Table 1 Clinical guidelines recommendations regarding diagnosis of low back pain

2078

Country Patient population Diagnostic classification Physical examination Imaging Psychosocial factors

123
Australia (2003) Acute (\3 months) Non-specific low back pain Conduct physical examination Not recommended unless Yellow flags associated with the
(divided into acute, to assess for the presence of alerting features of progression from acute to
subacute and chronic) serious conditions serious conditions are chronic should be assessed early
Specific low back pain Neurological examination in present to facilitate intervention
case it is suspected. (Physical
examination such as
inspection, range of motion
and posture may have low
reliability and validity and
should be used with caution)
Austria (2007) Acute (0–6 week), Non-specific LBP Inspection, palpation, range of Not useful in the first Evaluate psychosocial factors in
subacute (6–12 week) Specific LBP (based on list motion testing of lumbar 4 weeks of an episode patients who do not show
chronic ([12 week), of red flags) spine, neurological screening After 4–6 weeks may be improvement over time (with
and recurrent (strength, reflexes, indicated in search for a recommended treatment) and in
Including high-grade
sensibility, SLR) specific cause patients with recurrent LBP
spondylolisthesis, facet
arthrosis, severe
degenerative disc disease
Canada (2007) Acute, subacute and Simple back pain Physical examination in Not recommended for Assess patients’ perceived
persistent Back pain with patients with back pain and simple low back pain but disability and probability to
neurological involvement neurological involvement recommended for pain return to usual activity after
includes SLR, motor, with neurological 4 weeks of disability or at first
Back Pain with suspected
sensitivity, reflex signs involvement and consultation if patient has a
serious pathologies
suspected serious history of long-lasting back-
All divided into acute, pathology. MRI and CT related disability (Symptom
subacute and persistent scans recommended if Check List Back Pain Prediction
surgery is in question Model)
Europe (2006) Acute (\6 weeks) and Serious spinal pathology Physical assessment including Diagnostic imaging tests Assess for psychosocial factors
subacute (6– Nerve root pain/radicular neurological screening when (including X-rays, CT and and review them in detail if there
12 weeks) LBP pain appropriate MRI) are not routinely is no improvement
indicated for non-specific
Non-specific low back pain
low back pain
Europe (2006) Chronic LBP Specific spinal pathology Diagnostic triage, neuro- No radiographic imaging ‘We recommend the assessment of
([12 weeks) Nerve root pain/radicular screening MRI in case of red flags prognostic factors (yellow flags)
pain ‘We cannot recommend spinal in patients with chronic low back
X-ray in case of suspected
palpatory and range of pain’
Non-specific low back pain structural deformities
motion tests in the diagnosis
of chronic low back pain’
Eur Spine J (2010) 19:2075–2094
 Table 1 continued
Country Patient population Diagnostic classification Physical examination Imaging Psychosocial factors

Finland (2008) Acute, subacute and Non-specific LBP Inspection, palpation, spinal No imaging in first 6 weeks A list of psychosocial factors
chronic LBP Nerve root dysfunction mobility (flexion), SLR-test, Plain lumbar X-ray is basic (yellow flags) is included in the
(sciatic syndrome, strength, reflexes investigation before other guideline
intermittent claudication) imaging studies Assess illness behaviour,
Possible serious or specific MRI is first-line imaging depression in subacute LBP
disease investigation if special
examinations are needed
Eur Spine J (2010) 19:2075–2094

