Low Back Pain Guidelines

This section was compiled by Frank M. Painter, D.C.
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Guidelines From Around The World   

A Unique Series of Medical Guidlines

All 5 of the following guidelines reviewed the medical literature on low back pain and strongly advise medical doctors to first recommend non-pharmacologic therapies, including chiropractic, BEFORE resorting to offering NSAIDs, opiates or other more invasive treatments, for low back (spinal) pain patients.

These recommendations will:

  1. save money,
  2. will increase patient satisfaction,
  3. will improve patient outcomes and
  4. will reduce chronicity and potential addiction.

Guideline for Opioid Therapy and Chronic Noncancer Pain
CMAJ. 2017 (May 8);   189 (18):   E659–E666 ~ FULL TEXT

This new Canadian guideline published today (May 8, 2017) in the Canadian Medical Association Journal (CMAJ) strongly recommends doctors to consider non-pharmacologic therapy, including chiropractic, in preference to opioid therapy for chronic non-cancer pain.   The guideline is the product of an extensive review of evidence involving input from medical, non-medical, regulatory, and patient stakeholders.

National Clinical Guidelines for Non-surgical Treatment of
Patients with Recent Onset Low Back Pain
or Lumbar Radiculopathy

Eur Spine J. 2017 (Apr 20)[Epub]   1451–1460 ~ FULL TEXT

In 2012, the Danish Finance Act appropriated a total of €10.8 mio for the preparation of clinical guidelines. The Danish Health Authority (DHA) was subsequently commissioned to formulate 47 national clinical guidelines to support evidence-based decision making within health areas with a high burden of disease, a perceived large variation in practice, or uncertainty about which care was appropriate. [1] Two of these areas were low back pain (LBP) and lumbar radiculopathy (LR). Consequently in 2014, two working groups were formed with the aim of developing national clinical guidelines for non-surgical interventions for recent onset (<12 weeks) LBP and for recent onset (<12 weeks) LR. The primary target groups for these guidelines were primary sector healthcare providers, i.e., general practitioners, chiropractors, and physiotherapists, but also medical specialists or others in the primary or secondary healthcare sector handling patients with LBP or LR.

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm
for Acute Low Back Pain: Systematic Review and Meta-analysis

JAMA. 2017 (Apr 11);   317 (14):   1451–1460 ~ FULL TEXT

For the second time in as many months, a prominent medical journal has endorsed spinal manipulation for the management of low back pain. [1] On April 11th 2017, JAMA published a systematic review of 26 randomized clinical trials in order to evaluate the safety and effectiveness of spinal manipulation for low back pain.   The authors concluded:   “Among patients with acute low back pain, spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.”

Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an
American College of Physicians Clinical Practice Guideline

Annals of Internal Medicine 2017 (Apr 4);   166 (7):   493–505 ~ FULL TEXT

This report updates and expands on the earlier ACP/APS review [105] with additional interventions and newer evidence. We found evidence that mind–body interventions not previously addressed — tai chi (SOE, low) and mindfulness-based stress reduction (SOE, moderate) [45–47] — are effective for chronic low back pain; the new evidence also strengthens previous conclusions regarding yoga effectiveness (SOE, moderate). For interventions recommended as treatment options in the 2007 ACP/APS guideline [2], our findings were generally consistent with the prior review. Specifically, exercise therapy, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture are supported with some evidence of effectiveness for chronic low back pain (SOE, low to moderate). Unlike our previous report, which stated that higher-intensity multidisciplinary rehabilitation seemed to be more effective than lower-intensity programs, a stratified analysis based on currently available evidence [54] did not find a clear intensity effect. Our findings generally are consistent with recent systematic reviews not included in our evidence synthesis [106–117]. Although harms were not well-reported, serious adverse events were not described.

Noninvasive Treatments for Acute, Subacute, and Chronic
Low Back Pain: A Clinical Practice Guideline From
the American College of Physicians

Annals of Internal Medicine 2017 (Apr 4);   166 (7):   514–530 ~ FULL TEXT

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).

Noninvasive Treatments for Low Back Pain
Agency for Healthcare Research and Quality (AHRQ) ~ Comparative Effectiveness Review

The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based Practice Centers (EPCs), sponsors the development of systematic reviews to assist public- and privatesector organizations in their efforts to improve the quality of health care in the United States. These reviews provide comprehensive, science-based information on common, costly medical conditions, and new health care technologies and strategies.

