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. 2023 Feb 20;12(4):1685. doi: 10.3390/jcm12041685

Table 2.

Treatments.

Author Year Country Pharmacological Treatment Non Pharmacological Treatment
General Treatment Topical Treatment Spinal Injection Physical Activity Physiotherapy Information/Education Psychotherapy Multidisciplinary Treatment Other Treatments
van Wambeke [18] 2017 Belgium Recommended, if a medication is required:
- first line: oral NSAIDs
- second line: weak opioids ± acetaminophen
Not recommended:
- acetaminophen as a single medication nor opioids in routine
- selective serotonin-norepinephrine reuptake inhibitors
- tricyclic antidepressants or non-selective serotonin-norepinephrine reuptake inhibitors in routine
- anticonvulsants
- antibiotics, muscle relaxants 		No clear recommandation: topical NSAIDs Not recommended: non epidural spinal injections
No clear recommandation: facet joint infiltration 		Recommended: exercise programme (specific exercises or a combination of approaches) Recommended:
manipulation, mobilization or soft tissue techniques: only as part of a multimodal treatment with a supervised exercise program		 Recommended:
- provide advice and information to help self-management
- promote and facilitate return to work or normal activities of daily living as soon as possible		 Recommended:
psychological intervention using a cognitive behavioral approach:
- only as part of a multimodal treatment with a supervised exercise program
- optional and depending on patients risk stratification		 Recommended:
multidisciplinary rehabilitation program which combines physical and psychological component (cognitive behavioral approach, takes into account the person’s specific needs and capabilities):
- when people have psychological obstacles to recovery,
- when previous evidence-based management has not been effective
No clear recommandation: back school		 Not recommended:
- belts and corsets
- foot orthotics, rocker sole shoes
- manual traction
- ultrasounds
- percutaneous electrical nerve stimulation
- transcutaneous electrical nerve stimulation
- interferential therapy
No clear recommandation: acupuncture
TOP [13] 2015 Canada Recommended:
- acetaminophen
- NSAIDs
- muscle relaxants
- tricyclic antidepressants
- herbal medicines
Not recommended:
- selective Serotonin reuptake inhibitors
- antibiotics (based on MRI Modic Changes)
No clear recommendation:
- opioids and tapentadol
- marijuana (dried cannabis)
- Duloxetine		 Recommended: capsaicin frutescens
No clear recommendation: topical NSAIDs, Buprenorphine transdermal system		 Not recommended: prolotherapy as a sole treatment
No clear recommendation:
- prolotherapy as an adjunct
- epidural steroid injections
- therapeutic sacroiliac joint injections insufficient evidence
- trigger point injections		 Recommended:
exercise and therapeutic exercise:
- initiate gentle exercise and gradually increase the exercise level within pain tolerance
- may include unsupervised walking and group exercise programs
- when exercise exacerbates pain, programme should be assessed by a qualified physical therapist
- if exercise exacerbates pain, patients should be assessed by a physician
- therapeutic aquatic exercise
-Viniyoga and Iyengar types of yoga		 Recommended: massage therapy (as an adjunct to an active rehabilitation program) Recommended: provide brief education to optimize function
- review of clinical examination results
- provision of low back pain information and advice to stay active
- reduce fear and catastrophizing		 Recommended:
- when group chronic pain cognitive behavioral therapy programs are not available, consider referral for individual cognitive behavioral therapy
- respondent behavioral therapies (progressive relaxation or EMG biofeedback)		 Recommended:
- structured community-based self-management group program:
- for patients interested in learning pain coping skills- most community-based programs also include exercise and activity programming
- if not available: individual self-management counselling (trained professional)
- multidisciplinary treatment program: after no improvement with primary care management		 Recommended:
- acupuncture: short-term therapy or as an adjunct to a broader active rehabilitation program
Not recommended:
- motorized traction
- transcutaneous electrical nerve stimulation (as a sole treatment)
No clear recommendation:
- manual therapy (spinal manipulative treatment or spinal mobilization)
- therapeutic ultrasound
- gravity tables (inverted traction, self-traction, gravitational traction)
- ow-level laser therapy
- mindfulness-based meditation
- shock-wave treatment
- spa therapy
- back belts, corsets,
- non-motorized traction
- craniosacral massage/therapy
- intramuscular stimulation
- interferential current therapy
- touch therapies
Chenot [14] 2017 Germany Recommended:
- NSAID
- Metamizole
Not recommended:
- acetaminophen
- Flupirtine
- intravenously, intramuscularly or subcutaneously administered analgesic drugs, local anesthetics, glucocorticoids, or mixed infusions
No clear recommendation:
- COX-2-inhibitors: can be used if NSAIDs are contraindicated or poorly tolerated
- opioids:
  • ∘

    can be a treatment option for acute non-specific low back pain if non-opioid analgesics are contraindicated or have been ineffective

  • ∘

    regularly reassessed at intervals <4 weeks

  • ∘

    to treat chronic non-specific low back pain for 4 to 12 weeks initially

  • ∘

    if this brief period of treatment brings an improvement in the pain while causing only minor or no side effects, opioid drugs can be a long-term therapeutic option

