to manage
chronic low back pain and/or its consequences in the general
population and in workers.
Ensuring an evidence-based approach through the use
of systematic reviews and existing evidence-based guidelines,
supplemented (where necessary) by individual scientific
Providing recommendations that are generally acceptable
to a wide range of professions and agencies in all participating
Enabling a multidisciplinary approach, stimulating collaboration
between the various players potentially involved
in treatment, thus promoting consistency across
countries in Europe.
Identifying ineffective interventions to limit their use.
Highlighting areas where more research is needed.
The target population of this guideline on diagnosis and
treatment of chronic nonspecific low back pain comprises
individuals or groups that are going to develop new guidelines
(national or local) or update existing guidelines, and
their professional associations that will disseminate and
implement these guidelines. Indirectly, these guidelines
also aim to inform the general public, people with low
back pain, health care providers, health promotion agencies,
industry/employers, educationalists, and policy makers
When using this guideline as a basis, it is recommended
that guideline development and implementation groups
should undertake certain actions and procedures, not all of
which could be accommodated under COST B13. These
will include: taking patients’ preferences into account;
performing a pilot test among target users; undertaking external
review; providing tools for application; considering
organisational obstacles and cost implications; providing
criteria for monitoring and audit; providing recommendations
for implementation strategies (van Tulder et al 2004).
In addition, in the absence of a review date for this guideline,
it will be necessary to consider new scientific evidence
as it becomes available.
The recommendations are based primarily on the available
evidence for the effectiveness and safety of each
treatment. Availability of the treatments across Europe
will vary. Before introducing a recommended treatment
into a setting where it is not currently available, it would
be wise to consider issues such as: the special training
needs for the treating clinician; effect size for the treatment,
especially with respect to disability (the main focus
of treatments for CLBP); long-term cost/effectiveness in
comparison with currently available alternatives that use a
similar treatment concept.
Guidelines working group
The guideline group on chronic, nonspecific low back pain
was developed within the framework of the COST ACTION
B13 ‘Low back pain: guidelines for its management’,
issued by the European Commission, Research Directorate-
General, department of Policy, Co-ordination
and Strategy. The guidelines Working Group (WG) consisted
of experts in the field of low back pain research.
Members were invited to participate, to represent a range
of relevant professions. The core group consisted of three
women and eight men from various disciplines, representing
The WG for the chronic back pain guidelines had its
first meeting in May 2001 in Amsterdam. At the second
meeting in Hamburg, in November 2001, five sub-groups
were formed to deal with the different topics (patient assessment;
medical treatment and invasive interventions;
exercise and physical treatment and manual therapy; cognitive
behavioural therapy and patient education; multidisciplinary
interventions). Overall seven meetings took
place, before the outline draft of the guidelines was prepared
in July 2004, following which there was a final
meeting to discuss and refine this draft. Subsequent drafts
were circulated among the members of the working group
for their comments and approval. All core group members
contributed to the interpretation of the evidence and group
discussions. Anne Mannion played a major role in editing
(language and content) the whole document in the final
stages. The guidelines were reviewed by the members of
the Management Committee of COST B13, in Palma de
Mallorca on 23rd October 2004. The full guidelines are
available at: www.backpaineurope.org
van Tulder MW, Tuut M, Pennick V,
Bombardier C, Assendelft WJ (2004)
Quality of Primary Care Guidelines for Acute Low Back Pain
Spine (Phila Pa 1976). 2004 (Sep 1); 29 (17): E357–E362
Summary of the concepts of diagnosis in chronic low back pain (CLBP)
Physical examination and case history:
The use of diagnostic triage, to exclude specific spinal
pathology and nerve root pain, and the assessment of
prognostic factors (yellow flags) are recommended.
We cannot recommend spinal palpatory tests, soft tissue
tests and segmental range of motion or straight leg
raising tests (Lasegue) in the diagnosis of nonspecific
We do not recommend radiographic imaging (plain radiography,
CT or MRI), bone scanning, SPECT, discography
or facet nerve blocks for the diagnosis of
nonspecific CLBP unless a specific cause is strongly
MRI is the best imaging procedure for use in diagnosing
patients with radicular symptoms, or for those in
whom discitis or neoplasm is suspected. Plain radiography
is recommended for the assessment of structural
We cannot recommend electromyography for the diagnosis
of nonspecific CLBP.
We recommend the assessment of work related factors,
psychosocial distress, depressive mood, severity
of pain and functional impact, prior episodes of LBP,
extreme symptom reporting and patient expectations
in the assessment of patients with nonspecific CLBP.
Summary of the concepts of treatment of chronic low back pain (CLBP)
Cognitive behavioural therapy, supervised exercise
therapy, brief educational interventions, and multidisciplinary
(bio-psycho-social) treatment can each be
recommended for nonspecific CLBP. Back schools
(for short-term improvement), and short courses of
manipulation/mobilisation can also be considered. The
use of physical therapies (heat/cold, traction, laser, ultrasound,
short wave, interferential, massage, corsets)
cannot be recommended. We do not recommend
The short term use of
NSAIDs and weak opioids can be recommended for
pain relief. Noradrenergic or noradrenergic-serotoninergic
antidepressants, muscle relaxants and capsicum
plasters can be considered for pain relief. We cannot
recommend the use of Gabapentin.
Acupuncture, epidural corticosteroids, intra-articular
(facet) steroid injections, local facet nerve blocks, trigger
point injections, botulinum toxin, radiofrequency
facet denervation, intradiscal radiofrequency lesioning,
intradiscal electrothermal therapy, radiofrequency
lesioning of the dorsal root ganglion, and spinal cord
stimulation cannot be recommended for nonspecific
CLBP. Intradiscal injections and prolotherapy are not
recommended. Percutaneous electrical nerve stimulation
(PENS) and neuroreflexotherapy can be considered
where available. Surgery for nonspecific CLBP
cannot be recommended unless 2 years of all other
recommended conservative treatments – including
multidisciplinary approaches with combined programs
of cognitive intervention and exercises – have failed,
or such combined programs are not available, and only
then in carefully selected patients with maximum 2-
level degenerative disc disease.
