Chapter 3. European Guidelines for the management of acute non-specific low back pain in primary care [2004]

The Kovacs Foundation, Palma, Balearic Islands, Spain
European Spine Journal (Impact Factor: 2.07). 04/2006; 15 Suppl 2(Suppl. 2):S169-91. DOI: 10.1007/s00586-006-1071-2
Source: PubMed


Summary of recommendations for diagnosis of acute nonspecific 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 nonspecific 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 nonspecific 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 adding a short course of muscle relaxants on its own or added to NSAIDs, if paracetamol or NSAIDs have failed to reduce pain 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 subacute low back pain and sick leave for more than 4-8 weeks.

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    • "Guidelines for the management of PGP have been produced [8], but do not provide guidance for pregnancy-related LBP or combined LBP and PGP. Similarly, guidelines for the management of patients with LBP are limited to 'non-specific LBP', and do not include pregnancy-related LBP [9] [10]. A recent systematic review concluded that there is lowquality evidence that exercise reduces pain and disability from back pain alone, and moderate-quality evidence that acupuncture or exercise, tailored to the stage of pregnancy, reduces evening pelvic or lumbo-pelvic pain. "
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    ABSTRACT: Pregnancy-related low back pain (LBP) is very common. Evidence from a systematic review supports the use of exercise and acupuncture, although little is known about the care received by women with pregnancy-related back pain in the UK. To describe current acupuncture and standard care management of pregnancy-related LBP by UK physiotherapists. Cross-sectional survey of physiotherapists with experience of treating women with pregnancy-related LBP from three professional networks of the Chartered Society of Physiotherapy. In total, 1093 physiotherapists were mailed a questionnaire. The questionnaire captured respondents' demographic and practice setting information, and experience of managing women with pregnancy-related back pain, and investigated the reported management of pregnancy-related LBP using a patient case vignette of a specific, 'typical' case. The overall response rate was 58% (629/1093). Four hundred and ninety-nine physiotherapists had experience of treating women with pregnancy-related LBP and were included in the analysis. Most respondents worked wholly or partly in the UK National Health Service (78%). Most respondents reported that they treat patients with pregnancy-related LBP in three to four one-to-one treatment sessions over 3 to 6 weeks. The results show that a range of management strategies are employed for pregnancy-related LBP, and multimodal management is common. The most common reported treatment was home exercises (94%), and 24% of physiotherapists reported that they would use acupuncture with the patient described in the vignette. This study provides the first robust data on the management of pregnancy-related LBP by UK physiotherapists. Multimodal management is common, although exercise is the most frequently used treatment for pregnancy-related LBP. Acupuncture is used less often for this patient group. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.
    Full-text · Article · Apr 2015 · Physiotherapy
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    • "Low back pain (LBP) is defined as pain located below the costal margin and above the inferior gluteal folds [1]. Specific causes of LBP are uncommon, accounting for less than 15% of all back pain [2]. "
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    ABSTRACT: Objectives: Nonspecific neck pain is common, disabling, and costly. The objective of the current review was to assess the effectiveness of osteopathic manipulative treatment (OMT) in the management of chronic nonspecific neck pain regarding pain, functional status, and adverse events. Study selection: A systematic literature search unrestricted by language was performed in March 2014 in several electronic databases and in databases of ongoing trials. A manual search of reference lists and personal communication with experts identified additional studies. Only randomized clinical trials were included, and studies of specific neck pain or single treatment techniques were excluded. Primary outcomes were pain and functional status, and secondary outcome was adverse events. Data extraction: Studies were independently reviewed using a standardized data extraction form. Mean difference (MD) or standard mean difference (SMD) with 95% confidence intervals (CIs) and overall effect size were calculated for primary outcomes. GRADE was used to assess quality of the evidence. Data synthesis: Of 299 identified studies, 18 were evaluated and 15 excluded. The 3 reviewed studies had low risk of bias. Moderate-quality evidence suggested OMT had a significant and clinically relevant effect on pain relief (MD: -13.04, 95% CI: -20.64 to -5.44) in chronic nonspecific neck pain, and moderate-quality evidence suggested a non-significant difference in favour of OMT for functional status (SMD: -0.38, 95% CI: -0.88 to 0.11). No serious adverse events were reported. Conclusion: Based on the 3 included studies, the review suggested clinically relevant effects of OMT for reducing pain in patients with chronic nonspecific neck pain. Given the small sample sizes, different comparison groups, and lack of long-term measurements in the few available studies, larger, high-quality randomized controlled trials with robust comparison groups are recommended.