 Recommended:
- instruction to continue usual physical activities
- rehabilitative sports and functional training
- progressive muscle relaxation		 No clear recommendation: massage Recommended:
- explain the condition and the treatment to the patient
- encourage the pursuit of a healthful lifestyle, including regular physical exercise
- patients should be advised against bed rest
- initiation and coordination of psychotherapeutic care, if necessary
- possibly social counseling		 Recommended:
initiation and coordination of psychotherapeutic care, if necessary		 Recommended:
- exercise therapy combined with educative measures based on behavioral-therapeutic principles should be used in the primary treatment of chronic non-specific low back pain
- multimodal programs if less intensive evidence-based treatments have yielded an insufficient benefit:
  • ∘

    multidisciplinary assessment

  • ∘

    stepwise reintroduction to the workplace or initiation of occupational reintegration measures

No clear recommendation:
- self-administered heat therapy
- manual therapies (manipulation and mobilization)
- ergotherapy
- back school
- acupuncture
=> could be used to treat chronic low back pain in combination with activating therapeutic measures
Not recommended:
- interference-current therapy
- kinesiotaping
- short-wave diathermy
- laser therapy
- magnetic field therapy
- medical aids
- percutaneous electrical nerve stimulation (PENS)
- traction devices
- cryotherapy
- transcutaneous electrical nerve stimulation (TENS),
- therapeutic ultrasound
HAS [2] 2019 France First line: acetaminophen, non-steroidal anti-inflammatory drugs (low dose, short duration); Second line: opioids (risk of misuse). Antidepressants and anticonvulsants are not indicated in acute LBP, possible use in case of chronic pain. No opinion for nefopam, cortico-steroids. Not recommended: muscle relaxants. No indication for: vitamin D, antibiotic, anti-TNF alpha. No indication for lidocaine patch Generally no indication for LBP infiltration without root pain Physical exercise is the main treatment: self-management in first line: return to daily activities (and professional activities if possible), adapted physical activities and sports (progressive and fractional) Suggested/Recommended: physiotherapy (active participation of patient); patient education; mobilizations, manual therapy (only as part of a multimodal combination of treatments with supervised exercises and on second-line treatment) Suggested/Recommended: deliver reassuring information Suggested/Recommended: second-line treatment: cognitive behavioral therapy (only as part of a multimodal combination of treatments with supervised exercises) Suggested/Recommended: third-line treatment for patients with persistant pain and psychosocial risk factors or in case of failure of first- and second-line treatments Not recommended: ultra sound therapy; lumbar tractions; plantar orthosis
No clear recommendation: acupuncture, acupressure, dry needling; sophrology; relaxation; mindfulness; hypnosis; lumbar brace; lumbar belt
NICE [12] 2016 UK Recommended:
- oral NSAIDs:
- weak opioids (±acetaminophen): only if NSAID is contraindicated, not tolerated or has been ineffective.
Not recommended:
- acetaminophen alone
- opioids
- selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants
- gabapentinoids or anticonvulsants		 Not recommended:
spinal injections in LBP
Recommended:
- radiofrequency denervation, to consider in chronic LBP:
  • ∘

    when non-surgical treatment has not worked

  • ∘

    if the main source of pain is thought to come from structures supplied by the medial branch nerve

  • ∘

    for moderate or severe levels of localized back pain (5 or more on a visual analogue scale)

  • ∘

    only in people with chronic low back pain after a positive response to a diagnostic medial branch block

Recommended: group exercise program:
- biomechanical, aerobic, mind–body or a combination of approaches
- take people’s specific needs, preferences and capabilities into account when choosing the type of exercise		 Recommended:
- advice and information, tailored to their needs and capabilities,
- help them self-manage low back pain
- information on the nature of low back pain
- encouragement to continue with normal activities		 Recommended:
- psychological therapies using a cognitive behavioral approach
- as part of a treatment package including exercise		 Recommended:
- combined physical and psychological program
  • ∘

