EUROPEAN GUIDELINESFOR THE MANAGEMENT OF CHRONICNON-SPECIFIC LOW BACK PAIN
November 2004
O Airaksinen
J Hildebrandt
AF Mannion
H Ursin

JI Brox
J Klaber-Moffett
S ReisG Zanoli

C Cedraschi
F Kovacs
JB Staal

On behalf of the COST B13 Working Group on Guidelines for Chronic Low Back
Pain
Contributors:
Jan Hildebrandt

Anaesthesiologist/Algesiologist (DE) Chair + Chapters Multidisciplinary treatment,
Pharmacological procedures (antidepressants, opioids, antiepileptic drugs, capsicum plasters),
Injections and nerve blocks, Radiofrequency and electrothermal procedures, Spinal Cord
Stimulation
Holger Ursin
Biological and Medical Psychology (NO) Chair + Chapter Cognitive behavioural therapy
Physiologist/Clinical Researcher (CH) Editor + Chapters Exercise therapy, Manual Therapy
ANNE F. MANNION(manipulation/mobilization), Physical treatments, Brief educational interventions,
Rehabilitation Physician (FI) Chapters Patient assessment (imaging, electromyography),
OLAVI AIRAKSINEN
Pharmacological procedures (NSAIDs, muscle relaxants)
Physical Medicine (NO) Chapters Definition, epidemiology, patient assessment (physicalJENS IVAR BROX
examination and case history), Physical therapy, Manual Therapy (manipulation/mobilization)
Psychologist (CH) Chapters Cognitive behavioural therapy, Brief educational interventions
CHRISTINE CEDRASCHIJENNIFER KLABER-MOFFETT Rehabilitation/Physiotherapist (UK) Chapters Exercise therapy, Manual Therapy(manipulation/mobilization), Brief educational interventions
General practitioner (ES) Chapters Manual Therapy (manipulation/mobilization),
FRANCISCO KOVACS
Neuroreflexotherapy, Traction, Acupuncture
SHMUEL REIS
General practitioner (IL)
Epidemiologist/Physiotherapist (NL) Chapters Physical treatments, Manual Therapy
BART STAAL(Massage), PENS, Back schools, Brief educational interventions
Orthopaedic Surgeon (IT) Chapter Surgery
GUSTAVO ZANOLIMEMBERS WHO PARTICIPATED IN THE FIRST MEETINGS
LUC BROOS

Physical Medicine(BE)

IRENE JENSEN

Psychologist(SE)

MARTIN KRISMER

Orthopaedic surgeon(AT)

CHARLOTTE LEBOEUF-YDE

Epidemiologist(DK)

WILHELM NIEBLING

General practitioner(DE)

JOHAN VLAEYEN

Psychologist

(BE)

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ADDITIONAL CONTRIBUTORS TO THE GUIDELINES’ DOCUMENT
University of Bergen, Norway
STAFF AND STUDENTS OF
DEPT. OF BIOL & MED PSYCHAND HALOS/UNIFOB

Administrative and technical assistance.

DAVID O’RIORDON

Schulthess Klinik, Zürich

Assistance with summaries and quality rating of
exercise trials; assistance with literature management

EMMA HARVEY

University of Leeds

Assistance cross-checking the SRs/RCTs on exercise

JO JORDAN
KATHERINE DEANE

Chartered Soc Physio, UK
Uni Northumbria, UK

Assistance with summaries and quality rating foradditional exercise trials

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Objectives
The primary objective of the European evidence-based guidelines is to provide a setof recommendations that can support existing and future national and internationalguidelines or future updates of existing back pain guidelines.
This particular guideline intends to foster a realistic approach to improving thetreatment of common (non-specific) chronic low back pain (CLBP) in Europe by:
1. Providing recommendations on strategies to manage chronic low back pain
and/or its consequences in the general population and in workers.
2. Ensuring an evidence-based approach through the use of systematic reviews andexisting evidence-based guidelines, supplemented (where necessary) byindividual scientific studies.
3. Providing recommendations that are generally acceptable to a wide range ofprofessions and agencies in all participating countries.
4. Enabling a multidisciplinary approach, stimulating collaboration between thevarious players potentially involved in treatment, thus promoting consistency
across countries in Europe.
5. Identifying ineffective interventions to limit their use.
6. Highlighting areas where more research is needed.

Target population
The target population of this guideline on diagnosis and treatment of chronic nonspecific low back pain comprises individuals or groups that are going to develop new
guidelines (national or local) or update existing guidelines, and their professional
associations that will disseminate and implement these guidelines. Indirectly, theseguidelines also aim to inform the general public, people with low back pain, healthcare providers, health promotion agencies, industry/employers, educationalists, andpolicy makers in Europe.
When using this guideline as a basis, it is recommended that guideline
development and implementation groups should undertake certain actions andprocedures, not all of which could be accommodated under COST B13. These will
include: taking patients’ preferences into account; performing a pilot test amongtarget users; undertaking external review; providing tools for application; consideringorganisational obstacles and cost implications; providing criteria for monitoring andaudit; providing recommendations for implementation strategies (van Tulder et al2004). In addition, in the absence of a review date for this guideline, it will benecessary to consider new scientific evidence as it becomes available.
The recommendations are based primarily on the available evidence forthe effectiveness and safety of each treatment. Availability of the treatments acrossEurope will vary. Before introducing a recommended treatment into a setting where it
is not currently available, it would be wise to consider issues such as: the special
training needs for the treating clinician; effect size for the treatment, especially withrespect to disability (the main focus of treatments for CLBP); long-termcost/effectiveness in comparison with currently available alternatives that use asimilar treatment concept.

Guidelines working group
The guideline group on chronic, non-specific low back pain was developed within theframework 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(WG) consisted of experts in the field of low back pain research. Members wereinvited to participate, to represent a range of relevant professions. The core group3

consisted of three women and eight men from various disciplines, representing 9
countries. None of the 11 members believed they had any conflict of interest.
The WG for the chronic back pain guidelines had its first meeting in May 2001 in
Amsterdam. At the second meeting in Hamburg, in November 2001, five sub-groups
were formed to deal with the different topics (patient assessment; medical treatment
and invasive interventions; exercise and physical treatment and manual therapy;
cognitive behavioural therapy and patient education; multidisciplinary interventions).
Overall seven meetings took place, before the outline draft of the guidelines was
prepared in July 2004, following which there was a final meeting to discuss andrefine this draft. Subsequent drafts were circulated among the members of theworking group for their comments and approval. All core group members contributed
to the interpretation of the evidence and group discussions. Anne Mannion played amajor role in editing (language and content) the whole document in the final stages.
The guidelines were reviewed by the members of the Management Committee of
COST B13, in Palma de Mallorca on 23rd October 2004. The full guidelines areavailable at: www.backpaineurope.org

References
1. van Tulder MW, Tuut M, Pennick V, Bombardier C, Assendelft WJ (2004) Qualityof primary care guidelines for acute low back pain. Spine, 29(17): E357-62.

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Summary of the concepts of diagnosis in chronic low back pain (CLBP)• Patient assessment
Physical examination and case history:
The use of diagnostic triage, to exclude specific spinal pathology and nerve root
pain, and the assessment of prognostic factors (yellow flags) are recommended.
We cannot recommend spinal palpatory tests, soft tissue tests and segmental
range of motion or straight leg raising tests (Lasegue) in the diagnosis of nonspecific CLBP.
Imaging:
We do not recommend radiographic imaging (plain radiography, CT or MRI),
bone scanning, SPECT, discography or facet nerve blocks for the diagnosis of
non-specific CLBP unless a specific cause is strongly suspected.
MRI is the best imaging procedure for use in diagnosing patients with radicularsymptoms, or for those in whom discitis or neoplasm is suspected.
Electromyography:
We cannot recommend electromyography for the diagnosis of non-specific
CLBP.
• Prognostic factors
Assessment of work related factors, psychosocial distress, depressive mood,severity of pain and functional impact, prior episodes of LBP, extreme symptom
reporting and patient expectations should be included in the diagnosis ofpatients with non-specific CLBP.

Summary of the concepts of treatment of chronic low back pain (CLBP)• Conservative treatments:
Cognitive behavioural therapy, exercise therapy, brief educational interventions,and multidisciplinary (bio-psycho-social) treatment can each be recommended
for non-specific CLBP. Back schools, and short courses of manipulation canalso be considered. The use of physical therapy (TENS, heat/cold, traction,laser, ultrasound, short wave, interferential, massage, corsets) cannot berecommended.
• Pharmacological treatments:
Noradrenergic or noradrenergic-serotoninergic antidepressants, weak opioids
and the short term use of NSAIDs, muscle relaxants and capsicum plasters canbe recommended for pain relief; strong opioids can be considered in patients
who do not respond to all other treatment modalities.
• Invasive treatments:
Acupuncture, epidural corticosteroids, intra-articular (facet) steroid injections,
local facet nerve blocks, intradiscal injections, trigger point injections, botulinum
toxin, prolotherapy, radiofrequency facet denervation, intradiscal radiofrequency
lesioning, intradiscal electrothermal therapy, radiofrequency lesioning of thedorsal root ganglion, and spinal cord stimulation cannot be recommended for
CLBP. Percutaneous electrical nerve stimulation (PENS) and neuroreflextherapy
can be considered where available.
Surgery for non-specific CLBP cannot be recommended unless 2 years of allother recommended conservative treatment (inclusive multidisciplinary
approaches with combined programs of cognitive intervention and exercises)
have failed, or such combined programs are not available, and only then in
carefully selected patients.

5Overarching comments• In contrast to acute low back pain, only very few guidelines exist for the
management of CLBP.
• CLBP is not a clinical entity and diagnosis, but rather a symptom in patients withvery different stages of impairment, disability and chronicity. Therefore
assessment of prognostic factors before treatment is essential.
• Overall, there is limited positive evidence for numerous aspects of diagnostic
assessment and therapy in patients with non-specific CLBP.
• In cases of low impairment and disability, simple evidence-based therapies (i.e.
exercises, brief interventions, and medication) are sufficient.
• No single intervention is likely to be effective in treating the overall problem of
CLBP of longer duration and more substantial disability, owing to its
multidimensional nature.
• For most therapeutic procedures, the effect sizes are rather modest.
• The most promising approaches seem to be cognitive-behavioural interventions
encouraging activity/exercise.
• It is important to get all the relevant players onside and to provide a consistent
approach.

Summary of recommendations for further research
In planning further research in the field of chronic non-specific low back pain, thefollowing issues/areas requiring particular attention should be considered.
Methodology• Studies of treatment efficacy/effectiveness should be of high quality, i.e. where
possible, in the form of randomised controlled trials.
• Future studies should include cost-benefit and risk-benefit analyses.
General considerations• Studies are needed to determine how and by whom interventions are bestdelivered to specific target groups.
• More research is required to develop tools to improve the classification andidentification of specific clinical sub-groups of CLBP patients. Good quality RCTs
are then needed to determine the effectiveness of specific interventions aimed atthese specific risk/target groups.
• More research is required to develop relevant assessments of physical capacityand functional performance in CLBP patients, in order to better understand therelationship between self-rated disability, physical capacity and physicalimpairment.
• For many of the conservative treatments, the optimal number of sessions is
unknown; this should be evaluated through cost-utility analyses.
Specific treatment modalities
Physical therapy
Further research is needed to evaluate specific components of treatments commonlyused by physical therapists, by comparing their individual and combined use. The
combination of certain passive physical treatments for symptomatic pain relief withmore “active” treatments aimed at reducing disability (e.g. massage, hot packs or
TENS together with exercise therapy) should be further investigated. The applicationof cognitive behavioural principles to physiotherapy in general needs to be evaluated.

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Exercise therapy
The effectiveness of specific types of exercise therapy needs to be further evaluated.
This includes the evaluation of spinal stabilisation exercises, McKenzie exercises,
and other popular exercise regimens that are often used but inadequately
researched. The optimal intensity, frequency and duration of exercise should befurther researched, as should the issue of individual vs group exercises. The “active
ingredient” of exercise programmes is largely unknown; this requires considerably
more research, in order to allow the development and promotion of a wider variety of
low cost, but effective exercise programmes. The application of cognitive behaviouralprinciples to the prescription of exercises needs to be further evaluated.
Back schools, brief education The type of advice and information provided, themethod of delivery, and its relative effectiveness all need to be further evaluated, inparticular with regard to patient characteristics and baseline beliefs/behaviour. The
characteristics of patients who respond particularly well to minimal contact, brief
educational interventions should be further researched.
Cognitive-behavioural therapy
The relative value of different methods within cognitive-behavioural treatment needs
to be evaluated. The underlying mechanisms of action should also be examined, inorder to identify subgroups of patients who will benefit most from cognitivebehavioural therapy and in whom components of pain persistence need addressing.
Promising predictors of outcome of behavioural treatment have been suggested andneed further assessment, such as treatment credibility, stages of change,
expectations regarding outcome, beliefs (coping resources, fear-avoidance) andcatastrophising.
The use of cognitive behavioural principles by professionals not trained in clinicalpsychology should be investigated, to find out how the latter can best be educated toprovide an effective outcome.
Multidisciplinary therapy.
The optimal content of multidisciplinary treatment programmes requires further
research. More emphasis should be placed on identifying the right treatment for theright patient, especially in relation to the extensiveness of the multidisciplinary
treatment administered. This should be accompanied by cost-benefit analyses.
Pharmacological approaches
Only very few data exist concerning the use of opioids (especially strong opioids) for
the treatment of chronic low back pain. Further RCTs are needed. No studies haveexamined the effects of long term NSAIDs use in the treatment of chronic low backpain; further studies, including evaluation of function, are urgently required. RCTs on
the effectiveness of paracetamol and metamicol (also, in comparison with NSAIDs)
are also encouraged. The role of muscle relaxants, especially in relation to longerterm use, is unclear and requires further study.
Invasive treatments
Patient selection (in particular), procedures, practical techniques and choice of drug
all need further research. In particular, more high quality studies are required to
examine the effectiveness of acupuncture, nerve blocks, and radiofrequency andelectrothermal denervation procedures.

7Surgery
Newly emerging surgical methods should be firstly examined within the confines ofhigh quality randomized controlled trials, in which “gold standard” evidence-based
conservative treatments serve as the control. Patients with failed back surgery
should be systematically analysed in order to identify possible erroneous surgicalindications and diagnostic procedures.
Methods not recommended
It is possible that many of the treatments that ‘we cannot recommend’ in theseguidelines (owing to lack of/conflicting evidence of effectiveness) may indeed prove
to be effective, when investigated in high quality randomized controlled trials.
Many of these treatment methods are used widely; we therefore encourage theexecution of carefully designed studies to establish whether the further use of suchmethods is justified.
Non-responders
The treatments recommended in these guidelines are by no means effective for all
patients with CLBP. Further research should be directed at characterising the subpopulation of CLBP patients that are not helped by any of the treatments consideredin these guidelines.

8TABLE OF CONTENTS
Summary of evidence and recommendations
Chapter 1: Methods
Chapter 2: Low back pain definitions and epidemiology
Chapter 3: Patient assessment, and prognostic factors
A) Patient assessment
A1) Diagnostic triage
A2) Case history
A3) Physical examination: Lasegue test and spinal palpation and motion tests
A4) Imaging
A5) ElectromyographyB) Prognostic factors
Chapter 4: Physical treatments
A) Interferential therapyB) Laser therapyC) Lumbar supports
D) Shortwave diathermyE) Therapeutic ultrasoundF) ThermotherapyG) TractionH) Transcutaneous electrical nerve stimulation (TENS)
Chapter 5: Exercise therapy
Chapter 6: Manual therapyA) Manipulation/mobilisationB) Massage
Chapter 7: Back schools and brief educational interventions/advice to promote
self-careA) Back schools
B) Brief educational interventions/advice to promote self-care
Chapter 8: Cognitive-behavioural therapy
Chapter 9: Multidisciplinary treatment
Chapter 10: Pharmacological procedures
A) AntidepressantsB) Muscle relaxantsC) NSAIDsD) Opioids
E) Antiepileptic drugs (Gabapentin)F) Capsicum pain-plasters
Chapter 11: Invasive procedures
A) AcupunctureB) Injections and nerve blocks:
B1) Epidural corticosteroids and spinal nerve root blocks with steroids
B2) Facet block injections
B3) Intradiscal injections
B4) Intramuscular injections of botulinum toxin
B5) Sacroiliac joint injections
B6) Sclerosant injections (prolotherapy)
B7) Trigger point injectionsC) Neuroreflexotherapy
D) Percutaneous electrical nerve stimulation (PENS)
E) Radiofrequency (RF) and electrothermal denervation procedures
D1) RF facet denervation

9D2) IRFT and IDET
D3) RF lesioning of dorsal root ganglionF) Spinal cord stimulationG) Surgery
Appendix
Search strategies

10Chronic LBP
Summary of evidence and recommendations
Chapter 2: Low back pain definitions and epidemiology••••

The lifetime prevalence of low back pain is up to 84%.
After an initial episode of LBP, 44-78% people suffer relapses of pain occur and26-37%, relapses of work absence.
There is little scientific evidence on the prevalence of chronic non-specific low
back pain: best estimates suggest that the prevalence is approximately 23%; 1112% population are disabled by low back pain.
Specific causes of low back pain are uncommon (<15% all back pain).

Chapter 3: Patient assessment, and prognostic factors
C3 (A1-3) Patient assessment
Diagnostic triage, case history and physical examination
Summary of evidence• Studies do not enable a valid evaluation of diagnostic accuracy of the straightleg raising test (level B).
• No single test has a high sensitivity and specificity for radiculopathy, ankylosing
spondylitis or vertebral cancer (level B).
• There is conflicting evidence that spinal palpatory tests are reliable procedures
to diagnose back pain (level C)• Pain provocation tests are the most reliable of the palpatory tests (level B)• Soft tissue tests are unreliable (level A)• Regional range of motion is more reliable than segmental range of motion (level
A)• Intraexaminer reliability is better than interrater reliability for all palpatory tests(level A)• As palpatory diagnostic tests have not been established as reliable and valid, thepresence of the manipulable lesion remains hypothetical (B)Recommendation
Undertake diagnostic triage at the first assessment and at reassessment in patientswith chronic low back pain to exclude specific spinal pathology and nerve root pain.
We recommend the assessment of prognostic factors (yellow flags) in patients withchronic low back pain. The validity and relevance of these factors are discussed in
the section on prognostic factors.
We cannot recommend spinal palpatory and range of motion tests in the diagnosis ofchronic low back pain.

11C3 (A4) Imaging
Summary of evidence• There is moderate evidence that radiographic imaging is not recommended forchronic non-specific low back patients (level B).
•

There is moderate evidence that MRI is the best imaging procedure for use inpatients with radicular symptoms, or for those in whom discitis or neoplasm isstrongly suspected (level B).

•

There is moderate evidence that facet joint injections, MRI and discography are
not reliable procedures for the diagnosis of facet joint pain and discogenic pain
(level B)•

SPECT and scintigraphy may be useful for diagnosing pseudoarthrosis after
surgery for spinal fusion, in suspected stress fractures in the evaluation ofmalignancy, and in diagnosing symptomatic painful facet joints (level C).

Recommendation
We do not recommend radiographic imaging for chronic non-specific low backpatients.
We do recommend MRI in patients with serious red flags and for evaluation ofradicular symptoms. Plain radiography is recommended for structural deformities.
We do not recommend MRI, CT, or facet blocks for the diagnosis of facet joint pain
or discography for discogenic pain.

C3 (A5) Electromyography (EMG)
Summary of evidence• There is conflicting evidence that surface EMG is able to differentiate patients with
non-specific CLBP from controls and for monitoring rehabilitation programmes(level C).
• There is limited evidence that fear-avoidance is associated with increased muscle
activity on lumbar flexion (level C).
• There is conflicting evidence for the usefulness of needle EMG in patients withlumbar spinal stenosis and spinal radiculopathies (level C).
Recommendation
A role for electromyography in the diagnostic triage of chronic low back pain has notbeen established.

C3 (B) Prognostic factors
Summary of evidence• There is strong evidence that low work place support is a predictor of chronicity inpatients with acute back pain (level A).
• There is strong evidence that in the worker having difficulty returning to normal
occupational duties at 4-12 weeks the longer a worker is off work with LBP, the12lower the chances of ever returning to work; and that most clinical interventions
are quite ineffective at returning people to work once they have been off work for a
protracted period with LBP (level A).
• There is moderate evidence that psychosocial distress, depressive mood, severityof pain and functional impact and extreme symptom report, patient expectations,and prior episodes are predictors of chronicity (level B).
• There is moderate evidence that shorter job tenure, heavier occupations with nomodified duty, radicular findings, are predictors of chronicity (level B).
• There is moderate evidence that factors from physical examination, except
radicular findings are predictors of chronicity (level B).
Recommendation
Assess work related factors, psychosocial distress, patient expectations, andextreme symptom reporting in patients with chronic low back pain.

Chapter 4: Physical treatments
C4 (A) Interferential therapy
Summary of evidence• There is no evidence for the effectiveness of interferential therapy compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
• There is limited evidence that interferential therapy and motorized lumbar traction
plus massage are equally effective in the treatment of chronic low back pain (level
C).
Recommendation
We cannot recommend interferential therapy as a treatment for chronic low backpain.

C4 (B) Laser therapy
Summary of evidence• There is conflicting evidence that laser therapy is effective for chronic low backpain with regard to pain improvement (level C).
• There is limited evidence that there is no difference in effectiveness between laser
therapy, laser therapy and exercise and exercise (level C)
Recommendation
We cannot recommend laser therapy for the treatment of patients with chronic low
back pain.

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C4 (C) Lumbar supports
Summary of evidence• There is no evidence for the effectiveness of lumbar supports compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
• There is no evidence for the effectiveness of lumbar supports compared with othertreatments in the treatment of chronic low back pain (level D).
Recommendation
We cannot recommend the wearing of a lumbar support for the treatment of nonspecific chronic low back pain.

C4 (D) Shortwave diathermy
Summary of evidence• There is no evidence for the effectiveness of shortwave diathermy compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
• There is no evidence for the effectiveness of shortwave diathermy compared withother treatments in the treatment of chronic low back pain (level D).
Recommendation
We cannot recommend shortwave diathermy as a treatment for chronic low backpain.

C4 (E) Therapeutic ultrasoundSummary of evidence• There is limited evidence that therapeutic ultrasound is not effective in thetreatment of chronic low back pain (level C).
• There is no evidence for the effectiveness of therapeutic ultrasound comparedwith other treatments in the treatment of chronic low back pain (level D).
Recommendation
We cannot recommend therapeutic ultrasound as a treatment for chronic low backpain.

C4 (F) Thermotherapy
Summary of evidence• There is no evidence for the effectiveness of thermotherapy compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
• There is no evidence for the effectiveness of thermotherapy compared with othertreatments in the treatment of chronic low back pain (level D).
Recommendation
We cannot recommend thermotherapy/heat as a treatment for chronic low back pain.

14C4 (G) Traction
Summary of evidence• There is limited evidence that lumbar traction is not more effective than shamtraction (level C).
• There is no evidence for the effectiveness of lumbar traction compared with othertreatments in the treatment of chronic low back pain (level D).
Recommendation
We cannot recommend lumbar traction as a treatment for chronic low back pain.

C4 (H) Transcutaneous electrical nerve stimulation (TENS)Summary of evidence• There is strong evidence that TENS is not more effective than placebo or shamTENS in the treatment of chronic low back pain (level A).
• There is moderate evidence that TENS is not more effective than other treatmentsin the treatment of chronic low back pain (level B).
Recommendation
We cannot recommend TENS for the treatment of chronic low back pain.

Chapter 5: Exercise therapy
Summary of evidence• There is moderate evidence that exercise therapy is more effective in the
reduction of pain and/or disability, at least in the short-term, than passive
treatments intended/considered to be control treatments by the authors of therespective RCTs (level B).
• There is strong evidence that exercise therapy is more effective than “GP care” forthe reduction of pain and disability and return to work in at least the mid-term (3-6months) (level A).
• There is strong evidence that exercise therapy alone is not more effective thanconventional physiotherapeutic methods in the treatment of chronic LBP (level A).
• There is conflicting evidence regarding the effectiveness of exercise as comparedwith intensive multidisciplinary programmes (level C).
• There is strong evidence that strengthening/reconditioning exercises are no more
effective than other types of exercises in the treatment of chronic LBP (level A).
• There is limited evidence in each case that: there are no differences between
aerobic exercises, muscle reconditioning or physiotherapy exercises in relation topain or disability up to 12 months after treatment; there are no significant
differences between the effects on pain reduction of carrying out just 4 exercise
therapy sessions as opposed to 8 sessions; aerobic exercises are superior tolumbar flexion exercises in terms of pain immediately after the programme; ahome exercise programme with individualised exercises is more effective than
one using general exercises; a combined exercise and motivational programme
shows a significantly larger decrease in pain and disability up to 12 months posttreatment than does exercise alone (each, level C).
• There is conflicting evidence regarding the effectiveness of programmes involving
mainly trunk flexion exercises as compared with those involving mainly trunk
extension (level C).

15• There is moderate evidence that individually supervised exercise therapy is not
more effective than supervised groups exercise (level B).
• There is strong evidence that the changes in pain and disability reported after
various types of exercise therapy are not directly related to changes in any aspectof physical performance capacity (level A).
Recommendation
Supervised exercise therapy is recommended as a first-line treatment in the
management of chronic low back pain.
We advocate the use of exercise programmes that do not require expensive training
machines. The use of a cognitive-behavioural approach, in which graded exercises
are performed, using exercise quotas, appears to be advisable. Group exercise
constitutes an attractive option for treating large numbers of patients at low cost. We
do not give recommendations on the specific type of exercise to be undertaken(strengthening/ muscle conditioning, aerobic, McKenzie, flexion exercises, etc.). The
latter may be best determined by the exercise-preferences of both the patient andtherapist.

Chapter 6: Manual therapy
C6 (A) Manipulation/mobilisation
Summary of the evidence• There is moderate evidence that manipulation is superior to sham manipulation forimproving short-term pain and function in CLBP (level B).
• There is strong evidence that manipulation and GP care/analgesics are similarly
effective in the treatment of CLBP (level A)• There is moderate evidence that spinal manipulation in addition to GP care ismore effective than GP care alone in the treatment of CLBP (level B).
• There is moderate evidence that spinal manipulation is no less and no more
effective than physiotherapy/exercise therapy in the treatment of CLBP (level B).
• There is moderate evidence that spinal manipulation is no less and no more
effective than back-schools in the treatment of CLBP (level B).
Recommendation
Consider a short course of spinal manipulation/mobilisation as a treatment option for
CLBP.

C6 (B) Massage
Summary of evidence• There is limited evidence in each case that massage is more effective than: shamprocedures; remedial exercise and posture education; relaxation therapy (for pain
relief); acupuncture (long-term pain relief and function); self-care education (forshort-term pain relief and improvement of function); and general physicaltherapies (for mid-term pain relief (each, level C).
• There is limited evidence that spinal manipulation and massage are equallyeffective in pain relief, and that spinal manipulation results in better function thanmassage (each level C).
• There is limited evidence that there is no difference between massage andtranscutaneous muscle stimulation with regard to improvements in either pain or16

function (level C). There is limited evidence that TENS is better than massage inrelieving pain (level C).
• There is limited evidence that there is no difference in the effectiveness of
massage and the wearing of a corset (level C).
• There is limited evidence that a combined treatment of massage with remedial
exercises and education is better than massage alone, remedial exercises aloneor sham laser therapy for short-term pain relief and improved function (level C).
• There is limited evidence that therapeutic acupuncture massage is more effective
than classical massage (level C).
Recommendation
We cannot recommend massage therapy as a treatment for chronic low back pain.

Chapter 7: Back schools and brief educational
interventions/advice to promote self-care
C7 (A) Back schools
Summary of evidence• There is conflicting evidence for the effectiveness of back schools with regard topain, functional status and return to work, compared with waiting list controls or‘placebo’ interventions (level C).
• There is moderate evidence that back school is more effective than othertreatments examined (simple advice, exercises only, manipulation) with regards topain and functional status in the short-term (level B). There is moderate evidence
for no difference between back schools and these other treatments with regard totheir long-term effects on pain and functional status (level B).
Recommendation
Consider back schools where information given is consistent with evidence-based
recommendations for short-term (<6 weeks) pain relief and improvements infunctional status (level C). We do not recommend back schools as a treatment forchronic low back pain when aiming at long-term effects (>12 months) (level B).

C7 (B) Minimal contact/brief educational interventions to promote
self-care
Summary of evidence• There is moderate evidence that brief interventions addressing concerns andencouraging a return to normal activities are better than usual care in increasing
return to work rates (level B).
• There is moderate evidence that brief interventions encouraging self-care are
more effective than usual care in reducing disability (up to 6 months) but not pain
(level B).
• There is limited evidence that Internet-based discussion groups/educational
interventions are more effective than no intervention in reducing disability (levelC).
• There is conflicting evidence that Internet-based discussion groups/educational
interventions are more effective than no intervention in reducing pain (level C).
• There is strong evidence that brief interventions provided by a physiotherapist, ora physician and physiotherapist, and encouraging a return to normal activities, areas effective in reducing disability as routine physiotherapy or aerobic exercise(level A)

17• There is limited evidence that brief self-care interventions are as effective as
massage or acupuncture in terms of reducing pain and disability (level C).

Recommendation
We recommend brief educational interventions, which can be provided by aphysiotherapist or a physiotherapist and physician, and which encourage a return tonormal activities, to reduce sickness absence and disability associated with CLBP.
We do not give recommendations on the specific type of brief educational
intervention to be undertaken (face-to-face, Internet-based, one-to-one, group
education, discussion groups, etc.). The latter may best be determined by theavailable resources and the preferences of both the patient and therapist.
The emphasis should be on the provision of reassurance and positive messages thatencourage a return to normal activities.

Chapter 8: Cognitive-behavioural treatment methods
Summary Evidence• There is strong evidence that behavioural treatment is more effective for pain,
functional status and behavioural outcomes than placebo/no treatment/waiting
list control (level A).
• There is strong evidence that a graded activity programme using a behaviouralapproach is more effective than traditional care for returning patients to work
(level A).
• There is limited evidence that there is no difference between behavioural therapy
and exercise therapy in terms of their effects on pain, functional status or
depression up to 1 yr after treatment (level C).
• There is limited evidence that in patients with chronic LBP and evidence of lower
lumbar disc degeneration there is no difference between the effects of cognitivebehavioural therapy and spinal fusion in terms of disability 1 yr after treatment(level C).
• There is moderate evidence that the addition of cognitive behavioural treatment toanother treatment has neither short nor long tem effects on functional status andbehavioural outcomes (level B).
• There is strong evidence that there is no difference in effectiveness between thevarious types of behavioural therapy (level A).
Recommendation
We recommend cognitive-behavioural treatment for patients with chronic low back
pain.

18

Chapter 9: Multidisciplinary treatment
Summary of evidence• There is strong evidence that intensive multidisciplinary biopsychosocial
rehabilitation with a functional restoration approach reduces pain and improves
function in patients with chronic low back pain (level A).

• There is moderate evidence that intensive multidisciplinary biopsychosocial

rehabilitation with a functional restoration approach is more effective thanoutpatient non-multidisciplinary rehabilitation or usual care with respect to pain
(level B).

• There is strong evidence that intensive multidisciplinary biopsychosocial
interventions are effective in terms of return to work, work-readiness (level A).
• There is strong evidence that intensive physical training (“work hardening”)
programs with a cognitive-behavioural component are more effective than usual
care in reducing work absenteeism in workers with back pain (level A).
Recommendation
We recommend multidisciplinary biopsychosocial rehabilitation with functional
restoration for patients with chronic low back pain who have failed monodisciplinary
treatment options.

Chapter 10: Pharmacological procedures
C10 (A) AntidepressantsSummary of evidence• There is strong evidence that noradrenergic and noradrenergic-serotonergic
antidepressants are effective in relieving pain in patients with chronic low backpain (level A).
• There is moderate evidence that activities of daily living (function, disability) are
not improved by antidepressants (level B).
Recommendation
Consider the use of noradrenergic or noradrenergic-serotonergic antidepressants as
co-medication for pain relief in patients with chronic low back pain without renal
disease, glaucoma, pregnancy, chronic obstructive pulmonary disease and cardiac
failure.

C10 (B) Muscle relaxants
Summary of evidence• There is strong evidence that benzodiazepines are effective for pain relief (level A)
and conflicting evidence that they are effective for relieving muscle spasm (levelC).
• There is conflicting evidence that non-benzodiazepines are effective for pain relief(level C) and that they are not effective for the relief of muscle spasm.
Recommendation19

Muscle relaxants can be used for short-term pain relief in chronic LBP, but must be
used with caution due to their side effects (drowsiness, dizziness, addiction, allergic
side-effects, reversible reduction of liver function, gastrointestinal events). As they do
not appear to exert their effect by reducing muscle spasm, other pain relieving drugs
with fewer serious side-effects should be considered first.

C10 (C) NSAIDs
Summary of evidence
Most studies have examined the effectiveness for up to 3-month periods of time.
There is strong evidence that NSAIDs are effective for the relief of chronic low backpain (level A).
Recommendation
We recommend NSAIDs for pain relief in patients with chronic low back pain.
Because of the side-effects, NSAIDs should only be used for exacerbations or shortterm periods (up to 3 months).

C10 (D) Opioids
Summary of evidence• There is strong evidence that weak opioids relieve pain and disability in the
short-term in chronic low back pain patients (level A).
• There is limited evidence that strong opioids relieve pain in the short-term inchronic low back pain patients (level C).
Recommendation
We recommend the use of weak opioids (e.g. tramadol) in patients with non-specificchronic low back pain who do not respond to other treatment modalities. Due to therisk of addiction, slow-release opioids are preferable to immediate-release opioids,
and should be given regularly (around the clock) rather than as needed.

C10 (E) Antiepileptic drugs (Gabapentin)
Summary of evidence• There is limited evidence that gabapentin is not effective for the relief of chronic
low back pain.
Recommendation
We do not recommend the use of gabapentin in patients with non-specific chronic
low back pain.

C10 (F) Capsicum pain plasters (capsaicin)
Summary of evidence• There is strong evidence that capsicum pain plaster is more effective than placebo
for short term (3 weeks) treatment (level A).
Recommendation
Consider capsicum pain plaster for short-term symptomatic pain relief in chronic low
back pain.

20Chapter 11: Invasive procedures
C11 (A) Acupuncture
Summary of evidence• There is conflicting evidence that acupuncture is better than a sham procedure in
the treatment of chronic low back pain (level C).
• There is moderate evidence that acupuncture is not more effective than trigger
point injection and TENS (level B).
• There is limited evidence that acupuncture is less effective than massage andspinal manipulation (level C).
• There is limited evidence in each case that acupuncture is similar to self-care
education, and better than training of proper posture and motion in accordancewith Bruegger concepts (level C).
• There is limited evidence that the addition of acupuncture improves the results ofstandard GP treatment (defined as exercise, NSAIDs, aspirin and/or non-narcotic
analgesics) or conventional treatment (defined as physiotherapy, exercise, backschool, mud packs, infrared heat therapy and diclofenac) (level C).
Recommendation
We cannot recommend acupuncture for the treatment of chronic low back pain.

C11 (B) Injections and nerve blocks
C11 (B1) Epidural corticosteroids and spinal nerve root blocks
with steroids
Summary of evidence
There is no evidence for the effectiveness of epidural corticosteroids in patients with
non-radicular, non-specific low back pain (level D).
Recommendation
We cannot recommend the use of epidural corticosteroids in patients with nonradicular, non-specific low back pain.

C11 (B2) Facet injections
Summary of evidence
There is no evidence for the effectiveness of intraarticular injections of steroids or
facet nerve blocks in patients with non-specific low back pain (level D).
Recommendation
We cannot recommend the use of intraarticular injections of steroids or facet nerve
blocks in patients with non-specific chronic low back pain.

21

C11 (B3) Intradiscal injections
Summary of evidence
There is moderate evidence that local intradiscal injections (glucocorticoid or
glycerol) are not effective for chronic low back pain (level B).
Recommendation
We cannot recommend the use of intradiscal injections for the treatment of chronic
low back pain.

C11 (B4) Intramuscular injections of botulinum toxin
Summary of evidence
There is limited evidence that Botulinum toxin is effective for the treatment of chronic
low back pain (level C)
Recommendation
We cannot recommend the use of Botulinum toxin for the treatment of chronic nonspecific low back pain.

C11 (B5) Sacroiliac joint injections
Summary of evidence
There is limited evidence that injection of the sacroiliac joint with corticosteroids
relieves sacroiliac pain of unknown origin for a short time (level C).
Recommendation
We cannot recommend the use of sacroiliac joint injections with corticosteroids forthe treatment of non-specific chronic low back pain.

C11 (B6) Sclerosant injections (prolotherapy)
Summary of evidence
There is strong evidence that local injections with sclerosants (prolotherapy) in theligaments of the back are not effective for non-specific chronic low back pain (levelA).
Recommendation
We do not recommend the injection of sclerosants (prolotherapy) for the treatment of
non-specific chronic low back pain.

C11 (B7) Trigger point injections
Summary of evidence
There is conflicting evidence for the short-term effectiveness of local intramuscular or
ligament (lig. ilio-lumbale) infiltration with anaesthetics in chronic low back pain (level
C).
Recommendation
We cannot recommend the use of trigger point injections in patients with chronic low
back pain.

22

C11 (C) Neuroreflexotherapy
Summary of evidence• There is strong evidence that NRT is more effective than a sham procedure inproviding pain relief up to 30-45 days (level A)• There is limited evidence that NRT is more effective than a sham procedure in
improving return to work (level C).
• There is limited evidence that the addition of NRT to standard medical careprovides better outcomes than standard care alone with respect to short-term (upto 60 days) pain relief and disability, and for subsequent drug treatment,
healthcare utilisation and sick leave up to 1 year later (level C).
• Only minor and rare adverse events have been reported.
Recommendation
Consider NRT for patients with moderate or severe (≥3 points on a VAS) low backpain.

C11 (D) Percutaneous electrical nerve stimulation (PENS)
Summary of evidence• There is moderate evidence that PENS is more effective than sham PENS in thetreatment of chronic low back pain (level B).
• There is conflicting evidence that PENS is more effective than other treatments inthe treatment of chronic low back pain (level C).
• There is conflicting evidence that PENS treatments with 30 minutes duration ofelectrical stimulation, with an alternating frequency of 15 and 30 Hz, and withneedles probes positioned along the involved nerve roots at dermatomal levels
corresponding to the patients’ pain symptoms are more effective than PENS
treatments with other treatment characteristics (level C).
Recommendation
Consider PENS for symptomatic pain reduction in patients with chronic non-specific
low back pain.

C11 (E) Radiofrequency (RF) and electrothermal denervation
procedures
C11 (E1) Radiofrequency (RF) facet denervation
Summary of evidence• There is conflicting evidence that RF denervation of the facet joints is more
successful than placebo for eliciting short-term or long-term improvements in painor functional disability in mechanical chronic low back pain (level C). Proper
selection of the patients (successful diagnostic blocks) and an optimal technique
may be important to achieve better results.
• There is limited evidence that intra-articular denervation of the facet joints is more
effective than extra-articular denervation (level C).
Recommendation
We cannot recommend RF facet denervation for patients with non-specific chronic
low back pain.

23

C11 (E2) Intradiscal Radiofrequency Thermocoagulation (IRFT) andIntradiscal Electrothermal Therapy (IDET)
Summary of evidence• There is conflicting evidence that procedures aimed at reducing the nociceptive
input from painful intervertebral discs using either IRFT or IDET, in patients withdiscogenic low back pain pain, are not more effective than sham treatments(level C).
• There is limited evidence that RF lesioning of the ramus communicans iseffective in reducing pain up to 4 months after treatment (level C).
Recommendation
We cannot recommend the use of intradiscal radiofrequency, electrothermal
coagulation or radiofrequency denervation of the rami communicans for thetreatment of either non-specific or “discogenic” low back pain.

C11 (E3) Radiofrequency (RF) lesioning of dorsal root ganglion
Summary of evidence
There is limited evidence that radiofrequency lesions of the DRG are not effective inthe treatment of chronic LBP (level C).
Recommendation
We cannot recommend the use of RF lesioning of the dorsal root ganglion to treat
chronic low back pain.

C11 (F) Spinal cord stimulation
Summary of evidence
There is no evidence on the effectiveness of spinal cord stimulation in patients with
non-specific chronic low back pain (level D).
Recommendation
We cannot recommend the use of spinal cord stimulation for the treatment of chronic
non-specific LBP.

C11 (G) Surgery
Evidence Summary• There is limited evidence that in selected patients with severe CLBP anddegenerative changes at L4-L5 or L5-S1 level, who have failed to improve withconservative treatment, surgery is successful in relation to improvements infunctional disability (Oswestry) and pain up to 2 years after treatment whencompared to traditional non-specific conservative treatment in Sweden (level C)• There is moderate evidence that surgery is similar to a combined program ofcognitive intervention and exercises provided in Norway or UK in improving
functional disability (Oswestry) (level B)• There is strong evidence that demanding, expensive and higher risk surgical
techniques are not better than the most straightforward and least expensive
surgical technique of posterolateral fusion without internal fixation (level A)• There is conflicting evidence on the cost-effectiveness of surgery: it appeared tobe slightly more cost-effective than (or equal to) traditional non-specificconservative treatment in Sweden, but twice as expensive as a combined
program of cognitive intervention and exercises provided in UK, for which similar
clinical results had been obtained (level C)

24

• The complication rate after surgery has been reported to be around 17-18% (6 to31% depending on technique) with a 6-22% re-intervention rate; however, in thetrials examined, 4-22% of patients allocated to the non-surgical treatment arms
also underwent surgery.
Recommendation
We cannot recommend surgery for CLBP unless 2 years of all other recommended
conservative treatments have failed and combined programs of cognitive intervention
and exercises are not available in the given geographical area.
Considering the high complication rates of surgery, as well as the costs to society
and suffering for patients with failed back surgery, we strongly recommend that only
carefully selected patients with severe pain should be considered for this procedure.