A Narrative Review of Lumbar Fusion Surgery
With Relevance to Chiropractic Practice

Journal of Chiropractic Medicine 2016 (Dec);   15 (4):   259–271 ~ FULL TEXT

This article describes the indications for fusion, common surgical practice, potential complications, and relevant published chiropractic literature. This review includes 10 cases that showed positive benefits from chiropractic manipulation, flexion-distraction, and/or manipulation under anesthesia for postfusion lumbar pain. Chiropractic care may have a role in helping patients in pain who have undergone lumbar fusion surgery.

Low Back Pain and Sciatica in Over 16s: Assessment and Management
NICE Guideline, No. 59 (November 2016)~ FULL TEXT
National Guideline Centre (UK)

This guideline covers the assessment and management of low back pain and sciatica in adults over the age of 16 years.

Clinical Practice Guidelines for the Noninvasive Management of Low Back Pain:
A Systematic Review by the Ontario Protocol for Traffic Injury Management
(OPTIMa) Collaboration

Eur J Pain. 2016 (Oct 6).   doi: 10.1002/ejp.931 ~ FULL TEXT

We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high-quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed.

Clinical Practice Guideline: Chiropractic Care for Low Back Pain
J Manipulative Physiol Ther. 2016 (Jan);   39 (1):   1–22 ~ FULL TEXT

This publication is an update of the best practice recommendations for chiropractic management of LBP. [9, 10, 12] This guide summarizes recommendations throughout the continuum of care from acute to chronic and offers the chiropractic profession and other key stakeholders an up-to-date evidence- and clinical practice experience–informed resource outlining best practice approaches for the treatment of patients with LBP.

An Updated Overview of Clinical Guidelines for the Management
of Non-specific Low Back Pain in Primary Care

Eur Spine J. 2010 (Dec);   19 (12):   2075–2094 ~ FULL TEXT

This review of national and international guidelines conducted by Koes et. al. points out the disparities between guidelines with respect to spinal manipulation and the use of drugs for both chronic and acute low back pain.

Low Back Pain: Early Management of Persistent
Non-specific Low Back Pain

Royal College of General Practitioners, London, UK; (May 2009) ~ FULL TEXT
NICE Clinical Guidelines, No. 88

This guideline covers the early treatment and management of persistent or recurrent low back pain, defined as non-specific low back pain that has lasted for more than 6 weeks, but for less than 12 months. It does not address the management of severe disabling low back pain that has lasted over 12 months.
Here's the HTML version
You may also enjoy this glossy patient version

Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints
in Adults — An Evidence-Based Approach: Part 3: Spinal Disorders

J Manipulative Physiol Ther 2008 (Jan);   31 (1):   33-88 ~ FULL TEXT

Recommendations for diagnostic imaging guidelines of adult spine disorders are provided, supported by more than 385 primary and secondary citations. The overall quality of available literature is low, however. On average, 45 Delphi panelists completed 1 of 2 rounds, reaching more than 85% agreement on all 55 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility. Dissemination and implementation strategies are discussed.

Nonpharmacologic Therapies for Acute and Chronic Low Back Pain:
A Review of the Evidence for an American Pain Society/
American College of Physicians
Clinical Practice Guideline

Annals of Internal Medicine 2007 (Oct 2);   147 (7):   492–504 ~ FULL TEXT

Researchers sought to determine the benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain). Researchers conducted MEDLINE searchers and the Cochrane Database of Systematic Reviews and graded the methodologies of the studies. Researchers concluded that there was good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation were moderately effective for chronic or subacute low back pain.

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline
from the American College of Physicians and
the American Pain Society

Annals of Internal Medicine 2007 (Oct 2);   147 (7):   478–491 ~ FULL TEXT

Low back pain is the fifth most common reason for all physician visits in the United States. [1, 2] Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months [2], and 7.6% reported at least 1 episode of severe acute low back pain (see Glossary) within a 1-year period. [3] Low back pain is also very costly: Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $26.3 billion in 1998. [4] In addition, indirect costs related to days lost from work are substantial, with approximately 2% of the U.S. work force compensated for back injuries each year. [5] You will enjoy these recommendations because their ONLY recommendation for active treatment of acute low back pain is spinal adjusting (manipulation).