    when they have significant psychosocial obstacles to recovery

  • ∘

    when previous treatments have not been effective

- promote and facilitate return to work or normal activities of daily living		 Recommended:
- consider manual therapy (spinal manipulation, mobilization or soft tissue techniques) as part of a treatment package including exercise
Not recommended:
- belts or corsets
- foot orthotics
- rocker sole shoes
- traction
- acupuncture
- ultrasound
- percutaneous electrical nerve simulation (PENS)
- transcutaneous electrical nerve simulation (TENS)
- interferential therapy
Qaseem [17] 2017 USA Recommended (in patients who have had an inadequate response to nonpharmacologic therapy):
- first line: NSAIDs
- second line: tramadol or Duloxetine
- If failure: opioids if the potential benefits outweigh the risks		 Recommended: exercise, Tai Chi, yoga Recommended:
- motor control exercise
- progressive relaxation		 Recommended: multidisciplinary rehabilitation Recommended:
- acupuncture
- mindfulness-based stress reduction
- electromyography biofeedback
- low-level laser therapy, operant therapy
- spinal manipulation (low-quality evidence)
NASS [16] 2020 North America Suggested/Recommended: opioid pain medications (short duration)
Not recommended: oral or IV steroids; antidepressants
No clear recommendation: anticonvulsants; vitamin D; selective NSAIDs		 Suggested/Recommended: topical capsaicin
No clear recommendation: lidocaine patch		 No clear recommendation: caudal epidural steroid injections; interlaminar epidural steroid injections; zygapophyseal joint injection; intradiscal steroids; intradiscal platelet rich plasma Suggested/Recommended: yoga; aerobic exercise Suggested/Recommended: McKenzie method
No recommended: traction; ultrasound; addition of massage to an exercise program; lumbar stabilization
No clear recommendation: transcutaneous electrical nerve stimulation (TENS); dry needling		 Suggested/Recommended: back school
No clear recommendation: patient education		 Suggested/Recommended: cognitive behavioral therapy (in combination with physical therapy)
treatments targeting fear avoidance (combined with physical therapy)
ACOEM [23] 2020 USA Recommended:
- NSAIDs
- acetaminophen
- antidepressants
- skeletal muscle relaxants: for acute exacerbations of chronic LBP
Not recommended: opioids, antibiotics,
antidepressants,
anticonvulsants,
bisphosphonates, calcitonin and oral and intravenous colchicine
NMDA receptor/antagonists
skeletal muscle relaxants
glucocorticosteroids
TNF-a vitamin supplementation
No Clear recommendation: Thiocolchicoside		 Recommended: capsaicin
Not recommended:
- lidocaine patches
- Spiroflor
- DMSO, N-acetylcysteine, EMLA, and wheatgrass cream
No Clear recommendation: topical NSAIDs or other creams 		Recommended:
- exercise prescription
- self-administered or enacted through formal therapy appointments
- aerobic exercises (progressive walking program)
- directional exercises which centralize or abolish the pain
- slump stretching exercises 3 to 5 times a day
- strengthening exercises
- specific strengthening exercises
- yoga and tai chi for select, motivated patients
Not recommended:
- stretching exercises in the absence of significant range of motion deficits
- abdominal strengthening exercises as a sole or central goal of a strengthening program
No Clear recommendation: Pilates		 Recommended:
- massages for select use as an adjunct to more efficacious treatments (aerobic and strengthening exercise program)
- self-applications of low-tech heat therapies and cryotherapies
- aquatic therapy for select chronic LBP patients (extreme obesity, significant degenerative joint disease, etc.)
Not recommended:
- mechanical devices for administering massage
- reflexology
- high-tech devices of heat and/or cryotherapy
- diathermy
- lumbar extension machines
No Clear recommendation: myofascial release		 Recommended:
- maintaining maximal levels of activity, including work activities,
- work modifications should be tailored taking into consideration 3 main factors: (1) job physical requirements; (2) severity of the problem; and (3) the patient’s understanding of his or her condition
- fear avoidance belief training for patients with elevated fear avoidance beliefs
Not recommended: bed rest		 Recommended:
- lordotic sitting posture
- sleep posture comfortable
- manipulation or mobilization (component of an active exercise program)
- acupuncture
- transcutaneous electrical nerve simulation TENS
Not recommended:
- specific beds or other commercial sleep products
- kinesiotaping
- shoe lifts or insoles except for individuals with significant leg length discrepancy of more than 2 cm
- lumbar supports
- magnets
- traction
- low-level laser therapy
- microcurrent electrical stimulation
No Clear recommendation:
- specific mattresses, bedding, and water bed
- medical foods (Ther- amine, an amino acid formulation)
- herbal
- iontophoresis
- inversion therapy
- infrared therapy
- ultrasounds
VA/DOD [4] 2017 USA Recommended:
- NAIDs
- duloxetine
- non-benzodiazepine muscle relaxant for acute exacerbations of chronic low back pain
Not recommended:
- non-benzodiazepine muscle relaxant
- benzodiazepines
- oral or intramuscular injection corticosteroids
- long-term opioid therapy
- chronic use of oral acetaminophen
No clear recommendation:
time-limited opioid therapy, for acute exacerbations of chronic low back pain
time-limited (less than 7 days) acetaminophen therapy
anticonvulsants nutritional, herbal, and homeopathic supplements		 No clear recommendation: topical preparations Not recommended:
- spinal epidural steroid injections
- intra-articular facet joint steroid injections		 Recommended:
- clinician-directed exercises
- exercise program, which may include Pilates, yoga, and tai chi		 Recommended:
- provide evidence-based information with regard to their expected course
- advise patients to remain active,
- provide information about self-care options
- add structured education component as part of multicomponent self-management intervention		 Recommended:
- cognitive behaviral therapy 		Recommended:
- Multidisciplinary or interdisciplinary rehabilitation programme which should include at least one physical component and at least one other component of the biopsychosocial model (psychological, social, occupational)
- for selected patients not satisfactorily responding to more limited approaches		 Recommended:
- spinal mobilization/manipulation as part of a multimodal programme
- acupuncture
- mindfulness-based stress reduction.
No clear recommendation:
- lumbar supports
- ultrasound
- transcutaneous electrical nerve stimulation (TENS)
- lumbar traction
- electrical muscle stimulation
- medial branch blocks