25

Chapter 1. Methods
Literature search
The recommendations for treatments are based on a systematic review of systematic
reviews and randomized clinical trials on chronic low back pain (CLBP).
The following databases were searched for systematic reviews published before
November 2002: Cochrane, Medline, Health Star, Embase, Pascal, Psychoinfo,
Biosis, Lilacs and IME (Indice Medico Espanol). The general search strategies used
are shown in the Appendix.
Where a Cochrane review was found for a given procedure, this formed the basis for
putting together the recommendations for that procedure.
Additional RCTs (i.e. those possibly not included in the previously identified
systematic reviews) were identified from electronic searches that covered a time
period from January 1995 up to November 2002.
Other “additional studies” (both SRs and RCTs) were identified from the working
group’s personal knowledge of the literature, especially for papers published afterNovember 2002.
Methodological quality of the studies
The methodological quality of a systematic review (SR) identified by the search wasassessed using the Oxman & Guyatt index (Oxman and Guyatt 1991). SRs wererated from 0 to 7: SRs rating as 4 (or lower) were those for which it was difficult torule out major flaws (= low quality); SRs with a rating of 5 or higher were considered
to be “high quality”.
Additional relevant RCTs, not previously included in the latest systematic reviews,
were also assessed for their methodological quality, using criteria related to theinternal validity of the trial (van Tulder et al 1997). One point was awarded for eachcondition that was fulfilled. If a trial achieved a score of 5 or more out of 10, it wasconsidered “high quality”.
Checklist for methodological quality of therapy studies
1)
Adequate method of randomisation
2)
Concealment of treatment allocation
3)
Withdrawal/drop-out rate described and acceptable4)
Co-interventions avoided or equal
5)
Blinding of patients
6)
Blinding of observer
7)
Blinding of care provider
8)
Intention-to-treat analysis
9)Compliance10)
Similarity of baseline characteristics
Where additional RCTs were used to supplement the evidence derived from anexisting Cochrane Review, the rating scheme of the corresponding Cochrane review(which sometimes differed from that above, depending on the date of the review andthe treatment modality in question) was used to provide consistency in assessing theoverall evidence for a given treatment modality.
The additional RCTs were identified from the systematic electronic search (of papers
up to November 2002), from the working group’s personal knowledge of the literature26

(for papers between November 2002 and the time of submission of this document),and (as a final check that nothing of importance had been overlooked) from a final
search of Medline only, for all additional RCTs or systematic reviews sinceNovember 2002.
Final recommendations for treatments were classified according the followingclassification:
Level A (Strong Evidence): Generally consistent* findings provided by (asystematic review of) multiple high quality randomised controlled trials (RCTs)
Level B (Moderate Evidence): Generally consistent findings provided by (asystematic review of) multiple low quality RCTs
Level C (Limited or Conflicting Evidence): One RCT (either high or low quality) or
inconsistent findings from (a systematic review of) multiple RCTs
Level D (No Evidence): No RCTs(*consistent findings were considered as those for which ≥75% studies showed asimilar result)
Evaluation of the studies: criteria for inclusion/exclusion
Systematic reviews or RCTs involving individuals who were not, at the time, sufferingfrom CLBP and for whom the intervention in question was being examined within thecontext of “secondary prevention” were not included (these are discussed separately
in the “prevention” guidelines). Similarly, studies in which most of the patients hadacute pain were excluded, even if some subacute and CLBP patients had taken part
(unless the results for the chronic LBP patients were given separately). Thosestudies in which predominantly subacute and/or chronic LBP patients took part were
included.
Furthermore, unless explicitly stated, studies on patients with CLBP with a select anduniform pathology (e.g. all with spondylolysis/spondylolisthesis, all with postoperative pain) were excluded. Although we concede that (i) these are notuniversally-accepted diagnoses/indications, (ii) they are not necessarily the cause of
the chronic pain, and (iii) in any group of patients with non-specific pain these same
pathologies/indications may also exist, we felt that the inclusion of homogeneousgroups of only these patient types may limit the generalisability of the results.
It is rare for studies to include homogeneous groups of patients with just back pain
and no leg pain, or groups in which all patients have both back and leg pain. The
majority of studies are carried out on groups of patients “with non-specific back pain
and/or leg (radiating) pain”. Although this may appear to be a heterogeneouscollective, unless the leg pain is of a radicular nature (an exclusion criteria in moststudies), then the symptoms of both back and leg pain are in actual fact still mostaccurately covered by the term “non-specific chronic LBP”.
Studies in which patients with mixed complaints were grouped (e.g. with respect toeither the location of the chronic pain e.g. back and/or neck, back and/or generalmusculoskeletal pain, or its diagnosis e.g. non-specific LBP and/or chronic whiplash
associated disorder) were also excluded, unless the results for the CLBP patientswere given separately.
We have not examined treatment combinations (unless explicitly stated, e.g. for
multidisciplinary treatment) i.e. the recommendations are given in relation to single
treatments.

27

Treatment effectiveness was based on the outcome variables pain, disability, return
to work, and use of health care resources. If a procedure was not effective withregards to any of these, it was felt not to be clinically relevant, even if it elicitedchanges in other outcome variables e.g. range of motion, strength, etc. We wereunable to pass comment on effect sizes for each of the treatments, or theachievement of what might be considered ”clinically relevant changes”. In keepingwith the approach used in most of the Cochrane Reviews, the evidence was, instead,compiled in relation to the achievement of statistically significant differences intreatment outcomes.
Organisation of the work
Sub-groups were firstly formed to deal with the different topics. The searches for theSRs were carried out by three people (FK, JBS, CL), and the abstracts werecategorised into their respective topic categories (AFM) for consideration by each
sub-group. The sub-groups carried out their own searches for additional RCTs, anda later “top-up” search (in Medline only) was carried out by AFM for studies publishedafter November 2002. Information was exchanged amongst the whole groupregarding studies identified from their knowledge of the literature.
One or more members of each sub-group reviewed the evidence relating to the topic
to which they had been assigned, and wrote a first draft. All drafts were discussed,
revised, edited, and refereed by several members of the working groups.
All members of the Working Group have read and accepted the statements in theseguidelines.
References
1. Oxman AD, Guyatt GH (1991) Validation of an index of the quality of review
articles. J Clin Epidemiol, 44(11): 1271-8.
2. van Tulder MW, Assendelft WJ, Koes BW, Bouter LM (1997) Method guidelines
for systematic reviews in the Cochrane Collaboration Back Review Group for Spinal
Disorders. Spine, 22(20): 2323-30.

28Chapter 2: Chronic low back pain: definitions andepidemiology
Definitions
Low back pain is defined as pain and discomfort, localised below the costal margin
and above the inferior gluteal folds, with or without referred leg pain. In theseguidelines, chronic low back pain is defined as low back pain persisting for at least
12 weeks, unless specified otherwise. This means that we deal with cases that may
be characterised as subacute back pain, cases that have lasted for very long periodsof time, and cases of recurrent pain in which the current episode has lasted forapproximately 12 weeks. It also means that the type of patients being considered
range from those who continue to function well inspite of pain to those who areseverely incapacitated by persistent back pain. We do not deal specifically withrepeated, short bouts of pain.
A simple and practical classification, which has gained international acceptance, is todivide low back pain into three categories – the so-called “diagnostic triage” (Waddell
1987):• Specific spinal pathology• Nerve root pain/radicular pain
• Non-specific low back pain
The recommendations are given in relation to “non-specific” chronic low back pain,
i.e. low back pain that is not attributable to a recognisable, known specific pathology(e.g. infection, tumour, osteoporosis, fracture, structural deformity, inflammatory
disorder (e.g. ankylosing spondylitis), radicular syndrome or cauda equina
syndrome).
Epidemiology
Low back pain in general
Six systematic reviews on the epidemiology of low back pain wereidentified (Balague et al 1999, Bressler et al 1999, Ebbehoj et al 2002, Hestbaek et al
2003, Pengel et al 2003, Walker 2000). Two of these specifically focused onchildren (Balague et al 1999, Ebbehoj et al 2002) and one on the elderly (Bressler et
al 1999). None of the reviews gave specific prevalences for acute, recurrent, chronic,
or non-specific low back pain. The high number of patients with recurrent pain often
makes it difficult to distinguish between acute and chronic pain. There is a lack ofstandards for severity, location, and comorbid conditions.
One systematic review identified 56 population prevalence studies of low backpain (Walker 2000). Thirty studies were of acceptable quality. Point prevalence of low
back pain ranged from 12-33%, 1-year prevalence from 22-65% and lifetime
prevalence from 11-84%. Another systematic review included 12 studies thatspecifically examined the prevalence of back pain in the elderly (> 65 years)(Bressler et al 1999). It was concluded that the prevalence is not known withcertainty but is not comparable with that in the younger population.
The two reviews on LBP in schoolchildren and adolescents reported a prevalence
approaching that reported for adults (Balague et al 1999, Ebbehoj et al 2002). The
cumulative (lifetime) prevalence was between 30% and 51% for subjectively rated
morbidity and 14%-43% for objectively rated morbidity. The average annual
incidence of LBP was estimated to be approximately 16%, with 50% of cases
reporting recurrence, and 8% a chronic evolution (Balague et al 1999).

29

Low back pain fluctuates over time with frequent recurrences or exacerbations (vanTulder et al 2002).Two systematic reviews reported on the prognosis, long-termcourse or epidemiology of low back pain (Hestbaek et al 2003, Pengel et al 2003).
One SR included 36 studies (Hestbaek et al 2003) and one included 15
studies (Pengel et al 2003). The first review reported that, after a first episode of low
back pain, the proportion of patients who still experienced pain after 12 months wason average 62% (range 42-75%), the percentage of patients sick-listed after 6
months was 16% (range 3-40%), the percentage who experienced relapses of pain
was 60% (range 44-78%), and the percentage who had relapses of work absence
was 33% (range 26-37%) (Hestbaek et al 2003). The second review concluded that
rapid improvements in pain (mean reduction 58% of initial scores), disability (58%),
and return to work (82% of those initially off work) occurred in the first month after an
initial episode of LBP. Further improvement was apparent until about three months.
Thereafter levels for pain, disability, and return to work remained almost constant.
73% of patients had at least one recurrence within 12 months (Pengel et al 2003).
Two studies made a specific attempt to investigate the epidemiology of chronic
LBP (Andersson et al 1993, Cassidy et al 1998). One involved a survey of a sample
of 2184 Canadian adults between 20 and 69 years of age and revealed that, in the 6months preceding the survey, nearly 50% of respondents had experienced low
intensity/low disability low back pain, 12.3% high-intensity/low-disability low backpain and 11% high-disability low back pain (Cassidy et al 1998). A further study
carried out on a random sample of 15% of the population aged 25-74 in two Swedish
primary health care districts reported that the prevalence of chronic low back pain
lasting longer than 3 months was 23% (Andersson et al 1993).
Specific causes of back pain
It is frequently reported that low back pain symptoms, pathology and radiologicalfindings are poorly correlated. Pain is not attributable to specific pathology (asdefined earlier) or neurological encroachment in about 85% of people (Deyo 1988).
Clinicians should be aware of the incidence and characteristics of specific back pain.
About 4% of people seen with low back pain in primary care have compression
fractures and about 1% have a neoplasm (Deyo et al 1992). An observational study
in more than 7000 women > 65 years reported that 5% developed at least one
vertebral fracture in 4 years (Kado et al 2003).
The spondylarthropathies and spinal deformities commonly involve the whole spine.
Spondylarthropathies have been reported to occur at a rate of 0.8 to 1.9% of thegeneral population (Saraux et al 1999).
The prevalence of scoliotic deformities that appear as a rib prominence upon forwardbending is reported to be between 1 and 4% (Dickson et al 1980, Span et al 1973,
Strayer 1973). Kyphotic deformities such as Mb. Scheuerman are reported to occur
in 1.5 % of the general population (Sorensen 1964).
Spinal infections are rare, and chronic spinal infections are particularly rare.
Infectious diseases of the spine should be considered if the patient has fever, has
had previous surgery, has a compromised immune system, or is a drug addict.
Spondylolysis and spondylolisthesis are often classified as non-specific low backpain because a considerable proportion of patients with such anatomic abnormalities
are asymptomatic (Soler and Calderon 2000). The anatomic incidence is about
5% (Wiltse et al 1976). Spondylolisthesis is usually classified from grade 0(spondylolysis) to grade 5 (spondyloptosis). The onset of symptoms often coincides
with the adolescent growth spurt (Barash et al 1970).
To the best of our knowledge, the prevalence of lumbar radiculopathy has neverbeen examined. In one large epidemiological study, the one-year incidence of30

cervical radiculopathy was 83/100 000 (Radhakrishnan et al 1994); the incidence of
lumbar radiculopathy is probably much higher.
Back and leg pain after surgery represent a major problem addressed at specificconferences for failed back surgery. Failure rates range from 5-50%. Based on a
failure rate of 15%, it was estimated that 37500 new patients with failed back surgery
syndrome would be generated annually in the US (Follet and Dirks 1993). One of thecauses that is consistently reported in the literature includes poor patient
selection (Goupille 1996, Van Goethem et al 1997). This means that patients with
non-specific back pain are operated on for radiologically diagnosed disc bulging,herniation or degeneration, which turn out not to be responsible for their pain. Given
the considerable personal suffering for patients and the costs to society, more efforts
should be directed towards prevention of this situation. This is not solely the
responsibility of the surgeons (Koes 1998).
Summary• The lifetime prevalence of low back pain is up to 84%.
• After an initial episode of LBP, 44-78% people suffer relapses of pain occur and26-37%, relapses of work absence.
• There is little scientific evidence on the prevalence of chronic non-specific low
back pain: best estimates suggest that the prevalence is approximately 23%; 1112% population are disabled by low back pain.
• Specific causes of low back pain are uncommon (<15% all back pain).
References
1. Andersson HI, Ejlertsson G, Leden I, Rosenberg C (1993) Chronic pain in ageographically defined general population: studies of differences in age, gender,social class, and pain localization. Clin J Pain, 9(3): 174-82.
2. Balague F, Troussier B, Salminen JJ (1999) Non-specific low back pain in children
and adolescents: risk factors. Eur Spine J, 8(6): 429-38.
3. Barash HL, Galante JO, Lambert CN, Ray RD (1970) Spondylolisthesis and tighthamstrings. J Bone Joint Surg Am, 52(7): 1319-28.
4. Bressler HB, Keyes WJ, Rochon PA, Badley E (1999) The prevalence of low backpain in the elderly. A systematic review of the literature. Spine, 24(17): 1813-9.
5. Cassidy JD, Carroll LJ, Cote P (1998) The Saskatchewan health and back pain
survey. The prevalence of low back pain and related disability in Saskatchewan
adults. Spine, 23(17): 1860-6; discussion 7.
6. Deyo RA (1988) Measuring the functional status of patients with low back pain.
Arch Phys Med Rehabil, 69(12): 1044-53.
7. Deyo RA, Rainville J, Kent DL (1992) What can the history and physicalexamination tell us about low back pain? Jama, 268(6): 760-5.
8. Dickson RA, Stamper P, Sharp AM, Harker P (1980) School screening for
scoliosis: cohort study of clinical course. Br Med J, 281(6235): 265-7.
9. Ebbehoj NE, Hansen FR, Harreby MS, Lassen CF (2002) [Low back pain inchildren and adolescents. Prevalence, risk factors and prevention]. Ugeskr Laeger,164(6): 755-8.
10. Follet KA, Dirks BA (1993) Etiology and evaluation of the failed back surgery
syndrome. Neurosurgery Quarterly, 3: 40-59.
11. Goupille P (1996) Causes of failed back surgery syndrome. Rev Rhum Engl Ed,
63(4): 235-9.
12. Hestbaek L, Leboeuf-Yde C, Manniche C (2003) Low back pain: what is the longterm course? A review of studies of general patient populations. Eur Spine J, 12(2):149-65.

31

13. Kado DM, Duong T, Stone KL, Ensrud KE, Nevitt MC, Greendale GA, Cummings
SR (2003) Incident vertebral fractures and mortality in older women: a prospective
study. Osteoporos Int, 14(7): 589-94.
14. Koes BW (1998) Epidemilogy of the failed back surgery syndrome. In Conferenceof Pain Management, Failed Back Surgery Erasmus University, Rotterdam.
15. Pengel LH, Herbert RD, Maher CG, Refshauge KM (2003) Acute low back pain:
systematic review of its prognosis. Bmj, 327(7410): 323.
16. Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT (1994) Epidemiology ofcervical radiculopathy. A population-based study from Rochester, Minnesota, 1976
through 1990. Brain, 117 ( Pt 2): 325-35.
17. Saraux A, Guedes C, Allain J, Devauchelle V, Valls I, Lamour A, Guillemin F,
Youinou P, Le Goff P (1999) Prevalence of rheumatoid arthritis andspondyloarthropathy in Brittany, France. Societe de Rhumatologie de l'Ouest. J
Rheumatol, 26(12): 2622-7.
18. Soler T, Calderon C (2000) The prevalence of spondylolysis in the Spanish elite
athlete. Am J Sports Med, 28(1): 57-62.
19. Sorensen HK (1964) Scheuermans kyphosis. Clinical appearances.
Radiographs. Aetiology. Copenhagen: Munksgaard.
20. Span Y, Robin G, Markin M (1973) The incidence of scoliosis in schoolchildren in
Jerusalem. J Bone Joint Surg Am, 55A: 436.
21. Strayer LM (1973) The incidence of scoliosis in post-partum female on Cape
Cod. J Bone Joint Surg Am, 55A: 436.
22. Van Goethem JW, Parizel PM, van den Hauwe L, De Schepper AM (1997)
Imaging findings in patients with failed back surgery syndrome. J Belge Radiol, 80(2):81-4.
23. van Tulder MW, Koes B, Bombardier C (2002) Low back pain. Best Pract Res
Clin Rheumatol, 16(5): 761-75.
24. Waddell G (1987) 1987 Volvo award in clinical sciences. A new clinical model forthe treatment of low-back pain. Spine, 12(7): 632-44.
25. Walker BF (2000) The prevalence of low back pain: a systematic review of theliterature from 1966 to 1998. J Spinal Disord, 13(3): 205-17.
26. Wiltse LL, Newman PH, Macnab I (1976) Classification of spondylolisis andspondylolisthesis. Clin Orthop, (117): 23-9.

32

Chapter 3 Patient assessment, and prognostic
factors
C3 (A) Patient assessment
Most patients with chronic low back pain should have had a thorough history taking
and a clinical examination in the acute and subacute stage. A thorough clinicalexamination should be repeated in the chronic stage. The primary purpose of theexamination is the repeat screening for ‘red flags’, to assess ”yellow flags” and to
make a specific diagnosis. It is, however, well accepted that even in chronic low backpain it is often not possible to arrive at a diagnosis based on detectable pathologicalchanges. Several systems of diagnosis have been suggested, in which low back painis categorised based on pain distribution, pain behaviour, functional disability, clinicalsigns, etc. However, none of these systems of classification have been adequately
validated.
The simple and practical classification of low back pain into three categories (specificspinal pathology, nerve root pain/radicular pain, and non-specific low back pain) sets
the priority in the clinical examination procedure, including the history-taking andphysical examination. The first priority is to make sure that the problem is ofmusculoskeletal origin and to rule out non-spinal pathology. The next step is to
exclude the presence of specific spinal pathology. Suspicion of the latter is arousedby the history and/or the clinical examination and can be confirmed by further
investigations. Serious red flag conditions like neoplasm, infection, and cauda equina
syndromes are extremely rare (Carragee and Hannibal 2004). The examiner shouldhave the clinical knowledge and skill to diagnose serious spinal pathology andstructural deformities. The next priority is to decide whether the patient has nerve
root pain. The patient’s pain distribution and pattern will indicate that, and the clinicalexamination will often support it. If that is not the case, the pain is classified as nonspecific low back pain.
The examination serves other important purposes besides reaching a “diagnosis”.
Through a thorough history taking and physical examination, it is possible to evaluate
the degree of pain and functional disability. This enables the health care professional
to outline a management strategy that matches the magnitude of the problem.
Finally, a careful initial examination serves as a basis for providing the patient withcredible information regarding diagnosis, management and prognosis and may help
to reassure the patient. This information should be given in a common language
understandable to the patient. Preferably, the information should be given
consecutively during the clinical examination and when evaluating imaging. Terms
like “positive” findings for significant pathology are hard to accept and understand forthe patient. Concepts such as instability, disc displacement, slipping of the vertebra(spondylolisthesis) and hypo- and hypermobility, that refer to mechanical disordersthat are not readily definable or not verified by experimental or clinical studies, should
be avoided.
Psychosocial ‘yellow flags’ are factors that increase the risk of developing or
perpetuating chronic pain and long-term disability, including work-loss associatedwith low back pain (Kendall et al 1997). The validity and relevance of these factors
are discussed in the section on prognostic factors. Identification of ‘yellow flags’
should lead to appropriate cognitive and behavioural management. Examples of‘yellow flags’ include:• Inappropriate attitudes and beliefs about back pain (for example, the belief
that back pain is harmful or potentially severely disabling, or a highexpectation from passive treatments rather than the belief that active
participation will help),

33

•
•
•

Inappropriate pain behaviour (for example, fear-avoidance behaviour andreduced activity levels),Work related problems or compensation issues (for example, poor work
satisfaction)
Emotional problems (such as depression, anxiety, stress, tendency to lowmood and withdrawal from social interaction) (Kendall et al 1997).

C3 (A1) Diagnostic triage
Evidence from scientific studies
Although there is general consensus on the importance and basic principles ofdifferential diagnosis, no scientific studies have actually been carried out to evaluate
the effectiveness of the diagnostic triage system recommended in most guidelines.
Clinical guidelines
All guidelines propose some form of diagnostic triage in which patients are classified
as having: (a) possible specific spinal pathology e.g. tumour, infection, inflammatory
disorder, fracture, cauda equina syndrome (where the clinician is alerted to these by
the presence of ‘red flags’, such as: patient aged <20 or >55 years old, nonmechanical pain, thoracic pain, history of cancer, steroid use, structural changes,
general unwellness, loss of weight, diffuse neurological deficit); (b) nerve root pain;or (c) non-specific low back pain.
Comments
Individual red flags do not necessarily link to a specific pathology, but indicate ahigher probability of an underlying condition that may require further investigation.
Multiple red flags need further investigation. Screening procedures for diagnoses
that benefit from urgent treatment should be sensitive. Red flags have not been
evaluated comprehensively in any systematic review. A recent study of 33 academic
and 18 private practice settings (altogether 19,312 patient files) reported anincidence of spinal tumours of 0.69% and 0.12%, respectively (Slipman et al 2003).
Patients with spinal pain caused by neoplastic disease who presented to
musculoskeletal physiatrists were an average age of 65 years and reported a
relatively high likelihood of night pain, aching character of symptom manifestation,
spontaneous onset of symptoms, history of cancer, standing and walking provoking
symptoms, and unexplained weight loss. In addition, the pain intensity level ranged
widely, with an average VAS score of 6.8. (Slipman et al 2003). If there are no red
flags, one can be 99% confident that serious spinal pathology has not been missed.
It has been shown that, with careful clinical assessment revealing no red flags, Xrays detect significant spinal pathology in just one in 2500 patients (Waddell 1999).

C3 (A2) Case History
Evidence
One systematic review of 36 studies evaluated the accuracy of history-taking,physical examination and erythrocyte sedimentation rate in diagnosing low backpain. The review specifically examined the accuracy of signs and symptoms indiagnosing radiculopathy, ankylosing spondylitis and vertebral cancer (van den
Hoogen et al 1995). The review found that few of the studied signs and symptoms
seemed to provide valuable diagnostics. No single test seemed to have a highsensitivity and high specificity for radiculopathy; the combined history and theerythrocyte sedimentation rate had relatively high diagnostic accuracy in vertebral
cancer; getting out of bed at night and reduced lateral mobility seemed to be the only
moderately accurate items in ankylosing spondylitis.

34

Comments
The combination of history, signs and tests needs further evaluation. For example,
the combination of back pain, spinal deformity (scoliosis or kyphosis) and elevatedSR suggest further evaluation because spondylodiscitis is suspected (see imaging
for further evaluation)
Although these signs and symptoms are not specific, high sensitivity is more
important in order to detect patients with serious pathology that have a good
prognosis when they are given the appropriate treatment.

C3 (A3) Physical Examination
Lasegue (passive straight leg raise) test
Definition of the procedure
The passive straight leg raise test (PSLR) requires a firm level couch, with a supine,relaxed patient with trunk and hips without lateral flexion. The practitioner should
ensure that the patient’s knee remains extended, with the foot in the vertical plane.
The affected leg is supported at the heel and the limb gently elevated. The angle ofleg elevation at the onset of pain and the site of pain is recorded. If the PSLR isunilaterally limited, induces unilateral symptoms, or is bilaterally limited to less than50°, then each leg should be raised in turn to the onset of pain, lowered a few
degrees (to reduce pain) and, in turn, the ankle dorsiflexed, the hip medially rotated,
and the neck flexed. Symptom reproduction by one of these tests would beinterpreted as a positive PSLR outcome, suggesting increase root tension.
Results of search
Two systematic reviews were identified (Deville et al 2000, Hestbaek and LeboeufYde 2000). The review of Deville et al included 17 studies; all were surgical caseseries at non-primary care level and evaluated the diagnostic value of the Lasegue(or “straight leg raising”) test for disc herniation. The review of Rebain et al included
20 studies.
Additional trials
No additional trials were found.
Quality assessment of the evidence
The systematic review was of high quality.
Evidence
In the review of Deville et al was found that the pooled diagnostic odds ratio forstraight leg raising was 3.74 (95% CI 1.2 – 11.4); sensitivity was high 0.91 (0.820.94), but specificity was low 0.26 (0.16-0.38) (Deville et al. 2000). The pooled
diagnostic odds ratio for the crossed straight leg raising test was 4.39 (95% CI 0.74 –
25.9); with low sensitivity 0.29 (0.23-0.34) and high specificity 0.88 (0.86-0.90). The
authors concluded that the studies do not enable a valid evaluation of diagnostic
accuracy of the straight leg raising test. This does not imply that such tests are notuseful as a screening procedure, but that the straight leg test is not sufficient to makethe diagnosis of radiculopathy. A methodological weakness in many studies was thatdisc herniation was selected as outcome. Given the high number of disc herniationsin asymptomatic persons, a large number of false negatives (in terms of herniation)
might in fact have been true negatives in terms of herniation-related symptoms.
In the review of Rebain et al, the sensitivity of the test (0.8) was also far greater thanits specifity (0.4) (Deville et al 2000, Hestbaek and Leboeuf-Yde 2000). The authors
concluded that there remains no standard PSLR procedure, and no consensus oninterpretation of the results. The PSLR is apparently simple to carry out and interpret.

35

It is regarded as one of the diagnostic standards and is widely used. Until there is astandard procedure for carrying out and interpreting the PSLR, with known reliability
and validity, clinicians and researchers should treat the test with caution. Moreresearch is needed into the clinical use of the PSLR, its intraobserver andinterobserver reliability, the influences of age, gender, diurnal variation, psychosocial
factors, and its predictive value in lumbar intervertebral disc surgery.
Spinal palpation and motion tests
Definition of the procedure
In addition to history taking, the physical examination, and possibly also diagnostic
imaging and laboratory tests, spinal palpation tests are sometimes used to determine
whether manipulative therapy is indicated and/or to evaluate the effectiveness of anintervention. These tests essentially involve the assessment of symmetry of bonylandmarks, quantity and quality of regional and segmental motion, paraspinal tissue
abnormalities, and tenderness on provocation. The achievement of an accurate
palpatory assessment depends to a large extent on the validity and reliability of thespecific palpatory tests used.
Results of search.
Two systematic reviews (SR) were retrieved on the reliability of spinal palpation in
the diagnosis of lumbar, thoracic and neck pain (Seffinger et al 2004) and lumbopelvic pain (Seffinger et al 2004). The review of Seffinger et al included a total of 49
articles in relation to 53 studies. Only those dealing with lumbar spinal tests (n=22papers) were considered here: 1. intra and interexaminer reliability for motion
palpation tests (Bergstrom and Courtis 1986, Binkley et al 1995, Boline et al 1988,
Grant and Spadon 1985, Inscoe et al 1995, Lindsay et al 1994, Maher et al 1998,
Mastriani and Woodman 1991, Mootz et al 1989, Phillips and Twomey 2000, Rhudy
et al 1988, Richter and Lawall 1993, Strender et al 1997) 2. intraexaminer andinterexaminer reliability for pain provocation tests (Boline et al 1988, Boline et al
1993, Hsieh et al 2000, Maher and Adams 1994, McCombe et al 1989, Nice et al
1992, Richter and Lawall 1993, Strender et al 1997, Waddell et al 1982) and 3.
intraexaminer and interexaminer reliability for soft tissue tests (Binkley et al 1995,
Boline et al 1988, Byfield and Humphreys 1992, Downey et al 1999, Hsieh et al
2000, McKenzie and Taylor 1997).
The review of Hestbaek et al (2000) evaluated the reliability and validity ofchiropractic tests used to determine the need for spinal manipulative therapy of thelumbo-pelvic spine.
Additional trials
No additional trials were found.

36Quality assessment of the reviews
Both SRs were of high quality. In the review of Seffinger (2004) of the 22 papers it
included, 14 were rated as high quality and 8 low quality. No correlation was foundbetween quality score and outcome.
Conclusion of the SRs
The majority of lumbar spinal palpatory diagnostic tests demonstrated low reliability.
Data from higher quality studies showed acceptable reliability (Kappa value = 0.40 orgreater) only for the following spinal palpatory diagnostic procedures: intraexaminer
lumbar segmental vertrebral motion tests; interexaminer pain provocation test at
L4/L5 and L5/S1; interexaminer lumbar paraspinal trigger points. There were mixed
reliability results for interexaminer lumbar segmental vertrebral motion tests. Many
trials did not show a high degree of reliability. In the studies that used kappa
statistics, a higher percentage of the pain provocation studies demonstrated
acceptable reliability (64%), followed by motion studies (58%), landmark studies(33%) and soft tissue studies (0%). Among motion studies, regional range of motion
was more reliable than segmental range of motion. Overall, intraexaminer reliability
was better than interexaminer reliability. Paraspinal soft tissue palpatory tests had
low interexaminer reliability, even though they are one of the most commonly used
palpatory diagnostic procedures in clinical practice, especially by manual medicine
practitioners.
The level of clinical experience of the examiners did not improve the reliability of theprocedure. Contrary to common belief, examiners’ consensus on procedure used,training just before the study, or use of symptomatic subjects, did not consistently
improve reliability of spinal palpatory diagnostic tests.
Hestebaek and Leboef-Yde concluded that only tests for palpation of pain had
acceptable results (Seffinger et al 2004). Motion palpation tests were not reliable.
Palpation for muscle tension, palpation for misalignment, and visual inspection were
undocumented, unreliable, or not valid.
Summary of evidence• Studies do not enable a valid evaluation of diagnostic accuracy of the straight leg
raising test (level B).
• No single test has a high sensitivity and specificity for radiculopathy, ankylosing
spondylitis or vertebral cancer (level B).
• There is conflicting evidence that spinal palpatory tests are reliable procedures todiagnose back pain (level C)• Pain provocation tests are the most reliable of the palpatory tests (level B)• Soft tissue tests are unreliable (level A)• Regional range of motion is more reliable than segmental range of motion (level
A)• Intraexaminer reliability is better than interrater reliability for all palpatory tests(level A)• As palpatory diagnostic tests have not been established as reliable and valid, thepresence of the manipulable lesion remains hypothetical (B)Recommendation
Undertake diagnostic triage at the first assessment and at reassessment in patientswith chronic low back pain to exclude specific spinal pathology and nerve root pain.
We recommend the assessment of prognostic factors (yellow flags) in patients withchronic low back pain. The validity and relevance of these factors are discussed in
the section on prognostic factors.

37

We cannot recommend spinal palpatory and range of motion tests in the diagnosis ofchronic low back pain.

C3 (A4) Imaging
Definition of procedure
Imaging in patients with chronic low back pain serves two purposes: to evaluatepatients with red flags or radicular pain; and to plan surgical techniques in those forwhom surgery is being considered. In primary care settings, the most common spine
imaging tests are plain radiography, computed tomography (CT), magnetic
resonance imaging (MRI), and bone scanning. Other tests (myelography,
discography, and positron emission tomography) are usually ordered by specialists
before surgical intervention and were therefore not reviewed. In general, referral for
imaging should be based on a specific indication.
Plain Radiography
Low cost and ready availability make plain radiography the most common spinal
imaging test. The anteroposterior and lateral views demonstrate alignment, disc andvertebral body height, and gross assessment of bone density and architecture;
however, soft tissue structures are not evaluated extensively by these views. Oblique
views show the pars interarticularis in profile and are useful for diagnosing
spondylolysis when clinical suspicion of this disorder exists. Other special views
include flexion and extension views to assess instability, and angled views of thesacrum to assess sacroiliac joints for ankylosing spondylitis. Several investigators
have recommended discontinuing the use of routine oblique and spot lateral views
because they do not provide adequate clinically relevant findings (Bigos et al 1994).
Computed Tomography (CT)Computed tomography continues to play a vital role in spinal imaging. Computed
tomography uses X-rays to generate cross-sectional images of the spine. Althoughspine images can be obtained only in the frontal or slightly off-frontal plane, sagittaland coronal reconstructions can be made. Computed tomography can accurately
depict the foraminal and extraforaminal nerve root because surrounding fat provides
natural contrast.
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging offers several advantages over CT for spinal imaging,but is more expensive. Soft tissue contrast is better, which allows the different partsof the disc (the nucleus pulposus and annulus fibrosus) to be distinguished from one
another and allows visualization of the ligaments. Magnetic resonance imaging alsooffers better visualization of the vertebral marrow and the contents of the spinal canal.
It does not rely on reconstructed images because the sagittal and coronal images
can be obtained directly. Finally, MRI uses no ionizing radiation.
A disadvantage of MRI is that it cannot be used to visualize cortical bone directly.

38Bone Scanning (SPECT)
Bone scanning involves intravenous injection of radioactive compounds that adhere
to metabolically active bone. Since 1971, technetium-99m–labeled phosphatecomplexes have been the agents of choice. The primary objective of bone scanning
is to detect occult fractures, infections, or bony metastases and to differentiate themfrom degenerative changes
Results of search
Systematic reviews
Five systematic reviews were retrieved (Boos and Lander 1996, Jarvik and Deyo
2002, Littenberg et al 1995, Saal 2002, van Tulder et al 1997). All were high quality.
One review included 672 articles (from 1985 to 1995) that focused on thedevelopment or application of imaging modalities for lumbar spinal disorders (Boosand Lander 1996). The review concluded that the vast majority of studies evaluatedimaging only at the technical efficacy level. Articles assessing imaging on a higher
level of efficacy (e.g. diagnostic and therapeutic impact, patient outcome and costbenefit analysis) were sparse. The review recommended that the spine specialist bevery critical in his interpretation of such studies when attempting to apply the findings
in clinical practice.
In another review, which sought to examine the causal relationship between
radiographic findings and nonspecific low back pain, two reviewers independently
scored the methodologic quality of all relevant studies using a standardized set ofcriteria (van Tulder et al 1997). Degeneration, defined by the presence of disc space
narrowing, osteophytes, and sclerosis, turned out to be associated with nonspecific
low back pain, but odds ratios were low, ranging from 1.2 to 3.3. Spondylolysis andspondylolisthesis, spina bifida, transitional vertebrae, spondylosis and
Scheuermann's disease did not appear to be associated with low back pain. The
review concluded that there is no firm evidence for the presence or absence of acausal relationship between radiographic findings and non-specific low back pain.
A review on the diagnostic accuracy of imaging for patients with low back pain inprimary care settings (Jarvik and Deyo 2002) reached similar conclusions to those of
the1994 US guidelines (Bigos et al 1994). For adults younger than 50 years of age
with no signs or symptoms of systemic disease, symptomatic therapy without
imaging is appropriate. For patients 50 years of age and older, or those whosefindings suggest systemic disease, plain radiography together with simple laboratory
tests can almost completely rule out underlying systemic diseases. Advanced
imaging should be reserved for patients who are being considered for surgery or
those in whom systemic disease is strongly suspected.
Another review examined studies of diagnostic tests commonly used in theevaluation of chronic low back pain, with a focus on invasive techniques, such as
discography (Saal 2002). The conclusion of the review was that there are inherent
limitations in the accuracy of all diagnostic tests. The authors emphasised that any
tests used to diagnose the source of a patient's chronic low back pain require
accurate determination of the abolition or reproduction of the patient's painful
symptoms.
One review considered the clinical effectiveness of SPECT bone imaging for low
back pain (Littenberg et al 1995). Only 3 reports provided a gold standard reference
test (diagnostic test) and allowed the calculation of sensitivity and specificity for
SPECT. The review concluded that there was weak evidence that SPECT is usefulin:39

1. Detecting pseudarthroses after failed spinal fusion
2. Evaluating back pain in the young child, the adolescent (spondylolysis, osteoid
osteoma), and the young adult (stress fractures associated with anorexia or
hormonal disturbances)
3. Distinguishing benign from malignant lesions in cancer patients.
SPECT has not been sufficiently studied in the detection of other disorders. The
decision to use SPECT in most patients with CLBP is not supported by clinical trials.
Its effect on clinical management and cost-effectiveness is unknown.
Additional studies
A recent review reported that 73% and 69% of discs with a high intensity zone (HIZ)
were positive on discography in symptomatic and asymptomatic individuals
respectively (Carragee and Hannibal 2004). These studies suggest that HIZ is notpathognomonic for discogenic illness in patients with non-specific CLBP (seeComments). Multiple studies by Carragee et al. (summarised and referenced in(Carragee and Hannibal 2004)) have suggested that discography is an unreliableindicator of a chronic LBP patient’s primary cause of illness. The problems of making
a reliable diagnosis are related to: the high number of painful disc injections inasymptomatic individuals; the finding that painful injections are related to abnormal
psychometric testing, such as somatisation and emotional distress, and to litigation;and the finding that patients with non-spinal pain are reported to have painful
injections (see Comments).
In one study, 2108 consecutive adult patients were entered into the CLBP bone
scintigraphy database to examine the diagnostic benefit of bone SPECT, together
with planar flow study, blood pool and delayed three-phase imaging (Kanmaz et al1998). The study concluded that, when used to examine adult patients with CLBP,SPECT detects significantly more scintigraphic abnormalities than does planar
imaging. The addition of a flow study and blood pool imaging as part of these LBP
examinations improved sensitivity and specificity. However, the clinical utility of thisprocedure could not be confirmed; there were no documented changes in treatment
planning because of these positive findings. In a smaller study it was suggested that
SPECT scan might enhance the identification of patients benefiting from facet joint
injection (Dolan et al 1996).
The role of radiography in primary care patients with low back pain of at least 6
weeks duration was studied in a randomised (unblinded) controlled trial with 421
patients, described in two papers (Kendrick et al 2001a, Kendrick et al 2001b). The
use of lumbar spine radiography prior to treatment in primary care was not
associated with improved functioning, reduced pain or improved overall health status
after treatment, and was associated with an increase in GP workload. Participantsreceiving X-rays were more satisfied with their care, but were not less worried ormore reassured about serious disease causing their low back pain. A subsequent
paper by the same group on the cost-effectiveness of radiography, showed that only
when a 1-point increase in satisfaction is valued at more than 50 pounds sterling canit be claimed that radiography is cost-effective in these terms (incremental net
monetary benefit mean = 116 pounds sterling, 95% CI 7-225 pounds sterling). It
concluded that radiography is likely to be cost-effective only when satisfaction isvalued relatively highly. Strategies to enhance satisfaction for patients with low backpain without using lumbar radiography should be pursued (Miller et al 2002).
A recent randomized controlled study analysed the clinical and economic
consequences of replacing spine radiographs with rapid MRI in primary carepatients (Jarvik et al 2003). Although physicians and patients preferred the rapid
MRI, substituting rapid MRI for radiographic evaluations in the primary care setting

40

offered little additional benefit to patients (in terms of the subsequent pain anddisability levels 12 months after the original examination), and increased the costs ofcare. One further recent study (van den Bosch et al 2004) pointed out that theprevalence of degenerative changes was high in older patients, but the therapeutic
consequences of diagnosing these abnormalities were minor, which does not justify
the radiation exposure.
In one study, plain radiographs and flexion-extension radiographs of 215 patientswith clinically suspected lumbar spine instability were analysed (Pitkanen et al 2002).
Posterior and anterior sliding instability were strongly associated with various plainradiographic findings (anterior: with degenerative spondylolisthesis, spondylolyticspondylolisthesis; posterior: with retrolisthesis, traction spurs and spondylarthrosis).
The authors concluded that flexion/extension radiographs are thus only indicated forpreoperative planning.
Other studies have evaluated decision making (Gillan et al 2001), radiography inprimary care (Kerry et al 2002, Kerry et al 2000), early imaging (Gilbert et al 2004a,
Gilbert et al 2004b), and diagnosing cancer (Hollingworth et al 2003, Joines et al2001). Hollingworth et al concluded that there is currently not enough evidence tosupport the routine use of rapid MR to detect cancer as a cause of LBP in primarycare patients (Hollingworth et al 2003).
SafetyAdverse effects
Lumbar radiography and in particular computed tomography may be harmful
because they expose the gonads to ionizing radiation, especially with oblique views
or repeated exposures. The ionizing radiation associated with one conventional
lumbar radiograph is equivalent to that of 15 radiographic examinations of the thorax
or the average ionizing radiation experienced from all other sources for 8 months (2mSV) (Gron et al 2000). This is of particular concern in younger female patients.
Imaging identifies many abnormalities that are unrelated to back symptoms; theabnormalities are equally prevalent in persons with and without back pain (van den
Bosch et al 2004). Examples include spondylolysis, facet joint abnormalities, somecongenital anomalies, Schmorl’s nodes, herniated discs, disc dehydration (“black
discs”), disc protrusion, and mild scoliosis (Cobb angle < 10°).
Comments
1. In general, referral for imaging should be based on specific indication. The
referral should include information that a) documents that imaging is indicated, andb) clearly indicate the specific pathology suspected or the question to be evaluated.
The latter is important for choosing the best imaging modality and for the assessmentof the images.
2. In primary care patients, the presence of a lytic or blastic lesion on plainradiographs was 60% sensitive and 99.5% specific for cancer. This suggests thatplain radiography is not a good screening procedure for cancer and metastases.
Sensitivity was 70% and specificity 95% for compression fractures (Deyo and Diehl
1988). In one study the sensitivity varied from 0.83 to 1.00, and specificity from 0.85
to 0.96. This indicates that MRI is a good, but not perfect method to detect spinal
metastases (Kosuda et al 1996). In one study on planar imaging and SPECT,
estimates of sensitivity ranged from 0.74 to 0.98 (Jarvik and Deyo 2002).
Radiographs may be adequately sensitive, but their ability to distinguish acute fromold compression fractures is poor. Osteophytes or vertebral body fusion suggest an
old compression fracture (i.e. sequela from an acute fracture). Magnetic resonance41

imaging is more specific because it identifies marrow edema or hematoma
associated with an acute fracture (Yamato et al 1998).
In one study, computed tomography and MRI had a high sensitivity and low
specificity for herniated discs of (Jarvik and Deyo 2002).
A metaanalysis showed that for spinal stenosis the sensitivity of CT imaging ranges
from 0.7 to 1.0 and the specificity ranges from 0.8 to 0.96 (Kent et al 1992).
In one study, MRI was shown to be more accurate than plain radiography or bonescanning; sensitivity was 0.96 and specificity was 0.92 (Modic et al 1985).
3. MRI and discography are commonly used in the diagnosis of non-specific low
back pain when common degenerative changes are suspected to cause discogenic
pain. Studies of MRI have revealed that high proportions of asymptomatic individuals(up to 80%, depending on the “MRI-abnormality” in question) have suchchanges (Boden et al 1990, Jarvik et al 2001, Jensen et al 1994, Rankine et al 1999,
Savage et al 1997, Stadnik et al 1998, Weishaupt et al 1998) and some of theseincrease with age (Savage et al 1997). Among symptomatic subjects, MRI findingsof mild to moderate neurologic compression, disc degeneration or bulging, andcentral stenosis were not found to correlate with severity or symptoms (Boden et al
1990, Jarvik et al 2001).
The presence of a high intensity zone (HIZ) in T2-weighted MRI has been purported
to be highly specific for discogenic pain and indicative of internal disc disruption(IDD) (Aprill and Bogduk 1992, Yoshida et al 2002), although typical pain provocation
upon discography and signs of disc disruption in the post-discography CT are
required to consolidate the diagnosis. Much controversy surrounds both thediagnosis and management of IDD: some maintain that IDD is the main source of
discogenic (non-radicular) pain, accounting for up to 40% of the cases with nonspecific back pain (Schwarzer et al 1995a), whilst others question the importance of
IDD and the relevance of the HIZ (high specificity but very low sensitivity inrelationship to pain) (Carragee et al 2000, Smith et al 1998). Importantly, even the
proponents of IDD concede that no clinical tests exist for its diagnosis (Schwarzer et
al 1995a).
4. The zygapophysial (facet) joint may be a source of low back pain, but theexistence of a “facet syndrome” is controversial (Schwarzer et al 1994a). One study
concluded that pain relief after facet joint blocks does not correlate with facet
arthrosis (Schwarzer et al 1995c). Another study concluded that there remains nostandard test with which to establish the validity of facet blocks of any type in making
a diagnosis of facet joint pain (Schwarzer et al 1994b). Reproducibility of the facet
joint blocks is low; the specifity is only 65%. Approximately 30% of patients
undergoing lumbar facet joint blocks report complete relief of their pain after
subcutaneous injection of physiological saline (Schwarzer et al 1995b).
Summary of evidence• There is moderate evidence that radiographic imaging is not recommended forchronic non-specific low back patients (level B).
• There is moderate evidence that MRI is the best imaging procedure for use inpatients with radicular symptoms, or for those in whom discitis or neoplasm isstrongly suspected (level B).
• There is moderate evidence that facet joint injections, MRI and discography are
not reliable procedures for the diagnosis of facet joint pain and discogenic pain
(level B)

42• SPECT and scintigraphy may be useful for diagnosing pseudoarthrosis after
surgery for spinal fusion, in suspected stress fractures, in the evaluation ofmalignancy, and in diagnosing symptomatic painful facet joints (level C).
Recommendation
We do not recommend radiographic imaging for chronic non-specific low backpatients.
We do recommend MRI in patients with serious red flags and for evaluation ofradicular symptoms. Plain radiography is recommended for structural deformities.
We do not recommend MRI, CT, or facet blocks for the diagnosis of facet joint pain,
or discography for discogenic pain.