France (2000) Acute low back pain Acute & Chronic: Acute: Acute: Acute and Chronic:
\3 months Non-specific low back pain To rule out ‘‘so-called Not to be ordered in the first Recommended to assess
Chronic So-called symptomatic symptomatic acute low back 7 weeks except when the psychosocial factors
‘‘uncomplicated’’ low acute low back pain with pain’’ or emergencies treatment selected
back pain [3 months or without sciatica Rating of muscle strength (manipulation,
(fracture, neoplasm, infiltration) requires
Chronic:
infection, inflammatory formal elimination of
Musculoskeletal and specific form of low back
disease)
neurological examination to pain
Diagnostic and therapeutic identify specific cause
emergencies Chronic:
Assessment of function,
(hyperalgesic sciatica, X-rays not repeated. CT/
anxiety and/or depression
paralysing sciatica, cauda MRI only in exceptional
using validated measure
equina syndrome) circumstances
Germany (2007) Acute, subacute, Non-specific LBP Inspection, palpation, X-ray not useful in acute Evaluate risk factors for chronicity
chronic/recurrent LBP Radicular pain neurological screening; non-specific LBP (yellow flags); including
reflexes, SLR/Lasegue, CT, MRI only in cases with biological, psychological,
Specific LBP (based on red
sensibility, strength suspected radicular pain, occupational, lifestyle, and
flags)
Further investigation (e.g. lab or stenosis, or specific iatrogenic factors
Patients at risk for
testing) is based on red flags pathology such as
chronicity (based on
tumours
yellow flags)
After 6 weeks persistent
pain X-ray may be
indicated or after
6–8 weeks an MRI
Italy (2006) Acute, subacute and Non-specific LBP Pain/functional limitation on Useless for non-specific Screening after 2 weeks: yellow
chronic LBP Specific LBP trunk movement acute LBP flags, Waddell test (for pain
Palpation Option after 4–6 weeks if behaviour)
Sciatica
Postural evaluation surgery is indicated
(sciatica)
Neurological exam is
recommended (SLR,
sensibility)
2079

123
 Table 1 continued
2080

Country Patient population Diagnostic classification Physical examination Imaging Psychosocial factors

123
New Zealand (2004) Acute LBP (\3 months) Non-specific LBP Neurological screening Investigations in first Screen for yellow flags with the
Specific pathologic change Establish degree of functional 4–6 weeks do not provide Acute Low Back Pain Screening
limitation caused by the pain clinical benefit unless Red Questionnaire, and if at risk,
Flags present clinical assessment
There are risks associated
with unnecessary
radiology
Norway (2007) Acute and subacute Non-specific LBP Inspection, posture, deformity, Not recommended in acute, A list of yellow flags is presented
(\3 months) Radicular pain Spinal mobility, including subacute chronic LBP and as risk factors for chronicity, sick
Chronic ([3 months) finger-to-floor distance, radicular pain in the leave
Serious pathologies/acute
Neurological screening absence of red flags,
neurological conditions
(SLR/Lasegue) if radicular Recommended in case of
(Cauda equina syndrome)
pain is suspected red flag
First choice is MRI
Spain (2005) Non-specific acute, Specific spinal pathology Clinical history, red flags. Do Not useful in non-specific Assess psychological factors in 2–
subacute and chronic Nerve root pain/radicular not recommend palpation and LBP; X-rays, CT and 6 weeks after treatment if not
pain tests of intervertebral MRI use only in case of improving. Assess physiological
mobility red flags factors as prognostic factor only
Non-specific low back pain
The Netherlands (2003) Acute (0–12 week) and Non-specific LBP SLR-test, neurological Not useful in non-specific Assessment of psychosocial
chronic ([12 week) Specific LBP (based on a inspection; loss of motor acute LBP factors (yellow flags) is
LBP list of red flags) control, sensibility, miction. recommended. These include
Palpation of spine, Inspection emotional reaction, cognitions
of lumbar kyphosis or and behaviour
flattened lumbar lordosis
United Kingdom (2008) Acute \6 weeks, sub Non-specific low back pain: Rule out serious pathology Does not inform Recognise and manage
acute 6–12 weeks, Mechanical low back pain (identify red flags) management of non- psychosocial barriers (yellow
chronic [3 months Inflammatory low back pain Confirm pain is in the lower specific low back pain but flags) to recovery
and stiffness back, is mechanical, not may be indicated to rule
inflammatory in/out serious pathologies
Serious pathology
United States (2007) Acute and chronic LBP Non-specific LBP Neurological screening Only where progressive Assessment of psychosocial risk
LBP due to specific causes (including SLR, strength, neurological or serious factors strongly recommended
reflexes, sensory symptoms) pathology is suspected
LBP-Radiculopathy/Spinal
Stenosis Discouraged for non-
specific LBP
Recommended for
radiculopathy or spinal
stenosis only if patients
are potential candidates
for further intervention
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Eur Spine J (2010) 19:2075–2094 2081

