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)




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 2000. In December 2000, the first draft of the guidelines was prepared. Three subsequent meetings in February, April and May 2001 were used to discuss this draft. The draft was circulated through email among the members of the working group for their final comments and approval. Finally, the final draft was sent for peer review to the members of the Management Committee of COST B13 and discussed at two subsequent meetings in December 2001 and April 2002. Two meetings in December 2003 and March 2004 were used to update the evidence review and guideline recommendations. An update of the guidelines is recommended within three years, when new evidence has become available.


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 ( The literature search covered the period from 1966 to October 2003. A search for clinical guidelines was first performed in Medline. Since guidelines are only infrequently published in medical journals we extended the search on the Internet (using search terms ‘back pain’ and ‘guidelines’, and searching national health professional association and consumers websites) and identified guidelines by personal communication with experts in the field.


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.


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