C3 (A5) Electromyography (EMG)
Definition of procedure
For clinical purposes, needle EMG is used with neurography to distinguish, forexample, between diabetic neuropathy and radiculopathy. Surface EMG has notbeen established as a diagnostic procedure, but is commonly used in experimental
and clinical studies of patients with non-specific chronic low back pain, in order toexamine global trunk muscle activation or muscle fatigue characteristics.
Needle EMG is the primary source for providing information on the paraspinal
muscles in clinical practice. Immediately after nerve damage, needle EMG can detecta dropout of motor units ("decreased recruitment"). If the lesion is incomplete, motor
unit changes (increased amplitude and duration, increased complexity of motor unit
waveforms) occur in the subsequent weeks, indicating axonal sprouting and repair.
Thus, increased motor unit complexity implies previous injury. Selective activation ofparaspinal muscles in order to observe individual motor units is challenging. Reliablemotor unit estimates require isolation of 10 to 20 motor units per muscle, and there
are only limited data on the normal configuration of paraspinal motor units (Travlos etal 1995).
The role of the paraspinal muscles for the stabilisation and movement of the spine
was assessed in some of the earliest kinesiology studies using surface and wire
electromyography (EMG) (Floyd and Silver 1955). The absence of “flexionrelaxation” (electrical silence in the paraspinal muscles when in full trunk flexion) was
introduced as a characteristic particularly associated with the presence of CLBP.
In the 1980s, surface electromyography (SEMG) with power spectral analyses wasdeveloped for use in the objective evaluation of back muscle fatigue (De Luca 1993).
Most commonly, the rate of decline of the mean or median frequency of the SEMG
power spectrum (and occasionally the increase in the average EMG amplitude) wasused as an index of muscle fatigability (De Luca 1993).
Results of search
4 systematic reviews dealing with EMG and low back pain were identified (Fisher
2002, Mohseni-Bandpei et al 2000, Pullman et al 2000, van Dieen et al 2003).
Quality assessment of evidence
The reviews were all of high quality.
Systematic reviews

43One review article concluded that needle EMG is the best established of theavailable electrophysiological techniques for evaluating radiculopathies and candefine the presence of these lesions (Fisher 2002). The value of these studies islimited by the fact that only motor fibers are monitored, the specificity (forradiculopathy) of the physiological abnormalities measured, and the requirement thatthese abnormalities involve multiple muscles in a specific distribution. Needle EMG
may be least sensitive as a diagnostic tool in patients with lumbar spinal stenosis
where electrophysiological evaluation arguably could be most helpful for clinicalmanagement (Fisher 2002).
In one review (Mohseni-Bandpei et al 2000) thirty of the 38 studies reported
differences in surface EMG (SEMG) measures (e.g. higher or lower levels ofactivation; henceforth classified as “positive” studies) for CLBP patients, comparedwith controls, when tested in one or more postural positions. Eight studies found nodifference in SEMG between people with CLBP and controls. Ten of the 12 studies
that monitored rehabilitation programmes reported positive results (i.e. changes
moving in the direction of “normal”), while 2 studies found no change in SEMG after
rehabilitation. This review stated that there is a need for further research on theclassification of various subgroups of LBP patients using surface EMG and theidentification of individuals at risk of developing LBP.
Pullman and colleagues concluded that surface electromyography is to beconsidered unacceptable as a clinical tool in the diagnosis of low back pain at thistime (Pullman et al 2000). Surface electromyography is considered an acceptable
tool for assessment of muscular dysfunction in patients with chronic low back pain.
Another review concluded that the findings on trunk muscle recruitment in CLBP
patients (as assessed with surface electromyography) fit neither the pain–spasm–
pain model, nor the pain-adaptation model (van Dieen et al 2003). The changes
observed are task-dependent, related to the individual problem and hence highlyvariable between and probably within individuals.
Additional studies
After the review of De Luca (De Luca 1993) on the use of surface EMG power
spectral changes for distinguishing between the back muscle fatigability of normal
controls and CLBP patients, large numbers of experimental and clinical studies
followed, often with inconsistent findings: in some studies, CLBP patients were more
fatigable than controls, whilst in others, they were less fatigable; some patients
showed an increased fatigablity after exercise rehabilitation, whilst others showed adecreased fatigability; and the accurate classification of “patients” and “normal
controls” using the procedure as described in the early studies could not always be
reproduced (Elfving et al 2003, Mannion et al 1997, Mannion et al 2001a, Mannion etal 2001b, Mohseni-Bandpei et al 2000).
A recent study showed that pain-related fear shows a significant inverse correlation
with lumbar flexion and direct correlation with the EMG amplitude in full flexion inchronic low back patients (i.e. pain-related fear is related to the presence of theflexion-relaxation phenomenon) (Geisser et al 2004). The authors concluded that
pain-related fear is directly associated with musculoskeletal dysfunction (reduced
range of flexion, increased surface EMG amplitude in full flexion) observed in people
with chronic low back pain, and that these abnormalities may be involved in thedevelopment and maintenance of chronic low back pain.
Intramuscular wire EMG studies (most commonly of the deep trunk muscles, internus
oblique, transversus abdominus, and multifidus) have been carried out to investigate

44

the spine’s stability/motor control mechanisms during various tasks and havereported dysfunction in patients with chronic low back pain (Hodges 2003, Hodges
and Moseley 2003). However, the relationship between these dysfunction (aspotential diagnostic tools) and patient-orientated clinical parameters, such as painand disability, remains poorly investigated.
Conflicting with the conclusion of Fischer (Fisher 2002), in a recent study it was
concluded that paraspinal denervation observed by electromyography may be abetter marker than MRI findings for symptomatic spinal stenosis (Haig 2002).
Comments
The general consensus at present appears to be that the test procedures have noclear relevance to clinical diagnostics although they may still be useful inexperimental studies and/or in the rehabilitation environment for examining
mechanisms of back muscle function/dysfunction.
Summary of evidence• There is conflicting evidence that surface EMG is able to differentiate patients with
non-specific CLBP from controls and for monitoring rehabilitation programmes(level C).
• There is limited evidence that fear-avoidance is associated with increased muscle
activity on lumbar flexion (level C).
• There is conflicting evidence for the usefulness of needle EMG in patients withlumbar spinal stenosis and spinal radiculopathies (level C).
Recommendation
A role for electromyography in the diagnostic triage of chronic low back pain has notbeen established.
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C3 (B) Prognostic factors
In connection with patients with back pain, prognostic factors refer to all variables
that are predictive of future events such as repeated/continued back pain, disability,
return to work, costs, etc. Prognostic studies include both clinical studies of variables
that are predictive of future events and epidemiological studies of aetiological risk
factors. Ideally, in studies of prognostic factors, all patients should have received thesame treatment or been in a randomised trial (Altman 2001).
The purpose of studies of prognostic factors is not just to predict disease moreaccurately or parsimoniously, but also to guide clinical decision-making, improveunderstanding of the disease process, improve design of clinical trials and to definerisk groups.
Systematic reviews
Five SRs on risk factors were identified (Goldberg et al 2000, Hartvigsen et al 2000,
Leboeuf-Yde 2000a,b, Lings and Leboeuf-Yde 2000). These studies were excluded
because they evaluated risk factors for first-time back pain, which was evaluated in
the prevention guidelines.
One SR was identified that included only patients with acute low back pain (Pengel etal 2003). However, this study was included because its purpose was to describe thecourse of acute low back pain and sciatica and to identify clinically important
prognostic factors for the subsequent resolution or persistence of pain. The study did
not reveal any specific prognostic factors, reported that the methodology of mostpapers was poor, and concluded that prognostic factors should be assessed
separately for patients in and out of work, respectively.
Six systematic reviews on prognostic factors for chronicity were identified (Borge etal 2001, Hoogendoorn et al 2000, Hunter 2001, Pincus et al 2002, Shaw et al 2001,
Waddell and Burton 2001). Four papers included mixed populations of acute,subacute and chronic pain patients (Hoogendoorn et al 2000, Pincus et al 2002,
Shaw et al 2001, Waddell and Burton 2001). Two papers included only patients withchronic low back pain (Borge et al 2001, Hunter 2001).
One of the systematic reviews covered back pain in the occupational setting(Waddell and Burton 2001). Thirty-four systematic reviews, 28 narrative reviews, 22
additional relevant studies and 17 previous guidelines were included. Among theevidence statements given, the authors concluded that in the worker having difficulty
returning to normal occupational duties at 4-12 weeks: there is strong
epidemiological evidence that the longer the length of absence from work due to
CLBP, the lower the chances of ever returning to work, and that most clinicalinterventions are quite ineffective at returning people to work once they have beenabsent for a protracted period with CLBP; there is moderate evidence that changing
the focus from purely symptomatic treatment to a “back school” (or multidisciplinary)
type of rehabilitation, can produce faster return to work, less chronic disability andless sickness absence; and there is moderate evidence that temporary provision oflighter or modified duties facilitates return to work and reduces time off work (Waddell
and Burton 2001). The authors also highlighted that individual and work-related
psychosocial factors play an important role in persisting symptoms and disability, andinfluence response to treatment and rehabilitation. Workers' own beliefs that their low
back pain was caused by their work and their own expectations about inability toreturn to work are particularly important.
One systematic review of 25 publications (18 cohorts) evaluated psychologicalpredictors of chronicity/disability in prospective cohorts of low back pain
patients (Pincus et al 2002). Increased risk of chronicity (persisting symptoms and/or51

disability) as a result of psychological distress, depressive mood, and to a lesser
extent somatisation, emerged as the main finding. The authors highlighted the needto clarify the role of other potentially important psychological factors, in particular fear
avoidance and coping strategies, through rigorous prospective studies (Pincus et al2002).
One systematic review of 13 studies evaluated psychosocial factors at work and in
one’s private life as risk factors for chronic low back pain (Hoogendoorn et al 2000).
Insufficient evidence was found for an effect of a high work pace, high qualitative
demands, low job content, low job control, and psychosocial factors in private life.
Strong evidence was found for low workplace social support and low job satisfaction
as risk factors for back pain. However, the possibility that these risk factors may havebeen influenced by other confounding factors led the authors to conclude that thereis evidence for an effect of work-related psychosocial factors on low back pain, but
the evidence for the role of specific factors has not yet been established(Hoogendoorn et al 2000).
Prognostic factors predicting extended disability following acute occupational LBP
were evaluated in one systematic review of 22 studies (Shaw et al 2001). Significant
prognostic factors included low workplace support, personal stress, shorter job
tenure, prior episodes of LBP, heavier occupations with no modified duty, delayed
reporting, severity of pain and functional impact, radicular findings and extreme
symptom report.
No systematic reviews have been carried out on psychological predictors ofprognosis (in relation to either natural history or treatment) in patients who alreadyhave chronic low back pain.
One systematic review that evaluated the prognostic value of physical examination
findings in 10 studies reported that there is no satisfactory answer to the question ofwhether some physical examination tests have a prognostic value in the conservative
treatment of low back pain (Borge et al 2001).
One systematic review of 6 studies evaluated medical history (Hunter 2001). It was
concluded that there is moderate evidence that a history of similar pain and a longer
duration of previous pain each predict the recurrence but not duration of subsequent
pain episodes; limited evidence that a history of similar pain predicts poorer
outcomes after recurrent injury; and limited evidence that a longer time off work
before treatment predicts poorer activity and poorer participation outcomes afterrecurrent injury.
Additional studies
A prospective population-based study investigated prognostic factors for return towork in a cohort of 328 employees sicklisted for 3-4 months because of low backpain (van der Giezen et al 2000). One year after the first day of sick leave, 198
employees had returned to work. The most important predictors of being at work in
the final multivariate model were a positive subjective evaluation of the health status(OR 1.53) and a better job satisfaction (OR 1.26). These variables had a significantly
larger impact on work status than more physical aspects of disability and physicalrequirements of the job.
One cohort longitudinal study involving 192 subacute and 61 chronic compensatedworkers with low back injuries tested a multivariate predictive model of occupational
low back disability (Schultz et al 2002, 2004). The study found that positive
expectations of recovery and perception of health change were the key psychosocial

52

predictors of return-to-work 3 months after study's inception and of number of days
lost due to low back disability within 18 months after the injury. However, only a small
subsample (<30%) of the eligible chronic sample agreed to participate in the study,
and the results thus raise questions concerning the generalisability of the results.
A prospective cohort study investigating risk factors associated with the transition
from acute to chronic occupational low back pain (Fransen et al 2002) included 854
new cases of work-related back injury; 3 months after the initial claim, 204 individuals
were still receiving compensation payments. A combined multiple regression modelof individual, psychosocial and workplace risk factors showed that poor perceived
general health status (OR 1.9) was a significant predictor of chronicity while job
dissatisfaction and poor workplace relationships did not identify workers at risk ofdeveloping chronic occupational disability.
The two aforementioned studies (Fransen et al. 2002, Schultz et al 2004) both
involved a selected population (workers suffering a low back injury and receiving
compensation payments) and the generalisability of the results to other populations
needs further investigation.
A subanalysis of a randomised clinical trial compared patient expectations andtreatment effect in 135 chronic low back pain patients receiving either massage or
acupuncture (Kalauokalani et al 2001). Patient expectation regarding treatment
benefit was found to be associated significantly with clinical outcome. As comparedto patients with lower expectations, participants with higher expectation ratings forthe treatment received had a fivefold greater likelihood of improved function after
adjustment for sociodemographics, health status, and physical factors (95% CI 1.915.4., p=0.002). The patients with high expectations for a specific treatment hadsignificantly better functional outcomes if they actually received that treatment(p=0.03; R2=0.35).]
One additional prospective study (N=159) aimed to determine the prognostic value ofa comprehensive medical assessment for the prediction of return-to-work status in
subacute low back work-injured patients (Hunt et al 2002). A full medical assessment
was carried out at baseline and a repeat examination was performed 3 months later,when return-to-work status was determined. The authors were unable to identify any
medical variables (medical history subscales, physical examination subscales, andlumbar range-of-motion tests) that accounted for significant proportions of variance inreturn to work. They suggested that injured workers' subjective interpretations andappraisals may be more powerful predictors of the course of post-injury recovery
than are exclusively medical assessments.
A randomized study compared manipulation, exercise and physician consultation tophysician consultation alone in 204 patients with chronic low back pain. Severe
affective stress predicted poor response to manipulation (OR 3.8 (95% CI 1.3 to10.8)). Over 25 days sick leave during previous year (OR 19.6 (3.8 to 102.5)), poor
life control 9.4 (1.9 to 47.0), and generalized somatic symptoms predicted outcome
from physician consultation at 1 year (Niemisto et al 2004).
Summary of evidence• There is strong evidence that low work place support is a predictor of chronicity inpatients with acute back pain (level A).
• There is strong evidence that in the worker having difficulty returning to normal
occupational duties at 4-12 weeks the longer a worker is off work with LBP, thelower the chances of ever returning to work; and that most clinical interventions
are quite ineffective at returning people to work once they have been off work for a
protracted period with LBP (level A).

53• There is moderate evidence that psychosocial distress, depressive mood, severityof pain and functional impact and extreme symptom report, patient expectations,and prior episodes are predictors of chronicity (level B).
• There is moderate evidence that shorter job tenure, heavier occupations with nomodified duty, radicular findings, are predictors of chronicity (level B).
• There is moderate evidence that factors from physical examination, except
radicular findings are predictors of chronicity (level B).
Recommendations
Assess work related factors, psychosocial distress, patient expectations, andextreme symptom reporting in patients with chronic low back pain.
References
1. Altman DG (2001) Systematic reviews of evaluations of prognostic variables. Bmj,
323(7306): 224-8.
2. Borge JA, Leboeuf-Yde C, Lothe J (2001) Prognostic values of physicalexamination findings in patients with chronic low back pain treated conservatively: asystematic literature review. J Manipulative Physiol Ther, 24(4): 292-5.
3. Fransen M, Woodward M, Norton R, Coggan C, Dawe M, Sheridan N (2002) Risk
factors associated with the transition from acute to chronic occupational back pain.
Spine, 27(1): 92-8.
4. Goldberg MS, Scott SC, Mayo NE (2000) A review of the association between
cigarette smoking and the development of nonspecific back pain and related
outcomes. Spine, 25(8): 995-1014.
5. Hartvigsen J, Leboeuf-Yde C, Lings S, Corder EH (2000) Is sitting-while-at-work
associated with low back pain? A systematic, critical literature review. Scand J Public
Health, 28(3): 230-9.
6. Hoogendoorn WE, van Poppel MN, Bongers PM, Koes BW, Bouter LM (2000)
Systematic review of psychosocial factors at work and private life as risk factors forback pain. Spine, 25(16): 2114-25.
7. Hunt DG, Zuberbier OA, Kozlowski AJ, Berkowitz J, Schultz IZ, Milner RA, Crook
JM, Turk DC (2002) Are components of a comprehensive medical assessment
predictive of work disability after an episode of occupational low back trouble? Spine,
27(23): 2715-9.
8. Hunter J (2001) Medical history and chronic pain. Clin J Pain, 17(4 Suppl): S20-5.
9. Kalauokalani D, Cherkin DC, Sherman KJ, Koepsell TD, Deyo RA (2001) Lessons
from a trial of acupuncture and massage for low back pain: patient expectations andtreatment effects. Spine, 26(13): 1418-24.
10. Leboeuf-Yde C (2000a) Alcohol and low-back pain: a systematic literature
review. J Manipulative Physiol Ther, 23(5): 343-6.
11. Leboeuf-Yde C (2000b) Body weight and low back pain. A systematic literature
review of 56 journal articles reporting on 65 epidemiologic studies. Spine, 25(2): 22637.
12. Lings S, Leboeuf-Yde C (2000) Whole-body vibration and low back pain: asystematic, critical review of the epidemiological literature 1992-1999. Int Arch Occup
Environ Health, 73(5): 290-7.
13. Niemisto L, Sarna S, Lahtinen-Suopanki T, Lindgren KA, Hurri H (2004)
Predictive factors for 1-year outcome of chronic low back pain following manipulation,
stabilizing exercises, and physician consultation or physician consultation alone. J
Rehabil Med, 36(3): 104-9.
14. Pengel LH, Herbert RD, Maher CG, Refshauge KM (2003) Acute low back pain:
systematic review of its prognosis. Bmj, 327(7410): 323.

54

15. Pincus T, Burton AK, Vogel S, Field AP (2002) A systematic review ofpsychological factors as predictors of chronicity/disability in prospective cohorts oflow back pain. Spine, 27(5): E109-20.
16. Schultz IZ, Crook J, Meloche GR, Berkowitz J, Milner R, Zuberbier OA, Meloche
W (2004) Psychosocial factors predictive of occupational low back disability: towards
development of a return-to-work model. Pain, 107(1-2): 77-85.
17. Schultz IZ, Crook JM, Berkowitz J, Meloche GR, Milner R, Zuberbier OA,
Meloche W (2002) Biopsychosocial multivariate predictive model of occupational lowback disability. Spine, 27(23): 2720-5.
18. Shaw WS, Pransky G, Fitzgerald TE (2001) Early prognosis for low backdisability: intervention strategies for health care providers. Disabil Rehabil, 23(18):815-28.
19. van der Giezen AM, Bouter LM, Nijhuis FJ (2000) Prediction of return-to-work of
low back pain patients sicklisted for 3-4 months. Pain, 87(3): 285-94.
20. Waddell G, Burton AK (2001) Occupational health guidelines for the
management of low back pain at work: evidence review. Occup Med (Lond), 51(2):124-35.

55

Chapter 4: Physical treatments
C4 (A) Interferential therapy
Definition of the procedure
Interferential current is an electrophysical agent that is commonly used byphysiotherapists. It can be described as the application of a medium frequency
alternating current modulated to produce low frequencies up to 150 Hz (Hurley et al2001). The supposed effects of interferential therapy are pain relief, based on theGate control theory (Melzack and Wall 1965), and an increase of the blood flow to
the tissues.
Results of search
Systematic reviews
No SRs were found on the effects of interferential therapy in the treatment of chronic
low back pain.
Additional trials
Two trials were found (Hurley et al 2001, Werners et al 1999). One study concerned
acute LBP and was therefore excluded (Hurley et al 2001). The second compared
the effects of interferential therapy with those of motorized lumbar traction andmassage (combined) (Werners et al 1999).
Quality assessment of the evidence
The trial was rated as high quality.
Effectiveness
Effectiveness of interferential vs. sham/placebo treatments
No studies were found on this issue.
There is no evidence for the effectiveness of interferential therapy compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
Effectiveness of interferential vs. other treatments
One high quality trial found a significant reduction in pain and disability after
interferential therapy and after motorized lumbar traction plus massage, with nodifference between groups for the extent of the improvements (Werners et al 1999).
There is limited evidence that interferential therapy and motorized lumbar traction
plus massage are equally effective in the treatment of chronic low back pain (levelC).
Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (indications)
Not having shown evidence of effectiveness, it is not possible to define indications forinterferential therapy.

56

Comments
None
Summary of evidence
There is no evidence for the effectiveness of interferential therapy compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
There is limited evidence that interferential therapy and motorized lumbar traction
plus massage are equally effective in the treatment of chronic low back pain (level
C).
Recommendation
We cannot recommend interferential therapy as a treatment for chronic low back
pain.
References
1. Hurley DA, Minder PM, McDonough SM, Walsh DM, Moore AP, Baxter DG (2001)
Interferential therapy electrode placement technique in acute low back pain: apreliminary investigation. Arch Phys Med Rehabil, 82(4): 485-93.
2. Melzack R, Wall PD (1965) Pain mechanisms: a new theory. Science, 150(699):
971-9.
3. Werners R, Pynsent PB, Bulstrode CJ (1999) Randomized trial comparing
interferential therapy with motorized lumbar traction and massage in the
management of low back pain in a primary care setting. Spine, 24(15): 1579-84.

57

C4 (B) Laser therapy
Definition of the procedure
Laser therapy is a therapeutic non-invasive modality that is supposed to haveanalgesic effects, anti-inflammatory effects, effects on nerve regeneration, andeffects on regeneration of muscular and bone tissues (de Bie et al 1998).
Wavelength, dosage and dose-intensity are reported to determine the magnitude ofthe effects.
Lasers with different wavelengths are used in the treatment of musculoskeletal
disorders. The wavelengths vary from 632 to 904 nm. The physical properties of theinteraction between laser light and tissue can be distinguished in the processes ofabsorption and scattering. By means of absorption, light energy will transformed intoanother form of energy which results in warmth dissipation (de Bie et al 1998). By
scattering, the direction of light propagation will be changed. Absorption andscattering are dependent on the wavelength and determine the loss of laser energy
into the irradiated tissue. The electromagnetic energy that is applied to the bodytissues by means of laser therapy is thought to stimulate or inhibit biochemical,
physiological and proliferative activities in the cell (de Bie et al 1998). In general,
controversy exists with regard to the appropriate treatment parameters for thedifferent treatment indications.
Results of search
Systematic reviews
Two SRs were found (Bjordal et al 2003, de Bie et al 1998) that were not specifically
aimed at assessing the evidence for laser therapy in chronic low back pain. One SR
aimed at reviewing the effectiveness of 904 nm laser therapy in various
musculoskeletal disorders (de Bie et al 1998). It included one trial on the effects oflaser therapy for chronic low back pain (Klein and Eek 1990). The other SR reviewed
the effects of low level laser therapy with location-specific doses for pain from chronic
joint disorders (Bjordal et al 2003) and included three other relevant trials on theeffects of laser therapy in chronic low back pain patients (Basford et al 1999, Soriano
and Rios 1998, Toya et al 1994).
Additional trials
One additional trial was found (Gur et al 2003).
Quality assessment of the evidence
The two SRs (Bjordal et al 2003, de Bie et al 1998) and the four trials they contained(Basford et al 1999, Klein and Eek 1990, Soriano and Rios 1998, Toya et al 1994)
were all rated as high quality. The additional study (Gur et al 2003) was rated as low
quality.
Effectiveness
Effectiveness of laser therapy vs sham procedure
The SRs did not separately assess the effectiveness of laser therapy in chronic low
back pain. Therefore, the results of the four individual trials are examined here, inorder to then summarise the evidence.
One study compared 904 nm laser therapy with placebo laser (Klein and Eek 1990).
There were no statistically significant differences in pain improvements between thegroups.
One study compared 830 nm laser therapy with placebo laser and reported
statistically significant improvements in health status in favour of the laser groupwhen compared with the placebo group (Toya et al 1994). However, no results werereported for pain, functional status or work absenteeism.
A further study compared 904 nm laser therapy with placebo laser and also reported
statistically significant improvements in health status in favour of the laser group58

when compared with the placebo group (Soriano and Rios 1998). Results regarding
pain, functional status and work absenteeism were also lacking in this study.
One study compared NdYag laser therapy (1064 nm) with a placebo laser and foundstatistically significant differences in pain improvements between the groups (Basford
et al 1999).
The two trials that reported pain measurements (Basford et al 1999, Klein and Eek
1990) were both triple blinded (patient, therapist and observer). One of them did(Basford et al 1999) and the other one did not (Klein and Eek 1990) reportstatistically significant differences between the groups in favour of laser therapy.
There is conflicting evidence that laser therapy is effective for chronic low back painwith regard to pain improvement (level C).
Effectiveness of laser therapy vs. other treatments
One low quality trial found that there was no difference between laser, laser therapy
and exercise and exercise alone in terms of pain and function (Gur et al 2003)
There is limited evidence that there is no difference in effectiveness between laser
therapy, laser therapy and exercise and exercise (level C)
Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (indications)
Not having shown evidence of effectiveness, it is not possible to define indications forinterferential therapy.
Comments
The application of laser therapy in the aforementioned trials was heterogeneous withrespect to wavelength, dose-intensity and dosage. Future studies on the effects oflaser therapy should apply similar treatment parameters in order to increase thehomogeneity among studies.
Summary of evidence
There is conflicting evidence that laser therapy is effective for chronic low back painwith regard to pain improvement (level C).
There is limited evidence that there is no difference in effectiveness between laser
therapy, laser therapy and exercise and exercise (level C)
Recommendation
We cannot recommend laser therapy for the treatment of patients with chronic low
back pain.
References
1. Basford JR, Sheffield CG, Harmsen WS (1999) Laser therapy: a randomized,
controlled trial of the effects of low-intensity Nd:YAG laser irradiation on
musculoskeletal back pain. Arch Phys Med Rehabil, 80(6): 647-52.
2. Bjordal JM, Couppe C, Chow RT, Tuner J, Ljunggren EA (2003) A systematic
review of low level laser therapy with location-specific doses for pain from chronic
joint disorders. Aust J Physiother, 49(2): 107-16.
3. de Bie RA, Verhagen A, de Vet HCW, Lenssen T, van den Wildenberg FAJM,
Kootstra A, Knipschild PG (1998) Efficacy of 904 nm laser therapy in musculoskeletal
disorders. Physical Therapy Reviews, 3: 1-14.

59

4. Gur A, Karakoc M, Cevik R, Nas K, Sarac AJ (2003) Efficacy of low power laser
therapy and exercise on pain and functions in chronic low back pain. Lasers Surg
Med, 32(3): 233-8.
5. Klein RG, Eek BC (1990) Low-energy laser treatment and exercise for chronic low
back pain: double-blind controlled trial. Arch Phys Med Rehabil, 71(1): 34-7.
6. Soriano F, Rios R (1998) Gallium Arsenide Laser Treatment of chronic low backpain: a prospective randomised and double blind study. Laser Therapy, 10: 175-80.
7. Toya S, Motegi M, Inomata K, Ohshiro T, Maeda T (1994) Report on a computerrandomized double-blind clinical trial to determine the effectiveness of the GaAIA(830 nm) diode laser for attenuation in selected pain groups. Laser Therapy, 6: 1438.

60

C4 (C) Lumbar supports
Definition of the procedure
Lumbar supports (in this document considered synonymous with braces or orthoses)
are used in industry to prevent back injuries and also as a treatment for people withlow back pain. Several potential mechanisms of action of lumbar supports arereported in the literature that may support their use in the treatment of low back pain.
They are supposed to: (1) correct deformity; (2) limit spinal motion; (3) stabilize thelumbar spine; (4) reduce mechanical loading; and (5) provide miscellaneous effects
such as massage, heat or placebo (1).
Results of search
Systematic reviews
Two SRs were found by the electronic literature search (Jellema et al 2001, Koes
and Hoogen 1994). In one SR, the evidence was summarised for bed rest andorthoses for back pain (Koes and Hoogen 1994). In a more recent Cochrane review,the effects of lumbar supports for prevention and treatment of chronic low back pain
were assessed (Jellema et al 2001). This review was used as the starting point informulating these recommendations. The review included six RCTs (Coxhead et al
1981, Doran and Newell 1975, Hsieh et al 1992, Million et al 1981, Penrose et al
1991, Valle-Jones et al 1992), but only one used a patient population with chronic
low back pain (> 6 months duration of complaints) (Million et al 1981). The remainderused either mixed populations (both acute and chronic) or populations that were notclearly defined and these studies were therefore not considered further. The study on
CLBP patients compared the effects of corsets with and without lumbar
supports (Million et al 1981). However, as only subjectively-rated “global
improvement” was recorded (and no relevant outcomes such as pain, disability,
quality of life or return to work), this study was also not considered further.
Additional RCTs
No additional trials were found.
Quality assessment of the evidence
The two SRs were rated as high quality
Effectiveness
Effectiveness of lumbar supports vs. sham/placebo
Unknown (no studies were found on this issue)
There is no evidence for the effectiveness of lumbar supports compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
Effectiveness of lumbar supports vs. other treatments
Unknown (no studies were found on this issue)
There is no evidence for the effectiveness of lumbar supports compared with othertreatments in the treatment of chronic low back pain (level D).
Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyAdverse effects of lumbar supports which have been reported in the literature are:skin lesions, gastrointestinal disorders, muscle wasting, higher blood pressure andhigher heart rates (Calmels and Fayolle-Minon 1996, Jellema et al 2001, McGill
1993).
Subjects (indications)61

Not having shown evidence of effectiveness, it is not possible to define indications forthe use of lumbar supports.
Comments
None
Summary of evidence
There is no evidence for the effectiveness of lumbar supports compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
There is no evidence for the effectiveness of lumbar supports compared with othertreatments in the treatment of chronic low back pain (level D).
Recommendation
We cannot recommend wearing a lumbar support for the treatment of non-specificchronic low back pain.
References
1. Calmels P, Fayolle-Minon I (1996) An update on orthotic devices for the lumbar
spine based on a review of the literature. Rev Rhum Engl Ed, 63(4): 285-91.
2. Coxhead CE, Inskip H, Meade TW, North WR, Troup JD (1981) Multicentre trial ofphysiotherapy in the management of sciatic symptoms. Lancet, 1(8229): 1065-8.
3. Doran DM, Newell DJ (1975) Manipulation in treatment of low back pain: a
multicentre study. Br Med J, 2(5964): 161-4.
4. Hsieh CY, Phillips RB, Adams AH, Pope MH (1992) Functional outcomes of low
back pain: comparison of four treatment groups in a randomized controlled trial. J
Manipulative Physiol Ther, 15(1): 4-9.
5. Jellema P, van Tulder MW, van Poppel MN, Nachemson AL, Bouter LM (2001)
Lumbar supports for prevention and treatment of low back pain: a systematic review
within the framework of the Cochrane Back Review Group. Spine, 26(4): 377-86.
6. Koes BW, Hoogen HMMvd (1994) Efficacy of bed rest and orthoses of low backpain. Eur J Phys Med Rehabil, 4: 86-93.
7. McGill SM (1993) Abdominal belts in industry: a position paper on their assets,
liabilities and use. Am Ind Hyg Assoc J, 54(12): 752-4.
8. Million R, Nilsen KH, Jayson MI, Baker RD (1981) Evaluation of low back pain andassessment of lumbar corsets with and without back supports. Ann Rheum Dis,
40(5): 449-54.
9. Penrose KW, Chook K, Stump JL (1991) Acute and chronic effects of pneumatic
lumbar support on muscular strength, flexibility and functional impairment index.
Sports Train Med Rehabil, 2: 121-9.
10. Valle-Jones JC, Walsh H, O'Hara J, O'Hara H, Davey NB, Hopkin-Richards H(1992) Controlled trial of a back support ('Lumbotrain') in patients with non-specific
low back pain. Curr Med Res Opin, 12(9): 604-13.

62

C4 (D) Shortwave diathermy
Definition of the procedureContinuous and pulsed forms of shortwave diathermy are applied by physiotherapists
in the treatment of soft tissue disorders and arthritis (Kitchen and Partidge 1992).
The treatment consists of the application of shortwave electromagnetic radiation witha frequency range from 10 to 100 MHz. The hypothesized working mechanism of thistherapeutic application is the heating of tissues and the stimulation of tissue
repair (Kitchen and Partidge 1992).
Results of search
Systematic reviews
No SRs were found on the effects of diathermy in the treatment of chronic low backpain.
Additional trials
One additional trial was found which used sub-thermal shortwave diathermy as acontrol treatment in investigating the effectiveness of exercises andtraction (Sweetman et al 1993). However, as no relevant outcomes such as pain,
disability, quality of life or return to work were used, this study was not consideredfurther.
Effectiveness
Effectiveness of shortwave diathermy vs. sham procedure
Unknown (no studies were found on this issue)
There is no evidence for the effectiveness of shortwave diathermy compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
Effectiveness of shortwave diathermy vs. other treatment
Unknown (no studies were found on this issue)
There is no evidence for the effectiveness of shortwave diathermy compared withother treatments in the treatment of chronic low back pain (level D).
Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (indications)
Not having shown evidence of effectiveness, it is not possible to define indications for
shortwave diathermy.
Comments
None
Summary of evidence
There is no evidence for the effectiveness of shortwave diathermy compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
There is no evidence for the effectiveness of shortwave diathermy compared withother treatments in the treatment of chronic low back pain (level D).

63

Recommendation
We cannot recommend shortwave diathermy as a treatment for chronic low back
pain.
References
1. Kitchen S, Partidge C (1992) Review of shortwave diathermy continuous andpulses patterns. Physiotherapy, 78: 243-52.
2. Sweetman BJ, Heinrich I, Anderson JAD (1993) A randomized controlled trial of
exercises, short wave diathermy, and traction for low back pain, with evidence ofdiagnosis-related response to treatment. Journal-of-Orthopaedic-Rheumatology, 6:
159-66.

64

C4 (E) Therapeutic ultrasoundDefinition of the procedure
Ultrasound equipment consists of a generator and transducer. The generator
produces electromagnetic energy with a frequency of 0.5 to 3.5 MHz, which isconverted by the transducer to mechanical energy with similar frequency andintensity of up to 3 W/cm2 (Van der Windt et al 2003). According to laboratory
research, the application of ultrasound may result in an increase in cellular metabolic
rate and increased visco-elastic properties of collagen tissue (Maxwell1992).Ultrasound causes a rise in temperature which is assumed to be a mediating
mechanism for tissue repair, the enhancement of soft tissue extensibility, promotionof muscle relaxation, augmentation of blood flow, and alleviation of inflammatory
reactions of soft-tissue (Van der Windt et al 2003).
Results of search
Systematic reviews
One SR was found, which was part of the evidence review by the Philadelphia Panelon selected rehabilitation interventions (Philadelphia Panel 2001).
Additional trials
No additional trials were found.
Quality assessment of the evidence
The included SR was rated as high quality.
Effectiveness
Effectiveness of therapeutic ultrasound vs. placebo
The SR included only one trial from 1960 on the effects of ultrasound for chronic low
back pain compared to a placebo group (Roman 1960). There was no difference inpain improvement between the ultrasound group and a placebo group. No results
were presented for return to work or functional status.
There is limited evidence that therapeutic ultrasound is not effective in the treatmentof chronic low back pain (level C).
Effectiveness of therapeutic ultrasound vs other treatment
Unknown (no studies were found on this issue)
There is no evidence for the effectiveness of therapeutic ultrasound compared withother treatments in the treatment of chronic low back pain (level D).
Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (indications)
Not having shown evidence of effectiveness, it is not possible to define indications fortherapeutic ultrasound.
Comments
None65

Summary of evidence
There is limited evidence that therapeutic ultrasound is not effective in the treatmentof chronic low back pain (level C).
There is no evidence for the effectiveness of therapeutic ultrasound compared withother treatments in the treatment of chronic low back pain (level D).
Recommendation
We cannot recommend therapeutic ultrasound as a treatment for chronic low back
pain.
References
1. Maxwell L (1992) Therapeutic ultrasound. Its effects on the cellular and molecularmechanisms of inflammation and repair. Physiotherapy, 78: 421-6.
2. Philadelphia (2001) Philadelphia Panel evidence-based clinical practice guidelines
on selected rehabilitation interventions for low back pain. Phys Ther, 81(10): 164174.
3. Roman MP (1960) A clinical evaluation of ultrasound by use of a placebo technic.
Phys Ther Rev, 40: 649-52.
4. Van der Windt DAWM, Van der Heijden GJMG, Van der Berg SGM, Ter Riet G,
De Winter AF, Bouter LM (2003) Ultrasound therapy for acute ankle sprains.
(Cochrane Review). In The Cochrane Library, Issue 4. John Wiley & Sons, Ltd.:
Chichester, UK.

66

C4 (F) Thermotherapy / heat
Definition of the procedure
The application of heat is thought to have beneficial effects on blood circulation andmuscle stiffness. By these mechanisms it may result in relaxation, pain relief andimprovement in functional disability.
Results of search
Systematic reviews
Two systematic reviews were found: one was part of the evidence review by thePhiladelphia Panel on selected rehabilitation interventions (Philadelphia 2001) andthe other was part of a review on traction for low back pain (van der Heijden et al1995). No trials were found in either review that had examined the effects ofthermotherapy (alone) for chronic low back pain.
Additional trials
No additional trials were found.
Quality assessment of the evidence
The included SRs were rated as high quality.
Effectiveness of thermotherapy vs sham/placebo procedures
Unknown (no studies were found on this issue)
There is no evidence for the effectiveness of thermotherapy compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
Effectiveness of thermotherapy vs. other treatments
Unknown (no studies were found on this issue)
There is no evidence for the effectiveness of thermotherapy compared with othertreatments in the treatment of chronic low back pain (level D).
Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (indications)
Not having shown evidence of effectiveness, it is not possible to define indications forthermotherapy.
Comments
None
Summary of evidence
There is no evidence for the effectiveness of thermotherapy compared withsham/placebo treatments in the treatment of chronic low back pain (level D).
There is no evidence for the effectiveness of thermotherapy compared with othertreatments in the treatment of chronic low back pain (level D).