US) the measurement of yellow

recommended at a much earlier

In a few guidelines (Netherlands,

recommended. In Germany the

Summary of Common Recommendations for Diagnosis of Low back

flags are now more strongly

pain
* Diagnostic triage (non-specific low back pain, radicular
syndrome, serious pathology).

assessments is now
Psychosocial factors

* Screen for serious pathology using red flags.

* Physical examination for neurologic screening (including straight
leg raising test).
* Consider psychosocial factors (yellow flags) if there is no
stage
improvement.
* Routine imaging not indicated for non-specific low back pain.
(Finland, Germany) now
more explicit statements
regarding the use of CT
In some guidelines

Therapeutic recommendations
and MRI
Imaging

Table 2 compares therapeutic recommendations given in

the various guidelines. Patient advice and information is
recommended in all guidelines. The common message is
that patients should be reassured that they do not have a
serious disease, that they should stay as active as possible
and progressively increase their activity levels. Compared
recommended types of
physical examination

with the previous review, the current guidelines increas-

Physical examination

Almost no change in

ingly mention early return to work (despite having low

back pain) in their list of recommendations.
Recommendations for the prescription of medication
are generally consistent. Paracetamol/acetaminophen is
usually recommended as a first choice because of the
lower incidence of gastrointestinal side effects. Nonste-
roidal anti-inflammatory drugs are the second choice in
diagnostic classifications

cases where paracetamol is not sufficient. There is some

Diagnostic classification

used in the guidelines

variation between guidelines with regard to recommen-

Almost no change in

dations for opioids, muscle relaxants, steroids, antide-

pressant and anticonvulsive medication as co-medication
for pain relief. Where the mode of consumption of anal-
gesics is described, time-contingent rather than pain-
contingent use, is advocated.
There is now broad consensus that bed rest should be
addition to acute LBP.

discouraged as a treatment for low back pain. Some

includes subacute and
recommendations for
More countries (UK,

guidelines state that if bed rest is indicated because of

US) now include
Patient population

chronic LBP in

severity of pain, then it should not be advised for more than

recurrent LBP
Germany now

2 days (e.g., Germany, New Zealand, Spain, Norway). The

Italian guideline advises 2–4 days of bed rest for major
Most apparent changes since 2001

sciatica but does clearly describe how major sciatica differs

from sciatica where bed rest is contraindicated.
There is also consensus that a supervised exercise pro-
France, Italy, Norway,
from countries such as

gramme (as distinct from encouraging resumption of nor-

Addition of guidelines

Spain and a unified

mal activity) is not indicated for acute low back pain.

Table 1 continued

one from Europe

Austria, Canada,

Those guidelines that consider subacute and chronic low

back pain recommend exercise but note that there is no
evidence that one form of exercise is superior to another.
Country

The European guideline advises against exercise that

requires expensive training and machines. The one area of

123
 Table 2 Clinical guidelines recommendations regarding treatment of low back pain
2082

Country Education Medication Exercises Manipulation Bed rest Referral to specialist

