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Table 2

Clinical guidelines recommendations regarding treatment of low back pain

CountryEducationMedicationExercisesManipulationBed restReferral 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 careConflicting evidence of spinal manipulation versus placebo in first 2–4 weeksNot advisableWhen alerting features (red flags) or serious conditions are present

Austria (2007) [9]Acute LBP: expect a favourable course; maintain normal daily activitiesAcute 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 activitiesNSAIDs, muscle relaxants and analgesics for acute. Low evidence for NSAIDs and analgesics for subacute painStrengthening exercises, extension exercises and specific exercises are not recommended for acute but recommended for subacute and chronic with no superior form of exerciseRecommended for short- term pain reduction for acute. Recommended with low evidence for subacute and chronicNot recommendedRefer 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 possiblePrescribe 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 painConsider (referral for) spinal manipulation for patients who are failing to return to normal activitiesDo not prescribe bed rest as a treatmentRefer patients with neurological symptoms such as cauda equina syndrome

Europe (2006)
(chronic) [12]
Advice and reassurance to return to normal activitiesRecommend 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 reliefSupervised exercise therapy is advisable specifically approaches that don’t require expensive training and machines. Cognitive behavioural approach including graded activity and group therapy are advisableRecommend short course of spinal manipulation/mobilisationDiscouragedMost 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 goodAcute/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 beneficialAcute & 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 bedrestImmediate 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 workParacetamol 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 helpfulFirst 4–6 weeks only
May provide short-term symptom control
Bed rest >2 days harmfulSuspicion 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 activeParacetamol 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 weeksNot recommendedDiscouraged unless patient can not adopt another posture. Then bed rest for the maximum of 48 hRefer 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 bedrestChronic 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 possibleRegular 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 exerciseNo recommendations includedAcute 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 improvingEven if required for severe symptoms, patients should be encouraged to return to normal activities as soon as possibleFor 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 RTWNo 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 varyThe recommendation against bedrest is fairly consistent between 2001 and nowThe 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
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