67

Recommendation
We cannot recommend thermotherapy/heat as a treatment for chronic low back pain.
References
1. Philadelphia (2001) Philadelphia Panel evidence-based clinical practice guidelines
on selected rehabilitation interventions for low back pain. Phys Ther, 81(10): 164174.
2. van der Heijden GJ, Beurskens AJ, Koes BW, Assendelft WJ, de Vet HC, BouterLM (1995) The efficacy of traction for back and neck pain: a systematic, blinded
review of randomized clinical trial methods. Phys Ther, 75(2): 93-104.

68

C5 (G) Traction
Definition of the procedure
Lumbar traction is applied by putting a harness around the lower rib cage and asecond one around the iliac crest, and applying a force aiming at separating bothharnesses. The applied force must be at least 25% of the body weight (weaker
forces are considered as placebo). The duration and level of exerted traction can bevaried in a continuous or intermittent mode (van der Heijden et al 1995).
Different types of traction exist: manual traction (i.e. traction exerted by the therapist,
using the patient’s head, arms or legs), motorised traction (i.e. traction exerted by a
motorised pulley), suspension (i.e. traction exerted by gravitational forces, throughthe body weight of the patient), and bed-rest traction (i.e. traction by a pulley andweights) (van der Heijden et al 1995).
Results of search
Systematic reviews
One systematic review (SR) was found (van der Heijden et al 1995) .
Among the 17 RCTs included in the review, 16 were excluded for the following
reasons:• 3 focused on cervical traction (British 1966, Goldie and Landquist 1970,
Zylbergold and Piper 1985)• 5 included only acute low back pain patients (Coxhead et al 1981, Larsson etal 1980, Mathews et al 1987, Pal et al 1986, Walker et al 1982)• 2 did not provide information on the duration of pain (Mathews and Hickling
1975, Reust et al 1988)• 4 focused specifically on prolapsed lumbar disk, and not on common low backpain (Ljunggren et al 1984, Weber 1972, 1973, Weber et al 1984)• 1 used only “global treatment effect” as the outcome measure (Bihaug 1978)• 1 examined combination treatments (intermittent motorized traction andisometric abdominal exercises vs hot packs and rest vs hot packs, massage
and mobilisation) and also used only “global treatment effect” as the outcome
measure (Lidstrom and Zachrisson 1970)
The remaining RCT were used as the basis for formulating these recommendations(van der Heijden et al 1970).
Additional trials
No additional trials were found.
Quality assessment of the evidence
The systematic review was of high quality. The one relevant RCT on CLBP that it
included was of high quality (van der Heijden et al 1970).
Effectiveness
Effectiveness of traction vs. a sham procedure
The RCT compared motorized traction with sham traction and did not find any
significant differences between the treatments for any of the outcome measures
examined (van der Heijden et al 1970).
There is limited evidence that lumbar traction is not more effective than shamtraction (level C).
Effectiveness of traction vs other treatments
Unknown (no studies were found on this issue)
There is no evidence for the effectiveness of lumbar traction compared with othertreatments in the treatment of chronic low back pain (level D).

69

Cost/effectiveness
Unknown (no studies were found on this issue)
SafetyThe SR did not review studies on safety of lumbar traction, but cited case reportssuggesting that there is danger of adverse effects in heavy traction (lumbar traction
with forces exceeding 50% of the total body weight) (van den Hoogen et al 1995).
Those risks include increased blood pressure and respiratory constraints due to thetraction harness, and a theoretical potential increase of nerve impingement in casesof medial or distal disk protrusion.
Subjects (indications)
Not having shown evidence of effectiveness, it is not possible to define indications forlumbar traction.
Comments
None
Summary of evidence
There is limited evidence that lumbar traction is not more effective than shamtraction (level C).
There is no evidence for the effectiveness of lumbar traction compared with othertreatments in the treatment of chronic low back pain (level D).
Recommendation
We cannot recommend lumbar traction as a treatment for chronic low back pain.
References
1. Bihaug O (1978) Autotraksjon for ischialgpasienter; en kontrollert sammenlikning
mellom effekten av Auto-trakjson-B or isometriske ovelser ad modum Hume endall
eg enkins. Fysioterapeuten, 45: 377-9.
2. British (1966) Pain in the neck and arm: a multicentre trial of the effects ofphysiotherapy, arranged by the British Association of Physical Medicine. Br Med J,
5482: 253-8.
3. Coxhead CE, Inskip H, Meade TW, North WR, Troup JD (1981) Multicentre trial ofphysiotherapy in the management of sciatic symptoms. Lancet, 1(8229): 1065-8.
4. Goldie I, Landquist A (1970) Evaluation of the effects of different forms ofphysiotherapy in cervical pain. Scand J Rehabil Med, 2(2): 117-21.
5. Larsson U, Choler U, Lidstrom A, Lind G, Nachemson A, Nilsson B, Roslund J(1980) Auto-traction for treatment of lumbago-sciatica. A multicentre controlled
investigation. Acta Orthop Scand, 51(5): 791-8.
6. Lidstrom A, Zachrisson M (1970) Physical therapy on low back pain and sciatica.
An attempt at evaluation. Scand J Rehabil Med, 2(1): 37-42.
7. Ljunggren AE, Weber H, Larsen S (1984) Autotraction versus manual traction inpatients with prolapsed lumbar intervertebral discs. Scand J Rehabil Med, 16(3):117-24.
8. Mathews JA, Hickling J (1975) Lumbar traction: a double-blind controlled study for
sciatica. Rheumatol Rehabil, 14(4): 222-5.
9. Mathews JA, Mills SB, Jenkins VM, Grimes SM, Morkel MJ, Mathews W, Scott
CM, Sittampalam Y (1987) Back pain and sciatica: controlled trials of manipulation,
traction, sclerosant and epidural injections. Br J Rheumatol, 26(6): 416-23.
10. Pal B, Mangion P, Hossain MA, Diffey BL (1986) A controlled trial of continuous
lumbar traction in the treatment of back pain and sciatica. Br J Rheumatol, 25(2):181-3.
11. Reust P, Chantraine A, Vischer TL (1988) [Treatment of lumbar sciatica with or70without neurological deficit using mechanical traction. A double-blind study]. Schweiz
Med Wochenschr, 118(8): 271-4.
12. van den Hoogen HM, Koes BW, van Eijk JT, Bouter LM (1995) On the accuracyof history, physical examination, and erythrocyte sedimentation rate in diagnosing
low back pain in general practice. A criteria-based review of the literature. Spine,20(3): 318-27.
13. van der Heijden GJ, Beurskens AJ, Koes BW, Assendelft WJ, de Vet HC, BouterLM (1995) The efficacy of traction for back and neck pain: a systematic, blinded
review of randomized clinical trial methods. Phys Ther, 75(2): 93-104.
14. van der Heijden GJ, Bouter LM, Terpstra-Lindeman E (1970) De effectiviteit van
tractie bij lage rugklachten: de resultaten van een pilotstudy. Ned T Fysiotherapie, 2:
117-21.
15. Walker L, Svenkerud T, Weber H (1982) Traksjonsbehandling ved lumbagoischias: en kontrollert undersolske med Spina-trac. Fysioterapeuten, 48: 161-3.
16. Weber H (1972) Har traksjonbehandling noen effect ved ischias forarsaket
skiveprolpas? Tidskr Nor Laegeforen, 92: 2243-6.
17. Weber H (1973) Traction therapy in sciatica due to disc prolapse (does traction
treatment have any positive effect on patients suffering from sciatica caused by discprolapse?). J Oslo City Hosp, 23(10): 167-76.
18. Weber H, Ljunggren AE, Walker L (1984) Traction therapy in patients with
herniated lumbar intervertebral discs. J Oslo City Hosp, 34(7-8): 61-70.
19. Zylbergold RS, Piper MC (1985) Cervical spine disorders. A comparison of three
types of traction. Spine, 10(10): 867-71.

71

C4 (H) Transcutaneous electrical nerve stimulation (TENS)Definition of the procedure
Transcutaneous electrical nerve stimulation (TENS) is a therapeutic non-invasive
modality, which is primarily applied for pain relief. This technique consists ofelectrical stimulation of peripheral nerves via skin surface electrodes. The
development and application of TENS was based on the Gate control theory ofpain (Melzack and Wall 1965). According to this theory, the stimulation of the large
afferent fibers may cause the inhibition of the small nociceptive fibers by theactivation of the inhibitory interneurones in the substantia gelatinosa of the spinal
cord dorsal horn (Jette and Delitto 1997, Melzack and Wall 1965, Milne et al 2001).
By the application of TENS, these neuro-regulatory peripheral and central effects
would modulate the transmission of pain.
In clinical practice various types of TENS applications are used, which are different
with regard to intensity and electrical characteristics (Brosseau et al 2002, Jette andDelitto 1997, Milne et al 2001):1) high frequency (40-150 Hz, 50-100 usec pulse width, moderate intensity);2) low frequency (1-4 Hz, 100-400 usec pulse width, high intensity);3) burst frequency (1-4 Hz with high internal frequency, 100-250 usec pulse
width, high intensity)4) hyperstimulation (1-4 Hz, 10-500 msec pulse width, high intensity).
Results of search
Systematic reviews
Three SRs were found by the electronic literature search ( (Brosseau et al 2002,
Milne et al 2001) and (Philadelphia 2001, van Tulder et al 1999)).
Additional RCTs
Five additional RCTs were found. One of these compared the effects of TENS withvertebral axial depression (VAX-D) (Sherry et al 2001); two made a comparison
between TENS and percutaneous electrical nerve stimulation (Hsieh and Lee 2002)(Yokoyama et al 2004); and one compared TENS with electroacupuncture(Tsukayama et al 2002). One RCT was excluded because it specifically assessed
the effects of TENS in patients with multiple sclerosis who had low back pain (AlSmadi et al 2003).
Quality assessment of the evidence
The three SRs were rated as high quality ((Brosseau et al 2002, Milne et al 2001)
and (Philadelphia 2001, van Tulder et al 1999)). Among the four additional RCTs thatwere included (Hsieh and Lee 2002, Sherry et al 2001, Tsukayama et al 2002,
Yokoyama et al 2004), no effects were reported in favour of TENS; as this lack ofeffect did not change the general pattern of no effectiveness that was shown by theSRs, no rigorous quality assessment of these trials was carried out.
Effectiveness
Effectiveness of TENS vs sham/placebo procedures
Three SRs included studies comparing TENS versus a sham procedure or placebo.
The Philadelphia panel stated that they had found good evidence of no clinicallyimportant benefit with TENS (Philadelphia 2001). The conclusion of the Cochranereview was that the meta-analysis (based on 5 RCTs) suggests that TENS is not
more effective in reducing pain and improving functional status than sham orplacebo (Brosseau et al 2002, Milne et al 2001).
The Cochrane review on the effectiveness of acupuncture (van Tulder et al 1999)
included one trial which compared three treatments: acupuncture, TENS and placebo
TENS (Lehmann et al 1986). There was no difference in effects between the two
reference groups (TENS and placebo TENS) (Lehmann et al 1986).

72

There is strong evidence that TENS is not more effective than placebo or shamTENS in the treatment of chronic low back pain (level A).
Effectiveness of TENS vs. other treatments
One low quality trial included in the Cochrane review on the effectiveness ofacupuncture reported that neither TENS nor placebo TENS groups were as effective
as acupuncture (Lehmann et al 1986). The additional trials that compared othertypes of treatment with TENS also did not report effects in favour of the TENS
groups (Hsieh and Lee 2002, Sherry et al 2001, Tsukayama et al 2002).
There is moderate evidence that TENS is not more effective than other treatments inthe treatment of chronic low back pain (level B).
Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (indications)
Not having shown evidence of effectiveness, it is not possible to define indications fortherapeutic ultrasound.
Comments
Despite the lack of effects of TENS reported in the scientific literature there arearguments for more research on the effects of TENS, perhaps in combination withinterventions that aim to improve disability in chronic low back pain:
1. The five studies that were included in the Cochrane SR showed a trend towards agreater pain reduction in the TENS group compared to the placebo group.
2. The characteristics of the device parameters of the TENS application were
heterogeneous among the studies included and in some cases not even reported.
These application characteristics (optimal frequency-intensity, application
techniques, duration of treatment and site of application) may be critical in order toachieve treatment effects. Due to the small number of studies and lack ofreporting it was not possible to separate studies according to these criteria.
Summary of evidence
There is strong evidence that TENS is not more effective than placebo or shamTENS in the treatment of chronic low back pain (level A).
There is moderate evidence that TENS is not more effective than other treatments inthe treatment of chronic low back pain (level B).
Recommendation
We cannot recommend TENS for the treatment of chronic low back pain.
References
1. Al-Smadi J, Warke K, Wilson I, Cramp AF, Noble G, Walsh DM, Lowe-Strong AS(2003) A pilot investigation of the hypoalgesic effects of transcutaneous electricalnerve stimulation upon low back pain in people with multiple sclerosis. Clin Rehabil,
17(7): 742-9.
2. Brosseau L, Milne S, Robinson V, Marchand S, Shea B, Wells G, Tugwell P(2002) Efficacy of the transcutaneous electrical nerve stimulation for the treatment ofchronic low back pain: a meta-analysis. Spine, 27(6): 596-603.
3. Hsieh RL, Lee WC (2002) One-shot percutaneous electrical nerve stimulation vs.
transcutaneous electrical nerve stimulation for low back pain: comparison oftherapeutic effects. Am J Phys Med Rehabil, 81(11): 838-43.

73

4. Jette AM, Delitto A (1997) Physical therapy treatment choices for musculoskeletal
impairments. Phys Ther, 77(2): 145-54.
5. Lehmann TR, Russell DW, Spratt KF, Colby H, Liu YK, Fairchild ML, Christensen
S (1986) Efficacy of electroacupuncture and TENS in the rehabilitation of chronic low
back pain patients. Pain, 26(3): 277-90.
6. Melzack R, Wall PD (1965) Pain mechanisms: a new theory. Science, 150(699):
971-9.
7. Milne S, Welch V, Brosseau L, Saginur M, Shea B, Tugwell P, Wells G (2001)
Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain.
Cochrane Database Syst Rev, (2): CD003008.
8. Philadelphia (2001) Philadelphia Panel evidence-based clinical practice guidelines
on selected rehabilitation interventions for low back pain. Phys Ther, 81(10): 164174.
9. Sherry E, Kitchener P, Smart R (2001) A prospective randomized controlled study
of VAX-D and TENS for the treatment of chronic low back pain. Neurol Res, 23(7):780-4.
10. Tsukayama H, Yamashita H, Amagai H, Tanno Y (2002) Randomised controlled
trial comparing the effectiveness of electroacupuncture and TENS for low back pain:a preliminary study for a pragmatic trial. Acupunct Med, 20(4): 175-80.
11. van Tulder MW, Cherkin DC, Berman B, Lao L, Koes BW (1999) The
effectiveness of acupuncture in the management of acute and chronic low back pain.
A systematic review within the framework of the Cochrane Collaboration Back
Review Group. Spine, 24(11): 1113-23.
12. Yokoyama M, Sun X, Oku S, Taga N, Sato K, Mizobuchi S, Takahashi T, Morita
K (2004) Comparison of percutaneous electrical nerve stimulation withtranscutaneous electrical nerve stimulation for long-term pain relief in patients withchronic low back pain. Anesth Analg, 98(6): 1552-6.

74

Chapter 5: Exercise therapy
Definition of procedure“Exercise therapy” was defined as any programme in which, during the therapy
sessions, the participants were required to carry out repeated voluntary dynamic
movements or static muscular contractions (in each case, either “whole-body” or“region-specific”; and either with or without external loading), where such exercises
were intended as a treatment for low back pain. The exercise was to have beensupervised or “prescribed” (van Tulder et al 2003).
Systematic reviews and RCTs in which exercises represented part of a back schoolor multidisciplinary treatment program were excluded (these are covered separately
in their own categories). However, systematic reviews or RCTs in which exercises
were the main component of a therapy otherwise referred to as “physiotherapy”
were included.
In some previous SRs (van Tulder and Koes 2003, van Tulder et al 2003) the terms“active” and “inactive” treatments have been used to (roughly) indicate “index” and“control/placebo” treatments. We felt that their chosen nomenclature could confuse,
especially within the context of exercise therapy. In these recommendations we willattempt to specifically name the particular interventions under investigation, and informing sub-categories for the evidence rating we will use the term “passive
treatments considered/intended by the authors to be a control treatment” instead of
the term “inactive”. Nonetheless, the reader should bear in mind that categorisingsuch treatments together does not necessarily differentiate between the effects ofbeing put in a waiting list control group (which could have a nocebo effect) andbeing given hot packs and traction (which might have a powerful placebo effect).
The whole issue of developing appropriate control/placebo treatments in relation to
musculoskeletal treatment programmes remains to be resolved.
Results of search
Systematic reviews
The various searches returned a total of 16 hits regarding reviews of exercise
therapy for chronic back pain (Abenhaim et al 2000, Brox et al 1999, Colle et al
2001, Daniels and Denner 1999, Ebenbichler et al 2001, Evans and Richards 1996,
Faas 1996, Hilde and Bo 1998, Koes et al 1991, Maher et al 1999, Miltner et al
2001, Mior 2001, van Tulder and Koes 2003, van Tulder et al 1997, van Tulder et al2003). Two additional SRs were identified from the working group’s knowledge ofthe literature (Kool et al 2004, Liddle et al 2004).
4 of these reviews (Colle et al 2001, Daniels and Denner 1999, Ebenbichler et al
2001, Mior 2001) were not systematic reviews and/or did not deal with theeffectiveness, cost-effectiveness or safety of exercise therapy and were therefore
excluded.
Additional RCTs
4 older trials were identified that had not been included in the two main reviews (vanTulder and Koes 2003, van Tulder et al 2003), but had been considered in othersystematic reviews (Callaghan 1994, Klein and Eek 1990, Reilly et al 1989,
Sweetman et al 1993). Two were not considered further in producing theseguidelines: one included no comparison of exercise per se with another treatment(only exercise with laser versus exercise with placebo laser (Klein and Eek 1990);
and the other reported no pain or disability scores (Sweetman et al 1993). N.B. thesystematic reviews (van Tulder and Koes 2003, van Tulder et al 2003) included two
trials that we chose to exclude, as they did not focus on the treatment of nonspecific CLBP as defined in the introduction: one concerned prevention not75treatment (Soukup et al 1999); and the other examined only patients with a specifichomogeneous pathology of spondylysis/spondylolisthesis (O'Sullivan et al 1997).
Using the search criteria described in the introduction, 24 new RCTs were identified
that had not been included in or had been published subsequent to the tworeviews (Aure et al 2003, Bendix et al 2000, Descarreaux et al 2002, Ghoname et al
1999, Gur et al 2003, Hagen et al 2000, Hemmila et al 2002, Horneij et al 2001,
Hsieh et al 2002, Jousset et al 2004, Klaber Moffett et al 1999, McIlveen andRobertson 1998, Moseley 2002, Muller et al 2001, Niemisto et al 2003, Penttinen etal 2002, Petersen et al 2002, Preyde 2000, Rasmussen-Barr et al 2003, Rittweger
et al 2002, Staal et al 2004, Storheim et al 2003, Tritilanunt and Wajanavisit 2001,
UK BEAM trial team et al 2004).
8 of the RCTs were subsequently excluded in producing these recommendations:
one used a crossover design in which it was difficult to extract the effects ofexercise therapy alone and only the immediate short term effects wereconsidered (Ghoname et al 1999); in two studies, exercises were combined withmanipulation (Niemisto et al 2003) or manual therapy and education (Moseley
2002); another concerned prevention, not treatment (Horneij et al 2001); two wererather more back school/education than exercise therapy and are therefore
considered in the back school recommendations (Hsieh and Lee 2002, Penttinen etal 2002); in one, the patient group was poorly defined (and may actually have been
secondary prevention), the study was very low quality study, and only “global qualityof life” was measured, immediately after the treatment (Muller et al 2001); one wasconsidered to represent “advice/recommendations to remain active” rather than an
exercise therapy treatment as such (Hagen et al 2000).
Quality assessment of SRs
Of the 12 reviews (Abenhaim et al 2000, Brox et al 1999, Evans and Richards 1996,
Faas 1996, Hilde and Bo 1998, Koes et al 1991, Kool et al 2004, Liddle et al 2004,
Maher et al 1999, Miltner et al 2001, van Tulder and Koes 2003, van Tulder et al
1997, van Tulder et al 2003), two were sufficiently up to date and of high enoughmethodological rigour to be categorised as high-quality systematic reviews and to be
used as the basis for forming these recommendations: one was a Cochranereview (van Tulder et al 2003), and the other a shortened, regularly updated
summary of the Cochrane’s main findings (van Tulder and Koes 2003). The first
SR (van Tulder et al 2003) included 23 trials on non-specific CLBP or a mixture ofnon-specific chronic/sub-acute LBP (Bentsen et al 1997, Bronfort et al 1996, Buswell
1982, Deyo et al 1990, Elnaggar et al 1991, Frost et al 1995, Frost et al 1998,
Hansen et al 1993, Hemmila et al 1997, Johannsen et al 1995, Kendall and Jenkins
1968, Lidstrom and Zachrisson 1970, Lindström 1994, Lindstrom et al 1992a,
Lindstrom et al 1992b, Ljunggren et al 1997, Manniche et al 1993, Manniche et al
1988, Manniche et al 1991, Martin et al 1986, O'Sullivan et al 1997, Risch et al 1993,
Snook et al 1998, Torstensen et al 1998, Turner et al 1990, White 1966, 1969). The
second SR (van Tulder and Koes 2003)included a further 13 papers reporting on 8
RCTs (Bendix et al 1998, Bendix et al 1995, Franke et al 2000, Friedrich et al 1998,
Hildebrandt et al 2000, Kankaanpaa et al 1999, Kuukkanen and Malkia 2000,
Mannion et al 2001a, Mannion et al 1999, 2001b, Mannion et al 2001c, Soukup et al
1999, Soukup et al 2001). All other SRs were scrutinised for any additional RCTs notcovered by these two reviews. Further, some of the other reviews highlighted or
addressed a number of important issues regarding the recommendations for exercise
based on evidence found in the literature and these reviews were therefore taken
into consideration in attempting to formulate the final recommendations in a usefulmanner. For example, a high quality SR that emphasised the potential importance ofthe type and dose of exercise was considered worthy of mention (Hilde and Bo
1998).

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Quality assessment of additional trials
The RCTs finally included in examining the strength of evidence, along with their
quality ratings are listed in Table 1. This includes all those trials that we considered
relevant from the two main SRs (van Tulder and Koes 2003, van Tulder et al 2003),
from other systematic reviews (not previously included in the two main SRs), fromour search for additional RCTs, and from the working group’s knowledge of theliterature.
Table 1. List of all RCTs used in compiling the evidence for the effectiveness of
exercise therapy in CLBP.
Authors and reference
Aure 2003
Bendix 1995, 1998
Bendix 2000
Bentsen 1997
Bronfort 1996
Buswell 1982
Callaghan 1994
Descarreaux 2002
Deyo 1990
Elnaggar 1991
Franke 2000
Friedrich 1998
Frost 1995, 1998
Gur, 2003
Hansen 1993
Hemmila 1997, 2002
Hildebrandt 2000
Johanssen 1995
Jousset 2004
Kankaanpaa 1999
Kendall & Jenkins 1968
Klaber-Moffett 1999
Kuukkanen 2000
Lidström & Zachrisson 1970
Lindstrom 1992a,b, 1994
Manniche 1988, 1991
Mannion 1999, 2001a, b, c
Martin 1986
McIlveen and Robertson 1998
Moseley 2002
Peterson 2002
Preyde 2000
Rasmussen 2003
Reilly 1989
Risch 1993
Rittweger 2002
Snook 2003

Total score (out of 9)*
6
6
4
4
7
0
2
3
7
4
3
5
6
3
5
6
6
0
7
2
1
5
2
2
7
6
8
0
6
4
4
5
3
4
3
3
6

Quality rating
high
high
low
low
high
low
low
low
high
low
low
high
high
low
high
high
high
low
high
low
low
high
low
low
high
high
high
low
high
low
low
high
low
low
low
low
high

77

Staal 2004
8
highStorheim 2003
5high
Torstensen 1998
7
high
Tritilanunt &Wajanavisit 2001
4low
UK BEAM trial, 2004
7
highTurner 1990
2
lowWhite 1966
3
lowWhite 19692low
* using grading system of van Tulder et al 1997; ≥5 points = high quality
Effectiveness versus passive treatments intended/considered by the authorsof the RCT to be control treatments (hot packs plus rest, semi-hot packs plus
sham traction, waiting list control group, transcutaneous electrical stimulation(TENS), sham TENS, detuned ultrasound or short wave therapy).
Six RCTs from the earlier Cochrane review (van Tulder et al 2003) (searches up to1999) were included (Deyo et al 1990, Hansen et al 1993, Lidstrom and Zachrisson
1970, Martin et al 1986, Risch et al 1993, Turner et al 1990). One of the two highquality trials reported a larger decrease of pain (but not function) for stretching andrelaxation exercises than for TENS or sham TENS (Deyo et al 1990),whilst theother high quality trial reported a significantly better overall treatment effect forstrengthening/muscle reconditioning exercises compared with semihot packs plus
sham traction, but no difference in pain intensity between the twotreatments (Hansen et al 1993). The results of these two studies were considered tobe conflicting with respect to pain reduction. The results of the 4 lower quality
studies (Lidstrom and Zachrisson 1970, Martin et al 1986, Risch et al 1993, Turner
et al 1990) were also inconsistent for pain, functional status or overall improvement(two in favour of exercise, two showing no difference from “ineffective treatment”).
Four recent additional RCTs showed more favourable results for exercise therapy
compared with control/placebo/’ineffective’ treatments: in one low quality study(N=59), back muscle reconditioning exercises for 3 months were superior to an“ineffective” treatment (4 sessions of massage/thermal therapy) as regards pain
intensity and functional disability (Kankaanpaa et al 1999); in a high quality study(N=95), exercises in water (‘hydrotherapy’) were superior to waiting list control withregard to short-term clinically relevant improvements in functional status (McIlveen
and Robertson 1998); a high quality study (N=107) showed that light remedial
exercises were statistically better than sham low-level laser therapy with regard tofunction 1 month after treatment (Preyde 2000); and a low quality study (N=86)
showed that a 3 month home exercise programme (aimed at strength, endurance
and flexibility) resulted in a more lasting improvement in pain and function, up to 12
months after treatment, compared with control treatment (no physicalexercises) (Kuukkanen and Malkia 2000).
In summary, three of the four high quality trials showed superior results for exercise
therapy in relation to pain or function/disability (at least in the short-term), whilst one
showed no superiority for exercise with regards to pain, but did show that the“overall treatment effect” was more favourable after exercise therapy. Four out of six
low quality studies showed a favourable result for exercise therapy (with respect toeither pain or disability, at least in the short-term).
There is moderate evidence that exercise therapy is more effective in the reductionof pain and/or disability, at least in the short-term, than passive treatments
intended/considered to be control treatments by the authors of the respective RCTs
(level B).
Exercise versus “GP care”

78One high quality study (Lindström 1994, Lindstrom et al 1992a, Lindstrom et al
1992b) and one low quality study (White 1969) included in previous systematic
reviews compared exercises with GP care. Both reported better outcomes for the
exercise groups with regards to return to work. Of the additional trials, one (highquality) (N=187) found aerobic exercise to be better than GP care with regard to pain
12 months after treatment and with regard to function/disability 6 and 12 months after
treatment (Klaber Moffett et al 1999). Another high quality RCT (N=93) found that,
immediately after treatment, an exercise programme (including cardiovascular,
strength, and flexibility exercises, body awareness, and relaxation) was not better
than GP care with regards to four prospectively measured pain outcomes anddisability, although patients in the exercise group reported a greater reduction in pain
intensity, retrospectively, and were more satisfied with their care (Storheim et al2003). A high quality RCT (N=222) showed that Cesar therapy (postural training)
resulted in more patients reporting an improvement in back symptoms at 6 months(but not 12 months) compared with GP care (Hildebrandt et al 2000). Another highquality RCT (N=134) showed that graded activity was more effective than usual carein reducing the number of days of absence from work because of low back pain in
the 6 and 12 months after treatment (Staal et al 2004). Another high quality RCT(N=1334) that included primary care patients with subacute and chronic back pain
showed that “stay active GP care” together with general exercise therapy (as used inprevious studies (Frost et al 1995, Klaber Moffett et al 1999)) resulted in significantly
greater improvements in disability after 3 months, but not 12 months, compared with“stay active GP care” alone (the GPs had been previously trained in the active
management of CLBP). However, the compliance with the exercise programme wasquite poor.
There is strong evidence that exercise therapy is more effective than GP care forthe reduction of pain and disability and return to work in at least the mid-term (3-6months) (level A).
Exercise versus physiotherapeutic treatments
In the following trials, physiotherapeutic treatment often comprised a mixture of anyof the following, administered at the discretion of the treating physiotherapist:
manual therapy, massage, mobilisation, hot/cold packs, shortwave diathermy,
ultrasound, TENS, traction. The physiotherapy treatments administered often
included an exercise component.
Three high quality RCTs of exercise vs “conventional physiotherapy” (Hansen et al
1993, Hemmila et al 1997, Torstensen et al 1998) were included from the earlier
Cochrane review (van Tulder et al 2003). These did not show any significant
treatment group differences with regard to pain intensity, functional status, overall
improvement or return to work. One additional high quality trial (N=148) did not show
any difference between aerobic exercise or muscle reconditioning and ‘modern,active physiotherapy’ (i.e. mainly exercises, but supplemented where necessary withother physical therapy procedures) (Mannion et al 2001b). In one high quality RCT(N=98) light remedial exercise (stretching and encouragement to undertake aerobic
exercise) did not differ from massage with respect to short-term improvements infunction, and both were inferior to a combined programme of exercise and massage
with regard to short-term improvements in pain and function (Preyde 2000). An
additional low quality RCT (Rasmussen-Barr et al 2003) (N=47) compared
manipulation with stabilising exercises and reported that the latter were more
effective than manual treatment in terms of improvements in pain, general health andfunctional disability (3 months after treatment) and in terms of the need for recurrent
treatment (in the 12 months following the study treatment) (Rasmussen-Barr et al2003). However, drop out rates were high at the longer-term follow-up, and at this79

point the differences in the reduction of pain intensity and disability (ODI) were notsignificantly different between the groups. Another high quality RCT (N=1334)
showed that manipulation but not general exercise therapy showed significantly
greater improvements in disability after 12 months than did “best GP care”, although
no direct statistical comparison of manipulation and exercise was carried out (UKBEAM trial team et al 2004).
There is strong evidence that exercise therapy alone is not more effective thanconventional physiotherapeutic methods in the treatment of CLBP (level A).
Exercise (outpatient) versus intensive multidisciplinary treatment
One high quality RCT (N=123) included in the systematic review (van Tulder et al2003) found that a full time intensive 3 week multidisciplinary programme was more
effective than outpatient exercise in improving pain and function (at 4 and 24
months) but not return to work (Bendix et al 1998, Bendix et al 1995). A more recent
low quality RCT from the same research group (N=127), however, found that
intensive multidisciplinary treatment and exercise therapy showed no significant
differences in the resulting improvements in pain and function — only the global
rating of “overall improvement” was better in the group of patients receiving theintensive treatment (Bendix et al 2000). An additional high quality trial (N=86) on
patients with an average sick-leave of 6 months in the last 2 years found that themean number of sick-leave days was significantly lower in the functional restorationgroup, but there was no significant difference in the intensity of pain, the quality oflife, functional indexes, psychological characteristics, the number of contacts withthe medical system, or the drug intake (Jousset et al 2004).
There is conflicting evidence regarding the effectiveness of exercise as comparedwith intensive multidisciplinary programmes (level C).
Exercise versus various other treatments (back school, cognitive therapy,
limiting early morning flexion, laser therapy)
One high quality RCT (N=81) provided limited evidence (level C) that aerobic
exercise therapy shows improved outcomes on pain and functional status comparedwith back-school education (Frost et al 1995, Frost et al 1998). A low quality RCT(N=96) provided limited evidence (level C) that aerobic exercises with operantconditioning behavioural therapy results in better outcomes on pain and function
immediately post-treatment compared with aerobic exercises or operantconditioning behavioural therapy alone, but that all treatments are similarly effective
after 6 and 12 months (Turner et al 1990). One high quality RCT (N=93) provided
limited evidence (level C) that cognitive therapy and exercise therapy do not differ
significantly from each other with respect to their effects on disability and pain, andneither treatment reduces sickness absence; however, cognitive therapy and not
exercise therapy was significantly better than GP treatment with regard todisability (Storheim et al 2003). One high quality RCT (N=85) provided limited
evidence (level C) that exercises are less effective than the practice of ‘limiting theamount of early morning lumbar flexion’, with regard to pain and functional
status (Snook et al 2002, Snook et al 1998). One low quality trial (N=75) provided
limited evidence (level C) that exercise therapy, laser therapy, and laser therapy
combined with exercise all led to significant post-therapy improvements in pain anddisability, with no difference between the groups (Gur et al 2003).
Relative effectiveness of different types of exercise
Muscle reconditioning/strengthening exercises versus other types of exercise
Four RCTs from the previous SRs compared some type of muscle reconditioning/
strengthening exercises with other types of exercises (Bronfort et al 1996, Hansen
et al 1993, Johannsen et al 1995, Manniche et al 1988, Manniche et al 1991). Of

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the 3 high quality trials (Bronfort et al 1996, Hansen et al 1993, Manniche et al
1988, Manniche et al 1991), one reported better outcomes regarding pain andfunctional status for an intensive, dynamic strengthening programme than with mild
exercise (Manniche et al 1988, Manniche et al 1991). The other two reported nodifference between strengthening/reconditioning exercises and conventional
general physiotherapy exercises (Hansen et al 1993) or stretching
exercises (Bronfort et al 1996). One other study reported no significant differences
between intensive muscle reconditioning (for back muscle endurance) and coordination training in terms of the improvements in pain and disability (Johannsen etal 1995).
Four additional trials were identified comparing reconditioning/strengthening
exercises with other types of exercise. One high quality RCT (N=148) reported nodifference between muscle reconditioning exercises and either aerobic or
physiotherapy exercises (Mannion et al 1999, 2001b) with regard to improvementsin pain up to 1 year after treatment. Disability was significantly more reduced after 6
months in the muscle reconditioning and aerobics groups than in the active
physiotherapy, but the difference had disappeared by 12 months, at which time allgroups showed a similar significant reduction from baseline values (Mannion et al
1999, 2001b). A low quality study (Kuukkanen and Malkia 2000) (N=86; not truly
randomised, but controlled trial) showed no significant difference in relation to the
reduction in pain and disability between intensive reconditioning exercises using
gym equipment (pulleys, bar-bells, plinths, etc.) and home exercises (no equipment,
just using body weight exercises). A further low quality RCT (N=260) showed thatmuscle reconditioning exercises (similar to those used in previous
studies (Manniche et al 1988)) gave similar results to McKenzie exercises in termsof improvements in pain and disability (Petersen et al 2002). In a low quality RCT(N=60), the improvements in pain and disability did not differ significantly between agroup performing muscle reconditioning exercises (isodynamic lumbar extension,
MedX) and a group carrying out whole body vibration exercises (eliciting muscle
activity via stretch reflexes) (Rittweger et al 2002).
There is strong evidence that strengthening/reconditioning exercises are no more
effective than other types of exercises in the treatment of CLBP (level A).
Aerobic exercises versus other types of exercise
One high quality RCT (N=148) provided limited evidence (level C) that there are nodifferences between aerobic exercises and either muscle reconditioning or
physiotherapy exercises (Mannion et al 1999, 2001b) with regard to improvementsin pain up to 1 year after treatment (see above). Disability was significantly more
reduced after 6 months in the aerobics and muscle reconditioning groups than in
the active physiotherapy, but the difference had disappeared by 12 months, atwhich time all groups showed a similar significant reduction from baseline
values (Mannion et al 1999, 2001b). One low quality trial (N=72) provided limited
evidence (level C) that a programme of aerobic exercises combined with healtheducation is superior to lumbar flexion exercises and health education in terms ofpain immediately after the programme (Tritilanunt and Wajanavisit 2001).
Flexion exercises vs other types of exercise
One low quality trial (Tritilanunt and Wajanavisit 2001) provided limited evidence(level C) that a programme of lumbar flexion exercises combined with healtheducation is inferior to aerobic exercises with health education in terms of pain
immediately after the programme (Tritilanunt and Wajanavisit 2001).
Flexion vs extension exercises (either stretching or muscle reconditioning)81Three small (N<60 patients), low quality trials compared trunk flexion and extension
exercises (either stretching and/or strengthening) for CLBP. Two of these found nodifference between the approaches in their effectiveness; both programmes eliciteda similar reduction in pain (Buswell 1982, Elnaggar et al 1991). The third comparedmuscle reconditioning programmes for the trunk extensors and the trunk flexors andfound that the flexor reconditioning programme was superior in terms of the numberof patients who were symptom free after 3 months (Kendall and Jenkins 1968).
There is conflicting (level C) evidence regarding the effectiveness of programmes
involving mainly trunk flexion exercises as compared with those involving mainly
trunk extension.
Other considerations
Structure of exercise classes: group classes vs individual
One low quality RCT (N=190) found no significant differences between individualand group exercises for pain and disability 4 weeks after the end of treatment (ineach case, the exercise groups also received massage therapy) (Franke et al2000). A second, high quality RCT (N=148) of group aerobic exercises (10-12
participants per group) versus either small group (2-3 participants) reconditioning
exercises or individual physiotherapy exercises found no significant differences
between the treatments in the proportion of patients in each group reporting
clinically relevant improvements in pain and disability up to 1 year later (N.B. allwere exercise-based therapies, although the exact exercises carried out were not
identical in each case) (Mannion et al 2001b).
There is moderate evidence (level B) that individually supervised exercise therapy is
not more effective than supervised groups exercise.
Number of exercise sessions
One low quality RCT provided limited evidence (level C) that there are no significant
differences between the effects on pain reduction of carrying out just 4 exercise
therapy sessions (over two weeks) as opposed to 8 sessions (over 4 weeks)(Callaghan 1994).
General versus individualised exercise programmes
A very small (N=20) low quality RCT provided limited evidence (level C) that ahome exercise programme with specific exercises (individualised, based on preassessment of patient) is more effective than a home exercise programme using
general exercises (typical of those commonly prescribed in back schools)(Descarreaux et al 2002).

82

Exercise with motivation
One high quality trial (Friedrich et al 1998) provided limited evidence (level C) that a
combined exercise and motivational programme shows a significantly larger
decrease in pain and disability 4 and 12 months after the 4-week programmecompared with exercise alone.
Relationship between changes in clinical symptoms (pain and disability) and
improvements in performance (e.g. spinal range of motion, trunk strength) as aresult of the exercise therapy.
If specific exercise programmes are designed to target a particular aspect of physicalfunction, then it would seem to be important —especially in examining theeffectiveness of different modes of exercise— to examine whether improvements inperformance are related to improvements in symptoms. Only 7 studies from thoselisted in Table 1 examined whether improvements in objective indices of function,
recorded after exercise therapy, were in any way related to changes in self-rated
pain and disability/functional status (Elnaggar et al 1991, Hsieh and Lee 2002,
Johannsen et al 1995, Kuukkanen and Malkia 2000, Mannion et al 2001a, Mannion
et al 1999, Martin et al 1986, Rittweger et al 2002). Two studies found a weaknegative relationship between changes in LBP severity/disability and changes in 3D
spinal mobility in the sagittal plane (correlation coefficient, r, approx 0.2-0.4)(Elnaggar et al 1991, Mannion et al 1999). Using principal components analysis togroup the various aspects of performance (trunk strength in 3 planes, endurance,
EMG-determined back muscle fatigability, back extensor activation, trunk mobility in
3 planes) one study found no significant relationship between changes in any aspectof performance and changes in self-rated disability (Mannion et al 2001a). Twostudies reported no relationship between gross spinal flexibility and either
pain/disability at the start of the exercise programme or between changes in each
after therapy (Hsieh and Lee 2002, Kuukkanen and Malkia 2000). One study foundno correlation between the improvements in spinal mobility or back muscle strengthand the reduction in either pain or disability (Johannsen et al 1995). A further study
reported that the increase in trunk strength showed a moderate significant correlation
with the decrease in functional impairment after exercise therapy (r=0.48), butchanges in spinal mobility did not correlate with changes in either pain or functional
impairment (Martin et al 1986). One study found no correlation between the gain in
lumbar torque and pain relief or pain-related disability after exercise therapy(p>0.2) (Rittweger et al 2002).
There is strong evidence (level A) that the changes in pain and disability reported
after various types of exercise therapy are not directly related to changes in any
aspect of physical performance capacity.
Cost effectivenessFew studies have examined the cost effectiveness of different treatments. One
study reported that the relative costs of group aerobic exercises vs physiotherapy vsmuscle reconditioning were in a ratio of approximately1:3:4, for similar clinicaleffectiveness, indicating that group aerobic exercise constituted the most costeffective treatment (Mannion et al 1999, 2001b). However, no full economic
evaluations have been published so far.
SafetyAdverse effects were reported in only few studies: two studies reported
cardiovascular problems, apparently unrelated to the treatment programmes(coronary occlusion (Hansen et al 1993)) and myocardial infarction (Bronfort et al1996); and one study reported an increase in back pain at the start oftreatment (Manniche et al 1991).

