Table 2.

Clinical guidelines recommendations regarding treatment of low back pain

Country	Education	Medication	Exercises	Manipulation	Bed rest	Referral to specialist
Australia (2003) [8]	Provide information, assurance and advice to resume normal activity (stay active)	First choice paracetamol, second choice NSAIDs, third choice oral opioids Not recommended: anticonvulsants, antidepressants, muscle relaxants	There is conflicting evidence of the effect of exercises but evidence shows that it is no better than usual care	Conflicting evidence of spinal manipulation versus placebo in first 2–4 weeks	Not advisable	When alerting features (red flags) or serious conditions are present
Austria (2007) [9]	Acute LBP: expect a favourable course; maintain normal daily activities	Acute LBP: (1) Paracetamol; (2) NSAIDs 3) muscle relaxants or weak opioids as last option Chronic LBP: Options: NSAIDs/Coxibs; Opioids; Antidepressant; muscle relaxants; Anti-convulsion medication (for radicular pain), Capsaicin Only for short periods: (1) paracetamol, (2) tramadol or NSAID, (3) opioids	Acute LBP: Not specifically mentioned in the guideline Chronic LBP: Exercise therapy recommended as monotherapy or in combination with back school, massage	Acute LBP: Optional for patients who do not return to normal level of activity within the first weeks Chronic LBP: Optional for patients with persistent problems with performing daily activities	Acute LBP: Avoid bedrest (but if necessary, only for a short period)	In case of suspected specific LBP; Surgery is optional only after 2 years of recommended conservative treatment, persisting complaints and with a surgical indication
Canada (2007) [10]	Reassurance and advice to return to work and usual activities	NSAIDs, muscle relaxants and analgesics for acute. Low evidence for NSAIDs and analgesics for subacute pain	Strengthening exercises, extension exercises and specific exercises are not recommended for acute but recommended for subacute and chronic with no superior form of exercise	Recommended for short- term pain reduction for acute. Recommended with low evidence for subacute and chronic	Not recommended	Refer patients with neurological signs or symptoms if functional deficits are persistent or deteriorating after 4 weeks
Europe (2006) (acute) [11]	Reassure and 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. Third choice consider short course of muscle relaxants on its own or added to NSAIDs	Do not advise specific exercises (for example strengthening, stretching, flexion, and extension exercises) for acute low back pain	Consider (referral for) spinal manipulation for patients who are failing to return to normal activities	Do not prescribe bed rest as a treatment	Refer patients with neurological symptoms such as cauda equina syndrome
Europe (2006) (chronic) [12]	Advice and reassurance to return to normal activities	Recommend use of NSAID for short term pain relief and opioids in case patient is not responding to other treatment. Consider the use of noradrenergic or noradrenergic-serotonergic antidepressants as co-medication for pain relief	Supervised exercise therapy is advisable specifically approaches that don’t require expensive training and machines. Cognitive behavioural approach including graded activity and group therapy are advisable	Recommend short course of spinal manipulation/mobilisation	Discouraged	Most invasive treatments not recommended Surgery not recommended unless in carefully selected patients, 2 years of all recommended conservative treatments including multidisciplinary approaches with combined programmes of cognitive intervention and exercises have failed
Finland (2008) [13]	Benign nature of condition; prognosis is good; continue ordinary daily activities. Back pain may recur but even then recovery is usually good	Acute/Subacute LBP: (1) paracetamol, (2) NSAIDs, (3) adding a weak opiate to paracetamol/NSAID. (4) muscle relaxants Antidepressant only if clear depression. Benzodiazepines not recommended Chronic LBP Analgesics used periodically, be aware of side effect of NSAIDs (gastrointestinal, cardiovascular)	Acute LBP: Active exercises not effective in early stages Light exercises (e.g. walking) can be recommended Subacute: gradually increasing exercises Chronic: Intensive training effective for pain and function	Acute LBP: some effectiveness Similar effectiveness as GP in subacute LBP Chronic LBP: similar effectiveness as GP, analgesics, physiotherapy, etc.	Avoid bedrest; a short period of bedrest may be necessary due to intense back pain, but bedrest must not be considered as a treatment of back problems	Immediate referral: Cauda equina syndrome, sudden massive paresis, excruciating pain Referral: serious, non urgent conditions Multidisciplinary (bio-psycho-social) rehabilitation focused on improving functional capacity