123
Australia (2003) [8] Provide information, First choice paracetamol, There is conflicting Conflicting evidence of Not advisable When alerting features (red
assurance and advice second choice NSAIDs, evidence of the effect spinal manipulation flags) or serious
to resume normal third choice oral opioids of exercises but versus placebo in first conditions are present
activity (stay active) Not recommended: evidence shows that it 2–4 weeks
anticonvulsants, is no better than usual
antidepressants, muscle care
relaxants
Austria (2007) [9] Acute LBP: expect a Acute LBP: (1) Acute LBP: Acute LBP: Acute LBP: In case of suspected specific
favourable course; Paracetamol; (2) NSAIDs Not specifically Optional for patients Avoid bedrest LBP; Surgery is optional
maintain normal daily 3) muscle relaxants or weak mentioned in the who do not return to only after 2 years of
(but if necessary,
activities opioids as last option guideline normal level of recommended
only for a short
activity within the first conservative treatment,
Chronic LBP: Options: Chronic LBP: period)
weeks persisting complaints and
NSAIDs/Coxibs; Opioids; Exercise therapy with a surgical indication
Antidepressant; muscle recommended as Chronic LBP:
relaxants; Anti- monotherapy or in Optional for patients
convulsion medication combination with back with persistent
(for radicular pain), school, massage problems with
Capsaicin performing daily
Only for short periods: (1) activities
paracetamol, (2) tramadol
or NSAID, (3) opioids
Canada (2007) [10] Reassurance and advice NSAIDs, muscle relaxants Strengthening exercises, Recommended for Not recommended Refer patients with
to return to work and and analgesics for acute. extension exercises short- term pain neurological signs or
usual activities Low evidence for and specific exercises reduction for acute. symptoms if functional
NSAIDs and analgesics are not recommended Recommended with deficits are persistent or
for subacute pain for acute but low evidence for deteriorating after
recommended for subacute and chronic 4 weeks
subacute and chronic
with no superior form
of exercise
Europe (2006) Reassure and advise Prescribe medication, if Do not advise specific Consider (referral for) Do not prescribe bed Refer patients with
(acute) [11] patients to stay active necessary for pain relief; exercises (for example spinal manipulation rest as a treatment neurological symptoms
and continue normal Preferably to be taken at strengthening, for patients who are such as cauda equina
daily activities regular intervals; first stretching, flexion, and failing to return to syndrome
including work if choice paracetamol, extension exercises) normal activities
possible second choice NSAIDs. for acute low back
Third choice consider pain
short course of muscle
relaxants on its own or
added to NSAIDs
Eur Spine J (2010) 19:2075–2094
 Table 2 continued
Country Education Medication Exercises Manipulation Bed rest Referral to specialist

Europe (2006) Advice and reassurance Recommend use of NSAID Supervised exercise Recommend short Discouraged Most invasive treatments
(chronic) [12] to return to normal for short term pain relief therapy is advisable course of spinal not recommended
activities and opioids in case patient specifically manipulation/ Surgery not recommended
is not responding to other approaches that don’t mobilisation unless in carefully
treatment. Consider the require expensive selected patients, 2 years
use of noradrenergic or training and machines. of all recommended
noradrenergic- Cognitive behavioural conservative treatments
serotonergic approach including including
Eur Spine J (2010) 19:2075–2094

antidepressants as co- graded activity and multidisciplinary

medication for pain relief group therapy are approaches with
advisable combined programmes of
cognitive intervention and
exercises have failed
Finland (2008) [13] Benign nature of Acute/Subacute LBP: (1) Acute LBP: Acute LBP: some Avoid bedrest; Immediate referral: Cauda
condition; prognosis is paracetamol, (2) NSAIDs, Active exercises not effectiveness a short period of equina syndrome, sudden
good; continue (3) adding a weak opiate effective in early Similar effectiveness as bedrest may be massive paresis,
ordinary daily to paracetamol/NSAID. stages GP in subacute LBP necessary due to excruciating pain
activities. Back pain (4) muscle relaxants intense back pain, Referral: serious, non
Light exercises (e.g. Chronic LBP: similar
may recur but even Antidepressant only if clear but bedrest must urgent conditions
walking) can be effectiveness as GP,
then recovery is depression. not be considered
recommended analgesics, Multidisciplinary (bio-
usually good Benzodiazepines not as a treatment of
Subacute: gradually physiotherapy, etc. psycho-social)
recommended back problems rehabilitation focused on
increasing exercises
Chronic LBP Analgesics improving functional
Chronic: Intensive
used periodically, be capacity
training effective for
aware of side effect of
pain and function
NSAIDs (gastrointestinal,
cardiovascular)
France (2000) [14] Short-term education Acute & Chronic: Acute: Acute & Chronic: Acute and Chronic: Acute:
about the back, in Regular simple analgesics, Flexion exercises have Provides short-term Not recommended No recommendation
groups, is not non-steroidal anti- been not been shown benefit. No Chronic:
beneficial inflammatory drugs and to be of benefit. No recommendation for
Recommended
muscle relaxants. No recommendation on one form of manual
physiotherapy/
evidence for systemic extension exercises therapy over another
behavioural therapy/
corticosteroids Chronic: multidisciplinary
Chronic: Additional Physical exercise is programme if non-
recommendations for: recommended, no response to first-line care
acetylsalicylic acid, Level particular type is
II following failure to advocated
respond to Level I and
Level III (strong opioids)
on a case by case basis.
Tetrazepam, Tricyclic
antidepressants
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123
 Table 2 continued
2084