83

Comments
1. The overall effectiveness of exercise therapy for CLBP may be overestimated:
the studies on exercise have a certain bias because patients who do not like
exercise are less likely to volunteer to participate.
2. At present, the influence of exercise intensity, frequency of therapy sessions,and programme duration on outcome remains largely unknown. Few studies havedirectly examined dose-response, and the sheer diversity of exercise programmes
used in previous RCTs precludes the useful examination of pooled data e.g. inmeta-analyses (Hilde and Bo 1998).
3. It is difficult to accurately characterise the exercise programmes used in some of
the RCTs, as they involve a mixture of different exercise modes (stretching, aerobic
exercises, muscle reconditioning). Further, it is questionable whether the
categorisation of “flexion exercises” and “extension exercises” is justified, unless it
is clear whether the direction of the exercise (flexion or extension) refers to themuscles being stretched or strengthened (e.g. trunk-flexion stretching exercises
actually stretch the back and hip extensors; trunk-flexion strengthening exercises
train the trunk flexors).
4. The cost-benefit ratio for group exercise classes and individual exercise sessions
should be investigated more thoroughly, as this issue is highly relevant to theeconomics of CLBP.
5. The mechanisms of action by which exercise therapy appears to be an effective
treatment for CLBP are presently unclear. There is little relationship betweenchanges in clinical symptoms and changes in any “objectively measured” aspect offunctional capacity (e.g. strength, flexibility, muscular endurance, etc.) This may
explain the conclusion that there is no convincing evidence to endorse the use of
one type of exercise over another in the treatment of CLBP.
6. All the exercise programmes investigated were done so within the confines of a
research study and thus the individuals involved were under some sort ofsupervision/observation (even those in which the exercise sessions per se was
unsupervised). There is currently no evidence to show whether simply prescribing
exercise (e.g. just sending patients off to the local leisure centre to join an exerciseclass, or telling them to keep themselves fit and active) would be equally effective.
Summary of evidence• There is moderate evidence that exercise therapy is more effective in the
reduction of pain and/or disability, at least in the short-term, than passive
treatments intended/considered to be control treatments by the authors of therespective RCTs (level B).
• There is strong evidence that exercise therapy is more effective than “GP care”
for the reduction of pain and disability and return to work in at least the mid-term(3-6 months) (level A).
• There is strong evidence that exercise therapy alone is not more effective thanconventional physiotherapeutic methods in the treatment of CLBP (level A).
• There is conflicting evidence regarding the effectiveness of exercise ascompared with intensive multidisciplinary programmes (level C).
• There is strong evidence that strengthening/reconditioning exercises are no
more effective than other types of exercises in the treatment of CLBP (level A).
• There is limited evidence in each case that: there are no differences between
aerobic exercises, muscle reconditioning or physiotherapy exercises in relation topain or disability up to 12 months after treatment; there are no significant
differences between the effects on pain reduction of carrying out just 4 exercise
therapy sessions as opposed to 8 sessions; aerobic exercises are superior tolumbar flexion exercises in terms of pain immediately after the programme; ahome exercise programme with individualised exercises is more effective than
one using general exercises; a combined exercise and motivational programme84

shows a significantly larger decrease in pain and disability up to 12 months posttreatment than does exercise alone (each, level C).
• There is conflicting evidence regarding the effectiveness of programmes involving
mainly trunk flexion exercises as compared with those involving mainly trunk
extension (level C).
• There is moderate evidence that individually supervised exercise therapy is not
more effective than supervised groups exercise (level B).
• There is strong evidence that the changes in pain and disability reported after
various types of exercise therapy are not directly related to changes in any aspectof physical performance capacity (level A).
Recommendation
Supervised exercise therapy is recommended as a first-line treatment in the
management of chronic low back pain.
We advocate the use of exercise programmes that do not require expensive training
machines. The use of a cognitive-behavioural approach, in which graded exercises
are performed, using exercise quotas, appears to be advisable. Group exercise
constitutes an attractive option for treating large numbers of patients at low cost. We
do not give recommendations on the specific type of exercise to be undertaken(strengthening/muscle conditioning, aerobic, McKenzie, flexion exercises, etc.). The
latter may be best determined by the exercise-preferences of both the patient andtherapist.
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67. Preyde M (2000) Effectiveness of massage therapy for subacute low-back pain: arandomized controlled trial. Cmaj, 162(13): 1815-20.
68. Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I (2003) Stabilizing training
compared with manual treatment in sub-acute and chronic low-back pain. Man Ther,8(4): 233-41.
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Leggett SH (1993) Lumbar strengthening in chronic low back pain patients.
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71. Rittweger J, Just K, Kautzsch K, Reeg P, Felsenberg D (2002) Treatment ofchronic lower back pain with lumbar extension and whole-body vibration exercise: arandomized controlled trial. Spine, 27(17): 1829-34.
72. Snook SH, Webster BS, McGorry RW (2002) The reduction of chronic,
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75. Soukup MG, Lonn J, Glomsrod B, Bo K, Larsen S (2001) Exercises andeducation as secondary prevention for recurrent low back pain. Physiother Res Int,6(1): 27-39.
76. Staal JB, Hlobil H, Twisk JW, Smid T, Koke AJ, van Mechelen W (2004) Graded
activity for low back pain in occupational health care: a randomized, controlled trial.
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77. Storheim K, Brox JI, Holm I, Koller AK, Bo K (2003) Intensive group training
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78. Sweetman BJ, Heinrich I, Anderson JAD (1993) A randomized controlled trial of
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159-66.
79. Torstensen TA, Ljunggren AE, Meen HD, Odland E, Mowinckel P, Geijerstam S(1998) Efficiency and costs of medical exercise therapy, conventional physiotherapy,
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80. Tritilanunt T, Wajanavisit W (2001) The efficacy of an aerobic exercise and healtheducation program for treatment of chronic low back pain. J Med Assoc Thai, 84
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8983. van Tulder MW, Koes B (2003) Low back pain and sciatica: chronic. Clin Evid,(9).
84. van Tulder MW, Koes BW, Bouter LM (1997) Conservative treatment of acuteand chronic nonspecific low back pain. A systematic review of randomized controlled
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90Chapter 6 Manual Therapy
C6 (A) Spinal manipulation/mobilisation
Definition of the procedure
Spinal manipulation is defined as a high velocity thrust to a joint beyond its restricted
range of movement. Spinal mobilization involves low-velocity, passive movements
within or at the limit of joint range (Brox et al 1999, Koes et al 1996). Most studies do
not make a clear distinction between these two, because in clinical practice these
two techniques are part of a “spinal manipulation package” that is often referred to as
manual therapy (Harvey et al 2003).
For a discussion on differences between spinal manipulation and mobilisation
techniques see (CMAJ Oct 2004)
Results of search
Systematic reviews
22 studies were retrieved through the electronic search (Abenhaim and Bergeron
1992, Anderson et al 1992, Assendelft et al 1992, 1996, Assendelft and Lankhorst
1998, Assendelft et al 2003, 2004, Bronfort 1999, Cassidy et al 1993, Cherkin et al
2003, Cooperstein et al 2001, Ernst 2001, Ernst and Harkness 2001, Ferreira et al
2002, Gatterman et al 2001, Koes et al 1996, Koes et al 1991, Leboeuf-Yde et al
1997, Pustaver 1994, Shekelle et al 1992, Shekelle et al 1998, Stevinson and Ernst
2002). 5 of these were considered to be individual/observational studies or nonsystematic reviews and were hence excluded from further consideration (Bronfort
1999, Cooperstein et al 2001, Gatterman et al 2001, Leboeuf-Yde et al 1997,
Shekelle et al 1998). The remaining 17 were systematic reviews or meta-analyses. A
further 3 SRs were identified through the working group’s knowledge of theliterature (Brox et al 1999, Ottenbacher and DiFabio 1985, White and Ernst 2000). Of
these total 20 SRS, two were excluded: one because it focused on the description of
the manipulative method and not on the evidence of its effectiveness (Cassidy et al1993) and another because it was related to acute and not CLBP (Pustaver 1994).
Among the remaining 18 systematic reviews, one focused on an economic analysis
of complementary medicine (including spinal manipulation) (White and Ernst 2000)
and two on the safety of spinal manipulation (Ernst 2001, Stevinson and Ernst 2002).
Thirteen focused on the effectiveness of spinal manipulation and/or spinal
mobilization (considered as one and the same) vs. other procedures (some of themconsidered as being placebo) (Abenhaim and Bergeron 1992, Assendelft et al 1992,
1996, Assendelft and Lankhorst 1998, Assendelft et al 2003, 2004, Brox et al 1999,
Cherkin et al 2003, Ferreira et al 2002, Koes et al 1996, Koes et al 1991,
Ottenbacher and DiFabio 1985, Shekelle et al 1992); whilst two separated out spinal
manipulation and spinal mobilization (Anderson et al 1992, Ernst and Harkness2001).
The most up to date systematic review was an updated Cochrane review (Assendelft
et al 2004) (same review as (Assendelft et al 2003)) which presented separate
results for studies of CLBP.
Additional studies
Eight additional RCTs were identified (Aure et al 2003, Chiradejnant et al 2003,
Hemmila et al 2002, Hurwitz et al 2002, Licciardone et al 2003, Niemisto et al 2003,
Rasmussen-Barr et al 2003, UK BEAM trial team et al 2004b). Three of these were
excluded from further consideration: two studies (“manual therapy” vs. “exercise
therapy”), because the patients in the manual therapy group also received asubstantial amount of exercise therapy, making the respective effects of the manual
therapy and the exercise therapy difficult to ascertain (Aure et al 2003, Niemisto et al2003); and a third (“folk-medicine bone-setting” vs “exercise therapy” vs91

“physiotherapy”), because the treatment given in the “bone-setting” group was notcomparable with the type of manual therapy (administered by medically qualified
personnel) described in all the other trials used to form theserecommendations (Hemmila et al 2002). Furthermore, the physiotherapy group in
this trial also received manual therapy, and the descriptions of the treatments(especially the exercise therapy) were unclear and not consistent in the two papers
published from the trial.
Quality assessment of the evidence
Systematic reviews
Six of the final 18 SRs were assessed as being of high quality (Assendelft et al 1996,
Assendelft et al 2003, 2004, Brox et al 1999, Cherkin et al 2003, Koes et al 1991)
and 12 as being of low quality (Abenhaim and Bergeron 1992, Anderson et al 1992,
Assendelft et al 1992, Assendelft and Lankhorst 1998, Ernst 2001, Ernst andHarkness 2001, Ferreira et al 2002, Koes et al 1996, Ottenbacher and DiFabio 1985,
Shekelle et al 1992, Stevinson and Ernst 2002, White and Ernst 2000). As one ofthese was also an up-to-date Cochrane review (Assendelft et al 2004)(same as(Assendelft et al 2003)), it was used as the basis for forming theserecommendations. The quality ratings of the studies included in the Cochrane review
followed a slightly different 10-point scheme than that described in the introduction tothese guidelines, but was still based on the guidelines given by the Cochrane
Collaboration Back Review Group (van Tulder et al 1997). Manipulation wascompared with sham manipulation in three studies (scoring 7, 5, and 5 points
respectively) (Ongley et al 1987, Triano et al 1995, Waagen et al 1986); comparedwith treatments considered to be “ineffective”, such as traction, corsets, topical gels(based on the lack of evidence for their benefit or evidence for their harm in previous
systematic reviews) in 5 studies (scoring 6, 8, 6, 3 and 3 respectively) (Gibson et al
1985, Koes et al 1992, Pope et al 1994, Postacchini et al 1988, Timm 1994);
compared with GP care/analgesics in 5 studies (scoring 7, 7, 5, 8 and 3
respectively) (Andersson et al 1999, Bronfort et al 1996, Evans et al 1978, Koes et al
1992, Postacchini et al 1988); compared with physical therapy/exercise therapy in 4
studies (scoring 6, 8, 3 and 3 respectively) (Hemmila et al 1997, Koes et al 1992,
Postacchini et al 1988, Skargren et al 1997); and compared with back schools in 3
studies (scoring 3, 3 and 5 respectively) (Herzog et al 1991, Postacchini et al 1988,
Triano et al 1995).
Additional RCTs:
Using the same rating scheme as used by Assendelft et al (Assendelft et al 2004) thefour additional RCTs identified by the authors’ knowledge of the literature (Hurwitz etal 2002, Licciardone et al 2003, Rasmussen-Barr et al 2003, UK BEAM trial team etal 2004b) were scored 4, 4, 3, and 7 respectively.
Effectiveness
The Cochrane review carried out a series of meta-analyses to examine theeffectiveness of manipulation vs the various other procedures (grouped as describedabove) for the outcomes pain and disability, in both the short-term (<6 weeks after
randomisation; outcome measurement closest to 3 weeks) and long-term (<6 weeks
after randomisation; outcome measurement closest to six months) (Assendelft et al2004).

92

Effectiveness of manipulation vs. a sham procedure
Based on 3 studies (quality ≥ 5/10) (Ongley et al 1987, Triano et al 1995, Waagen etal 1986), the Cochrane review meta-analyses revealed that manipulation was
superior to sham manipulation for short-term and long-term pain relief, and for shortterm improvement in function (Assendelft et al 2004). The pooled difference in pain
intensity (on a 0-100 mm VAS) was 10 mm (95% CI, 3-17mm) in the short-term and
19 mm (95% CI, 3-35 mm) in the long-term; short-term improvement in function on
the 24-point Roland Morris Disability scale was 3.3 points (95% CI, 0.6 – 6.0). There
were no significant benefits in relation to long-term function. The findings of the
Cochrane review conflict somewhat with those of an earlier low quality systematic
review of manipulation for various conditions, which concluded that serious
methodological flaws in two of the studies on manipulation for back pain (alsoincluded in the Cochrane review) prevented any firm conclusions from being
reached (Ernst and Harkness 2001). One additional RCT (quality, 4/10) compared
manipulation with sham manipulation and with a “no additional intervention” control
group (Licciardone et al 2003). All groups were allowed to continue with their usual orother back care for back pain (with the exception of manipulative therapy). Treatment
was delivered by third- and fourth-year medical students in the process of completingan additional year of training devoted to osteopathic theory and practice (seeComments section). One month after the last treatment, the outcomes for
manipulation and sham manipulation (each with additional access to usual care) did
not differ, and both were better than the control treatment (usual care only) withregards to pain, physical functioning and satisfaction with care (Licciardone et al2003).
There is moderate evidence (generally consistent findings; 3 out of 4 studies) thatmanipulation is superior to sham manipulation for improving short-term pain andfunction (level B).
Effectiveness of manipulation vs. treatments considered to be ineffective
Based on 5 studies (scoring 6, 8, 6, 3 and 3 quality points respectively) (Gibson et al
1985, Koes et al 1992, Pope et al 1994, Postacchini et al 1988, Timm 1994), theCochrane review meta-analyses revealed that manipulation was superior totreatments considered to be “ineffective” (see earlier) for short-term pain relief andfor short-term improvement in function (Assendelft et al 2004). The pooled differencein pain intensity (on a 0-100 mm VAS) was just 4 mm (95% CI, 0-8mm) and infunction on the 24-point Roland Morris Disability scale, 2.6 points (95% CI, 0.5 – 4.8).
There were no significant benefits in relation to long-term pain or function.
There is strong evidence that manipulation is superior to treatments considered to beineffective for improving short-term pain and function (level A).
Effectiveness of manipulation vs. GP care or analgesics
Based on 5 studies (scoring 7, 7, 5, 8 and 3 respectively) (Andersson et al 1999,
Bronfort et al 1996, Evans et al 1978, Koes et al 1992, Postacchini et al 1988), theCochrane review meta-analyses revealed that spinal manipulation showed nostatistically or clinically significant differences from general practitioner care or
analgesics with regard to either short-term or long-term changes in pain anddisability (Assendelft et al 2004).
One additional RCT (quality score 4) compared manipulation with usual medical care(instructions/recommendations on back care and exercise) (Hurwitz et al 2002) andfound that the mean changes in low back pain intensity and disability of participantsin the medical and chiropractic care-only groups were similar at each follow-up
assessment (adjusted mean differences at 6 months for most severe pain, 0.27, 95%
confidence interval, -0.32-0.86; average pain, 0.22, -0.25-0.69; and disability, 0.75, 0.29-1.79) (Hurwitz et al 2002).

93

There is strong evidence (level A) that manipulation and GP care/analgesics are
similarly effective in the treatment of CLBP.
Effectiveness of manipulation plus GP care vs GP care only
One additional trial (quality rating, 4) showed that manipulation in addition tocontinued medical care was superior to continued medical care alone, with regards
to pain, physical functioning and satisfaction with care 1 month after the last
manipulation treatment (Licciardone et al 2003).
Another additional large trial (N=1334) (quality rating, 7), that included primary carepatients with subacute and chronic back pain from all over the UK, showed thatmanipulation, when added to “stay active GP care”, improved pain and disability
significantly more than “stay active GP care” in both the short and long-term (up to 12
months) (UK BEAM trial team et al 2004b).
There is moderate evidence that spinal manipulation in addition to GP care is more
effective than GP care alone in the treatment of CLBP (level B).
Effectiveness of manipulation vs. physiotherapy/exercise therapy
Based on 4 studies (scoring 6, 8, 3 and 3 respectively) (Hemmila et al 1997, Koes etal 1992, Postacchini et al 1988, Skargren et al 1997), the Cochrane review metaanalyses revealed that spinal manipulation showed no statistically or clinicallysignificant differences from exercise therapy or physiotherapy with regard to shortterm or long-term changes in pain and disability (Assendelft et al 2004).
N.B. The longer follow-up (Hemmila et al 2002) from one of these studies (Hemmila
et al 1997) was excluded from our own considerations, as the manipulative therapy
administered (“folk-medicine bone-setting”) was not considered to be comparablewith the type of manual therapy, administered by medically qualified personnel,
described in the other trials.
An additional study (quality rating, 3) (Rasmussen-Barr et al 2003) compared
manipulation with spine-stabilising exercises and reported that the latter were more
effective than manual treatment in terms of improvements in pain, general health andfunctional disability (3 months after treatment) and in terms of the need for recurrent
treatment (in the 12 months following the study treatment) (Rasmussen-Barr et al2003). However, drop out rates were high at the longer-term follow-up, and at thispoint the differences in the reduction of pain intensity and disability (ODI) were notsignificantly different between the groups.
There is moderate evidence that spinal manipulation is no less and no more effective
than physiotherapy/exercise therapy in the treatment of CLBP (level B).
Effectiveness of manipulation vs. back school
Based on 3 studies (scoring 3, 3 and 5 respectively) (Herzog et al 1991, Postacchini
et al 1988, Triano et al 1995) the Cochrane review meta-analyses revealed thatspinal manipulation showed no statistically or clinically significant differences fromback school with regard to short-term or long-term changes in pain and short-termchanges in disability (long-term disability was not studied in any of theRCTs) (Assendelft et al 2004).
There is moderate evidence that spinal manipulation is no less and no more effective
than back-schools in the treatment of CLBP (level B).
The finding that spinal manipulation shows no difference from other conventionallyadvocated therapies (such as GP care, analgesics, exercise therapy, physiotherapy
or back school) confirmed the general findings of all the earlier, high quality

94SRs (Assendelft et al 1996, Assendelft et al 2003, Brox et al 1999, Cherkin et al
2003, Koes et al 1991).
Cost/effectivenessOne low quality SR focused on economic analysis of complementary medicine(including spinal manipulation). With regard to this procedure, it concluded that there
is no convincing evidence that manipulative therapy for back pain improves
cost/effectiveness of treatment or saves costs for the primary care provider (Whiteand Ernst 2000).
One high quality SR, based on two RCTs, reported that the cost-effectiveness for
manipulation was not better than for an educational booklet or
physiotherapy (Cherkin et al 2003).
One high quality RCT carried out in the UK showed that manipulation, as carried out
by chiropractors, osteopaths or physiotherapists, was more cost-effective than “stayactive GP care” in terms of the use of healthcare resources in the following year (UKBEAM trial team et al 2004a).
SafetyThree SRs focused specifically on prospective studies on the safety of spinal
manipulation (not mobilization) (Assendelft et al 1996, Ernst 2001, Stevinson and
Ernst 2002). The studies they included may or may not have included patients with
CLBP amongst all patients who were given spinal manipulations. One other review
focused on effectiveness of both spinal manipulation and mobilization and gavesome data on safety (Shekelle et al 1992). The SRs concur in stating that cervicalmanipulation (which is infrequently used by manipulators treating low back pain) has
been linked with a greater number of complications and of a more serious naturethan lumbar manipulation. The most serious side effects are vertebrobasilar
accidents, disk herniation, and cauda equina syndromes. Estimates of the incidenceof serious complications range from 1 per 2 million manipulations to 1 per 400
000 (Ernst 2001, Stevinson and Ernst 2002).
Minor, transient adverse effects occur in approximately half of all patients receiving
spinal manipulation. Local discomfort, headache, fatigue and discomfort outside thearea of treatment were the most frequent complaints. They appear the same day as
the treatment or the day after, and disappear within 24-48 hours, although they may
last longer in about one fifth of the patients (Ernst 2001, Stevinson and Ernst 2002).
Subjects (indications)
The patient populations described in the majority of trials were heterogenous but
were often primary care patients who appeared to be moderately disabled with backpain but not sick-listed. No specific indications for spinal manipulation are known.

95Comments
1. The studies considered in the various SRs included patients with and without
referred pain. All studies considered included a substantial proportion of “chronic”
LBP patients, although definitions of CLBP were inconsistent across reviews.
2. In many of the RCTs upon which the conclusions of the Cochranereview (Assendelft et al 2004) were based, the study sample included mixed
populations of patients with subacute and chronic neck, thoracic and low back pain.
Although this was not necessarily compatible with our own general criteria for theserecommendations (see Methods, in the Introduction), it was difficult to tease out thestudies only dealing with CLBP and this probably reflecting the treatments given in
the clinics of chiropractors and manual therapists.
3. The best systematic reviews stated that the general quality of RCTs on spinal
manipulation is low, making it difficult to draw firm conclusions, although recent,additional trials appear to be of higher quality.
4. Most of the manipulation/mobilisation treatments were administered bypersonnel that were considered “qualified” within their own medical specialty(osteopathy, chiropractic, manual medicine, physiotherapy), although therequirements for qualification differ markedly amongst these professions. The study
that showed no difference between manipulation and sham manipulation was carriedout by third and fourth year medical students in the process of completing an
additional year of training devoted to osteopathic theory and practice (Licciardone etal 2003). The authors of the study conceded that “it was possible that the predoctoral
fellows may not have had sufficient practical experience to provide the treatment withthe same efficacy as more seasoned practitioners or to provide nontherapeutic shammanipulation”. However, the failure to identify any difference between sham and real
manipulation may also have arisen as a result of the small size of the control andsham groups. Further, the study had a relatively high drop-out rate, especially in the
manipulation group.
In general, it would seem prudent to recommend that the treatment only be carriedout by suitably qualified/trained practitioners within the given medical specialty.
5. The manipulative/mobilization treatments used in the RCTs to date were mostcommonly administered twice per week (range, 1-7 times per week), and mostcommonly for a period of 2-3 weeks (range, 2-9 weeks). There is no evidence tosuggest that long-term manipulative treatment contributes any additional benefit.
6. Most of the systematic reviews on effectiveness included RCTs on spinal
manipulation and spinal mobilization, and in fact considered both as the same
treatment. As such, it is impossible to determine the relative effectiveness of spinal
manipulation or mobilization. Nonetheless, in practice, they are usually used together
as part of a treatment package (Harvey et al 2003).
7. One recent study sought to examine whether a mobilisation technique selected by
the treating physiotherapist is more effective in relieving low back pain than arandomly selected mobilisation technique. There was no suggestion that this was thecase (Chiradejnant et al 2003).
Summary of the evidence• There is moderate evidence that manipulation is superior to sham manipulation forimproving short-term pain and function in CLBP (level B).
• There is strong evidence that manipulation and GP care/analgesics are similarly
effective in the treatment of CLBP (level A)• There is moderate evidence that spinal manipulation in addition to GP care ismore effective than GP care alone in the treatment of CLBP (level B).
• There is moderate evidence that spinal manipulation is no less and no more
effective than physiotherapy/exercise therapy in the treatment of CLBP (level B).
• There is moderate evidence that spinal manipulation is no less and no more
effective than back-schools in the treatment of CLBP (level B).

96

Recommendation
Consider a short course of spinal manipulation/mobilisation as a treatment option for
CLBP.
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low back pain: a treatment package agreed by the UK chiropractic, osteopathy andphysiotherapy professional associations. Manual Therapy, 8: 46-51.
25. Hemmila HM, Keinanen-Kiukaanniemi SM, Levoska S, Puska P (1997) Does folk
medicine work? A randomized clinical trial on patients with prolonged back pain. Arch
Phys Med Rehabil, 78(6): 571-7.
26. Hemmila HM, Keinanen-Kiukaanniemi SM, Levoska S, Puska P (2002) Longterm effectiveness of bone-setting, light exercise therapy, and physiotherapy for
prolonged back pain: a randomized controlled trial. J Manipulative Physiol Ther,
25(2): 99-104.
27. Herzog W, Conway PJW, Wilcox BJ (1991) Effects of different treatment
modalities on gait symmetry and clinical measures for sacroiliac joint patients. J
Manipulative Physiol Ther, 14: 104-9.
28. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Belin TR, Yu F, Adams AH(2002) A randomized trial of medical care with and without physical therapy andchiropractic care with and without physical modalities for patients with low back pain:
6-month follow-up outcomes from the UCLA low back pain study. Spine, 27(20):2193-204.
29. Koes B, Bouter L, H vM, Essers A, Verstegen G, Hofhuizen D, Houben J,
Knipschild P (1992) The effectiveness of manual therapy, physiotherapy, andtreatment by the general practitioner for nonspecific back and neck complaints: A
randomized clinical tria. Spine, 17(1): 28-35.
30. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM (1996) Spinal
manipulation for low back pain. An updated systematic review of randomized clinical
trials. Spine, 21(24): 2860-71; discussion 72-3.
31. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM, Knipschild PG (1991)
Spinal manipulation and mobilisation for back and neck pain: a blinded review. Bmj,
303(6813): 1298-303.
32. Leboeuf-Yde C, Hennius B, Rudberg E, Leufvenmark P, Thunman M (1997) Side
effects of chiropractic treatment: a prospective study. J Manipulative Physiol Ther,
20(8): 511-5.
33. Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W, Swift J, Jr. (2003)
Osteopathic manipulative treatment for chronic low back pain: a randomized
controlled trial. Spine, 28(13): 1355-62.
34. Niemisto L, Lahtinen-Suopanki T, Rissanen P, Lindgren K-A, Sarna S, Hurri H(2003) A randomized trial of combined manipulation, stabilising exercises, andphysician consultation compared to physician consultation alone for chronic low backpain. Spine, 28(19): 2185-91.
35. Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ (1987) A new approach to
the treatment of chronic low back pain. Lancet, 2(8551): 143-6.
36. Ottenbacher K, DiFabio RP (1985) Efficacy of spinal manipulation/mobilization
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9837. Pope MH, Phillips RB, Haugh LD, Hsieh CY, MacDonald L, Haldeman S (1994) A
prospective randomized three-week trial of spinal manipulation, transcutaneousmuscle stimulation, massage and corset in the treatment of subacute low back pain.
Spine, 19(22): 2571-7.
38. Postacchini F, Facchini M, Palieri P (1988) Efficacy of various forms ofconservative treatment in low back pain: a comparative study. Neurol Orthop, 6: 1136.
39. Pustaver MR (1994) Mechanical low back pain: etiology and conservative
management. J Manipulative Physiol Ther, 17(6): 376-84.
40. Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I (2003) Stabilizing training
compared with manual treatment in sub-acute and chronic low-back pain. Man Ther,8(4): 233-41.
41. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH (1992) Spinal
manipulation for low-back pain. Ann Intern Med, 117(7): 590-8.
42. Shekelle PG, Coulter I, Hurwitz EL, Genovese B, Adams AH, Mior SA, Brook RH(1998) Congruence between decisions to initiate chiropractic spinal manipulation for
low back pain and appropriateness criteria in North America. Ann Intern Med, 129(1):
9-17.
43. Skargren E, Oberg B, Carlsson P, Gade M (1997) Cost and Effectiveness
Analysis of Chiropractic and Physiotherapy Treatment for Low Back and Neck Pain.
Six-Month Follow-Up. Spine, 22(18): 2167-77.
44. Stevinson C, Ernst E (2002) Risks associated with spinal manipulation. Am J
Med, 112(7): 566-71.
45. Timm KE (1994) A randomized-control study of active and passive treatments forchronic low back pain following L5 laminectomy. J Orthop Sports Phys Ther, 20(6):276-86.
46. Triano JJ, McGregor M, Hondras MA, Brennan PC (1995) Manipulative therapy
versus education programs in chronic low back pain. Spine, 20(8): 948-55.
47. UK BEAM trial team. Brealey S, Coulton S, Farrin A, Morton V, Torgerson D,
Burton AK, Garratt A, Harvey E, Letley L, Martin J, Vickers M, Whyte K, Manca A,
Klaber Moffett J, Russell I, Underwood M, Williams M (2004a) UK Back pain
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Klaber Moffett J, Russell I, Underwood M, Williams M (2004b) UK Back pain
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Nov 29; [Epub ahead of print])
49. van Tulder MW, Assendelft WJ, Koes BW, Bouter LM (1997) Method guidelines
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50. Waagen GN, Haldeman S, Cook G, Lopez D, DeBoer KF (1986) Short term trialof chiropractic adjustments for the relief of chronic low back pain. Manual Med, 2: 637.
51. White AR, Ernst E (2000) Economic analysis of complementary medicine: asystematic review. Complement Ther Med, 8(2): 111-8.

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C6 (B) Massage therapy
Definition of the procedure.
Massage can be defined as soft tissue manipulation using the hands or a mechanicaldevice (Furlan et al 2002). Different techniques can be used, such as: effleurage,
petrissage, friction, kneading, or hacking. Either a classical approach is used, or an
approach in which the rules of massage from physical medicine are combined withthose of acupuncture from neural therapy (treats one unique point with a special
vibrating instrument that stimulates the acupuncture point superficially (but not withneedle insertion)). In clinical practice, massage is often applied in combination withother therapies such as exercises and other interventions but sometimes also as asole treatment.
Results of search
Systematic reviews
Two SRs were found that dealt with the effects of massage in low back pain
patients (Ernst 1999, Furlan et al 2002). One of them was a Cochrane SR, which
described the effects of massage in adults with acute, sub-acute and chronic (>12
weeks) low back pain (Furlan et al 2002). The latter SR formed the basis for thisevidence review.
Additional trials
Two additional trials were found (Hsieh et al 2004, Walach et al 2003). In one, theeffects of massage were compared with standard medical care in a group of patientswith chronic pain (Walach et al 2003). However, this study was excluded from theevidence review because it was not clear from the publication what proportion of thestudy population had low back pain at the start of the study. In the second trial,
acupressure was compared with physical therapy (consisting of either infrared lighttherapy, thermotherapy, electrical stimulation, exercise therapy or pelvic manual
traction) (Hsieh et al 2004).
Quality assessment of the evidence
The two SRs were of a high quality.
The Cochrane SR included 7 RCTs that were reported in 8 publications (Cherkin etal 2001, Franke et al 2000, Hernandez-Reif et al 2001, Hoehler et al 1981, Hsieh et
al 1992, Melzack et al 1983, Pope et al 1994, Preyde 2000). In these studies
massage therapy was compared with a variety of treatments.
The additional trial (Hsieh et al 2004) was high quality.
Effectiveness
Effectiveness of massage versus sham procedure
One high quality RCT (according to the Cochrane Review) showed that massage
was significantly better than sham laser therapy with regard to both pain and function
up to 1 month after treatment (i.e. disability) (Preyde 2000).
There is limited evidence that massage is more effective than sham procedures inthe treatment of chronic low back pain (level C).
Effectiveness of massage versus remedial exercises and posture education
One high-quality study reported that, immediately after treatment, massage therapy
led to significantly greater disability and pain improvements compared with remedial
exercise and posture education (Preyde 2000).
There is limited evidence that massage is better than remedial exercise and posture
education in reducing short-term pain and improving function (level C).

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Effectiveness of massage versus relaxation therapy
One low quality study reported significantly more pain relief after massage therapy incomparison to progressive relaxation therapy (Hernandez-Reif et al 2001).
There is limited evidence that massage is more effective than relaxation therapy for
pain relief (level C).
Effectiveness of massage versus acupuncture
One high quality study compared 10 sessions (over 10 weeks) of either massage or
acupuncture (Cherkin et al 2001). Patients in the massage group had better function
scores than those in the acupuncture group, at both short-term (10 weeks) and longterm (52 weeks) follow-ups. Differences in pain scores in favour of massage were
found only at the longer-term follow-up.
There is limited evidence that massage is more effective than acupuncture in
reducing pain (long-term) and improving function (short-term and long-term) (level
C).
Effectiveness of massage versus self-care education
One high quality study compared 10 sessions (over 10 weeks) of massage therapy
with self-care education (Cherkin et al 2001). Patients in the massage group had
more pain relief and better function scores at the short-term follow-up (i.e. 10 weeks).
These differences were not maintained at long-term follow-up (i.e. 52 weeks).
There is limited evidence that massage is better than self-care education in reducing
pain and improving function in the short term but not the longer term (level C).
Effectiveness of massage versus spinal manipulation
In one low quality study, the effectiveness of spinal manipulation was compared withthat of massage therapy, where the latter was serving as a control
treatment (Hoehler et al 1981). The manipulation group had better results in relation
to pain reduction immediately after the first session, but the difference was not
maintained at the longer term. One high quality trial (reported in two papers (Hsieh et
al 1992, Pope et al 1994)) showed that spinal manipulation resulted in greater
improvements in function compared with massage; there were no differences in pain
improvements between the groups.
There is limited evidence that spinal manipulation and massage are equally effectivein pain relief, and that spinal manipulation results in better function than massage(each level C).
Effectiveness of massage versus general physical therapies
One high quality study found that acupressure had a significant effect on pain
compared with various physical therapies up to 6 months after treatment.
There is limited evidence that acupressure massage is more effective than general
physical therapies for mid-term pain relief (level C).
Effectiveness of massage versus electrical stimulation
One high quality RCT showed no differences in pain and function scores between a
massage group and a group receiving transcutaneous muscle stimulation (Hsieh et
al 1992, Pope et al 1994).
Another high quality RCT showed that massage resulted in significantly less pain
relief compared with TENS (Melzack et al 1983).

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There is limited evidence that there is no difference between massage andtranscutaneous muscle stimulation with regard to improvements in either pain orfunction (level C). There is limited evidence that TENS is better than massage inrelieving pain (level C).
Effectiveness of massage versus corset
One high quality RCT, reported in two papers, compared massage to the wearing ofa corset (Hsieh et al 1992, Pope et al 1994). No differences between the treatments
were found for function or pain.
There is limited evidence that there is no difference in the effectiveness of massage
and the wearing of a corset (level C).
Effectiveness of massage as a component of combined therapy
One high quality study showed that massage in combination with remedial exercisesand education was better for pain relief than massage alone, immediately after
treatment (Preyde 2000). The combination therapy was also better than remedial
exercises only or sham laser therapy, in terms of both pain relief and improvement offunction up to 1 month after treatment (Preyde 2000).
There is limited evidence that massage in combination with remedial exercises andeducation is better than massage alone, remedial exercises alone or sham laser
therapy for short-term pain relief and improved function (level C).
Effectiveness of different types of massage vs each other
One high quality study compared the effectiveness of therapeutic acupuncture
massage with classical massage (each combined with either individual medical
exercises or group exercises) (Franke et al 2000).
Immediately after therapy, acupuncture massage showed significantly better effects
for both disability and pain compared with classical massage.
There is limited evidence that therapeutic acupuncture massage is more effective
than classical massage (level C).
Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (indications)
Not having shown evidence of effectiveness, it is not possible to define indications formassage.

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Comments
None
Summary of evidence• There is limited evidence in each case that massage is more effective than: shamprocedures; remedial exercise and posture education; relaxation therapy (for pain
relief); acupuncture (long-term pain relief and function); self-care education (forshort-term pain relief and improvement of function); and general physicaltherapies (for mid-term pain relief (each, level C).
• There is limited evidence that spinal manipulation and massage are equallyeffective in pain relief, and that spinal manipulation results in better function thanmassage (each level C).
• There is limited evidence that there is no difference between massage andtranscutaneous muscle stimulation with regard to improvements in either pain orfunction (level C). There is limited evidence that TENS is better than massage inrelieving pain (level C).
• There is limited evidence that there is no difference in the effectiveness of
massage and the wearing of a corset (level C).
• There is limited evidence that a combined treatment of massage with remedial
exercises and education is better than massage alone, remedial exercises aloneor sham laser therapy for short-term pain relief and improved function (level C).
• There is limited evidence that therapeutic acupuncture massage is more effective
than classical massage (level C).
Recommendation
We cannot recommend massage therapy as a treatment for chronic low back pain.
References
1. Cherkin DC, Eisenberg D, Sherman KJ, Barlow W, Kaptchuk TJ, Street J, Deyo
RA (2001) Randomized trial comparing traditional Chinese medical acupuncture,therapeutic massage, and self-care education for chronic low back pain. Arch InternMed, 161(8): 1081-8.
2. Ernst E (1999) Massage therapy for low back pain: A systematic review. J Pain
Symptom Manage, 17: 65-9.
3. Franke A, Gebauer S, Franke K, Brockow T (2000) [Acupuncture massage vsSwedish massage and individual exercise vs group exercise in low back pain
sufferers--a randomized controlled clinical trial in a 2 x 2 factorial design]. Forsch
Komplementarmed Klass Naturheilkd, 7(6): 286-93.
4. Furlan AD, Brosseau L, Imamura M, Irvin E (2002) Massage for low-back pain: asystematic review within the framework of the Cochrane Collaboration Back Review
Group. Spine, 27(17): 1896-910.
5. Hernandez-Reif M, Field T, Krasnegor J, Theakston H (2001) Lower back pain is
reduced and range of motion increased after massage therapy. Int J Neurosci,
106(3-4): 131-45.
6. Hoehler FK, Tobis JS, Buerger AA (1981) Spinal manipulation for low back pain.
Jama, 245(18): 1835-8.
7. Hsieh CY, Phillips RB, Adams AH, Pope MH (1992) Functional outcomes of low
back pain: comparison of four treatment groups in a randomized controlled trial. J
Manipulative Physiol Ther, 15(1): 4-9.
8. Hsieh LL, Kuo CH, Yen MF, Chen TH (2004) A randomized controlled clinical trial
for low back pain treated by acupressure and physical therapy. Prev Med, 39(1):168-76.
9. Melzack R, Vetere P, Finch L (1983) Transcutaneous electrical nerve stimulation
for low back pain. A comparison of TENS and massage for pain and range of motion.
Phys Ther, 63(4): 489-93.

10310. Pope MH, Phillips RB, Haugh LD, Hsieh CY, MacDonald L, Haldeman S (1994) A
prospective randomized three-week trial of spinal manipulation, transcutaneousmuscle stimulation, massage and corset in the treatment of subacute low back pain.
Spine, 19(22): 2571-7.
11. Preyde M (2000) Effectiveness of massage therapy for subacute low-back pain: arandomized controlled trial. Cmaj, 162(13): 1815-20.
12. Walach H, Guthlin C, Konig M (2003) Efficacy of massage therapy in chronic
pain: a pragmatic randomized trial. J Altern Complement Med, 9(6): 837-46.

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Chapter 7 Back schools and and brief educational
interventions/advice to promote self-care
C7 (A) Back schools
Definition of the procedure
A back school can be defined as an intervention that consists of an education and askills program, including exercises, in which all lessons are given to groups ofpatients and supervised by a paramedical therapist or medical specialist (van Tulder
et al 2004). The original ‘Swedish back school’, introduced in 1980, consisted of four
sessions of 45 minutes (Forssell 1980). The content of the sessions included
information on the anatomy and function of the back, discussion of the mechanicalstrain in different positions and teaching of the semi-Fowler position. Since then, thecontent of back schools has changed and is also very variable. An evaluation of backschools must, therefore, consider the content of the program.
Results of search
Systematic reviews
Four SRs were found (Cohen et al 1994, Koes et al 1994, Maier-Riehle and Harter
2001, van Tulder et al 2004); one of them was a Cochrane SR (van Tulder et al2004). The Cochrane SR included 15 RCTs on the effects of back schools on chronic
LBP and covered a search period up to December 1997. In May 2003 the Cochrane
SR was updated and four additional RCTs were included (Heymans et al 2004). Thisupdated Cochrane SR served as the starting point in formulating theserecommendations. The review was based on 9 reports of 6 trials in which backschools had been compared with waiting-list controls or ‘placebo’interventions (Dalichau et al 1998, Dalichau et al 1999, Glomsrod et al 2001, Keijsers
et al 1989, Keijsers et al 1990, Lankhorst et al 1983, Linton et al 1989, Lonn et al
1999, Postacchini et al 1988) and 10 reports of 5 trials in which back schools had
been compared with other conservative treatments (exercises, spinal or joint
manipulation, myofascial therapy and instructions/advice) (Harkapaa et al 1989,
Harkapaa et al 1990, Hurri 1989a, b, Julkunen et al 1988, Klaber Moffett et al 1986,
Mellin et al 1990, Mellin et al 1989, Penttinen et al 2002, Postacchini et al 1988).
Additional RCTs
No additional trials were found.
Quality assessment of the evidence
The updated Cochrane SR was rated as high quality. Of the relevant trials that it
contained, 3 were of high quality (Glomsrod et al 2001, Linton et al 1989, Lonn et al1999) (one trial, two papers) (Klaber Moffett et al 1986) and the rest were of low
quality.
Effectiveness
Effectiveness of back schools versus waiting-list controls or ‘placebo’interventions for chronic low back pain
Six trials (Dalichau et al 1998, Dalichau et al 1999, Keijsers et al 1989, Keijsers et al
1990, Lankhorst et al 1983, Linton et al 1989, Lonn et al 1999, Postacchini et al1988) (Glomsrod et al 2001), two of which were high quality (Linton et al 1989, Lonn
et al 1999) and (Glomsrod et al 2001) (one trial, two papers), compared backschools with waiting-list controls or placebo interventions. One high quality trial
reported statistically significant effects on pain at 6 weeks and 6 months after
treatment in favour of a back school group compared with a waiting-list control
group (Linton et al 1989). The other high quality trial reported a significantly earlier

105return to work (reduction of sick leave days) for a back school treatment comparedwith no treatment (Lonn et al 1999) (Glomsrod et al 2001). The remaining trials
reported a mixture of results (some positive, some negative).
There is conflicting evidence for the effectiveness of back schools with regard topain, functional status and return to work, compared with waiting list controls or‘placebo’ interventions (level C).
Effectiveness of back school versus other treatments for chronic low backpain
In comparing back school with various other treatments (such as simple advice,
exercises only and manipulation), one high quality trial (Klaber Moffett et al 1986)
and four low quality trials (Harkapaa et al 1989, Harkapaa et al 1990, Hurri 1989a, b,
Julkunen et al 1988, Mellin et al 1990, Mellin et al 1989, Penttinen et al 2002,
Postacchini et al 1988) showed effects in favour of the back school group for pain
relief and functional status in the short term (< 6 weeks follow-up). Two low quality
studies (Harkapaa et al 1989, Harkapaa et al 1990, Hurri 1989a, b, Mellin et al 1990,
Mellin et al 1989) showed no differences in long-term outcomes (> 12 months followup).
There is moderate evidence that back school is more effective than other treatments
examined (simple advice, exercises only, manipulation) with regards to pain andfunctional status in the short-term (level B). There is moderate evidence for nodifference between back schools and these other treatments with regard to theirlong-term effects on pain and functional status (level B).
Cost-effectiveness
Unknown (no studies identified on this issue)
SafetyUnknown (no studies identified on this issue)
Subjects (indications)
As back schools are generally very heterogeneous in their content, it is not possible
to strictly define ideal indications regarding the type of patient that will best benefit
from this treatment.
Comments
Back schools often show a lot of overlap with other interventions such as functional
restoration, work hardening, multidisciplinary rehabilitation, and graded activity.
Furthermore, the labels that are assigned to these differing interventions do notnecessarily indicate a correspondingly standardised or consistent content.
It should be noted that, for the purposes of this guideline, a back school was only
considered to be such, if the content closely matched the definition of the procedure
as given in the introduction.
Summary of evidence• There is conflicting evidence for the effectiveness of back schools with regard topain, functional status and return to work, compared with waiting list controls or‘placebo’ interventions (level C).
• There is moderate evidence that back school is more effective than othertreatments examined (simple advice, exercises only, manipulation) with regards topain and functional status in the short-term (level B). There is moderate evidence
for no difference between back schools and these other treatments with regard totheir long-term effects on pain and functional status (level B).