In contrast to acute low back pain, only very few
guidelines exist for the management of CLBP.
CLBP is not a clinical entity and diagnosis, but rather a
symptom in patients with very different stages of impairment,
disability and chronicity. Therefore assessment
of prognostic factors before treatment is essential.
Overall, there is limited positive evidence for numerous
aspects of diagnostic assessment and therapy in
patients with nonspecific CLBP.
In cases of low impairment and disability, simple evidence-based therapies (i.e. exercises, brief interventions,
and medication) may be sufficient.
No single intervention is likely to be effective in treating
the overall problem of CLBP of longer duration
and more substantial disability, owing to its multidimensional
For most therapeutic procedures, the effect sizes are
The most promising approaches seem to be cognitive-behavioural
interventions encouraging activity/exercise.
It is important to get all the relevant players onside
and to provide a consistent approach.
Summary of recommendations for further research
In planning further research in the field of chronic
nonspecific low back pain, the following issues/areas requiring
particular attention should be considered.
Studies of treatment efficacy/effectiveness should be
of high quality, i.e. where possible,
in the form of randomised controlled trials.
Future studies should include cost-benefit and risk-benefit
Studies are needed to determine how and by whom interventions
are best delivered to specific target groups.
More research is required to develop tools to improve
the classification and identification of specific clinical
sub-groups of CLBP patients. Good quality RCTs are
then needed to determine the effectiveness of specific
interventions aimed at these specific risk/target groups.
More research is required to develop relevant assessments
of physical capacity and functional performance
in CLBP patients, in order to better understand the relationship
between self-rated disability, physical capacity
and physical impairment.
For many of the conservative treatments, the optimal
number of sessions is unknown; this should be evaluated
through cost-utility analyses.
Specific treatment modalities
Further research is needed to evaluate specific components
of treatments commonly used by physical therapists,
by comparing their individual and combined use.
The combination of certain passive physical treatments
for symptomatic pain relief with more “active” treatments
aimed at reducing disability (e.g. massage, hot
packs or TENS together with exercise therapy) should
be further investigated. The application of cognitive behavioural
principles to physiotherapy in general needs to
The effectiveness of specific types of exercise therapy
needs to be further evaluated. This includes the evaluation
of spinal stabilisation exercises, McKenzie exercises,
and other popular exercise regimens that are often
used but inadequately researched. The optimal intensity,
frequency and duration of exercise should be further researched,
as should the issue of individual versus group
exercises. The “active ingredient” of exercise programmes
is largely unknown; this requires considerably
more research, in order to allow the development and
promotion of a wider variety of low cost, but effective
exercise programmes. The application of cognitive behavioural
principles to the prescription of exercises
needs to be further evaluated.
Back schools, brief education
The type of advice and information
provided, the method of delivery, and its relative
effectiveness all need to be further evaluated, in particular
with regard to patient characteristics and baseline
beliefs/behaviour. The characteristics of patients who respond
particularly well to minimal contact, brief educational
interventions should be further researched.
The relative value of different methods within cognitivebehavioural
treatment needs to be evaluated. The underlying
mechanisms of action should also be examined, in
order to identify subgroups of patients who will benefit
most from cognitive-behavioural therapy and in whom
components of pain persistence need addressing.
Promising predictors of outcome of behavioural treatment
have been suggested and need further assessment,
such as treatment credibility, stages of change, expectations
regarding outcome, beliefs (coping resources, fearavoidance)
The use of cognitive behavioural principles by professionals
not trained in clinical psychology should be
investigated, to find out how the latter can best be educated
to provide an effective outcome.
The optimal content of multidisciplinary treatment programmes
requires further research. More emphasis
should be placed on identifying the right treatment for
the right patient, especially in relation to the extensiveness
of the multidisciplinary treatment administered.
This should be accompanied by cost-benefit analyses.
Only very few data exist concerning the use of opioids
(especially strong opioids) for the treatment of chronic
low back pain. Further RCTs are needed. No studies
have examined the effects of long term NSAIDs use in
the treatment of chronic low back pain; further studies,
including evaluation of function, are urgently required.
RCTs on the effectiveness of paracetamol and metamicol
(also, in comparison with NSAIDs) are also encouraged.
The role of muscle relaxants, especially in relation
to longer-term use, is unclear and requires further study.
Patient selection (in particular), procedures, practical
techniques and choice of drug all need further research.
In particular, more high quality studies are required to
examine the effectiveness of acupuncture, nerve blocks,
and radiofrequency and electrothermal denervation procedures.
Newly emerging surgical methods should be firstly examined
within the confines of high quality randomized
controlled trials, in which “gold standard” evidence-based
conservative treatments serve as the control. Patients
with failed back surgery should be systematically
analysed in order to identify possible erroneous surgical
indications and diagnostic procedures.
Methods not able to be recommended
It is possible that many of the treatments that ‘we cannot
recommend’ in these guidelines (owing to lack of/conflicting
evidence of effectiveness) may indeed prove to
be effective, when investigated in high quality randomized
Many of these treatment methods are used widely;
we therefore encourage the execution of carefully designed
studies to establish whether the further use of
such methods is justified.
The treatments recommended in these guidelines are by
no means effective for all patients with CLBP. Further
research should be directed at characterising the subpopulation
of CLBP patients that are not helped by any
of the treatments considered in these guidelines.
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