Country Education Medication Exercises Manipulation Bed rest Referral to specialist

123
Germany (2007) [15] Acute LBP: stimulate Acute and Chronic LBP: Acute LBP: Acute LBP: Maximum of 2 days Immediate surgery
daily activities, (1) paracetamol, (2) exercise therapy not Optional within the first bedrest indicated for cauda equina
explain moving is not NSAIDs (oral or topical), effective 4–6 weeks syndrome
dangerous, (3) Muscle relaxants (in Optional referral for
Subacute and Chronic Chronic LBP: option if
Chronic LBP more cases with muscle spasms, LBP: Exercise therapy shortlasting surgery: therapy resistant
intense psychotherapy (4) Opioids well supported by ([6 weeks) ? signs of
indicated in case of evidence nerve root compression
psychological co- Surgery may be an option if
morbidity after 2 years conservative
treatment, including
biopsychosocial treatment
programme was
unsuccessful
Italy (2006) [16] Give information and Paracetamol as preferred Acute LBP After 2–3 weeks and Discouraged for Radiculopathy and
reassurance about drug No specific exercises before 6 weeks, acute LBP, except suspicion of specific
possible cause, NSAIDs recommended recommended prescribed by 2–4 days for major causes
provoking factors, risk physicians, done by sciatica Multidisciplinary psycho-
Muscle relaxants no Chronic LBP
factors, and structural trained therapists Contraindicated for social intervention for
additional effect Individual specific
or postural alterations, Chronic LBP: sciatica patients at high risk of
reassurance about Steroids not recommended exercises
Consider for pain relief No recommended in chronicity and chronic
good prognosis, keep in acute LBP, but can be
Chronic LBP pain
active and if possible, useful for a short time in
stay at work sciatica
Tramadol and adding light
opioid to paracetamol
may be useful for sciatica
New Zealand (2004) Advise to stay active Paracetamol and NSAIDs Specific back exercises First 4–6 weeks only Bed rest [2 days Suspicion of specific causes
[17] and working, or early recommended not helpful May provide short-term harmful (red flags), cauda equina
return to work, Opiates or diazepam may symptom control syndrome, or after
reassurance be harmful 4–8 weeks
Education pamphlets
not helpful
Norway (2007) [18] Stay active, return to (1) Paracetamol No specific exercises in After 1-2 weeks for pain Not recommended Referral within primary
normal activity (2) NSAID the first weeks reduction and In rare cases, not care for cognitive
including work asap, In chronic LBP improvement of longer than 2– behavioural treatment is
(3) Paracetamol ? opioid
exercises are function (for small to 3 days optional
or Tramadol
recommended moderate effects) Referral for surgical
(4) Antidepressants in cases
intervention after 2 years’
with depression
LBP
Eur Spine J (2010) 19:2075–2094
 Table 2 continued
Country Education Medication Exercises Manipulation Bed rest Referral to specialist