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Recommendation
Consider back schools where information given is consistent with evidence-based
recommendations for short-term (<6 weeks) pain relief and improvements infunctional status (level C). We do not recommend back schools as a treatment forchronic low back pain when aiming at long-term effects (>12 months) (level B).
References
1. Cohen JE, Goel V, Frank JW, Bombardier C, Peloso P, Guillemin F (1994) Group
education interventions for people with low back pain. An overview of the literature.
Spine, 19(11): 1214-22.
2. Dalichau S, Perrey RM, Solbach T, Elliehausen H-J (1998) Erfahrungen bei derDurchfuhrung eines berufsbezogenen Rückenschulmodells in Baugewerbe.
Arbeitsmedizin, 48: 72-80.
3. Dalichau S, Scheele K, Perrey RM, Solbach T, Elliehausen H-J, Huebner J (1999)
Ultraschall gestützte Haltungs- und Bewegungsanalyse der Lendenwirbelsäule zum
Nachweis der Wirksamkeit einer Rückenschule. Arbeitsmedizin, 49: 148-56.
4. Forssell MZ (1980) The Swedish Back School. Physiotherapy, 66(4): 112-4.
5. Glomsrod B, Lonn JH, Soukup MG, Bo K, Larsen S (2001) "Active back school",
prophylactic management for low back pain: three-year follow-up of a randomized,
controlled trial. J Rehabil Med, 33(1): 26-30.
6. Harkapaa K, Jarvikoski A, Mellin G, Hurri H (1989) A controlled study on theoutcome of inpatient and outpatient treatment of low back pain. Part I. Pain,
disability, compliance, and reported treatment benefits three months after treatment.
Scand J Rehabil Med, 21(2): 81-9.
7. Harkapaa K, Mellin G, Jarvikoski A, Hurri H (1990) A controlled study on theoutcome of inpatient and outpatient treatment of low back pain. Part III. Long-term
follow-up of pain, disability, and compliance. Scand J Rehabil Med, 22(4): 181-8.
8. Heymans MW, Van Tulder MW, Esmail R, Bombardier C, Koes BW (2004) Backschools for non-specific low back pain. In The Cochrane Library, Issue 3. John Wiley& Sons, Ltd.: Chichester, UK.
9. Hurri H (1989a) The Swedish back school in chronic low back pain. Part I.
Benefits. Scand J Rehabil Med, 21(1): 33-40.
10. Hurri H (1989b) The Swedish back school in chronic low back pain. Part II.
Factors predicting the outcome. Scand J Rehabil Med, 21(1): 41-4.
11. Julkunen J, Hurri H, Kankainen J (1988) Psychological factors in the treatment ofchronic low back pain. Follow-up study of a back school intervention. Psychother
Psychosom, 50(4): 173-81.
12. Keijsers JF, Groenman NH, Gerards FM, van Oudheusden E, Steenbakkers M(1989) A back school in The Netherlands: evaluating the results. Patient EducCouns, 14(1): 31-44.
13. Keijsers JFME, Steenbakkers WHL, Meertens RM, Bouter LM, Kok GJ (1990)
The efficacy of the back school: a randomized trial. Arthritis Care and Research, 3:
204-9.
14. Klaber Moffett JA, Chase SM, Portek I, Ennis JR (1986) A controlled, prospective
study to evaluate the effectiveness of a back school in the relief of chronic low backpain. Spine, 11(2): 120-2.
15. Koes BW, van Tulder MW, van der Windt WM, Bouter LM (1994) The efficacy ofback schools: a review of randomized clinical trials. J Clin Epidemiol, 47(8): 851-62.
16. Lankhorst GJ, Van de Stadt RJ, Vogelaar TW, Van der Korst JK, Prevo AJ(1983) The effect of the Swedish Back School in chronic idiopathic low back pain. A
prospective controlled study. Scand J Rehabil Med, 15(3): 141-5.
17. Linton SJ, Bradley LA, Jensen I, Spangfort E, Sundell L (1989) The secondary
prevention of low back pain: a controlled study with follow-up. Pain, 36(2): 197-207.

107

18. Lonn JH, Glomsrod B, Soukup MG, Bo K, Larsen S (1999) Active back school:
prophylactic management for low back pain. A randomized, controlled, 1-year followup study. Spine, 24(9): 865-71.
19. Maier-Riehle B, Harter M (2001) The effects of back schools--a meta-analysis. Int
J Rehabil Res, 24(3): 199-206.
20. Mellin G, Harkapaa K, Hurri H, Jarvikoski A (1990) A controlled study on theoutcome of inpatient and outpatient treatment of low back pain. Part IV. Long-term
effects on physical measurements. Scand J Rehabil Med, 22(4): 189-94.
21. Mellin G, Hurri H, Harkapaa K, Jarvikoski A (1989) A controlled study on theoutcome of inpatient and outpatient treatment of low back pain. Part II. Effects on
physical measurements three months after treatment. Scand J Rehabil Med, 21(2):91-5.
22. Penttinen J, Nevala-Puranen N, Airaksinen O, Jaaskelainen M, Sintonen H,
Takala J (2002) Randomized controlled trial of back school with and without peer
support. J Occup Rehabil, 12(1): 21-9.
23. Postacchini F, Facchini M, Palieri P (1988) Efficacy of various forms ofconservative treatment in low back pain: a comparative study. Neurol Orthop, 6: 1136.
24. van Tulder MW, Esmail R, Bombardier C, Koes BW (2004) Back schools for nonspecific low back pain. In The Cochrane Library, Issue 3. John Wiley & Sons, Ltd.:
Chichester, UK.

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C7 (B) Brief educational interventions to promote self-care
Definition of the procedure
Brief educational interventions (as distinct from back schools) include interventions
that involve minimal contact with a healthcare professional (normally just one or two
sessions), the use of self-management patient-led groups, the provision of
educational booklets, and the use of Internet and e-mail discussion groups. Theinterventions aim to encourage active self-management and to reduce concerns.
Some such interventions are described as ‘mobilisation’ in some studies, to indicate
the attempt to encourage the patient to become more active; this should not be
confused with the manual therapy treatment of spinal mobilisation.
Results of search
No systematic reviews on the topic were identified.
One general descriptive review was identified, which had a section covering “othereducational interventions” for chronic LBP (Turner 1996). This included two low
quality studies that investigated the provision of an educational booklet. One included
a mixed population of primary care patients (Roland and Dixon 1989) and the othermainly acute patients (Cherkin et al 1996). They were therefore not consideredfurther.
Additional studies
Twelve RCTs were identified through the search and the working group’s knowledgeof the literature (Buhrman et al 2004, Cherkin et al 2001, Frost et al 2004, Hagen etal 2000, Indahl et al 1998, Karjalainen et al 2004, Karjalainen et al 2003, Lorig et al
2002, Storheim et al 2003, Triano et al 1995, Von Korff et al 1998). One of these was
excluded as it included an education programme rather than “brief” education (Triano
et al 1995). One study was reported in two papers (Karjalainen et al 2004,
Karjalainen et al 2003). Thus, ten RCTs were included.
Quality assessment of the evidence
Among the ten RCTs, four were high quality (Cherkin et al 2001, Frost et al 2004,
Karjalainen et al 2004, Karjalainen et al 2003, Storheim et al 2003). Four others were
low quality (Buhrman et al 2004, Lorig et al 2002, Moore et al 2000, Von Korff et al1998). Two that used Zelen’s design appeared to have high internal validity but using
the Cochrane quality criteria were rated as low quality (Hagen et al 2000, Indahl et al1998).
Effectiveness
Effectiveness of minimal contact/brief educational interventions vs usual care
Two trials investigated the effects of a light mobilisation (i.e. “activating”) program
comprising a physical examination and information and advice to stay active, ascompared with usual care (Hagen et al 2000, Indahl et al 1998). Another trial, which
included a 2 year follow up, evaluated a mini-intervention consisting of a detailed
assessment of the patients' history, beliefs and physical findings by a physician and aphysiotherapist, followed by recommendations and advice (Karjalainen et al 2004,
Karjalainen et al 2003).
Two of these trials (one high and one low quality) reported statistically significant
effects on sick leave reduction at 12 months (Hagen et al 2000) and at 2
years (Karjalainen et al 2004, Karjalainen et al 2003) in the groups receiving
information and advice to stay active as compared with the groups receiving usualcare. One trial (Indahl et al 1998) showed that light mobilisation and information
increased return to work up to five years after the intervention.

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A fourth trial, also carried out in Scandinavia, compared a brief cognitive intervention
provided by a physician and a physiotherapist with usual care and with aerobic
exercise (Storheim et al 2003). There was no difference between the treatments withregard to sick-listing.
There is moderate evidence that brief interventions addressing concerns andencouraging a return to normal activities are better than usual care in increasing
return to work rates (level B).
One high quality trial (Karjalainen et al 2004, Karjalainen et al 2003) found nodifferences between a brief-education group and a usual care group in relation topain, disability, and health-related quality of life, at 12 months and 2 years follow up.
However, another high quality trial (Storheim et al 2003) found that, 18 weeks after
inclusion into the study, patients receiving a brief cognitive intervention by aphysician and physiotherapist improved significantly more in relation to disability,
self-efficacy for pain, emotional distress, general health and life satisfaction, but not
pain intensity, compared with usual care.
Two low quality studies carried out in the USA compared a short group education
programme encouraging self-care with usual care in the primary care setting. One
found that a lay-led self-management group intervention of 4 sessions was more
successful than usual care supplemented by a book on back pain care in reducing
disability at 6 months but not pain intensity (Von Korff et al 1998). The other foundthat a brief cognitive-behavioural group programme led by a psychologist andencouraging self-care reduced disability at 3 months and pain intensity at 6 months
significantly more than usual care supplemented by a book on back pain care (Moore
et al 2000).
There is moderate evidence that brief interventions encouraging self-care are more
effective than usual care in reducing disability (up to 6 months) but not pain (level B).
Effectiveness of minimal contact (internet-based) interventions vs nointervention or waiting list control
Two trials evaluated internet-based brief interventions (Buhrman et al 2004, Lorig et
al 2002). One examined the use of a closed, moderated, e-mail discussion group inpeople with chronic back pain having at least 1 outpatient visit in the past year, no"red-flag" symptoms, and access to e-mail (Lorig et al 2002). Participants also
received a book and videotape about back pain. Controls received a subscription to a
non-health-related magazine of their choice. It showed statistically significant
improvements in pain, disability, role function, and health distress at one year after
treatment. It also found a tendency towards a decline in physician visits. The otherstudy evaluated a 6-week long internet-based cognitive-behavioural intervention with
telephone support for patients with chronic back pain (Buhrman et al 2004).
Improvements in control over pain, and coping strategies were found immediately
after the intervention, but pain measures (pain diary reports and the MPI) did not
improve with the intervention.
There is limited evidence that Internet-based discussion groups/educational
interventions are more effective than no intervention, in reducing disability (level C).
There is conflicting evidence that Internet-based discussion groups/educational
interventions are more effective than no intervention, in reducing pain (level C).

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Effectiveness of minimal contact/brief educational interventions vsphysiotherapy or exercise therapy
Two high quality trials were identified (Frost et al 2004, Storheim et al 2003) thatcompared a brief educational intervention with routine physiotherapy and with
exercise, respectively.
One trial measured the effectiveness of routine physiotherapy compared with anassessment session and advice from a physiotherapist for patients with low backpain of more than six weeks' duration (N=286) (Frost et al 2004). There was no
significant difference in disability at 12 months and the authors concluded that routine
physiotherapy seemed to be no more effective than one session of assessment andadvice from a physiotherapist. Another study compared a brief cognitive intervention
with aerobic exercise of 45 sessions (Storheim et al 2003) and reported no significant
differences between the treatments with regard to either disability or prospectively
measured pain (although, retrospectively, the exercise group reported a greater pain
reduction and were more satisfied with their care).
There is strong evidence that brief interventions provided by a physiotherapist, or aphysician and physiotherapist, and encouraging a return to normal activities, are aseffective in reducing disability as routine physiotherapy or aerobic exercise (level A)
Effectiveness of minimal contact/brief educational interventions versus othertreatments
One high quality study (Cherkin et al 2001) compared the effectiveness ofacupuncture, therapeutic massage, and self-care education for persistent back pain
(N=262). Self-care intervention consisted of a book and 2 video-tapes (one on selfmanagement and the other demonstrating exercises). After 1 year, self-care was nodifferent from massage or acupuncture, in terms of pain and disability.
There is limited evidence that brief self-care interventions are as effective as
massage or acupuncture in terms of reducing pain and disability (level C).
Cost-effectivenessNo full cost-effectiveness analyses alongside the trials were found. One high quality
trial (Karjalainen et al 2004, Karjalainen et al 2003) reported lower costs from low
back pain in the mini intervention group (A) compared with a mini intervention plus awork site visit (B) or usual care (C): A=4670 Euros, B=5990 Euros, C = 9510 Euros.
(A vs. C, P = 0.04; and B vs. C, not significant). The average number of days on sickleave was 30 in A, 45 in B, and 62 in C (A vs. C, P = 0.03; B vs. C, not significant).
The authors concluded that, despite a lack of significant effect on pain intensity andperceived disability, mini-intervention including proper recommendations and advice
according to the "active approach" was able to reduce LBP-related costs.
SafetyUnknown (no studies were found on this issue)
Subjects (indications)
In particular, sick-listed people with a high perceived risk of not recovering may
benefit from appropriate advice and information in a brief educational intervention
provided by a physician and physiotherapist. It should be noted that many of thestudies have been carried out with patients who were more at the subacute end of
the subacute-chronic spectrum (especially the Scandinavian ones that provided
moderate evidence that brief educational interventions addressing concerns andencouraging a return to normal activities are better than usual care in increasing
return to work rates).
Comments111

1. It is difficult to define how intense or how extensive a brief intervention should be.
It may be that a stepped approach as recommended by Von Korff (2001), where
patients are initially offered a minimal intervention to address their worries andconcerns, is all that is needed for the majority, while more intensive interventions
may be required for those with on-going activity limitations.
2. The brief/minimal interventions varied considerably in how they were applied, forexample whether they were face-to-face or not (e.g. internet or a booklet). They also
varied in content and delivery. One common factor appeared to be the focus on
return to normal activities and work. More research is needed to investigate whichapproach is most effective for any particular group of patients.
3. “Return to work” is only relevant for populations who are all in paid employment
but off sick on entry to the trial, as in four of the Scandinavian studies cited above.
“Sickness absence” is a broader term, but is difficult to measure in mixed populations
that include people who are not in paid employment. It is important to measuresickness absence wherever it is relevant.
4. Internet interventions, used as “minimal contact/brief educational interventions”,
are unlikely to reach all back pain populations e.g. older people, deprived people.
5. Individual beliefs and communication skills of the care provider, as related toactive management, are likely to influence the credibility and the effectiveness of thedelivery.
6. The option of brief or minimal contact interventions should be made more widelyand explicitly available to patients, helping them to avoid more intensive and perhaps
unnecessary treatments.
7. The use of brief or minimal contact interventions for chronic back pain appears to
be a promising area for further research, particularly as this approach could result insignificant cost-savings if it proves to be as effective as more intensive treatment.
Evidence Summary• There is moderate evidence that brief interventions addressing concerns andencouraging a return to normal activities are better than usual care in increasing
return to work rates (level B).
• There is moderate evidence that brief interventions encouraging self-care are
more effective than usual care in reducing disability (up to 6 months) but not pain
(level B).
• There is limited evidence that Internet-based discussion groups/educational
interventions are more effective than no intervention in reducing disability (levelC).
• There is conflicting evidence that Internet-based discussion groups/educational
interventions are more effective than no intervention in reducing pain (level C).
• There is strong evidence that brief interventions provided by a physiotherapist, ora physician and physiotherapist, and encouraging a return to normal activities, areas effective in reducing disability as routine physiotherapy or aerobic exercise(level A)• There is limited evidence that brief self-care interventions are as effective as
massage or acupuncture in terms of reducing pain and disability (level C).

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Recommendations
We recommend brief educational interventions, which can be provided by aphysiotherapist or a physiotherapist and physician, and which encourage a return tonormal activities, to reduce sickness absence and disability associated with CLBP.
We do not give recommendations on the specific type of brief educational
intervention to be undertaken (face-to-face, Internet-based, one-to-one, group
education, discussion groups, etc.). The latter may be best determined by theavailable resources and the preferences of both the patient and therapist.
The emphasis should be on the provision of reassurance and positive messages thatencourage a return to normal activities.
References
1. Buhrman M, Faltenhag S, Strom L, Andersson G (2004) Controlled trial of Internetbased treatment with telephone support for chronic back pain. Pain, 111(3): 368-77.
2. Cherkin DC, Eisenberg D, Sherman KJ, Barlow W, Kaptchuk TJ, Street J, Deyo
RA (2001) Randomized trial comparing traditional Chinese medical acupuncture,therapeutic massage, and self-care education for chronic low back pain. Arch InternMed, 161(8): 1081-8.
3. Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S (2004) Randomised
controlled trial of physiotherapy compared with advice for low back pain. Bmj,
329(7468): 708.
4. Hagen EM, Eriksen HR, Ursin H (2000) Does early intervention with a lightmobilization program reduce long-term sick leave for low back pain? Spine, 25(15):1973-6.
5. Indahl A, Haldorsen EH, Holm S, Reikeras O, Ursin H (1998) Five-year follow-up
study of a controlled clinical trial using light mobilization and an informative approach
to low back pain. Spine, 23(23): 2625-30.
6. Karjalainen K, Malmivaara A, Mutanen P, Roine R, Hurri H, Pohjolainen T (2004)
Mini-intervention for subacute low back pain: two-year follow-up and modifiers ofeffectiveness. Spine, 29(10): 1069-76.
7. Karjalainen K, Malmivaara A, Pohjolainen T, Hurri H, Mutanen P, Rissanen P,
Pahkajarvi H, Levon H, Karpoff H, Roine R (2003) Mini-intervention for subacute lowback pain: a randomized controlled trial. Spine, 28(6): 533-40; discussion 40-1.
8. Lorig KR, Laurent DD, Deyo RA, Marnell ME, Minor MA, Ritter PL (2002) Can a
Back Pain E-mail Discussion Group improve health status and lower health carecosts?: A randomized study. Arch Intern Med, 162(7): 792-6.
9. Moore JE, Von Korff M, Cherkin D, Saunders K, Lorig K (2000) A randomized trialof a cognitive-behavioral program for enhancing back pain self care in a primary caresetting. Pain, 88(2): 145-53.
10. Storheim K, Brox JI, Holm I, Koller AK, Bo K (2003) Intensive group training
versus cognitive intervention in sub-acute low back pain: short-term results of asingle-blind randomized controlled trial. J Rehabil Med, 35(3): 132-40.
11. Triano JJ, McGregor M, Hondras MA, Brennan PC (1995) Manipulative therapy
versus education programs in chronic low back pain. Spine, 20(8): 948-55.
12. Turner JA (1996) Educational and behavioral interventions for back pain inprimary care. Spine, 21(24): 2851-7; discussion 8-9.
13. Von Korff M, Moore JE, Lorig K, Cherkin DC, Saunders K, Gonzalez VM, Laurent
D, Rutter C, Comite F (1998) A randomized trial of a lay person-led self-management
group intervention for back pain patients in primary care. Spine, 23(23): 2608-15.

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Chapter 8: Cognitive-behavioural treatment methods
Definition of procedure
Cognitive and behavioural methods involve procedures where changes in the
cognitions and behaviours are the main aspect of the treatment offered.
Psychological components may be involved in back school programmes andmultidisciplinary treatment programmes, but these are dealt with in their own
separate chapters.
Cognitive and behavioural interventions are commonly used in the treatment ofchronic (disabling) low back pain. The main assumption of a behavioural approach isthat pain and pain disability are not only influenced by somatic pathology, if found,but also by psychological and social factors (e.g., patient's attitudes and beliefs,
psychological distress, and illness behaviour) (Waddell 1987).
Consequently, the treatment of chronic low back pain is not primarily focused on
removing an underlying organic pathology, but at the reduction of disability throughthe modification of environmental contingencies and cognitive processes. In general,
three behavioural treatment approaches can be distinguished: operant, cognitive andrespondent (Turk and Flor 1984) (Vlaeyen et al 1995). Each of these focuses on themodification of one of the three response systems that characterize emotional
experiences, that is behaviour, cognitions, and physiological reactivity.
Operant treatments are based on the operant conditioning principles ofSkinner (Skinner 1953) and applied to pain by Fordyce (Fordyce 1976) and include
positive reinforcement of healthy behaviours and consequent withdrawal of attention
towards pain behaviours, time-contingent instead of pain-contingent pain
management, and spouse involvement. The graded activity programme is one
example of operant treatment for chronic low back pain (Lindstrom et al 1992a).
Cognitive treatment aims to identify and modify patients' cognitions regarding theirpain and disability. Cognitions (the meaning of pain, expectations regarding control
over pain) can be modified directly by cognitive restructuring techniques (such asimagery and attention diversion), or indirectly by the modification of maladaptive
thoughts, feelings and beliefs (Turner and Jensen 1993).
Respondent treatment aims to modify the physiological response system directly,
e.g., by reduction of muscular tension. Respondent treatment includes providing thepatient with a model of the relationship between tension and pain, and teaching thepatient to replace muscular tension by a tension-incompatible reaction, such as therelaxation response. Electromyographic (EMG) biofeedback, progressive relaxation
and applied relaxation are frequently used (Turk and Flor 1984) (Vlaeyen et al1995).
A large variety of behavioural treatment modalities are used for chronic low backpain, because there is no general consensus about the definition of operant andcognitive methods. Furthermore, behavioural treatment often consists of a
combination of these modalities or is applied in combination with other therapies(such as medication or exercises). Although they may vary in aims and methods,
cognitive and behavioural treatments have in common 1) the assumption that theindividual's feelings and behaviours are influenced by his/her thoughts; 2) the use ofstructured techniques to help patients identify, monitor and change maladaptive
thoughts, feelings and behaviours; 3) an emphasis on teaching skills that patients
can apply to a variety of problems (Turner 1996).
Results of search
Systematic reviews
One systematic Cochrane review (search date 1999; 20 RCTs) was identified (vanTulder et al 2000, van Tulder et al 2004).

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Additional studies
Four subsequent RCTs were identified (Brox et al 2003, Spinhoven et al 2004, Staal
et al 2004, van den Hout et al 2003). One of these randomised patients withevidence of disc degeneration at L4-5 and/or L5-S1 to either lumbar fusion or acognitive intervention with exercises. Another randomised airline workers sick-listedwith back pain to a behavioural graded activity group or usual care (Staal et al 2004).
The trial dealt with an exercise programme (and is accordingly dealt with in thesection on Exercise Therapy) but it used behavioural therapeutic principles which
aimed at helping sick-listed workers to unlearn pain behaviours through graded
activity/exercise, i.e. operant-conditioning principles, and the study was therefore
also included in this chapter. A further study (Spinhoven et al 2004) concerned areanalysis of a previous RCT (Kole-Snijders et al 1999) included in the Cochranereview (van Tulder et al 2000, van Tulder et al 2004). In another, although the study
was presented as describing a secondary preventive intervention, 67% of the study
population were suffering from chronic LBP and 28% from subacute LBP at the timeof investigation, and so the trial was still included (van den Hout et al 2003).
Quality Assessment
The Cochrane review (van Tulder et al 2000, van Tulder et al 2004) and additional
trials (Brox et al 2003, Spinhoven et al 2004, Staal et al 2004, van den Hout et al2003) were all considered high quality.
Effectiveness
Effectiveness of cognitive-behavioural treatment vs placebo, no treatment, or
waiting list control
The review, which statistically pooled the data from 2 high quality RCTs (Nouwen
1983, Turner and Clancy 1988) and 5 low quality RCTs (Newton-John et al 1995,
Stuckey et al 1986, Turner 1982, Turner et al 1990, Turner and Jensen 1993)(N=419 patients altogether) found that behavioural therapy significantly reduced pain
intensity compared with no treatment, placebo, or waiting list control (pain: pooled
effect size was 0.62, 95% CI 0.25 to 0.98; behavioural outcomes: pooled effect size
was 0.40, 95% CI 0.10 to 0.70) (van Tulder et al 2000, van Tulder et al 2004)). It
found that behavioural therapy did not significantly increase function (pooled effectsize was 0.35, 95% CI -0.04 to +0.74).
There is strong evidence that behavioural treatment is more effective for pain,
functional status and behavioural outcomes than placebo/no treatment/waiting list
control (level A).
Effectiveness of cognitive-behavioural treatment vs traditional care
One high quality RCT (Lindstrom et al 1992b) identified by the review (van Tulder et
al 2000, van Tulder et al 2004) showed that behavioural therapy statisticallysignificantly increased the proportion of people who had returned to work after 12
weeks compared with traditional care (rest, analgesics, or unspecific physicaltreatment modalities). An additional high quality trial (Staal 2003, Staal et al 2004)
showed that behavioural treatment statistically significantly increased return to work
rates as compared with usual care (guidance and advice from the occupational
physician and GP care), but had no effect on pain or function.
There is strong evidence that a graded activity programme using a behaviouralapproach is more effective than traditional care for returning patients to work (level
A).
Effectiveness of cognitive-behavioural treatment vs other treatments
One low quality trial (Turner et al 1990) found no difference between behaviouraltherapy and exercise therapy in relation to pain or depression after 6 or 12 months.

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There is limited evidence that there is no difference between the effects of
behavioural therapy and exercise therapy in terms of pain, functional status or
depression up to 1 yr after treatment (level C).
Effectiveness of cognitive-behavioural treatment vs fusion surgery
One additional, high-quality trial of patients with chronic low back pain and evidenceof severe disc degeneration at L4-5 and/or L5-S1, randomized to either lumbar fusion
or a cognitive intervention with exercises, found that there was no significant
difference between the groups in relation to their improvement in the primary
outcome measure, disability (Oswestry), at the 1-year follow-up (Brox et al 2003).
There is limited evidence that in patients with chronic LBP and lower lumbar discdegeneration there is no difference between the effects of cognitive-behaviouraltherapy and spinal fusion in terms of disability 1 yr after treatment (level C).
Effectiveness of cognitive-behavioural treatment as an adjunct to othertreatments
The review identified six low quality RCTs (Altmaier et al 1992, Basler et al 1997,
Nicholas et al 1991, 1992, Strong 1998, Turner et al 1990) that had compared
behavioural therapy plus other treatments to those treatments alone (physiotherapy
and back education, inpatient pain management programmes, and back exercises);
there was moderate evidence that the addition of cognitive behavioural treatment toanother treatment has neither short nor long-tem effects on functional status andbehavioural outcomes (level B).
There is moderate evidence that the addition of cognitive behavioural treatment toanother treatment has neither short nor long tem effects on functional status andbehavioural outcomes (level B).
Effectiveness of different types of behavioural therapy vs each other
The review identified 7 RCTs (N=308) that together indicated no statisticallysignificant difference between different types of behavioural therapy in functional
status or pain (van Tulder et al 2000, van Tulder et al 2004). Two were high quality
trials (Kole-Snijders et al 1999, Turner and Clancy 1988) and five were low quality
trials (Nicholas et al 1991) (Bru et al 1994) (Turner 1982) (Turner and Jensen
1993) (Newton-John et al 1995).
A reanalysis of the data of a high quality RCT (Kole-Snijders et al 1999)(included in
the Cochrane review) found no statistically significant difference between operant
behavioural treatment associated either with cognitive coping skills training or group
discussion in changes in pain beliefs (Spinhoven et al 2004). Catastrophisingdecreased and perceived control over pain increased at one year in both groups.
However, the exact nature of the contribution of the treatment to these changes
remained unclear. The subsequent RCT (84 people recently on sick leave with low
back pain) compared problem-solving therapy versus group education (van den Houtet al 2003). All participants also received behavioural graded activity. The RCT
found that problem-solving therapy significantly reduced total sick leave comparedwith group education between 6 months and 1 year after treatment (8.3 days atbaseline to 18.5 days with problem solving vs 10.4 days at baseline to 37.9 days withgroup education, P < 0.05) (van den Hout et al 2003). However, at baseline, people
in the problem-solving group had had fewer days sick leave and more had returned
to work than people allocated to group education. The results of the RCT may,therefore, be confounded by these factors, and not due to differences in relative
effectiveness of the treatments. The RCT found no significant difference between
problem-solving therapy and group education in return-to-work rates at one year
(return to normal work: 8.9% at baseline to 75% at 6 months and 85.4% at 12116

months with problem solving vs 20.5% at baseline to 70.3% at 6 months and 62.9%
at 12 months with group education (p-value not presented).
There is strong evidence that there is no difference in effectiveness between thevarious types of behavioural therapy (level A).
Cost-effectivenessOne study conducted a full economic evaluation of a behavioural treatment(Goossens et al 1998). The population consisted of patients with chronic pain
including chronic low back pain. The study showed that adding a cognitive
component to an operant treatment did not lead to significant differences in costs andimprovement in quality of life when compared with the operant treatment alone.
Economic endpoints were the costs of the programme and other health careutilisation, costs for the patient, and indirect costs associated with production losses
due to low back pain. Compared with the common individual rehabilitation therapy
the same effects could be reached at the same or lower costs with a short andintense standardised group programme (Goossens et al 1998).
SafetyUnknown (no studies found on this issue)
Subjects
In most trials included in the review, patients with severe, long-lasting chronic nonspecific low back pain were recruited. Patients were usually not selected throughscreening for psychosocial factors.
Comments
1. One recent RCT examined the effectiveness of cognitive/behavioural treatment
in chronic LBP patients who had persisting symptoms 6 weeks after discsurgery (Ostelo et al 2003). The study found no differences between the behavioural
treatment and usual care (mixed physiotherapy techniques) at 1 year, for any of theclinical outcome measures (functional status or pain) (Ostelo et al 2003).
2. There is a problem with attempting to use a meaningful “sham” or “blind” control
group in the RCTs, as this can provide a variably powerful placebo effect. This isespecially problematic in evaluating psychological treatments. The procedures
offered to the controls should also be monitored for “nocebo” effects, which may givefalse positive effects.
3. The results of the Cochrane review of behavioural treatment for chronic low backpain are similar to another systematic review of behavioural treatment for chronic
pain, excluding headache, which showed that behavioural treatments are more
effective than waiting list controls (Morley et al 1999). However, in contrast to thelatter review, the Cochrane review did not find any differences when comparing
behavioural treatment to alternative active treatments.
4. Most studies included in the Cochrane review and in the additional trials
evaluated a cognitive-behavioural treatment consisting of various components thatwere applied in many different ways. At present, we know little about the actual orcomparative value of different methods within cognitive-behavioural treatment. It is
still unclear which type of behavioural treatment is the most effective. Similarly,
subgroups of patients need to be better defined in order to address specificcomponents of pain persistence such as excessive pain-related fear, increased
muscle tone or environmental contingencies. This seems especially relevant now
that the biopsychosocial model has been widely accepted and multimodal or
multidimensional treatment programs (that may include cognitive-behavioural117

treatment programs) are becoming more and more popular in the treatment ofchronic (back) pain patients.
5. Health care providers’ attitudes and beliefs about activity, including return towork, seem to be highly variable (Rainville et al 2000) and to influence their selfreported practice behaviours for back pain patients (Linton et al 2002). A survey oforthopaedic surgeons and family physicians indicated that their recommendations
regarding the appropriate level of function for chronic low back pain may reflect
personal attitudes of the physician and his/her perception of the severity of thesymptoms (Rainville et al 2000). Along the same lines, a study on fear-avoidance
beliefs in GPs and physiotherapists showed that those with high levels of fearavoidance beliefs had an increased risk of believing sick leave to be a goodtreatment and not encouraging a return to activity, compared with those with lowlevels of fear-avoidance beliefs (Linton et al 2002).
6. Promising predictors of outcome of behavioural treatment have been suggested,such as treatment credibility (Kole-Snijders et al 1999), stages of change (Kerns et al1997), patient profiles such as the multidimensional pain inventory (Turk et al 1998),
the patient’s own expectancy of the prognosis (Jensen et al 2000), and the patient’s
expectancy of the outcome of therapy (Kalauokalani et al 2001). Other importantvariables are the belief that the complaints would be worse with continued working or
physical exercise, lack of personal control over the pain, catastrophisinginterpretations of pain, and whether or not the patient believes him or herself to beable to do something him or herself (Haldorsen et al 1998, Spinhoven et al 2004,
Vlaeyen and Linton 2000); these may lead to fear of movement and fear-avoidance
behaviours and thus, in turn, to inactivity, reduced mobility, increased disability,
anger, anxiety and depression (Vlaeyen and Linton 2000). More research is stillneeded on possible underlying mechanisms to define subgroups of patients who may
benefit most from behavioural treatments.
Summary Evidence• There is strong evidence that behavioural treatment is more effective for pain,
functional status and behavioural outcomes than placebo/no treatment/waiting
list control (level A).
• There is strong evidence that a graded activity programme using a behaviouralapproach is more effective than traditional care for returning patients to work
(level A).
• There is limited evidence that there is no difference between behavioural therapy
and exercise therapy in terms of their effects on pain, functional status or
depression up to 1 yr after treatment (level C).
• There is limited evidence that in patients with chronic LBP and lower lumbar discdegeneration there is no difference between the effects of cognitive-behaviouraltherapy and spinal fusion in terms of disability 1 yr after treatment (level C).
• There is moderate evidence that the addition of cognitive behavioural treatment
to another treatment has neither short nor long tem effects on functional status
and behavioural outcomes (level B).
• There is strong evidence that there is no difference in effectiveness between thevarious types of behavioural therapy (level A).
Recommendations
We recommend cognitive-behavioural treatment for patients with chronic low back
pain.

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Chapter 9: Multidisciplinary interventions
Definition of the procedure
Multidisciplinary treatment programs for chronic low back pain were originally basedon a model of operant conditioning (Fordyce et al 1973). Because chronic LBP isbelieved to be associated with physical deconditioning effects, an exercise
component is always included. Because many patients with chronic LBP haveproblems at the work-place and are relatively young (mean age in the most studies
42 years), there has been a strong belief in so-called work hardening or conditioning
exercises, and these are included in the treatment in most trials.
The content of multidisciplinary treatment programmes usually consists of an
extensive combination of physical, vocational, and behavioural components, and themodification of medication use. Commonly, such programmes are carried out for aconsiderable number of hours per week, sometimes even on an inpatient basis. The
content of these programmes and the way they are labelled or described varies
widely. For example, multidisciplinary biopsychosocial rehabilitation, rehabilitation
programmes, behavioural programmes, back schools, or functional restoration (FR)programmes may all involve one or more of these components. True multidisciplinary
treatment programs have to include medical (pharmacological treatment, education),
physical (exercise), vocational and behavioural components and have to be provided
at least by three health care professionals with different clinical backgrounds(physician, physiotherapist, psychologist).
Result of search
Systematic reviews
Five reviews of multidisciplinary treatment were retrieved through the search (DiFabio 1995, Guzman et al 2001, Scheer et al 1997, Staal et al 2002, Teasell andHarth 1996), and an additional review was identified from the working group’s
knowledge of the literature (Schonstein et al 2003). The latter SR determined theeffect on time lost from work of physical conditioning programs for workers with backand neck pain (see comments).
Four of these SRs were excluded because they concentrated on back schools (DiFabio 1995) or return to work interventions (Staal et al 2002); included allinterventions for industrial LBP without presenting results for multidisciplinary
treatment separately (Scheer et al 1997); or were not systematic reviews (Teaselland Harth 1996).
The remaining two systematic reviews (both Cochrane reviews) were consideredfurther (Guzman et al 2001, Schonstein et al 2003). These included 10 randomized,
controlled trials (Alaranta et al 1994, Basler et al 1997, Bendix et al 1995, Bendix et
al 1996, Harkapaa et al 1990, Jackel et al 1990, Lukinmaa 1989, Mitchell andCarmen 1994, Nicholas et al 1991, 1992).
Additional RCTs
13 papers described 11 further randomized trials (Altmaier et al 1992, Bendix et al
1998a, Bendix et al 1998b, Bendix et al 1997, Bendix et al 2000, Corey et al 1996,
Haldorsen et al 2002, Haldorsen et al 1998, Jousset et al 2004, Keel et al 1998,
Keller et al 1997, Rose et al 1997, Turner et al 1990).
One additional paper provided a health economic assessment of multidisciplinary
treatment (Skouen et al 2002).
Quality assessment of the evidence
Systematic reviews

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The two Cochrane reviews (Guzman et al 2001, Schonstein et al 2003) were of highquality.
Additional studies
Among the additional RCTs, six were of high quality (Altmaier et al 1992, Bendix et al
1998a, Bendix et al 1998b, Haldorsen et al 2002, Haldorsen et al 1998, Jousset et al2004), and six were of low quality (Bendix et al 2000, Corey et al 1996, Keel et al
1998, Keller et al 1997, Rose et al 1997, Turner et al 1990).
One low quality trial (Turner et al 1990) was excluded because the treatment was notreally multidisciplinary (was provided by just one healthcare professional).
Effectiveness
Effectiveness of multidisciplinary treatment versus sham procedures
No studies were found on this issue.
Effectiveness of multidisciplinary treatment programmes versus othertreatments (e.g. standard rehabilitation programs, intense vs. less intense programs,
vs outpatient physical programs, vs usual care)
One Cochrane systematic review (Guzman et al 2001) included ten trials evaluating
12 randomised comparisons (Alaranta et al 1994, Basler et al 1997, Bendix et al
1995, Bendix et al 1996, Harkapaa et al 1990, Jackel et al 1990, Lukinmaa 1989,
Mitchell and Carmen 1994, Nicholas et al 1991,1992). Together, they randomised a
total of 1964 patients with chronic low back pain.
The conclusions from the review were:• There is strong evidence that intensive multidisciplinary biopsychosocial
rehabilitation with functional restoration reduces pain and improves function inpatients with chronic low back pain (level A).
• There is moderate evidence that intensive multidisciplinary bio-psycho-social
rehabilitation with a functional restoration approach improves pain whencompared with outpatient non-multidisciplinary rehabilitation or usual care (level
B).
• There is contradictory evidence regarding vocational outcomes of intensive
multidisciplinary bio-psycho-social intervention (level C).
Additional studies
Effectiveness of multidisciplinary treatment programmes vs controls
One study compared a multidisciplinary rehabilitation program (n=36) in an outpatientsetting (2 hours treatment, three times a week for 6 weeks) with a control group ofpatients on a waiting list (these served as controls only for the immediate posttreatment effects) (Keller et al 1997). Although no psychologists were directly
involved in the treatment, both the physicians and physiotherapists had received
training in pain management by an experienced psychologist and were closely
supervised by clinical psychologists to ensure a strict application of operant
techniques for the modification of the patient’s behaviour. At the end of the program
pain frequency, pain intensity and disability caused by pain (scale of functional
capacity) improved significantly in the treatment group only. Up to 6 months after
treatment, patients in the treatment group continued to show beneficial effects interms of pain intensity, pain frequency, posture, self-efficacy, well-being, strengthand endurance, compared with their pre-treatment status.
Effectiveness of multidisciplinary treatment programmes versus less intensive
programmes
Two trials were carried out by one research group (Bendix et al 1998a, Bendix et al
1998b, Bendix et al 1997). In the first trial, 132 patients were randomized to three123treatment programs: a) intensive 3-week multidisciplinary program (“functional
restoration”; FR) 8 hours a day (n= 40), b) active physical training and back school
twice a week for 6 weeks (n=28), c) psychological pain management and active
physical training twice a week for 6 weeks (n= 34). The results were presented forthe one-year follow up (Bendix et al 1997), 2-year follow up (Bendix et al 1998b), andfive-year follow up (Bendix et al 1998a). At all follow up times the functional
restoration program was superior to the other programs except in relation to thevariables leg pain and medication use. After five years the superior effect of the FR
program was less marked but still evident in some regards (more patients were
working). In the second trial, a FR program (n=50) was compared with treatment as
usual (n=49) (Bendix et al 1998a, Bendix et al 1998b): the patients in the FR group
had significantly fewer sick leave days and health care contacts and more of themwent back to work, but all other parameters (pain, function (activities of daily living
scale), work ability) were not different between the groups.
In one additional low quality trial from the same research group (Bendix et al 2000),
patients where treated with either FR (whole day for 3 weeks) (N=64) or intensive
outpatient physical treatment of a lesser intensity than the FR program (1.5 hoursessions three times a week for 8 weeks) (N=74). At the one-year follow-up
evaluation, overall global assessment but not working capability, sick leave (for thoseat work), healthcare contacts, pain, or self-reported activities of daily living weresignificantly better in the FR group. Another high additional study combined theeffects of functional restoration versus 3 hours per week physical therapy: arandomized controlled study (Jousset et al 2004). It found that the mean number ofsick-leave days was significantly lower in the functional restoration group. Physicalcriteria and satisfaction with the treatment were also better, but there was no
significant difference in the intensity of pain, the quality of life and functional indexes,
the number of contacts with the medical system or the medication intake.
In one trial, a FR program (6.5 hours a day for a maximum of 35 days) was
compared with usual care (Corey et al 1996). 100 patients were treated in eachgroup, but only half of them were back patients. Nonetheless, the results for the backpatients and non-back patients were given separately. 18 months after treatment, theFR patients reported less pain and more improved sleep, and more of them wereback to work compared with the control group. However, the follow-up included onlyin 74 patients with treatment and 64 controls.
One research group conducted two trials, one with 469 patients sick listed withtreatment group (n=312) and a control group (normal GP care with no further advice)musculoskeletal pain divided into multimodal (n=312) and a control group (normal
GP care with no further advice) (n=158) (Haldorsen et al 1998). The multimodal
program lasted for 4 weeks. At one year, the treatment group had not returned towork at a higher rate but had an improved work potential, quality of life, and physicaland psychological health. In this study, only 40-50% of the patients had LBP (the rest
were shoulder/neck problems); however, the authors maintained that the location of
the pain did not influence the overall results.
A further study compared an experimental inpatient group undergoing FR (n=243) indifferent Swiss rehabilitation clinics with inpatients who were treated as usual in theclinics (n= 168) (Keel et al 1998). There was a high drop out rate of 31.1%. The FR
approach showed slightly but significantly better (p<o.o5) long-term results(impairment at work, hours worked a day, spatial distribution of pain, quality of life)
than the traditional group.
Together these studies strengthen the evidence for the Cochrane review for thegreater effectiveness of intensive multidisciplinary treatments compared with less124

intensive treatments, especially in relation to return to work or work capacity (level
A).
Effectiveness of group vs individual multidisciplinary treatment programmes
One study examined the differences in outcome between group programs (N=26)
and individual treatment (n= 24) (Rose et al 1997). The second part of the study (withother patients n= 60) was concerned with identifying the optimum duration oftreatment. The follow-up was 6 months. The study showed no differences between
group or individual treatment and between 15-, 30-, or 60-hour programs.
Effectiveness of intensive physical conditioning (“work hardening”) programs
for workers with back and neck pain
A Cochrane systematic review evaluated the effectiveness of physical conditioning
programs for workers with back and neck pain in reducing time lost from work
(Schonstein et al 2003).
These programs aim to facilitate return to work, improve the status of workers
performing modified duties, or enable the achievement of a higher level of function byincreasing strength, endurance, flexibility, and cardiovascular fitness. Such programs
simulate work or functional tasks in a supervised environment and may include
workplace visits and ergonomic adaptations of the workplace. Sometimes theexercise part of simulated work is called “work hardening”. So-called work hardening
or work conditioning is also used for decreasing fear-avoidance behaviour (Vlaeyen
and Linton 2000). A total of 21 published articles on 19 trials were included in thereview. The authors stated that, unlike earlier reviews, they were able to perform ameta-analysis because they had obtained additional information and data from theauthors of the original trials. Trials on treatment of subacute LBP were also included.
The authors concluded that physical conditioning programs for chronic back pain
patients can be effective in reducing the number of sick days lost due to back pain
when compared with usual care. A closer analysis of the trials that showed positive
results revealed that all had significant cognitive-behavioural components (such asteaching the patients that it was safe to move) combined with intensive physicaltraining that included training of aerobic capacity, muscle strength and endurance,and coordination. All the trials with positive results included vocational interventions.
All subjects included in trials that showed a treatment effect were either off work or
on modified duties, with an explicit capacity to return to their previous jobs.
There is strong evidence that “work hardening” programs with a cognitivebehavioural component are more effective than usual care in reducing workabsenteeism in workers with back pain (level A).
Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)