France (2000) [14]	Short-term education about the back, in groups, is not beneficial	Acute & Chronic: Regular simple analgesics, non-steroidal anti-inflammatory drugs and muscle relaxants. No evidence for systemic corticosteroids Chronic: Additional recommendations for: acetylsalicylic acid, Level II following failure to respond to Level I and Level III (strong opioids) on a case by case basis. Tetrazepam, Tricyclic antidepressants	Acute: Flexion exercises have been not been shown to be of benefit. No recommendation on extension exercises Chronic: Physical exercise is recommended, no particular type is advocated	Acute & Chronic: Provides short-term benefit. No recommendation for one form of manual therapy over another	Acute and Chronic: Not recommended	Acute: No recommendation Chronic: Recommended physiotherapy/behavioural therapy/multidisciplinary programme if non-response to first-line care
Germany (2007) [15]	Acute LBP: stimulate daily activities, explain moving is not dangerous, Chronic LBP more intense psychotherapy indicated in case of psychological co-morbidity	Acute and Chronic LBP: (1) paracetamol, (2) NSAIDs (oral or topical), (3) Muscle relaxants (in cases with muscle spasms, (4) Opioids	Acute LBP: exercise therapy not effective Subacute and Chronic LBP: Exercise therapy well supported by evidence	Acute LBP: Optional within the first 4–6 weeks Chronic LBP: option if shortlasting	Maximum of 2 days bedrest	Immediate surgery indicated for cauda equina syndrome Optional referral for surgery: therapy resistant (>6 weeks) + signs of nerve root compression Surgery may be an option if after 2 years conservative treatment, including biopsychosocial treatment programme was unsuccessful
Italy (2006) [16]	Give information and reassurance about possible cause, provoking factors, risk factors, and structural or postural alterations, reassurance about good prognosis, keep active and if possible, stay at work	Paracetamol as preferred drug NSAIDs recommended Muscle relaxants no additional effect Steroids not recommended in acute LBP, but can be useful for a short time in sciatica Tramadol and adding light opioid to paracetamol may be useful for sciatica	Acute LBP No specific exercises recommended Chronic LBP Individual specific exercises	After 2–3 weeks and before 6 weeks, prescribed by physicians, done by trained therapists Chronic LBP: Consider for pain relief	Discouraged for acute LBP, except 2–4 days for major sciatica Contraindicated for sciatica No recommended in Chronic LBP	Radiculopathy and suspicion of specific causes Multidisciplinary psycho-social intervention for patients at high risk of chronicity and chronic pain
New Zealand (2004) [17]	Advise to stay active and working, or early return to work, reassurance Education pamphlets not helpful	Paracetamol and NSAIDs recommended Opiates or diazepam may be harmful	Specific back exercises not helpful	First 4–6 weeks only May provide short-term symptom control	Bed rest >2 days harmful	Suspicion of specific causes (red flags), cauda equina syndrome, or after 4–8 weeks
Norway (2007) [18]	Stay active, return to normal activity including work asap,	(1) Paracetamol (2) NSAID (3) Paracetamol + opioid or Tramadol (4) Antidepressants in cases with depression	No specific exercises in the first weeks In chronic LBP exercises are recommended	After 1-2 weeks for pain reduction and improvement of function (for small to moderate effects)	Not recommended In rare cases, not longer than 2–3 days	Referral within primary care for cognitive behavioural treatment is optional Referral for surgical intervention after 2 years’ LBP