European Guidelines for Acute and Chronic LBP

Chronic Low Back Pain. Good Clinical Practice (GCP)
Belgian Health Care Knowledge Centre (KCE),
Brussels, Belgium; (Dec 2006)
Report No.: 48 C (D/2006/10.273/71) ~ FULL TEXT

Like the proverbial bad penny that keeps turning up, chronic low back pain is a real curse that seems to keep coming back the more you try to get rid of it. But in addition to the pain and discomfort caused to individuals, the social cost of this disorder in terms of medical treatments and absenteeism is also a problem that clearly needs to be addressed. It was therefore inevitable that the KCE would one day be invited to tackle this problem in the hope that it would find, if not radical solutions, at least a number of clear and effective strategies.

European Guidelines for the Management of
Acute Nonspecific Low Back Pain in Primary Care

European Spine Journal 2006 (Mar);   15 Suppl 2:  S169–191 ~ FULL TEXT

The primary objective of these European evidence-based guidelines is to provide a set of recommendations that can support existing and future national and international guidelines or future updates of existing guidelines.
Refer also to their 55-page document:   Amended version

European Guidelines for the Management of
Chronic Nonspecific Low Back Pain

European Spine Journal 2006 (Mar);   15 Suppl 2:  S192–300 ~ FULL TEXT

This particular guideline intends to foster a realistic approach to improving the treatment of common (nonspecific) chronic low back pain (CLBP).
Refer also to their 206-page document:   Amended version June 14th 2005
You may also like their:   Backpain Europe website

New Zealand Acute Low Back Pain Guide
New Zealand Guidelines Group. ~ FULL TEXT
Accident Compensation Corporation (ACC), Wellington, New Zealand; October 2004.

This publication replaces the previous New Zealand Acute Low Back Pain Guide and incorporates the Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain. The New Zealand Acute Low Back Pain Guide provides a best practice approach, taking into account relevant evidence, for the effectiveness of treatment of acute low back pain for the prevention of chronic pain and disability. It follows an extensive review of the international literature and wide consultation with professional groups in New Zealand.

Evidence-based Management of Acute Musculoskeletal Pain
Australian Acute Musculoskeletal Pain Guidelines Group (June 2003) ~ FULL TEXT

This document is the outcome of a multi-disciplinary review of the scientific evidence for the diagnosis, prognosis and treatment of acute musculoskeletal pain. The evidence is summarised in the form of a management plan and key messages that may be used to inform practice. The aim in conducting an evidence review is to facilitate the integration of the best available evidence with clinical expertise and the values and beliefs of patients.

Royal College of General Practitioners
Clinical Guidelines for the Management
of Acute Low Back Pain

Royal College of General Practitioners ~ December 2001

This is Britian's follow-up to:   Bigos, Stanley J et al. “Acute Low Back Problems in Adults” released December 2001. Their comments on spinal manipulation were: “In acute and sub-acute back pain, manipulation provides better short-term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared.” AND “The risks of manipulation for low back pain are very low, provided patients are selected and assessed properly and it is carried out by a trained therapist or practitioner. Manipulation should not be used in patients with severe or progressive neurological deficit in view of the rare but serious risk of neurological complication.”

British Occupational Health Guidelines for the Management
of Low Back Pain at Work –– Principal Recommendations

Faculty of Occupational Medicine, London ~ March 2000

Disability from back pain in people of working age is one of the most dramatic failures of health care in recent years. Its greatest impact is on the lives of those affected and their families. This review and the guidelines based on it aim to reduce the toll of harm by providing a new approach to back pain management at work which is based on the best available scientific evidence and uses this to make practical recommendations on how to tackle the occupational health aspects of the problem.

Low-Back Pain:   Frequency, Management and Prevention
DIHTA - Danish Institute for Heath Technology Assessment ~ January 1999
The Danish Institute for Health Technology Assessment (DIHTA) describes LBP, then labels treatments in 3 categories: Generally recommended, recommended in certain conditions, or not recommended. The FIRST recommended “treatment” is manual therapy (which includes chiropractic).

Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain:
Risk Factors for Long–Term Disability and Work Loss

New Zealand Guidelines Group ~ 1997

This guide is to be used in conjunction with the New Zealand Acute Low Back Pain Guide. It provides an overview of risk factors for long–term disability and work loss, and an outline of methods to assess these at risk. Identification should lead to appropriate early management targeted towards the prevention of chronic pain and disability.