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Subjects (indications)
All ten trials included in the Cochrane review (Guzman et al 2001), and also theadditional studies described above, excluded patients with significant radiculopathy
or other indications for surgery. In the Cochrane review, most subjects were workers
selected from insurance listings (Alaranta et al 1994, Harkapaa et al 1989, Mitchelland Carmen 1994) or patients referred to pain centres (Basler et al 1997, Bendix et
al 1995, Bendix et al 1996, Jackel et al 1990, Lukinmaa 1989, Nicholas et al 1991,
1992).
Multidisciplinary biopsychosocial rehabilitation or functional restoration (FR) is
indicated if the ergonomic behaviour, work potential, quality of life, and physical andpsychological health of a patient with chronic non-specific mechanical low back pain
are substantially disturbed. Because of the high costs of treatment, a screening
instrument addressing the prognosis of the individual patient (see (Haldorsen et al2002)) is necessary to avoid under or over treatment. Treatment should be early inthe course of disability.
Comments
1) In all studies, the treatment, patient characteristics, treatment modalities andtreatment intensity varied substantially. It is at present unclear what the optimal
content of multidisciplinary treatment programmes is and which health care
professionals should be involved. More research is needed.
2) From a health care policy point of view it is not clear whether the benefits of these
programmes outweigh their costs - these intensive programmes might result in alarge drain on health care resources. However, assigning monetary values to qualityof life issues such as pain and function, in order to complete cost-benefit analyses, iscontentious and challenging. A crucial element in cost-benefit analyses concerns thesavings in wage replacement costs achieved by treatment.
3) One study investigated 654 patients sick listed for at least 8 weeks withmusculoskeletal pain (45% back pain, 34% neck/shoulder pain, 11% generalizedmuscle pain and 10% other musculoskeletal pain) (Haldorsen et al 2002). The
patients were categorized into three groups differing in their prognosis score for
return to work (good, medium, poor). They were then randomly assigned to three
outpatients treatment programs (ordinary treatment, light multidisciplinary andintensive multidisciplinary). Patients in the different prognosis groups (see above)were equally randomized into the different treatment groups. Follow up was 14
months. The patients with a good prognosis for return to work did just as well withordinary treatment as with the two more intensive treatments. The patients with amedium prognosis benefited equally from the two multidisciplinary programs, and thepatients with a poor prognosis returned to work at a significantly higher rate (p<o.o5)
after the intensive multidisciplinary program than did patients who received ordinary
treatment or light multidisciplinary treatment.
The authors concluded that multidisciplinary treatment is effective concerning return
to work, when given to patients who are most likely to benefit from that treatment.
4) The data from the study described above (Haldorsen et al 2002) were used to
examine the cost-benefit ratio of multidisciplinary programs (Skouen et al 2002).
However, as none of the three programmes had any effect on return to work for
women, only men were examined in the analysis. Benefit was judged by return towork, in the 3 groups examined (control-treatment as usual, n=86; lightmultidisciplinary treatment, n=52; and extensive multidisciplinary treatment, n=57).
The authors concluded that, for male patients, multidisciplinary treatment, especiallythe light program, could save a substantial amount of money. After subtracting costs,

126the net productivity gains for society from light multidisciplinary treatment were about
U.S. $ 852.000 for 57 male patients during the first 2 years.
5) There is a need for further trials to examine whether the effects of job status, interms of the availability of the previous job or modified duties for workers with backpain, is also to be considered when reporting return-to-work outcomes. Further
studies are also recommended to investigate whether men and women responddifferently in relation to vocational outcomes.
6) Differences between studies in the effects concerning vocational outcomes most
likely depend to a large extent on the healthcare and economic systems of thedifferent countries.
Summary of evidence• There is strong evidence that intensive multidisciplinary biopsychosocial
rehabilitation with a functional restoration approach reduces pain and improves
function in patients with chronic low back pain (level A).

• There is moderate evidence that intensive multidisciplinary biopsychosocial

rehabilitation with a functional restoration approach is more effective thanoutpatient non-multidisciplinary rehabilitation or usual care with respect to pain
(level B).

• There is strong evidence that intensive multidisciplinary biopsychosocial
interventions are effective in terms of return to work, work-readiness (level A).
• There is strong evidence that intensive physical training (“work hardening”)
programs with a cognitive-behavioural component are more effective than usual
care in reducing work absenteeism in workers with back pain (level A).
Recommendation
We recommend multidisciplinary biopsychosocial rehabilitation with functional
restoration for patients with chronic low back pain who have failed monodisciplinary
treatment options.
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129Chapter 10 Pharmacological procedures
The treatment most commonly prescribed for back pain is medication; particularly
nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and narcotic
analgesics. In one longitudinal study of primary care patients with low back pain,
69% were prescribed nonsteroidal anti-inflammatory drugs, 35% muscle relaxants,
12% narcotics, and 4% acetaminophen; 20% received no medications (Cherkin et al1998). Patients with more severe symptoms were more likely to receive narcotics ormuscle relaxants. Patients with greater dysfunction were also more likely to receive
narcotics. The efficacy of drug treatment for chronic back pain is less clear, partly
because of the complexity of the mechanisms causing chronic pain and the greaterrole of social, psychological, and economic factors.
Cherkin DC, Wheeler KJ, Barlow W, Deyo RA (1998) Medication use for low backpain in primary care. Spine, 23(5): 607-14.

C10 (A) AntidepressantsDefinition of the procedure
Antidepressants have often been used as adjuncts in the treatment of chronic low
back pain and other chronic pain syndromes with an effect distinct from theirantidepressants properties. The most commonly studied have been the tricyclic
antidepressants (noradrenergic and serotonin-noradrenergic antidepressants). The
rationale for the use of these drugs is that they block the reuptake ofneurotransmitters (e.g. norepineprhrine and serotonin) and so modulate pain
sensations, but a complete understanding of the antinoceptive actions is still unclear.
Selective serotonin reuptake inhibitors (SSRI), e.g. fluoxetine, paroxetine, citalopram,trazodone, have been available since 1988. As antidepressives they have afavourable side-effect profile compared with the traditional tricyclic
antidepressants (Ansari 2000). Their analgesic properties are unclear andcontroversial.
Results of search
Systematic reviews
3 systematic reviews were found (Ansari 2000, Fishbain 2000, Salerno et al 2002).
One of these (Ansari 2000) was excluded because it had only one study on low backpain (Goodkin et al 1990), which was already included in two other reviews.
The remaining two reviews included a total of 14 RCTs.
Additional studies
One additional systematic review (Staiger et al 2003) was identified.
One additional RCT was retrieved, but was excluded because it dealt with patientswith chronic musculoskeletal pain in general, including both whiplash injuries and
LBP (Schreiber et al 2001).
Quality assessment of the evidence
Systematic reviews
The three included reviews were of high quality (Fishbain 2000, Salerno et al 2002,
Staiger et al 2003).

130

Randomised controlled trials included in the reviews
5 RCTs included in the reviews were of high quality (Alcoff et al 1982, Atkinson et al
1999, Atkinson et al 1998, Dickens et al 2000, Goodkin et al 1990) and the rest of
low quality (Gardela 1991, Hameroff et al 1982, Hameroff et al 1984, Jenkins et al
1976, Pheasant et al 1983, Storch and Steck 1982, Treves et al 1991, Ward et al
1984, Ward 1986). Three studies dealt with selective serotonin reuptake
inhibitors (Atkinson et al 1999, Dickens et al 2000, Goodkin et al 1990) and theothers dealt with noradrenergic and serotonin-noradrenergic reuptake inhibitors.
Two of these studies were excluded from contributing to our recommendations, forthe following reasons:• one dealt mainly with specific back pain (radicular pain) and included only 5-6
patients with non-specific back pain (Storch and Steck 1982)• one treated the patients with intravenous maprotilene and only for a shorttime (Treves et al 1991)• one dealt with acute LBP only (Gardela 1991)• two dealt with both neck and back pain together (Hameroff et al 1982, Hameroff
et al 1984)
Effectiveness
Effectiveness versus placebo
One high quality review (Fishbain 2000) concluded that of the 10 trials withserotonergic-noradrenergic reuptake inhibitors seven or 70% reported theantidepressants to have an antinoceptive effect. For the five trials with noradrenergic
reuptake inhibitors, four (80%) reported an antinoceptive effect. The two trials on
selective serotonin reuptake inhibitor s showed that the latter were not effective.
The second review (Salerno et al 2002) concluded that patients with antidepressantswere significantly more likely to improve in pain severity than those taking placebo(0.41; 95%confidence interval, 0.22-0.61) but not in activities of daily living (0.24;
95% confidence interval, -0.21-0.69).
The third high quality review (Staiger et al 2003) reported that, among studies using
antidepressants that inhibit norepinephrine reuptake (tricyclic or tetracyclic
antidepressants), four out of five found significant improvements in at least one
relevant outcome measure. Assessment of these agents’ impact on functional
measures produced mixed results. No benefit in pain or functional status was foundin three studies of antidepressants that do not inhibit norepinephrine reuptake.
Effectiveness versus other treatments (only vs. other antidepressants)
Two high quality systematic reviews (Salerno et al 2002, Staiger et al 2003)
concluded that noradrenergic-serotonergic and noradrenergic antidepressants are
more effective than selective serotonin reuptake inhibitors (which seem to have noeffect).
Cost/effectiveness
Unknown (no studies were found on this issue)
Safety20% of the patients undergoing antidepressive therapy experienced an adverse
reaction (placebo 14%), mainly drowsiness, dry mouth, dizziness andconstipation (Salerno et al 2002). In many trials, the reporting of side effects wasinsufficient, so this percentage probably underestimates the degree to which theyoccurred.
Patients with renal disease, glaucoma, pregnancy, chronic obstructive pulmonary
disease and cardiac failure should not be treated with antidepressants.
Subjects (indications)131

Patients with chronic low back pain with or without depression. The benefit appears
to be independent of depression status (Staiger et al 2003).
Comments
None
Summary of evidence• There is strong evidence that noradrenergic and noradrenergic-serotonergic
antidepressants are effective in relieving pain in patients with chronic low backpain (level A).
• There is moderate evidence that activities of daily living (function, disability) are
not improved by antidepressants (level B).
Recommendation
Consider the use of noradrenergic or noradrenergic-serotonergic antidepressants as
co-medication for pain relief in patients with chronic low back pain without renal
disease, glaucoma, pregnancy, chronic obstructive pulmonary disease and cardiac
failure.
References
1. Alcoff J, Jones E, Rust P, Newman R (1982) Controlled trial of imipramine forchronic low back pain. J Fam Pract, 14(5): 841-6.
2. Ansari A (2000) The efficacy of newer antidepressants in the treatment of chronic
pain: a review of current literature. Harv Rev Psychiatry, 7(5): 257-77.
3. Atkinson JH, Slater MA, Wahlgren DR, Williams RA, Zisook S, Pruitt SD, EppingJordan JE, Patterson TL, Grant I, Abramson I, Garfin SR (1999) Effects ofnoradrenergic and serotonergic antidepressants on chronic low back pain intensity.
Pain, 83(2): 137-45.
4. Atkinson JH, Slater MA, Williams RA, Zisook S, Patterson TL, Grant I, Wahlgren
DR, Abramson I, Garfin SR (1998) A placebo-controlled randomized clinical trial of
nortriptyline for chronic low back pain. Pain, 76(3): 287-96.
5. Dickens C, Jayson M, Sutton C, Creed F (2000) The relationship between painand depression in a trial using paroxetine in sufferers of chronic low back pain.
Psychosomatics, 41(6): 490-9.
6. Fishbain D (2000) Evidence-based data on pain relief with antidepressants. Ann
Med, 32(5): 305-16.
7. Gardela G (1991) [Value of adjuvant treatment with imipramine for lumbosacralpain syndrome]. Pol Tyg Lek, 46(30-31): 544-6.
8. Goodkin K, Gullion CM, Agras WS (1990) A randomized, double-blind, placebocontrolled trial of trazodone hydrochloride in chronic low back pain syndrome. J Clin
Psychopharmacol, 10(4): 269-78.
9. Hameroff SR, Cork RC, Scherer K, Crago BR, Neuman C, Womble JR, Davis TP(1982) Doxepin effects on chronic pain, depression and plasma opioids. J Clin
Psychiatry, 43(8 Pt 2): 22-7.
10. Hameroff SR, Weiss JL, Lerman JC, Cork RC, Watts KS, Crago BR, Neuman
CP, Womble JR, Davis TP (1984) Doxepin's effects on chronic pain and depression:a controlled study. J Clin Psychiatry, 45(3 Pt 2): 47-53.
11. Jenkins DG, Ebbutt AF, Evans CD (1976) Tofranil in the treatment of low backpain. J Int Med Res, 4(2 Suppl): 28-40.
12. Pheasant H, Bursk A, Goldfarb J, Azen SP, Weiss JN, Borelli L (1983)
Amitriptyline and chronic low-back pain. A randomized double-blind crossover study.
Spine, 8(5): 552-7.
13. Salerno SM, Browning R, Jackson JL (2002) The effect of antidepressanttreatment on chronic back pain: a meta-analysis. Arch Intern Med, 162(1): 19-24.

13214. Schreiber S, Vinokur S, Shavelzon V, Pick CG, Zahavi E, Shir Y (2001) A
randomized trial of fluoxetine versus amitriptyline in musculo-skeletal pain. Isr J
Psychiatry Relat Sci, 38(2): 88-94.
15. Staiger TO, Gaster B, Sullivan MD, Deyo RA (2003) Systematic review ofantidepressants in the treatment of chronic low back pain. Spine, 28(22): 2540-5.
16. Storch H, Steck P (1982) [Concomitant thymoleptic therapy in the frame of acontrolled study with maprotiline (Ludiomil) in the treatment of backache].
Nervenarzt, 53(8): 445-50.
17. Treves R, Montaine de la Roque P, Dumond JJ, Bertin P, Arnaud M, DesprogesGotteron R (1991) [Prospective study of the analgesic action of clomipramine versus
placebo in refractory lumbosciatica (68 cases)]. Rev Rhum Mal Osteoartic, 58(7):549-52.
18. Ward N, Bokan JA, Phillips M, Benedetti C, Butler S, Spengler D (1984)
Antidepressants in concomitant chronic back pain and depression: doxepin anddesipramine compared. J Clin Psychiatry, 45(3 Pt 2): 54-9.
19. Ward NG (1986) Tricyclic antidepressants for chronic low-back pain.
Mechanisms of action and predictors of response. Spine, 11(7): 661-5.

133

C10 (B) Muscle Relaxants
Definition of procedure
The term "muscle relaxants" is very broad and includes a wide range of drugs withdifferent indications and mechanisms of action. Muscle relaxants can be divided into
two main categories: antispasmodic and antispasticity medications. Antispasmodics
decrease muscle spasm associated with painful conditions such as low back pain
and can be subclassified into benzodiazepines and non-benzodiazepines.
Benzodiazepines (e.g. diazepam, tetrazepam) are used as anxiolytics, sedatives,
hypnotics, anticonvulsants, and/or skeletal muscle relaxants.
Nonbenzodiazepines (e.g. cyclobenzaprine, tolperisone, tizanidine, flupirtin) include
a variety of drugs that can act at the brain stem or spinal cord level. The mechanismsof action with the central nevous system are still not completely understood.
Antispasticity medications (e.g. dantrolene, baclofen) reduce spasticity that interfereswith therapy or function, such as cerebral pulsy, multiple sclerosis, and spinal cord
injuries.
Results of search:
Systematic reviews
One systematic review was identified (van Tulder et al 2003b), which was also a
Cochrane review (van Tulder et al 2003a).
Additional RCTs
No additional trials were found.
Quality assessment of evidence
Systematic reviews
The systematic review (van Tulder et al 2003a, b) was of high quality and included
six RCTs dealing with chronic LBP: four of these were of high quality (Arbus et al
1990, Pratzel et al 1996, Salzmann et al 1992, Worz et al 1996) and two were of low
quality (Basmajian 1978, Pipino et al 1991). One low quality study dealt with acuteexacerbations of chronic low back pain (Casale 1988) and so this was notconsidered further.
Effectiveness
Effectiveness of antispasmodics vs. placeboa) Benzodiazepines vs. placebo Two high quality trials (N=222) showed that
tetrazepam 50 mg t.i.d. is more effective than placebo for short-term pain relief andoverall improvement (Arbus et al 1990, Salzmann et al 1992). The pooled relativerisk (RR) and 95% CIs for pain intensity were 0.82 (0.72 to 0.94) after 5-7 days’
follow-up and 0.71 (0.54 to 0.93) after 10-14 days. The pooled RRs and 95% CIs foroverall improvement were 0.63 (0.42 to 0.97) after 10-14 days’ follow-up.
With regards to muscle spasm, one high quality trial (N=50) showed that in the shortterm tetrazepam is more effective than placebo (Arbus et al 1990). Another trial(N=76 people) showed no difference between diazepam and placebo regarding theeffects on muscle spasm (Basmajian 1978).
b) Non-benzodiazepines vs. placebo
One high quality trial (N=107) showed that flupirtin is more effective than placebo forpatients with chronic LBP for short-term (after 7 days) pain relief and overall
improvement, but not for the reduction of muscle spasm (Worz et al 1996).

134

One high quality trial (N=112) showed that tolperisone is more effective than placebo
for short-term (after 21 days) overall improvement, but not for pain relief or reductionof muscle spasm (Pratzel et al 1996).
One low quality trial (N=76 people) showed no difference in short-term (after 18days) reduction of muscle spasm between cyclobenzaprine and placebo (Basmajian1978).
Effectiveness of antispasmodics vs. other treatments
Unknown (no studies were found on this issue)
Effectiveness of antispasticity medication vs. placebo
Unknown (no trials were found on this issue)
Effectiveness of antispasticity medication vs. other treatments
Unknown (no trials were found on this issue)
Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyThe studies examined indicate that muscle relaxants are associated with adverse
events. Central nervous system events were more prevalent in patients on muscle
relaxants, with the most common complaints being drowsiness, dizziness andaddiction (van Tulder et al 2003b). All these side-effects were consistently reported
for many of the benzodiazepines and non-benzodiazepines reviewed, with the
exception of addiction for non-benzodiazepines. However, two high quality trials
showed that neither flurpirtin (Worz et al 1996) nor tolperisone (Pratzel et al 1996)
were associated with a higher incidence of adverse events compared with placebo. It
is known that tolperisone can have severe allergic side-effects and that flurpirtin can
induce reversible reduction of liver function.
For gastrointestinal events, the difference between muscle relaxants and placebo
was not significant (van Tulder et al 2003b). The most common complaint wasnausea.
The adverse effects of muscle relaxants, especially those involving the central
nervous system, indicate that they should be used with caution.
Subjects (indications)
The studies included both chronic low back pain patients without any further
specification (Arbus et al 1990, Salzmann et al 1992, Worz et al 1996) or chronic low
back pain patients with muscle spasm (Basmajian 1978, Pipino et al 1991),
undergoing short-term use of muscle relaxants.
Comments
1. Muscle relaxants are prescribed to relieve the pain that supposedly arises inconnection with muscle spasm. The studies examined in these guidelines indicate
that, whilst muscle relaxants appear to be effective for the short-term relief of pain,
they have no effect on muscle spasm. The mechanism of action for these drugs, inrelieving pain, remains unclear.
2. Trials are needed to examine whether muscle relaxants are as effective as
analgesics or nonsteroidal anti-inflammatory drugs in the relief of pain.

135Summary of evidence• There is strong evidence that benzodiazepines are effective for pain relief (level A)
and conflicting evidence that they are effective for relieving muscle spasm (levelC).
• There is conflicting evidence that non-benzodiazepines are effective for pain relief(level C) and that they are not effective for the relief of muscle spasm.
Recommendation
Muscle relaxants can be used for short-term pain relief in chronic LBP, but must be
used with caution due to their side effects (drowsiness, dizziness, addiction, allergic
side-effects, reversible reduction of liver function, gastrointestinal events). As they do
not appear to exert their effect by reducing muscle spasm, other pain relieving drugs
with fewer serious side-effects should be considered first.
References
1. Arbus L, Fajadet B, Aubert D, Morre M, Goldfinger E (1990) Activity of tetrazepam
in low back pain. Clinical Trials Journal, 27(4): 258-67.
2. Basmajian JV (1978) Cyclobenzaprine hydrochloride effect on skeletal muscle
spasm in the lumbar region and neck: two double-blind controlled clinical andlaboratory studies. Arch Phys Med Rehabil, 59(2): 58-63.
3. Casale R (1988) Acute low back pain: Symptomatic treatment with a muscle
relaxant drug. The Clinical Journal of Pain, 4: 81-8.
4. Pipino F, Menarini C, Lombardi G, Guerzoni P, Ferrini A, Pizzoli A, Grangie A,
Beltrame A, Sorbilli G, Gottardo R, Cilento F (1991) A direct myotonolytic (Pridinol
Mesilate) for the management of chronic low back pain: A multicentre, comparative
clinical evaluation. European Journal of Clinical Research, 1: 55-70.
5. Pratzel HG, Alken RG, Ramm S (1996) Efficacy and tolerance of repeated oral
doses of tolperisone hydrochloride in the treatment of painful reflex muscle spasm:
results of a prospective placebo-controlled double-blind trial. Pain, 67(2-3): 417-25.
6. Salzmann E, Pforringer W, Paal G, Gierend M (1992) Treatment of chronic lowback syndrome with tetrazepam in a placebo controlled double-blind trial. J Drug
Dev, 4: 219-28.
7. van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM (2003a) Muscle
relaxants for non-specific low back pain. Cochrane Database Syst Rev, (2):CD004252.
8. van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM (2003b) Muscle
relaxants for nonspecific low back pain: a systematic review within the framework of
the cochrane collaboration. Spine, 28(17): 1978-92.
9. Worz R, Bolten W, Heller B, Krainick JU, Pergande G (1996) [Flupirtine incomparison with chlormezanone in chronic musculoskeletal back pain. Results of amulticenter randomized double-blind study]. Fortschr Med, 114(35-36): 500-4.

136

C10 (C) Non Steroidal Anti Inflammatory Drugs (NSAIDs)
Definition of procedure
Non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequently prescribed
medications worldwide and are widely used for patients with low back pain. The
rationale for using NSAIDs in the treatment of low back pain is based on theiranalgesic potential and their anti-inflammatory action.
Results of search
Systematic reviews
Two systematic reviews were retrieved (van Tulder et al 1997, van Tulder et al2004), one of which was a Cochrane review (van Tulder et al 2004). Together thereviews included 51 studies on both acute and chronic low back pain patients.
Four of the 51 studies reported exclusively on chronic low back pain (Berry et al
1982, Hickey 1982, Vetter et al 1988, Videman and Osterman 1984). One
study (Postacchini et al 1988) included a mixed population of acute and chronic low
back pain patients, but because some analyses pertained only to chronic low backpain, this report was considered further. The other 46 studies did not adequately
specify whether patients with acute or chronic low back pain were examined.
The studies of Berry, Hickey, Postacchini, Vetter, Videman (Berry et al 1982, Hickey
1982, Postacchini et al 1988, Vetter et al 1988, Videman and Osterman 1984) wereused to formulate these guidelines.
Additional trials
Five recent papers describing 4 additional RCTs on COX2 NSAIDS vs placebo wereidentified (Birbara et al 2003, Ju et al 2001, Katz et al 2003, Katz et al 2004, Pallay
et al 2004).
In addition, one trial was found comparing Doloteffin, a proprietary extract ofHarpagophytum (a phyto-antiinflammatory drug), and rofecoxib (Vioxx), a selective
inhibitor of cyclo-oxygenase-2 (COX-2) in the treatment of low back pain (Chrubasik
et al 2003).
Quality assessment of evidence
Systematic reviews
Both systematic reviews were of high quality. Of the 5 relevant studies from the SRs,
only one was of high quality (Hickey 1982) and the others were of low quality (Berryet al 1982, Postacchini et al 1988, Vetter et al 1988, Videman and Osterman 1984).
Additional trials
The four additional RCTs on COX2 inhibitors vs placebo, described in the five papers(Birbara et al 2003, Ju et al 2001, Katz et al 2003, Katz et al 2004, Pallay et al 2004),
were all high quality.
The trial comparing Doloteffin and rofecoxib (Vioxx) was of high quality, but it used avery low dose (12.5 mg) of rofecoxib, and had a relatively small sample size
(N=88) (Chrubasik et al 2003).
Effectiveness
Effectiveness of NSAIDs vs. placebo
One high quality study from the systematic review compared diflunisal vs. placebo,and reported better outcomes for the NSAID group in patients with chronic low backpain (Hickey 1982).
One low quality study from the systematic review compared diflunisal vs. placebo vs.
naproxen sodium (Berry et al 1982). Naproxen was superior to placebo in relieving137

global pain and, depending on the method of measurement, in relieving night pain
and pain on movement. Diflunisal showed no significant differences from placebo.
Three additional papers from the same group summarised the results of two 4-week
trials to compare rofecoxib 25 mg (N=228), rofecoxib 50 mg (N=233) and placebo(N=229) (Ju et al 2001, Katz et al 2003, Katz et al 2004). Both rofecoxib groups
showed a significantly greater reduction in pain intensity (VAS) compared with theplacebo group, after one week of treatment. Disability (Roland Morris) scores also
reduced significantly. Both regimens were superior to placebo in eight of ninesecondary endpoints. Fifty mg provided no advantage over 25 mg, although 25 mg
had a slightly better safety profile. (N.B. see Comments section)
In another additional RCT (N=319) it was found that, compared with placebo,
etoricoxib (60 mg and 90 mg) significantly decreased pain (by 12.9 and 10.3 points
respectively, on a 0-100 VAS) and improved functioning after 12 weeks (by 2.24 and2.06 points respectively on the 0-24 Roland Morris Disability Scale) (Birbara et al2003).
A further trial (N=325) used a similar design to that of Birbara et al (2003) to study
the effects of 3 months’ treatment with either etoricoxib 60 mg, etoricoxib 90 mg orplacebo; the improvements in disability and pain reduction were similar to thosereported by Birbara et al (2003), with no differences between the dosages (Pallay etal 2004).
Effectiveness of NSAIDs vs. other treatments
One low quality study from the systematic review aimed to assess the effectivenessof adding vitamin B to an NSAID treatment by comparing diclofenac (50 mg) with a
combined therapy of diclofenac (50 mg) and vitamins B1, B6, and B12 (thiamine
nitrate, pyridoxine hydrochloride, and cyanocobalamine, resp.; in dosages of 50 mg,
50 mg, and 0.25 mg, respectively) in 256 patients (Vetter et al 1988). All parameters
used as a measure of pain relief indicated significantly superior results with the Bvitamin supplemented therapy when compared with results obtained with diclofenac
alone.
Two low quality studies from the systematic review compared different kinds of
NSAIDs. In a 3-way, double-blind, cross-over study, diflunisal (500 mg twice daily)
was compared with naproxen sodium (550 mg twice daily) and each was comparedwith placebo (Berry et al 1982). Whilst naproxen showed significantly better results
than placebo, diflunisal did not, indicating that naproxen was superior to diflunisal. In
the second study, patients received either indomethacin (25 mg t.i.d.) or piroxicam(20 mg in the morning; and a placebo at lunchtime and before dinner) for six
weeks (Videman and Osterman 1984). The overall results of both treatment groups(with regard to pain and improvements in the ability to do everyday tasks) weresimilar.
One low quality study from the systematic review examined diclofenac vs.
chiropractic manipulation vs. physiotherapy vs bed rest vs back school (Postacchini
et al 1988). The greatest reduction in pain was found in the NSAID group, but thedifference was not statistically significant. The intervention group sample sizes werealso small in this study.
One high quality study showed no differences in the pain relief afforded by Doloteffinand rofecoxib (Chrubasik et al 2003).
Cost-effectiveness138

Unknown (no studies were found on this issue)
SafetyNo back pain specific studies examined the side-efffects of NSAIDs.
However, gastrointestinal complications (irritation, ulcers and bleeding) are generally
known side effects of NSAIDS that may lead to hospitalization. COX2 inhibitors havebeen shown to have a better GI safety profile in osteoarthritis and rheumatoid
arthritis studies (Bombardier et al 2000, Silverstein et al 2000). However, one ofthese drugs (rofecoxib) increases cardiovascular risk (myocardial infarction andstroke) with long-term use (>18 months) (Topol 2004), and the drugs are presently
being evaluated for continued registration (November 2004).
None of the other NSAIDs, including other COX2 inhibitors, have been thoroughly
examined in relation to such serious long-term risks.
Subjects (indications)
The study populations examined were usually described as having lumbar
degenerative spondylosis.
Comments
1. In many of the studies used to formulate these recommendations, the sample
size was low (N=37 (Berry et al 1982); N=30 (Hickey 1982); N=459, but in thesubgroup with chronic LBP N=81 (Postacchini et al 1988); N= 28 (Videman andOsterman 1984)) and the follow-up was short (2-6 weeks).
2. No RCTs have been carried out to compare NSAIDs and acetaminophen(paracetamol) or metamizol in patients with chronic low back pain. In patients withknee and hip pain due to osteoarthritis, NSAIDs have proven superior toacetaminophen for improving pain but not function (Amadio and Cummings 1983,
Towheed et al 2003). However, in the studies reviewed, the size of the treatment
effect was modest and the mean trial duration was only six weeks (Towheed et al
2003, Amadio et al. 1983). Trials are required comparing NSAIDs with otheranalgesics for chronic low back pain.
3. Three recent studies showed that COX2 inhibitors are effective in the treatmentof LBP (Birbara et al 2003, Katz et al 2003, Pallay et al 2004); however, one of these
COX2 inhibitors (rofecoxib) has since been withdrawn from the market. (see Safety).
Summary of evidence
Most studies have examined the effectiveness for up to 3-month periods of time.
There is strong evidence that NSAIDs are effective for the relief of chronic low backpain (level A).
Recommendation
We recommend NSAIDs for pain relief in patients with chronic low back pain.
Because of the side-effects, NSAIDs should only be used for exacerbations or shortterm periods (up to 3 months).
References
1. Amadio P, Cummings DM (1983) Evaluation of acetaminophen in the
management of osteoarthirits of the knee. Curr Ther Res, 34(1): 59-66.
2. Berry H, Bloom B, Hamilton EB, Swinson DR (1982) Naproxen sodium, diflunisal,and placebo in the treatment of chronic back pain. Ann Rheum Dis, 41(2): 129-32.
3. Birbara CA, Puopolo AD, Munoz DR, Sheldon EA, Mangione A, Bohidar NR, Geba
GP (2003) Treatment of chronic low back pain with etoricoxib, a new cyclooxygenase-2 selective inhibitor: improvement in pain and disability--a randomized,
placebo-controlled, 3-month trial. J Pain, 4(6): 307-15.
4. Bombardier C, Laine L, Reicin A, Shapiro D, Burgos-Vargas R, Davis B, Day R,
Ferraz MB, Hawkey CJ, Hochberg MC, Kvien TK, Schnitzer TJ (2000) Comparison of139

upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid
arthritis. VIGOR Study Group. N Engl J Med, 343(21): 1520-8, 2 p following 8.
5. Chrubasik S, Model A, Black A, Pollak S (2003) A randomized double-blind pilot
study comparing Doloteffin and Vioxx in the treatment of low back pain.
Rheumatology (Oxford), 42(1): 141-8.
6. Hickey RF (1982) Chronic low back pain: a comparison of diflunisal withparacetamol. N Z Med J, 95(707): 312-4.
7. Ju WD, Krupa DA, Walters DJ, Newman TL, Borenstein DG, Katz N, Group VC(2001) A placebo-controlled trial of rofecoxib in the treatment of chronic low backpain. Pain Med, 2(3): 242-3.
8. Katz N, Ju WD, Krupa DA, Sperling RS, Bozalis Rodgers D, Gertz BJ, Gimbel J,
Coleman S, Fisher C, Nabizadeh S, Borenstein D (2003) Efficacy and safety ofrofecoxib in patients with chronic low back pain: results from two 4-week,
randomized, placebo-controlled, parallel-group, double-blind trials. Spine, 28(9): 8518; discussion 9.
9. Katz N, Rodgers DB, Krupa D, Reicin A (2004) Onset of pain relief with rofecoxib
in chronic low back pain: results of two four-week, randomized, placebo-controlled
trials. Curr Med Res Opin, 20(5): 651-8.
10. Pallay R, Seger W, Adler J, Ettlinger R, Quaidoo E, Lipetz R, O'Brien K, Mucciola
L, Skalky C, Petruschke R, Bohidar N, Geba G (2004) Etoricoxib reduced pain anddisability and improved quality of life in patients with chronic low back pain: a 3month, randomized, controlled trial. Scand J Rheumatol, 33(4): 257-66.
11. Postacchini F, Facchini M, Palieri P (1988) Efficacy of various forms ofconservative treatment in low back pain: a comparative study. Neurol Orthop, 6: 1136.
12. Silverstein FE, Faich G, Goldstein JL, Simon LS, Pincus T, Whelton A, Makuch
R, Eisen G, Agrawal NM, Stenson WF, Burr AM, Zhao WW, Kent JD, Lefkowith JB,
Verburg KM, Geis GS (2000) Gastrointestinal toxicity with celecoxib vs nonsteroidal
anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study:
A randomized controlled trial. Celecoxib Long-term Arthritis Safety Study. Jama,
284(10): 1247-55.
13. Topol EJ (2004) Failing the Public Health -- Rofecoxib, Merck, and the FDA. N
Engl J Med.
14. Towheed TE, Judd MJ, Hochberg MC, Wells G (2003) Acetaminophen for
osteoarthritis. Cochrane Database Syst Rev, (2): CD004257.
15. van Tulder MW, Koes BW, Bouter LM (1997) Conservative treatment of acuteand chronic nonspecific low back pain. A systematic review of randomized controlled
trials of the most common interventions. Spine, 22(18): 2128-56.
16. van Tulder MW, Scholten RJ, Koes BW, Deyo RA (2004) Non-steroidal antiinflammatory drugs for low back pain. In: The Cochrane Library, Issue 3. John Wiley& Sons, Ltd: Chichester, UK.
17. Vetter G, Bruggemann G, Lettko M, Schwieger G, Asbach H, Biermann W,
Blasius K, Brinkmann R, Bruns H, Dorn E, et al. (1988) [Shortening diclofenac
therapy by B vitamins. Results of a randomized double-blind study, diclofenac 50 mg
versus diclofenac 50 mg plus B vitamins, in painful spinal diseases with degenerativechanges]. Z Rheumatol, 47(5): 351-62.
18. Videman T, Osterman K (1984) Double-blind parallel study of piroxicam versus
indomethacin in the treatment of low back pain. Ann Clin Res, 16(3): 156-60.

C10 (D) Opioids
Definition of procedure
Oral or transdermal drug treatment with either weak opioids (e.g. tramadol, codeine,
tilidin) or strong opioids (e.g. morphine, oxycodone, hydromorphone, fentanyl,buprenorphine) in patients with chronic non-specific low back pain.

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Result of search
Systematic review
No systematic reviews were found.
Additional trials
8 RCTs were found (Hale et al 1999, Jamison et al 1998, Maier et al 2002, Mullicanand Lacy 2001, Palangio et al 2000, Raber et al 1999, Ruoff et al 2003, Schnitzer et
al 2000).
Four of these studies were excluded for the following reasons:• One investigated only 45.6% LBP patients, and the results for these could not
be separated our from those of all patients (Palangio et al 2000).
• One compared only tramadol immediate release versus sustained releasecapsules without control and had no follow up (Raber et al 1999).
• One compared only sustained and immediate release oxycodone with nocontrol (Hale et al 1999).
• One investigated both chronic LBP patients and patients with osteoarthritis(only 24% with only chronic LBP only) (Mullican and Lacy 2001).
Quality assessment of the evidence
Of the included RCTs, four were of high quality (Maier et al 2002, Ruoff et al 2003,
Schnitzer et al 2000) although one had a very small sample size (Maier et al 2002)
and one had short treatment and follow-up periods (Schnitzer et al 2000).
The third study was of low quality (Jamison et al 1998).
Effectiveness
Effectiveness of opioids versus placebo
One high quality study (Schnitzer et al 2000) compared Tramadol (N=127) withplacebo (N=127) for treating chronic patients with non-specific low back pain,
showing that tramadol was highly significantly superior on all parameters (VAS painscores, pain relief scores, pain description and disability).
One high quality study (Maier et al 2002) compared morphine with placebo forpatients with either non-specific low back pain (N=12) or low back pain plus radicular
pain (neuropathic pain associated with spinal stenosis, epidural fibrosis after discsurgery or arthrodesis) (N=12). It showed that, with regard to pain relief, morphine
was superior to placebo in cases of neuropathic (radicular) pain (NNT 2-4 for 50%
pain relief) but not in cases of severe non-specific low back pain (NNT 12 for 50%
pain relief).
Another high quality trial (Ruoff et al 2003) compared a mixture of Tramadol (37.5mg) and acetaminophen (paracetamol; 325 mg) (N=161) with placebo (N=157) for 3
months in patients with at least moderate (VAS pain > 40mm on a 0-100mm scale)chronic low back pain. Tramadol/acetaminophen significantly improved pain,
disability (Roland Morris) and quality of life compared with placebo.

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Effectiveness of opioids versus other treatments (naproxen)
One low quality study (Jamison et al 1998) compared three drug regimes: (i) an
NSAID, naproxen (n=12); (ii) set-dose oxycodone (n=13); and (iii) titrated-dose
oxycodone plus sustained-release morphine (n=11). All three medications
significantly reduced pain and emotional distress (p<0.05) even in the long-term (28weeks), but the opioid groups were significantly better than the naproxene group(p<0.001). All medications had little effect on activity and sleep.
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetySide effects were moderate (mainly constipation, dizziness or sweating, but sexual
impotence also in many cases) for long-term use of opioids. Most side effects(except constipation and impotence) subsided over time. In the studies examined, nocases of dependence were reported, but dependence on opioids is always possible.
Subjects (indications)Patients with moderate to severe chronic non-specific low back pain who do notrespond to analgesics or NSAIDs or experience side effects with these medications.
Comments
1. Only few data exist concerning the use of opioids (especially strong opioids) for
the treatment of chronic low back patients, and further RCTs are needed.
2. Strong opioids should be used only if all other available therapeutic treatments forpain relief have failed.
Summary of evidence• There is strong evidence that weak opioids relieve pain and disability in the
short-term in chronic low back pain patients (level A).
• There is limited evidence that strong opioids relieve pain in the short-term inchronic low back pain patients (level C).
Recommendation
We recommend the use of weak opioids (e.g. tramadol) in patients with non-specificchronic low back pain who do not respond to other treatment modalities. Due to therisk of addiction, slow-release opioids are preferable to immediate-release opioids,
and should be given regularly (around the clock) rather than as needed.
References
1. Hale ME, Fleischmann R, Salzman R, Wild J, Iwan T, Swanton RE, Kaiko RF,
Lacouture PG (1999) Efficacy and safety of controlled-release versus immediaterelease oxycodone: randomized, double-blind evaluation in patients with chronic
back pain. Clin J Pain, 15(3): 179-83.
2. Jamison RN, Raymond SA, Slawsby EA, Nedeljkovic SS, Katz NP (1998) Opioid
therapy for chronic noncancer back pain. A randomized prospective study. Spine,
23(23): 2591-600.
3. Maier C, Hildebrandt J, Klinger R, Henrich-Eberl C, Lindena G (2002) Morphine
responsiveness, efficacy and tolerability in patients with chronic non-tumor
associated pain - results of a double-blind placebo-controlled trial (MONTAS). Pain,
97(3): 223-33.
4. Mullican WS, Lacy JR (2001) Tramadol/acetaminophen combination tablets andcodeine/acetaminophen combination capsules for the management of chronic pain: acomparative trial. Clin Ther, 23(9): 1429-45.

