European guidelines for
the management of acute nonspecific low back pain in primary care
Maurits van
Tulder*
* On behalf of the
COST B13 Working Group on Guideline for the Management of Acute Low Back Pain
in Primary Care.
Maurits van Tulder
(chairman) Epidemiologist (NL)
Annette Becker General
practitioner (GER)
Trudy Bekkering Physiotherapist
(NL)
Alan Breen Chiropractor (UK)
Tim Carter Occupational physician
(UK)
Maria Teresa Gil
del Real Epidemiologist (ESP)
Allen Hutchinson Public Health
Physician (UK)
Bart Koes Epidemiologist
(NL)
Peter
Kryger-Baggesen Chiropractor (DK)
Even Laerum General
practitioner (NO)
Antti Malmivaara Rehabilitation
physician (FIN)
Alf Nachemson Orthopaedic
surgeon (SWE)
Wolfgang Niehus Orthopaedic /
anesthesiologist (AUS)
Etienne Roux Rheumatologist
(SUI)
Sylvie Rozenberg Rheumatologist
(FR)
GUIDELINES
FOR ACUTE NONSPECIFIC LOW BACK PAIN
Based
on systematic reviews and existing clinical guidelines Summary of
recommendations for diagnosis of acute non-specific low back pain:
•
Case history and brief examination should be carried out
•
If history taking indicates possible serious spinal pathology or nerve root syndrome, carry out more extensive physical examination
including neurological screening when appropriate
•
Undertake diagnostic triage at the first assessment as basis for management
decisions • Be aware of psychosocial factors, and review them in detail if
there is no improvement
•
Diagnostic imaging tests (including X-rays, CT and MRI) are not routinely
indicated for non-specific low back pain
•
Reassess those patients who are not resolving within a few weeks after the
first visit, or those who are following a worsening course
Summary
of recommendations for treatment of acute non-specific low back pain:
•
Give adequate information and reassure the patient • Do not prescribe bed rest
as a treatment
•
Advise patients to stay active and continue normal daily activities including
work if possible
•
Prescribe medication, if necessary for pain relief; preferably to be taken at
regular intervals; first choice paracetamol, second choice NSAIDs
•
Consider (referral for) spinal manipulation for patients who are failing to
return to normal activities • Multidisciplinary treatment programmes in
occupational settings may be an option for workers with sub-acute low back pain
and sick leave for more than 4 - 8 weeks These guidelines intend to improve the
primary care management of acute non-specific low back pain for adult patients
in Europe, by:
1.
Providing recommendations on the clinical management of acute nonspecific low
back pain in primary care.
2.
Ensuring an evidence-based approach through the use of systematic reviews and
existing clinical guidelines.
3.
Providing recommendations that are generally acceptable by all health professions
in all participating countries.
4.
Enabling a multidisciplinary approach; stimulating collaboration between primary
health care providers and promoting consistency across providers and countries
in Europe.
Target
population The target population of the guidelines
consists of individuals or groups that are going to develop new guidelines 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, patients with low back
pain, health care providers (for example, general practitioners,
physiotherapists, chiropractors, manual therapists, occupational physicians,
orthopaedic surgeons, rheumatologists, rehabilitation physicians, neurologists,
anaesthesiologists and other health care providers dealing with patients
suffering from acute non-specific low back pain), and policy makers in Europe.
Guidelines
working group The guidelines were 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, Coordination and Strategy. The
guidelines working group consisted of experts in the field of low back pain research in primary care who have been involved in the
development of national guidelines for low back pain in their countries.
Members
were invited to participate, taking into account that all relevant health
professions should be represented. The group consisted of 10 men and 4 women
with various professional backgrounds. All countries that had
already issued national guidelines were represented [NL: Bekkering, Koes, Van
Tulder; Fra: Rozenberg; Ger: Becker; UK: Breen, Carter, Hutchinson; DK:
Kryger-Baggesen; Fin: Malmivaara; Sui: Roux; Swe: Nachemson].
Because
the United Kingdom and the Netherlands have produced most of the systematic reviews
and clinical guidelines, these two countries were represented by more than one participant.
The
guidelines working group had its first meeting in November
Evidence
The main evidence was not systematically reviewed
again for the purpose of this guideline, because 1) there already is a large
amount of evidence on diagnosis and treatment of acute non-specific low back
pain, 2) this evidence has already been summarised in many systematic reviews,
and 3) this evidence has already been translated into clinical recommendations
in various national clinical guidelines. To ensure an evidence-based approach,
the recommendations were based on Cochrane reviews (and on other systematic
reviews if a Cochrane review was not available) and on existing national
guidelines.
Additional
trials that were not included in the reviews were also used.
The
systematic reviews and additional trials were identified using the results of
validated search strategies in the Cochrane Library, Medline, Embase and, if
relevant, other electronic databases, performed for Clinical Evidence, a monthly,
updated directory of evidence on the effects of common clinical interventions,
published by the BMJ Publishing Group (www.evidence.org).
The literature search covered the period from 1966 to October
A
three-stage development process was undertaken. First, recommendations were
derived from systematic reviews. Secondly, existing national guidelines were
compared and recommendations from these guidelines summarised. Thirdly, the
recommendations from the systematic (Cochrane) reviews and guidelines were
discussed by the group. A section was added to the guidelines in which the main
points of debate are described. The recommendations are put in a clinically relevant
order; recommendations regarding diagnosis have a letter D, treatment T.
A
grading system was used for the strength of the evidence (Appendix 1). This
grading system is simple and easy to apply, and shows a large degree of
consistency between the grading of therapeutic and preventive, prognostic and
diagnostic studies. The system is based on the original ratings of the AHCPR
Guidelines (1994) and levels of evidence recommended
in the method guidelines of the Cochrane Back Review group [1,2]. To avoid a
conflict of interest, authors were not involved in the quality assessment or discussion
of their own papers. The strength of the
recommendations was not graded.
Several
of the existing systematic reviews have included non-English language
literature, usually publications in French, German, and Dutch language and
sometimes also Danish, Norwegian, Finnish and Swedish. All existing national
guidelines included studies published in their own language. Consequently, the
non-English literature is covered for countries that already have developed
guidelines. The group additionally included the Spanish literature, because
this evidence was not covered by existing reviews and guidelines (see Appendix
IV).
The
Working Group aimed to identify gaps in the literature and included
recommendations for future research.
Recommendations
for future research: •
There is an urgent need for validated instruments to assess psychosocial risk factors.
•
There is a need to identify the relative effect of specific types of or
components of behavioural treatment.
•
There is a need to identify relevant sub-groups of patients with a high risk of
psychosocial factors or a high risk of chronicity.
•
Future RCTs concerning therapeutic strategies should focus primarily on interventions
with an activating approach and the prevention of chronicity as one of the main
outcomes.
•
There is a need to identify effective implementation strategies for low back pain
guidelines.
The
complete article is available under: www.backpaineurope.org