Spain (2005) [19] Reassurance and advice Paracetamol every 6 h, can Exercise as far as pain Not recommended Discouraged unless Refer patient in case of red
to stay active also be associated with allows including work patient can not flags
opioids and NSAID activities. As there is adopt another
although the last one no evidence for any posture. Then bed
should not be prescribed specific type of rest for the
for longer than 3 months exercise, choose the maximum of 48 h
Opioids are indicated for one that patients
patients with high levels prefer. Not indicated
Eur Spine J (2010) 19:2075–2094

of pain who did not for patients with pain

improve with usual care for less than 6 weeks
The Netherlands (2003) Acute and Chronic Acute LBP: Acute LBP: Acute and Chronic Acute and Chronic Chronic LBP: Refer
[20] LBP: (1) Paracetamol Consider after 4– LBP: LBP: Avoid patients with severe
Stay active as much as 6 weeks for patients Option as part of an bedrest disability who do not
(2) NSAIDs,
possible (despite the who do not improve activating strategy for respond to recommended
(3) muscle relaxants or conservative treatments
pain), increase activity their functioning patients who do not
weak opioids or for multidisciplinary
level on a time Chronic LBP: show a favourable
combinations with treatment focused on
contingent basis Recommended are course
paracetamol/NSAIDS as functional recovery
last option due to side time-contingent,
effects varying and
supervised exercises
Chronic LBP: Only for
focused at improving
short periods:
function
(1) Paracetamol,
(2) Tramadol or NSAID,
(3) Opioids
United Kingdom (2008) Provide information and Regular paracetamol Advise patient to stay as No recommendations Acute LBP: If progressive neurological
[21] advice to foster (preferred) or NSAID as active as possible. No included Rest in bed is less deficit
positive attitude and first line care. For specific effective than If pain or disability remain
realistic additional analgesia recommendations staying active problematic for more than
expectations—back combine paracetamol and regarding exercise a week or two consider
pain is not serious, NSAID or add a weak referral for physio/
temporary, tends to opioid (codeine or physical therapy
recur, physical not tramadol). For non-
If pain/disability continue
psychological, responders consider
to be a problem despite
mechanical. Stay benzodiazepine, tricyclic
pharmacotherapy and
active as possible antidepressant
physical therapy consider
Not recommended: Topical referral to
NSAIDs, antiepileptic multidisciplinary back
drugs (other than pain service or chronic
gabapentin), herbal pain clinic
remedies
2085

123
 Table 2 continued
2086

Country Education Medication Exercises Manipulation Bed rest Referral to specialist

123
United States (2007) Provide information on Paracetamol, NSAIDs Not effective for acute For acute LBP if not Even if required for For interdisciplinary
[22] prognosis, staying recommended as first-line LBP improving severe symptoms, intervention if chronic
active, self drugs Recommended for patients should be If suspicion of significant
management For acute (\4 weeks)— subacute or chronic encouraged to nerve root impingement
Self-care education muscle relaxants, LBP return to normal or spinal stenosis
books recommended benzodiazepines, activities as soon
tramadol, opioids as possible
For subacute or chronic
([4 weeks)—
antidepressants,
benzodiazepines,
tramadol, opioids
Most apparent changes since 2001
The advice to stay No change regarding The advice that exercise Recommendations for The The recommendations for
active remains similar. recommendation of therapy is not useful in spinal manipulation, recommendation referral appear more
Now some guidelines paracetamol and NSAIDs acute LBP has not the timing of against bedrest is explicit regarding : (1)
(european, NZ, as first-line treatments and changed application and target fairly consistent immediate referral (cauda
Canada, Italy, recommendation Now more explicit group continue to vary between 2001 and equina syndrome), (2)
Norway) explicitly regarding muscle recommendations in now medical specialist in case
mention continuation/ relaxants favour of exercise of red flags, (3) referral
early RTW Now more often explicit therapy in subacute within primary care
recommendations (for or and chronic LBP (physiotherapy/cognitive
against) anti-depressants, behavioural therapy, (4)
opioids, benzodiazepines multidisciplinary
and combinations of treatments and (5)
medications consider surgery if
2 years of recommended
conservative care has
failed
Eur Spine J (2010) 19:2075–2094