Evaluation of the Low Back Industrial Injury
California Industrial Medical Council ~ April 17, 1997
Low back problems are common among workers. In the majority of injured workers with low back problems, recovery occurs within the first month of symptoms. Those who have not improved at the end of one month of treatment may need further diagnostic evaluation and consideration of other treatment options. Management of low back problems in injured workers includes consideration of environmental and personal factors which may be causing or aggravating the problem, as well as providing appropriate treatment that leads to a return to productive work.

Manga Guidelines August 1993 & February 1998
Pran Manga, Ph.D., Professor of Health Economics @ University of Ottawa

Includes the original 1993 and the updated 1998 recommendations to the Canadian Government about inclusion of chiropractic in their Health Care System..

Chiropractic Care for Common Industrial Low Back Conditions
Chiropractic Technique 1993 (Aug);   5 (3):   119–125 ~ FULL TEXT

This is the first guideline I have seen which actually states the number of visits which may be appropriate for a variety of common low back conditions.   I have used these “Care Plans” for years, presenting them to third party's as a “working diagnosis” care plan, which need ongoing “fine tuning” during patient care. Check out this Chiropractic Technique article, and the attached care plans, which have been released exclusively to Chiro.Org by the National College of Chiropractic. Thanks, Dana! You will find other information like this in the GUIDELINES Section.

Guidelines for Chiropractic Quality Assurance and Practice Parameters --
Major Recommendations
  (The Mercy Conference)
Aspen Publishers ~ 1993

This outline of the “Mercy Center” Consensus Statement covers history and exam, diagnostic imaging, instrumentation (including Questionnaires, Algometry, Inclinometers and Thermography), clinical laboratory recommendations, and a detailed section on record keeping and patient consent.
You can purchase a copy of it right here


Council on Chiropractic Guidelines and Practice Parameters   (CCGPP)
The Low Back Pain Guidelines

Clinical Practice Guideline:
Chiropractic Care for Low Back Pain

J Manipulative Physiol Ther. 2016 (Jan);   39 (1):   1–22 ~ FULL TEXT

To facilitate best practices specific to the chiropractic management of patients with common, primarily musculoskeletal disorders, the profession established the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) in 1995. [6] The organization sponsored and/or participated in the development of a number of “best practices” recommendations on various conditions. [21-32] With respect to chiropractic management of LBP, a CCGPP team produced a literature synthesis [8] which formed the basis of the first iteration of this guideline in 2008. [9] In 2010, a new guideline focused on chronic spine-related pain was published, [12] with a companion publication to both the 2008 and 2010 guidelines published in 2012, providing algorithms for chiropractic management of both acute and chronic pain. [10] Guidelines should be updated regularly. [33, 34] Therefore, this article provides the clinical practice guideline (CPG) based on an updated systematic literature review and extensive and robust consensus process. [9-12]

Algorithms for the Chiropractic Management of Acute and
Chronic Spine-Related Pain

Topics in Integrative Health Care 2012 (Dec 31);   3 (4) ~ FULL TEXT

The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain. [1-3]

Management of Chronic Spine-Related Conditions:
Consensus Recommendations of a Multidisciplinary Panel

J Manipulative Physiol Ther 2010 (Sep);   33 (7):   484–492 ~ FULL TEXT

A multidisciplinary panel of experienced practitioners was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for complex patients with chronic spine-related conditions, based on both the scientific evidence and their clinical experience.

Chiropractic Management of Low Back Disorders:
Report From a Consensus Process

J Manipulative Physiol Ther 2008 (Nov);   31 (9):   651–658 ~ FULL TEXT

A broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience.

Chiropractic Management of Low Back Pain and Low Back-Related
Leg Complaints: A Literature Synthesis

J Manipulative Physiol Ther 2008 (Nov);   31 (9):   659–674 ~ FULL TEXT

As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence.   There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.
You will also enjoy the Original CCGPP LBP Document


AHCPR's “Acute Low Back Problems in Adults” Series      

Acute Low Back Problems in Adults   (Clinical Guide)
Bigos, Stanley J et al.
December 1994 (AHCPR Publication No. 95–0642).
U.S. Agency for Health Care Policy and Research

Acute Low Back Problems in Adults   (Quick Reference Guide)
Bigos, Stanley J et al.
December 1994 (AHCPR Publication No. 95–0643).
U.S. Agency for Health Care Policy and Research

Understanding Acute Low Back Problems   (Consumer/Patient Guideline)
Bigos, Stanley J et al.
December 1994 (AHCPR Publication No. 95-0644).
U.S. Agency for Health Care Policy and Research

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Updated 11–21–2017

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