GUIDELINES FOR ACUTE NONSPECIFIC
LOW BACK PAIN
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 inclu-
ding neurological screening when appropriate
• Undertake diagnostic triage at the first assessment as basis for
• 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
• 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
European guidelines for
the management of acute nonspecific
low back pain in primary care
* 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)
Maria Teresa Gil del Real
Public Health Physician
Orthopaedic / anesthesiologist
Maurits van Tulder*
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 non-
specific 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.
The target population of the guidelines consists of individuals or groups that
are going to develop new guidelines or update existing guidelines, and their pro-
fessional 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, phy-
siotherapists, chiropractors, manual therapists, occupational physicians, ortho-
paedic surgeons, rheumatologists, rehabilitation physicians, neurologists,
anaesthesiologists and other health care providers dealing with patients suffe-
ring 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, Co-
ordination 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
The main evidence was not systematically reviewed again for the pur-
pose 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 recommenda-
tions 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
(www.evidence.org). 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 consu-
mers websites) and identified guidelines by personal communication with
experts in the field.
A three-stage development process was undertaken. First, recom-
mendations 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 recommenda-
tions 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
Several of the existing systematic reviews have included non-English
language literature, usually publications in French, German, and Dutch lan-
guage and sometimes also Danish, Norwegian, Finnish and Swedish. All exist-
ing 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.
the BMJ Publishing Group
Recommendations for future research:
• There is an urgent need for validated instruments to assess psychosocial risk
• There is a need to identify the relative effect of specific types of or compo-
nents 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
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