Spain (2005) [19]	Reassurance and advice to stay active	Paracetamol every 6 h, can also be associated with opioids and NSAID although the last one should not be prescribed for longer than 3 months Opioids are indicated for patients with high levels of pain who did not improve with usual care	Exercise as far as pain allows including work activities. As there is no evidence for any specific type of exercise, choose the one that patients prefer. Not indicated for patients with pain for less than 6 weeks	Not recommended	Discouraged unless patient can not adopt another posture. Then bed rest for the maximum of 48 h	Refer patient in case of red flags
The Netherlands (2003) [20]	Acute and Chronic LBP: Stay active as much as possible (despite the pain), increase activity level on a time contingent basis	Acute LBP: (1) Paracetamol (2) NSAIDs, (3) muscle relaxants or weak opioids or combinations with paracetamol/NSAIDS as last option due to side effects Chronic LBP: Only for short periods: (1) Paracetamol, (2) Tramadol or NSAID, (3) Opioids	Acute LBP: Consider after 4–6 weeks for patients who do not improve their functioning Chronic LBP: Recommended are time-contingent, varying and supervised exercises focused at improving function	Acute and Chronic LBP: Option as part of an activating strategy for patients who do not show a favourable course	Acute and Chronic LBP: Avoid bedrest	Chronic LBP: Refer patients with severe disability who do not respond to recommended conservative treatments for multidisciplinary treatment focused on functional recovery
United Kingdom (2008) [21]	Provide information and advice to foster positive attitude and realistic expectations—back pain is not serious, temporary, tends to recur, physical not psychological, mechanical. Stay active as possible	Regular paracetamol (preferred) or NSAID as first line care. For additional analgesia combine paracetamol and NSAID or add a weak opioid (codeine or tramadol). For non-responders consider benzodiazepine, tricyclic antidepressant Not recommended: Topical NSAIDs, antiepileptic drugs (other than gabapentin), herbal remedies	Advise patient to stay as active as possible. No specific recommendations regarding exercise	No recommendations included	Acute LBP: Rest in bed is less effective than staying active	If progressive neurological deficit If pain or disability remain problematic for more than a week or two consider referral for physio/physical therapy If pain/disability continue to be a problem despite pharmacotherapy and physical therapy consider referral to multidisciplinary back pain service or chronic pain clinic
United States (2007) [22]	Provide information on prognosis, staying active, self management Self-care education books recommended	Paracetamol, NSAIDs recommended as first-line drugs For acute (<4 weeks)—muscle relaxants, benzodiazepines, tramadol, opioids For subacute or chronic (>4 weeks)—antidepressants, benzodiazepines, tramadol, opioids	Not effective for acute LBP Recommended for subacute or chronic LBP	For acute LBP if not improving	Even if required for severe symptoms, patients should be encouraged to return to normal activities as soon as possible	For interdisciplinary intervention if chronic If suspicion of significant nerve root impingement or spinal stenosis
Most apparent changes since 2001
	The advice to stay active remains similar. Now some guidelines (european, NZ, Canada, Italy, Norway) explicitly mention continuation/early RTW	No change regarding recommendation of paracetamol and NSAIDs as first-line treatments and recommendation regarding muscle relaxants Now more often explicit recommendations (for or against) anti-depressants, opioids, benzodiazepines and combinations of medications	The advice that exercise therapy is not useful in acute LBP has not changed Now more explicit recommendations in favour of exercise therapy in subacute and chronic LBP	Recommendations for spinal manipulation, the timing of application and target group continue to vary	The recommendation against bedrest is fairly consistent between 2001 and now	The recommendations for referral appear more explicit regarding : (1) immediate referral (cauda equina syndrome), (2) medical specialist in case of red flags, (3) referral within primary care (physiotherapy/cognitive behavioural therapy, (4) multidisciplinary treatments and (5) consider surgery if 2 years of recommended conservative care has failed