    Full-text · Article · Aug 2014 · BMC Musculoskeletal Disorders
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    • "Even the Physical Therapy Journal sponsored by the APTA has used acupuncture and dry needling interchangeably in a recent publication.52 It would therefore be a mistake to ignore the findings of high-quality, randomized controlled trials,37,40,53,54,63,81,84,89,90,92,99,100,107,114,115,119,125,132,143 systematic reviews,17,19,23,56,83,97,121,144 meta-analyses,24,85 Cochrane reviews,62,108,145 the British practice guidelines,124 the European practice guidelines,146,147 and the joint clinical practice guidelines from the American College of Physicians and the American Pain Society117 simply because they used the term ‘acupuncture’ instead of dry needling in their title and/or methods section. Moreover, ignoring RCTs published by PhD and licensed acupuncturists (LAc) in well-respected, peer-reviewed journals would be shortsighted. "
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    ABSTRACT: Background: Wet needling uses hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants, botulinum toxins, or other agents. In contrast, dry needling requires the insertion of thin monofilament needles, as used in the practice of acupuncture, without the use of injectate into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue. Dry needles may also be inserted in the vicinity of peripheral nerves and/or neurovascular bundles in order to manage a variety of neuromusculoskeletal pain syndromes. Nevertheless, some position statements by several US State Boards of Physical Therapy have narrowly defined dry needling as an ‘intramuscular’ procedure involving the isolated treatment of ‘myofascial trigger points’ (MTrPs). Objectives: To operationalize an appropriate definition for dry needling based on the existing literature and to further investigate the optimal frequency, duration, and intensity of dry needling for both spinal and extremity neuromusculoskeletal conditions. Major findings: According to recent findings in the literature, the needle tip touches, taps, or pricks tiny nerve endings or neural tissue (i.e. ‘sensitive loci’ or ‘nociceptors’) when it is inserted into a MTrP. To date, there is a paucity of high-quality evidence to underpin the use of direct dry needling into MTrPs for the purpose of short and long-term pain and disability reduction in patients with musculoskeletal pain syndromes. Furthermore, there is a lack of robust evidence validating the clinical diagnostic criteria for trigger point identification or diagnosis. High-quality studies have also demonstrated that manual examination for the identification and localization of a trigger point is neither valid nor reliable between-examiners. Conclusions: Several studies have demonstrated immediate or short-term improvements in pain and/or disability by targeting trigger points (TrPs) using in-and-out techniques such as ‘pistoning’ or ‘sparrow pecking’; however, to date, no high-quality, long-term trials supporting in-and-out needling techniques at exclusively muscular TrPs exist, and the practice should therefore be questioned. The insertion of dry needles into asymptomatic body areas proximal and/or distal to the primary source of pain is supported by the myofascial pain syndrome literature. Physical therapists should not ignore the findings of the Western or biomedical ‘acupuncture’ literature that have used the very same ‘dry needles’ to treat patients with a variety of neuromusculoskeletal conditions in numerous, large scale randomized controlled trials. Although the optimal frequency, duration, and intensity of dry needling has yet to be determined for many neuromusculoskeletal conditions, the vast majority of dry needling randomized controlled trials have manually stimulated the needles and left them in situ for between 10 and 30 minute durations. Position statements and clinical practice guidelines for dry needling should be based on the best available literature, not a single paradigm or school of thought; therefore, physical therapy associations and state boards of physical therapy should consider broadening the definition of dry needling to encompass the stimulation of neural, muscular, and connective tissues, not just ‘TrPs’.
    Full-text · Article · Aug 2014 · Physical Therapy Reviews
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