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5. Palangio M, Damask MJ, Morris E, Doyle RT, Jr., Jiang JG, Landau CJ, dePadova A (2000) Combination hydrocodone and ibuprofen versus combination
codeine and acetaminophen for the treatment of chronic pain. Clin Ther, 22(7): 87992.
6. Raber S, Hofmann S, Junge K, Momberger H, Kuhn D (1999) Analgesic effect andtolerability of Tramadol 100mg sustained-release capsules in patients with moderate
to severe chronic low back pain. Clin Drug Invest, 17: 415-23.
7. Ruoff GE, Rosenthal N, Jordan D, Karim R, Kamin M (2003)
Tramadol/acetaminophen combination tablets for the treatment of chronic lower backpain: a multicenter, randomized, double-blind, placebo-controlled outpatient study.
Clin Ther, 25(4): 1123-41.
8. Schnitzer TJ, Gray WL, Paster RZ, Kamin M (2000) Efficacy of tramadol intreatment of chronic low back pain. J Rheumatol, 27(3): 772-8.

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C10 (E) Antiepileptic drugs (Gabapentin)
Definition of the procedure
The amino acid antiepileptic drug, gabapentin, is normally indicated for adjunctive
use in the treatment of partial epileptic seizures. Recently it has also been used inpain treatment (mainly neuropathic pain). Possible mechanisms of action include
biochemical effects enhancing the ratio of gamma-aminobutyric acid (GABA) toglutamate, ion-channel action, and/or enhancement of nonsynaptic GABA release.
Results of search
Systematic reviews
No systematic reviews were found on gabapentin for the treatment of non-specificchronic LBP.
Additional trials
One RCT was found on the effectiveness of gabapentin for the treatment of chronic
LBP (McCleane 2001).
Quality assessment of the evidence
The RCT (McCleane 2001) was of high quality.
Effectiveness
Effectiveness of gabapentin vs. placebo
In the one RCT (McCleane 2001), 80 patients were randomized to groups receiving
either gabapentin up to 1200 mg/day or placebo. 65 patients provided analyzable
results. Pain was measured using a 0-10 NRS. Gabapentin failed to improve pain
significantly compared with placebo.
Effectiveness of gabapentin vs. other treatments
Unknown (no studies were found on this issue)
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetySide effects in the gabapentin group were comparable with those in the placebogroup. Gabapentin has few and minor side effects, except for in patients with genetic
lactose deficiency (“Lapp lactase deficiency”).
Subjects (indications)
Not having shown evidence of effectiveness, it is not possible to define indications forthe use of gabapentin.
Comments
Normally gabapentin is used in patients with neuropathic pain. In the one RCT thatwas identified, these patients were excluded from the study (McCleane 2001).
The dose of gabapentin that was used in this trial (up to 1200 mg/day) was low, but
within recommended therapeutic doses. Higher doses were avoided since theauthor’s experience was that these were not well tolerated by the patients. No data
are available on the potential effectiveness of higher doses of gabapentin in chronic
LBP.
Summary of evidence

144There is limited evidence that gabapentin is not effective for the relief of chronic low
back pain.
Recommendation
We do not recommend the use of gabapentin in patients with non-specific chronic
low back pain.
References
1. McCleane GJ (2001) Does Gabapentin have an analgesic effect on background,movement and referred pain? A randomised, double-blind, placebo controlled study.
Pain Clinic, 13: 103-7.

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C10 (F) Capsicum pain plasters (capsaicin)
Definition of the procedure
Capsaicin, from chilli peppers, binds to nociceptors in the skin, causing excitation of
the neurons and a period of enhanced sensitivity perceived as itching, pricking, orburning, with cutaneous vasodilatation. This is followed by a refractory period with
reduced sensitivity and, after repeated applications, persistent desensitization. The
desensitizing effect is fully reversible.
Results of search
Systematic reviews
One systematic review was retrieved (Mason et al 2004). This review dealt with
topical capsaicin for the treatment of chronic pain in general (neuropathic andmusculoskeletal pain). Only one trial of low back pain was included (Keitel et al2001): 154 patients were randomized to placebo or local capsicum treatment.
Additional trials
One additional RCT was retrieved (Frerick et al 2003). 301 patients (148 withcapsicum and 153 with placebo) completed the study and follow up. Outcome wasmeasured by pain questionnaire, impairment of movement and disability.
Quality assessment of the evidence
The systematic review (Mason et al 2004) and the one relevant trial it included (Keitel
et al 2001) were both of high quality. The additional trial (Frerick et al 2003) was alsoof high quality.
Effectiveness
Effectiveness of capsicum pain plasters vs sham procedure
A double-blind, randomised study compared capsicum plaster with a placebo for 3
weeks in 154 patients with chronic, non-specific back pain (Keitel et al 2001). The
sum of 3 separate pain scales decreased more markedly in the capsicum group thanin the placebo group (38.5% compared to 28.0%; p = 0.002) and the proportion of
responders (i.e. individuals in whom pain was reduced by at least 30% of thebaseline value) was also significantly higher for the capsicum group (60.8% vs 42.1%
in the placebo group; p = 0.0219). A second study from the same group of authors,which involved 320 patients with chronic, non-specific back pain who were randomly
assigned to capsicum plaster (N=160) or placebo plaster (N=160), produced similar
results: after three weeks treatment, the compound pain sub-score was reduced by
42% and 31% (p=0.002) for capsicum and placebo plasters respectively, andresponder rate was 67% versus 49% (p=0.002) respectively (Frerick et al 2003). The
authors claimed that the superiority of the capsicum plaster was highly statisticallysignificant and clinically relevant.
The authors of the systematic review reported that trials of capsicum plaster formusculoskeletal pain (in general) suggested moderate to poor efficacy (number
needed to treat (NNT) was 8.1 for 50% pain reduction) (Mason et al 2004).
In the additional trial (Frerick et al 2003), NNT for 50% pain reduction was 9 (OR
2.1).
There is strong evidence that capsicum pain plaster is more effective than placebo
for the short term (3 weeks) relief of pain (level A).

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Effectiveness of capsicum pain plasters vs other treatments
Unknown (no studies found)Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyAround one third of patients experienced local adverse effects (unpleasant burning,
itching sensation).
Subjects (indications)Patients with chronic low back pain with an intensity ≥5 on an 11-point scale.
Comments
Both trials were carried out by the same research group in Germany and both weresponsored by a drug company (Beiersforf AG).
Summary of evidence
There is strong evidence that capsicum pain plaster is more effective than placebo
for short term (3 weeks) treatment (level A).
Recommendation
Consider capsicum pain plaster for short-term symptomatic pain relief of chronic low
back pain.
References
1. Frerick H, Keitel W, Kuhn U, Schmidt S, Bredehorst A, Kuhlmann M (2003) Topicaltreatment of chronic low back pain with a capsicum plaster. Pain, 106(1-2): 59-64.
2. Keitel W, Frerick H, Kuhn U, Schmidt U, Kuhlmann M, Bredehorst A (2001)
Capsicum pain plaster in chronic non-specific low back pain. Arzneimittelforschung,51(11): 896-903.
3. Mason L, Moore RA, Derry S, Edwards JE, McQuay HJ (2004) Systematic review
of topical capsaicin for the treatment of chronic pain. Bmj, 328(7446): 991.

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Chapter 11 Invasive procedures
C11 (A) Acupuncture
Definition of the procedure.
Acupuncture is defined as the insertion of needles (1 cm to 10 cm (Leake andBroderick 1998)) at specific points for the treatment or prevention of symptoms andconditions. Those specific points (i.e. “acupuncture points”) are defined by theirlocation (Shanghei 1960) and some specific characteristics: they coincide with the
migration pathways of some radioactive tracers (Kovacs et al 2000, Kovacs et al
1992, 1993, Vernejoul et al 1985) and have special electrical characteristics (Kovacs
et al 1992, 1993, Niboyet 1963). Stimulation of non-acupuncture points of the skin isalso considered by some to be acupuncture (Leggett Tait et al 2002).
Alternative methods of stimulation exist. Moxibustion refers to the use of the herb
Artemisia vulgaris (mugwort) which is burned over the acupuncture site for warming
purposes (van Tulder et al 2004). Electroacupuncture refers to the technique of
applying an electrical current to the inserted needles at various frequencies. Laser
acupuncture refers to directing a laser beam at the acupuncture site. Fire needles
involve inserting red-hot needles at an acupuncture point. Cupping is a technique by
which a vacuum force is applied to acupuncture sites. Bloodletting refers to thepricking of the skin for the purpose of releasing blood. Acupressure refers to themanual stimulation of a point with pressure (Leggett Tait et al 2002).
For the purpose of this Guideline, only studies on acupuncture involving puncturingof the skin (either at acupuncture points or non-acupuncture sites) are considered.
Studies on laser acupuncture, acupressure, and acupuncture-like TENS are coveredby the recommendations of this Guideline dealing with laser, massage or PENS
respectively.
Results of search.
Systematic reviews
Sixteen systematic reviews (Berman 2001, Brosseau et al 2002, Ernst 1998, Ernst
and White 1998, Ezzo et al 2000, Flowerdew and Gadsby 1997, Gadsby andFlowerdew 2000, Leake and Broderick 1998, Leggett Tait et al 2002, Milne et al
2001, Reed 1996, Smith et al 2000, van Tulder et al 1999, van Tulder et al 2004, vanTulder et al 1997, White and Ernst 2000) were retrieved through the electronic
search. Twelve were excluded for the following reasons:• Four were actually not systematic reviews, but rather narrative reviews or
proposals for future research on acupuncture (Berman 2001, Leake andBroderick 1998, Leggett Tait et al 2002, Reed 1996)• Four focused on TENS (including acupuncture-like TENS) (Brosseau et al
2002, Flowerdew and Gadsby 1997, Gadsby and Flowerdew 2000, Milne et al
2001)• One mixed acupuncture and laser-acupuncture (Smith et al 2000), which is
not consistent with the definition of acupuncture that is being used in thisGuideline.
• One focused on acupuncture for all kinds of chronic pain (not only back pain)and did not provide separate results for back pain (Ezzo et al 2000)• One focused on the economic analysis of complementary medicine (not only
acupuncture, although it included this procedure), and did not deal with148

acupuncture for back pain (in fact, it included no studies on this subject)(White and Ernst 2000)• One (van Tulder et al 1999) was a previous report of a lately updated
Cochrane review (van Tulder et al 2004)• One (Ernst 1998) was basically redundant with another review that had
already been included (Ernst and White 1998)
The remaining three systematic reviews were included (Ernst and White 1998, vanTulder et al 2004, van Tulder et al 1997). They covered original studies published up
to the first issue of 1997 (in the Cochrane Library) or up to the end of 1996 (in therest of databases).
Among the three systematic reviews that were included, one included studies onboth neck and back pain (Ernst and White 1998) and two included only studies onback pain (van Tulder et al 2004, van Tulder et al 1997).
Additional RCTs
An additional search on individual RCTs published after the period covered by thesystematic reviews, led to the identification of 22 additional papers (Carlsson and
Sjolund 2001, Ceccherelli et al 2003, Cherkin et al 2001, Franke et al 2000, Giles
and Muller 1999, Grant et al 1999, Hogeboom et al 2001, Hsieh et al 2004,
Kalauokalani et al 2001, Kerr et al 2003, Kittang et al 2001, Leibing et al 2002,
MacPherson et al 1999, Meng et al 2003, Molsberger et al 2002, SatorKatzenschlager et al 2004, Sprott 1998, Thomas et al 1999, Wang and Tronnier
2000, Wedenberg et al 2000, Wehling and Reinecke 1997, Yi-Kai et al 2000).
Fourteen of these studies were excluded for the following reasons:• One dealt only with acute patients (Kittang et al 2001)• Three didn’t study the effectiveness of acupuncture, but compared different
acupuncture techniques (electrical vs manual acupuncture) (SatorKatzenschlager et al 2004) or focused on the consistency among different
practitioners (Hogeboom et al 2001) or the correlation between the number ofsessions and the therapeutical effect (Ceccherelli et al 2003)• Two focused on “acupuncture massage” (i.e. massage on the “meridians” thatunite acupuncture points) (Franke et al 2000) or acupressure (i.e. massage on
acupuncture points) (Hsieh et al 2004) but did not involve needling• One focused on patients with fibromyalgia, and not with back pain (Sprott 1998)• One compared a treatment consisting of acupuncture and cytokine inhibiting
natural herbs versus two other procedures (local anaesthetics and steroid
injections) for sciatica, making it impossible to determine to what extent each of
the two treatments given to the patients in the “acupuncture group” wasresponsible for the overall effects (Wehling and Reinecke 1997)• Three were not randomized controlled trials (one was a short-term follow-up of agroup of patients treated with acupuncture, with no comparison group (Yi-Kai etal 2000), the objective of the second one was to pilot procedures which weregoing to be used in a RCT (MacPherson et al 1999), and the third one presented
the research protocol for a pragmatic study, but was not a research
report (Thomas et al 1999)).
• One RCT included patients undergoing disc surgery (Wang and Tronnier 2000).
• Two reports (on pregnant women and elderly) did not provide information on the
duration of pain (Grant et al 1999, Wedenberg et al 2000).
Among the remaining eight additional reports, two analyzed different aspects of thesame study: the first one focused on the results of the study (Cherkin et al 2001), andthe other one on the relationship between patients’ expectations and thoseresults (Kalauokalani et al 2001).

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Among these eight reports, six dealt only with chronic patients (Carlsson and Sjolund
2001, Giles and Muller 1999, Kerr et al 2003, Leibing et al 2002, Meng et al 2003,
Molsberger et al 2002), and two with subacute (> 6 weeks) and chronic patients (bothpapers corresponded to the same study) (Cherkin et al 2001, Kalauokalani et al2001).
Quality assessment of the evidence.
Systematic reviews
Among the three systematic reviews which were included, two were of highquality (van Tulder et al 2004, van Tulder et al 1997), reaching the maximum possible
score on methodological quality, and one was of low quality (Ernst and White 1998).
Additional RCTs
Among the eight additional RCTs that were identified, four were of highquality (Cherkin et al 2001, Kalauokalani et al 2001, Leibing et al 2002, Molsberger et
al 2002) and four were of low quality (Carlsson and Sjolund 2001, Giles and Muller
1999, Kerr et al 2003, Meng et al 2003).
Effectiveness
Effectiveness of acupuncture vs. sham procedures or no treatment
Systematic reviews
The three systematic reviews all included studies comparing acupuncture versus asham procedure or placebo (Ernst and White 1998, van Tulder et al 2004, van Tulder
et al 1997). All three concurred in concluding that there is no evidence that
acupuncture has an effect beyond the placebo effect. The two systematic reviews
reaching the maximum methodological quality concluded that there is limited
evidence that acupuncture is not more effective than placebo or sham acupuncture
for the treatment of chronic low back pain (van Tulder et al 2004, van Tulder et al1997).
No systematic review gave separate results for different outcome variables. Most
studies that were included in the systematic reviews focused on pain, but some also
included range of movement, global assessment by the physician, work status,
disability, and patient’s assessment of condition.
Additional studies
One high-quality RCT with a follow-up period of 9 months compared acupuncture toa sham procedure (Leibing et al 2002). No differences were found between thegroups in terms of improvement of pain intensity or disability (Leibing et al 2002).
One high quality RCT compared: a) conservative treatment (defined asphysiotherapy, physical exercise, back school, mud packs, infrared heat therapy anddiclofenac 50 mg up to 3 times a day), b) conservative treatment plus real
acupuncture and c) conservative treatment and sham acupuncture (defined asneedle insertion to a depth of less than 1 cm in non-acupuncture points of the lumbar
region). The percentage of patients showing a ≥50% reduction of pain was
significantly greater in group b) than both in groups a) and c), although there were nodifferences in the intake of diclofenac (Molsberger et al 2002).
Two low-quality RCTs compared acupuncture and sham (disconnected)
TENS (Carlsson and Sjolund 2001, Kerr et al 2003). One found differences in favourof acupuncture for pain, return to work, disturbance of sleep and analgesic
intake (Carlsson and Sjolund 2001), while the other did not find differences in pain,
length of pain relief post-treatment and satisfaction with treatment (Kerr et al 2003).

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There is conflicting evidence that acupuncture is better than a sham procedure in thetreatment of low back pain (level C).
Effectiveness of acupuncture vs. other procedures
Systematic reviews
Three systematic reviews compared the effectiveness of acupuncture with othertreatments (Ernst and White 1998, van Tulder et al 2004, van Tulder et al 1997).
The two high quality reviews concluded that acupuncture is not more effective thantrigger point injection or TENS (van Tulder et al 2004, van Tulder et al 1997). The
third systematic review, which was a low quality one, stated that acupuncture has
proven to be superior to various control interventions (Ernst and White 1998).
However, its results did not appear to support its conclusion.
Additional RCTs
Six RCTs compared acupuncture with other procedures (Cherkin et al 2001, Giles
and Muller 1999, Kalauokalani et al 2001, Leibing et al 2002, Meng et al 2003,
Molsberger et al 2002).
One high quality study compared acupuncture, sham-acupuncture and ”active”
physiotherapy (defined as training of proper posture and motion in accordance with
Bruegger concepts (Bruegger 1990) and found that acupuncture was better thanphysiotherapy but not better than placebo-acupuncture, in terms of improvement ofpain and disability (Leibing et al 2002).
One high quality RCT compared: a) conservative treatment (defined asphysiotherapy, physical exercise, back school, mud packs, infrared heat therapy anddiclofenac 50 mgs up to 3 times a day), b) conservative treatment plus real
acupuncture and c) conservative treatment and sham acupuncture (defined asneedle insertion to a depth of less than 1 cm in non-acupuncture points of the lumbar
region). The percentage of patients showing a ≥50% reduction of pain was
significantly greater in group b) than both in groups a) and c), although there were nodifferences in mobility (Schober’s sign and finger to ground distance) nor in theintake of diclofenac (Molsberger et al 2002).
One high quality RCT compared acupuncture, massage and self-care educational
material, and found that acupuncture provided results similar to those for self-care
educational material, and worse than those for massage in terms of improvement ofsymptoms and disability (Cherkin et al 2001). Sub-group analysis of the data of thatstudy showed that patients’ expectations regarding each treatment were associatedwith its effectiveness (i.e., patients improved to a larger extent with those treatmentsthat they believed were going to be more effective) (Kalauokalani et al 2001). One
low quality RCT comparing spinal manipulation, non steroidal anti inflammatory
drugs (NSAIDs) and acupuncture, found spinal manipulation to be better than theother two alternatives in terms of improvement of disability and pain (Giles and Muller
1999).
One low quality RCT compared: a) standard treatment (defined as any of thefollowing treatments or their combinations, as prescribed by the general practitioner:home exercises, exercises with a physical therapist, non-steroidal anti-inflammatory
drugs, aspirin, non-narcotic analgesics), with b) standard treatment plus
electroacupuncture, in patients aged 60 yr and over. It found that the addition ofacupuncture to standard treatment resulted in an improvement in disability (sixweeks after treatment) and an improvement in pain (at 9 weeks, but not 6 weeks
after treatment)(Meng et al 2003). Although the study was not able to demonstratethat expectations regarding treatment per se effected outcome, within the two151treatment groups the patients “impressions of acupuncture” influenced their outcome
within the given treatment groups (positive impressions were associated with a morepositive response in the acupuncture group, whilst negative impressions led to amore positive result in standard treatment).
There is moderate evidence that acupuncture is not more effective than trigger point
injection or TENS for the treatment of low back pain (level B).
There is limited evidence that acupuncture is less effective than massage and spinal
manipulation (level C).
There is limited evidence in each case that acupuncture is similar to self-care
education and better than training of proper posture and motion in accordance with
Bruegger concepts (level C).
There is limited evidence that the addition of acupuncture improves the results ofstandard GP treatment (defined as exercise, NSAIDs, aspirin and/or non-narcotic
analgesics) or conventional treatment (defined as physiotherapy, exercise, backschool, mud packs, infrared heat therapy and diclofenac) (level C).
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetySystematic reviews
No papers focusing on the systematic assessment of adverse events derived fromacupuncture were included in the systematic reviews.
One systematic review reported on the number (but not relative incidence) ofcomplications from acupuncture for back and neck pain. Adverse reactions toacupuncture (Ernst and White 1998) included drowsiness/syncope/fainting (274cases), hepatitis (127 cases), other infections (endocarditis, osteomyelitis,
septicemia, perichondritis, etc.) (100 cases), increased pain (70 cases),pneumothorax (65 cases), and cardiac trauma (7 cases). However, the proportion ofsuch events in all patients treated with acupuncture remains unknown.
Additional RCTs
Among the additional RCTs, only two provided information on adverse effects. One
study comparing acupuncture, massage and self-care education stated that 11% of
patients reported significant discomfort or pain during or shortly after acupuncture
treatment (Leibing et al 2002). This rate was similar to that reported after massage(13%) (Leibing et al 2002).
One study comparing acupuncture and TENS stated that 10% of patients in theacupuncture group reported dizziness (Grant et al 1999).
One study on electroacupuncture stated that 21% of patients reported aching, 12.5%
bruising and 4.2% light-headedness. An additional 4.2% of patients withdrew fromthe study because of pain (Meng et al 2003).
Subjects (indications).
Patients treated in the studies included subacute or chronic patients, with and without
referred pain and with or without sciatica. Not having proven effective in thetreatment of chronic LBP, it is impossible to define ideal indications for the use ofacupuncture.
Comments:
1. There is some evidence suggesting that the proportion of patients improving in thesham acupuncture groups (i.e. superficial needling or needling at non-indicatedpoints) is higher than the proportion improving with other “inert” placebo groups152

(sham TENS, sugar pills or placebo acupuncture –in which no needles are inserted).
This may be due to acupuncture triggering an especially powerful placebo effect, tochance, to an unknown confounder, to the fact that this evidence comes from indirectcomparisons across studies performed in different settings and populations bydifferent research groups, or to sham acupuncture not being a really physiologicallyinert placebo (Ernst and White 1998, Ezzo et al 2000).
2. There is lively debate among the acupuncture community to determine what
procedures fall within the definition of acupuncture. The variability of techniquescalled acupuncture makes it difficult to assess its quality, and might lead toinappropriate pooling of different techniques within a systematic review. However, todate, no individual acupuncture technique has consistently shown effectiveness.
3. The quality of the vast majority of the RCTs was low, and their results areconflicting. Therefore, more thorough research is needed in this field.
4. In general, the evidence derived from additional RCTs is consistent with that of
the systematic reviews in three respects:a) There is no consistent evidence that acupuncture provides anything more thana placebo effect in the treatment of low back pain.
b) Acupuncture provides results that are comparable with (as effective as, slightly
better or slightly worse) than those of other techniques that have notconsistently shown effectiveness vs. a sham procedure. Therefore, it is notpossible to rule out the notion that those studies are just comparing the size ofthe placebo effect triggered by different procedures.
c) Adverse effects are potentially serious.
Summary of evidence• There is conflicting evidence that acupuncture is better than a sham procedure in
the treatment of low back pain (level C).
• There is moderate evidence that acupuncture is not more effective than trigger
point injection and TENS for the treatment of low back pain (level B).
• There is limited evidence that acupuncture is less effective than massage andspinal manipulation (level C).
• There is limited evidence in each case that acupuncture is similar to self-care
education and better than training of proper posture and motion in accordancewith Bruegger concepts (level C).
• There is limited evidence that the addition of acupuncture improves the results ofstandard GP treatment (defined as exercise, NSAIDs, aspirin and/or non-narcotic
analgesics) or conventional treatment (defined as physiotherapy, exercise, backschool, mud packs, infrared heat therapy and diclofenac) (level C).
Recommendation
We cannot recommend acupuncture for the treatment of chronic low back pain.
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the number of sessions and therapeutical effect in patients suffering from low backpain treated with acupuncture: a randomized controlled blind study]. Minerva Med,
94(4 Suppl 1): 39-44.
6. Cherkin DC, Eisenberg D, Sherman KJ, Barlow W, Kaptchuk TJ, Street J, Deyo
RA (2001) Randomized trial comparing traditional Chinese medical acupuncture,therapeutic massage, and self-care education for chronic low back pain. Arch InternMed, 161(8): 1081-8.
7. Ernst E (1998) The use, efficacy, safety and costs of complementary/alternative
therapies for low back pain. J. Phys. Med. Rehabil., 8: 53-7.
8. Ernst E, White AR (1998) Acupuncture for back pain: a meta-analysis ofrandomized controlled trials. Arch Intern Med, 158(20): 2235-41.
9. Ezzo J, Berman B, Hadhazy VA, Jadad AR, Lao L, Singh BB (2000) Is
acupuncture effective for the treatment of chronic pain? A systematic review. Pain,
86(3): 217-25.
10. Flowerdew MW, Gadsby JG (1997) A review of the treatment of chronic low backpain with acupuncture-like transcutaneous electrical nerve stimulation andtranscutaneous electrical nerve stimulation. Complement Ther Med, 5: -2299.
11. Franke A, Gebauer S, Franke K, Brockow T (2000) [Acupuncture massage vsSwedish massage and individual exercise vs group exercise in low back pain
sufferers--a randomized controlled clinical trial in a 2 x 2 factorial design]. Forsch
Komplementarmed Klass Naturheilkd, 7(6): 286-93.
12. Gadsby JG, Flowerdew MW (2000) Transcutaneous electrical nerve stimulation
and acupuncture-like transcutaneous electrical nerve stimulation for chronic low backpain. In The Cochrane Library, Issue 3. John Wiley & Sons, Ltd.: Chichester, UK.
13. Giles LG, Muller R (1999) Chronic spinal pain syndromes: a clinical pilot trial
comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal
manipulation. J Manipulative Physiol Ther, 22(6): 376-81.
14. Grant DJ, Bishop-Miller J, Winchester DM, Anderson M, Faulkner S (1999) A
randomized comparative trial of acupuncture versus transcutaneous electrical nerve
stimulation for chronic back pain in the elderly. Pain, 82(1): 9-13.
15. Hogeboom CJ, Sherman KJ, Cherkin DC (2001) Variation in diagnosis andtreatment of chronic low back pain by traditional Chinese medicine acupuncturists.
Complement Ther Med, 9(3): 154-66.
16. Hsieh LL, Kuo CH, Yen MF, Chen TH (2004) A randomized controlled clinical trial
for low back pain treated by acupressure and physical therapy. Prev Med, 39(1):168-76.
17. Kalauokalani D, Cherkin DC, Sherman KJ, Koepsell TD, Deyo RA (2001)
Lessons from a trial of acupuncture and massage for low back pain: patient
expectations and treatment effects. Spine, 26(13): 1418-24.
18. Kerr DP, Walsh DM, Baxter D (2003) Acupuncture in the management of chronic
low back pain: a blinded randomized controlled trial. Clin J Pain, 19(6): 364-70.
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20. Kovacs FM, Garcia A, Mufraggi N, Garcia F, Pavia J, Prandi D, Gotzens V, Giralt
I, Piera C, Setoain J (2000) Migration pathways of hypodermically injected
technetium-99m in dogs. Eur Radiol, 10(6): 1019-25.
21. Kovacs FM, Gotzens V, Garcia A, Garcia F, Mufraggi N, Prandi D, Setoain J, San
Roman F (1992) Experimental study on radioactive pathways of hypodermicallyinjected technetium-99m. J Nucl Med, 33(3): 403-7.
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Roman F (1993) Kinetics of hypodermically injected technetium-99m and correlation
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26. MacPherson H, Gould AJ, Fitter M (1999) Acupuncture for low back pain: resultsof a pilot study for a randomized controlled trial. Complement Ther Med, 7(2): 83-90.
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for chronic low back pain in older patients: a randomized, controlled trial.
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Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain.
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30. Niboyet JEH (1963) La moindre résistance à l'électricité de surfaces
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Finster G, Schiesser AW, Heinze G, Kress HG (2004) The short- and long-term
benefit in chronic low back pain through adjuvant electrical versus manual auricularacupuncture. Anesth Analg, 98(5): 1359-64, table of contents.
33. Shanghei A-MTGoCMAo (1960)Aku-Moxi therapy treatise., in Medicine Academyof Shanghai: Shanghai.
34. Smith LA, Oldman AD, McQuay HJ, Moore RA (2000) Teasing apart quality andvalidity in systematic reviews: an example from acupuncture trials in chronic neckand back pain. Pain, 86(1-2): 119-32.
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M (1999) Longer-term clinical and economic benefits of offering acupuncture topatients with chronic low back pain assessed as suitable for primary caremanagement. Complement Ther Med, 7(2): 91-100.
37. van Tulder MW, Cherkin DC, Berman B, Lao L, Koes BW (1999) The
effectiveness of acupuncture in the management of acute and chronic low back pain.
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C11 (B) Injections and nerve blocks
Injections for low back pain include epidural corticosteroids (glucocorticoids) (with orwithout local anaesthetics), spinal nerve root blocks, facet blocks (intra-articular or
block of the ramus dorsalis of the spinal nerves), sacro-iliacal joint blocks (injections
into the sacro-iliacal joint or into the sacro-ilical ligaments), intradiscal injections,
sympathetic blocks (at the lumbar sympathetic chain) and local injections (intomuscles and/or ligaments). The procedures are defined under the different topic
headings.

C11 (B1) Epidural Corticosteroids and Spinal Nerve Root Blocks with
Steroids
Definition of procedure
Epidural injections are possible by caudal, sacral, sacral transforaminal, lumbar
midline, paralumbar (lateral) and lumbar transforaminal approaches. They can begiven “blindly” or with x-ray guidance (either by fluoroscopy or CT). Various
glucocorticoids can be used, alone or in combination with a local anaesthetic or
saline. The volume is usually in the 1 to 5 ml range, although some clinicians use 10
ml or more.
Spinal nerve root blocks, which aim at the same target, are normally carried out
under fluoroscopy or CT guidance and are given either “periradicularly” (i.e. in thevicinity of the nerve root) or directly into the nerve root sleeve.
Different corticosteroids are used: mainly methyprednisolone, triamcinolone ore
dexamethazone.
The procedure aims to target the high level of phospholipase A2 at the interface ofthe epidural space and the herniated disc material, believed to cause inflammation of
the nerve root in lumbar spinal radicular pain.
Result of search
Systematic reviews
Seven systematic reviews were retrieved (Cannon and Aprill 2000, Koes et al 1999,
McQuay et al 1997, Nelemans et al 2004, Rozenberg 1998, Tonkovich-Quaranta and
Winkler 2000, Watts and Silagy 1995).
One SR (Koes et al 1999) was an updated version of a previous review by the sameauthors (Koes et al 1995).
All reviews included only trials of epidural steroids for radicular pain. There were no
systematic reviews dealing with steroids for non-specific LBP without radicular pain.
Additional RCTs
Eight additional RCTs, published after the period covered by the systematic reviews
or not included in them, were retrieved (Devulder et al 1999, Heavner et al 1999,
Karppinen et al 2001a, Karppinen et al 2001b, Kraemer et al 1997, Lutze et al 1997,
Riew et al 2000, Vad et al 2002). Seven of these RCTs dealt only with radicular pain,
whilst one (Devulder et al 1999) dealt only with patients with failed back surgery
syndrome.

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Quality assessment
Four systematic reviews were of high quality (Koes et al 1999, Nelemans et al 2004,
Rozenberg 1998, Watts and Silagy 1995) and three were of low quality (Cannon and
Aprill 2000, McQuay et al 1997, Tonkovich-Quaranta and Winkler 2000).
Of the additional RCTs on radicular pain, four were of high quality (Karppinen et al
2001a, Karppinen et al 2001b, Riew et al 2000, Vad et al 2002), and three were of
low quality (Heavner et al 1999, Kraemer et al 1997, Lutze et al 1997).
Effectiveness
There is no evidence for the effectiveness of epidural steroids for non-specificchronic low back pain (no RCTs were found on this issue) (level D).
Although we acknowledge that none of the SRs or the additional RCTs dealt with themain theme of these guidelines — non-specific LBP — the results of the studies
carried out in relation to chronic radicular pain will be briefly discussed for theinterested reader.
Effectiveness of corticosteroid injections vs. a sham procedure for radicularpain
Systematic reviews
One review addressed, in particular, some of the technical problems of injecting
epidural corticosteroids (uncontrolled injections without X-ray guidance and theimprecise application of the steroid in relation to the target, the nerve root) (Cannon
and Aprill 2000). The authors concluded that, although the literature does notresoundingly vindicate their use, epidural corticosteroids seem to have a favourable
role in the non-operative treatment of true radicular pain, with the highest successbeing achieved when the corticosteroid can be delivered to the pathologic side,usually the disc-root interface.
One SR stated that convincing evidence is lacking on the effect of epidural injection
therapy for low back pain and that there is a need for more, well designed
explanatory trials in this field (Nelemans et al 2004).
A further review concluded that the effectiveness of epidural administration ofcorticosteroids has not been established (half of the studies showed positive, theother half negative results) and that the benefits, if any, seem to be of a shortduration only (Koes et al 1999).
Another review, that included the same studies as Koes et al. (1999), came to thesame conclusion, although they scored the studies in a different way, mostly withlower quality scores (Rozenberg 1998). There was no association between
methodological score and outcome.
One SR stated that, based on the available studies, epidural corticosteroids may be
an effective treatment for chronic radicular pain (Tonkovich-Quaranta and Winkler
2000). They concluded that their use is warranted in patients who have failed
conservative therapy.
In an SR that included in nearly all the same studies as Koes et al. (1999), but
statistically pooled the results of the trials, it was concluded that epidural
corticosteroids effectively reduced lumbosacral radicular pain (Watts and Silagy
1995). The pooled odds ratio was 2.61 (95% confidence interval 1.90-3.77) for shortterm (60 days) pain relief. For long-term pain (up to 12 months) the OR was 1.87
(95% CI 1.3-2.68).

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One SR (McQuay et al 1997) compared two previous reviews that had included thesame studies (Koes et al 1995, Watts and Silagy 1995) and stated that the number
needed to treat (NNT) for short term improvement (1-60 days) and 75% relief wasjust under 7.3, with 95% confidence intervals from 4.7 to 16; for 50% relief, the NNT
was just under 3. From the 5 trials that measured the long-term improvement (12weeks up to a year) the NNT for a pain-relief of 50% was about 13, with 95%
confidence intervals from 6.6 to 314. This means that for every 13 patients treatedwith epidural steroids, one patient will obtain more relief in the long-term than he/shewould have with the control treatment (placebo or local anaesthetic).
The main difference between the two previous reviews concerned the pooling of theresults of individual trials: in one (Koes et al 1995) (and its update (Koes et al 1999)),
it was decided that the studies were too heterogeneous to perform a meta-analysis;in the other, all data were used to estimate the overall pooled odds ratio that showedthat the treatment is effective (Watts and Silagy 1995).
In conclusion, although all three reviews were of high quality, the studies that they
included had very small sample sizes; some trials also had serious methodologicalflaws and some had inadequate outcome measures. Studies were also
heterogeneous with respect to the injection volume used, the control treatment,
outcome criteria, time at which outcome was assessed, average symptom duration at
the time of treatment and indications for the injection. Furthermore, one main
problem with all the trials was that the injection was not carried out under either
fluoroscopic or CT guidance; it is well known that many injections do not reach theirtarget (either the epidural space or the ventral part of this space close to the spinal
ganglion) (Cannon and Aprill 2000, Kraemer et al 1997, Riew et al 2000). Even thehighest quality RCT (Carette et al 1997) used a blind injection technique with highvolume (10 ml).
Summary from SRs
The general conclusion from the systematic reviews is that there is conflicting
evidence for the effectiveness of epidural/perineural corticosteroid injections forradicular pain (level C).
Additional studies
One RCT reported that the injection of a combination of methylprednisolone andbupivacaine at the affected nerve root had a better short-term effect than theinjection of saline on leg pain, straight-leg raising and patient satisfaction in patientswith subacute/chronic sciatica (Karppinen et al 2001a). However, these effects were
not maintained beyond 4 weeks.
Another controlled trial showed that epidural perineural (lateral and ventral part of the
epidural space) injections with steroids (N=24 patients) had a better effect (MacNab
criteria: leg pain, back pain, return to work, ability to do sport) than saline injections(N=25 patients) in patients with lumbar radicular syndromes (Kraemer et al 1997).
Follow up was 3 weeks and three months.

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Effectiveness of corticosteroid injections vs. other procedures for radicularpain
Systematic reviews
The general conclusion from the systematic reviews is that there is conflicting
evidence for the effectiveness of epidural/perineural corticosteroid injections forradicular pain compared with other procedures (level C).
Additional studies
One study reported that epidural perineural (lateral and ventral part of the epiduralspace) injections with steroids (N=40 patients) had a better effect (MacNab criteria:
leg pain, back pain, return to work, ability to do sport) than conventional epidural
injections (N=47 patients) in patients with lumbar radicular syndromes (Kraemer et al1997). Follow up was 3 weeks and three months.
Another showed that CT guided injections of the nerve root (N=20 patients) were justas effective as fluoroscopic guided injections (N=20 patients) (Lutze et al 1997). Bothpatient groups improved significantly (p<0.05) as measured by % improvement in
VAS pain (in both groups: 65% reported good to excellent results after one month,
42% of patients after 6 months).
In one RCT, selective nerve root injection with betamethasone and bupivacaine
resulted in a better outcome (reduction in the number of patients going on to surgery)than did injection with bupivacaine alone (altogether N=55 patients) (Riew et al2000).
In one RCT transforaminal epidural steroid injections had better results than trigger
point injections. After an average follow-up period of 1.4 years, the group receiving
transforaminal epidural steroid injections had a success rate of 84%, as comparedwith 48% for the group receiving trigger-point injections (P < 0.005) (Vad et al 2002).
The final RCT examined four treatments in patients with radiculopathy plus low backpain: a) hypertonic saline plus hyaloronidase (N=17); b) hypertonic saline (N=15); c)
isotonic saline (N=17); d) isotonic saline plus hyaloronidase (N=10) – each incombination with corticosteroid and local anaesthetic (Heavner et al 1999). Eachtreatment had the same (generally positive) outcome (VAS pain difference).
Cost/effectiveness
Cost/effectiveness was not addressed in any of the systematic reviews. One trial
among the additional RCTs (Karppinen et al 2001b) addressed the costeffectiveness of periradicular steroid injections in patients with unilateral sciatica. In
comparing steroid with saline injections it showed that 1 year after treatment, steroid
seemed to have prevented operations for contained herniations, costing $12,666 lessper responder in the steroid group (P < 0.01). For extrusions, steroid seemed toincrease the operation rate, and the steroid infiltration was more expensive, costing$4445 per responder (P < 0.01).
In one study, although no formal cost-effectiveness analysis was carried out, it was
shown that the subsequent operative rate was much lower in a group of patients
receiving nerve–root injections with bupivacaine and betamethasone than it was in agroup that received only bupivacaine P<0.004) (Riew et al 2000).

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Safety
Systemic corticosteroids side effects: suppression of adrenocorticotropic hormone(ACTH) and Cushingoid symptoms (mainly if high doses of corticosteroid are used or
the injections are given too often) (Abram and O'Connor 1996, Weyland et al 1992).
Technical complications: accidental dural puncture (5% of the cases) withconsequent postdural puncture headache; and epidural haematoma (very rare).
Infectious complications: several cases of epidural abscess after epidural steroid
injection have been documented, most of which occurred in diabetic patients;
however, the incidence is very rare.
Neurological complications: neurological squeal (chemical meningitis) can occur after
intrathecal application of steroids, mainly of depot-corticosteroids, probably due topolyethylene glycol in the vehicle (Nelson 1993), but also in cases of water-soluble
corticosteroid (Devoize et al 1993). Arachnoiditis after epidural injection of steroids isvery rare (Abram and O'Connor 1996).
The reported side effects are uncommon if the procedure is carried out under aseptic
conditions and in consideration of the contraindications (local or systemic infection,
bleeding diathesis, severe congestive heart failure and uncontrolled
diabetes) (Rozenberg 1998).
Subjects (indications)
Not having shown evidence of effectiveness for non-specific low back pain, it is notpossible to define indications for epidural corticosteroid injections.
Comments
1. Epidural corticosteroid injections would only be considered for radicular pain, if acontained disc prolapse is the cause of the pain and if the corticosteroid is injectedclose to the target (nerve root).
2. The injection should be X-ray guided and should aim at:a) The ventral part of the epidural space, near the spinal nerve root, orb) The spinal nerve root through a transforaminal approach.
3. There is conflicting evidence that conventional epidural steroids (without X-ray
guidance) are effective in radicular pain.
Summary of evidence
There is no evidence for the effectiveness of epidural corticosteroids in patients with
non-radicular, non-specific low back pain (level D).
Recommendation
We cannot recommend the use of epidural corticosteroids in patients with nonradicular, non-specific low back pain.
References
1. Abram SE, O'Connor TC (1996) Complications associated with epidural steroid
injections. Reg Anesth, 21(2): 149-62.
2. Cannon DT, Aprill CN (2000) Lumbosacral epidural steroid injections. Arch Phys
Med Rehabil, 81(3 Suppl 1): S87-98; quiz S9-100.
3. Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, Truchon R,
Parent F, Levesque J, Bergeron V, Montminy P, Blanchette C (1997) Epidural
corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J
Med, 336(23): 1634-40.
4. Devoize JL, Fuzeau C, Pin JC, Bonnefoy M (1993) [Chemical meningitis after
intradural injection of corticosteroids. Recovery without antibiotics]. Presse Med,
22(18): 879.
5. Devulder J, Deene P, De Laat M, Van Bastelaere M, Brusselmans G, Rolly G(1999) Nerve root sleeve injections in patients with failed back surgery syndrome: acomparison of three solutions. Clin J Pain, 15(2): 132-5.

161

6. Heavner JE, Racz GB, Raj P (1999) Percutaneous epidural neuroplasty:
prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidase.
Reg Anesth Pain Med, 24(3): 202-7.
7. Karppinen J, Malmivaara A, Kurunlahti M, Kyllonen E, Pienimaki T, Nieminen P,
Ohinmaa A, Tervonen O, Vanharanta H (2001a) Periradicular infiltration for sciatica:a randomized controlled trial. Spine, 26(9): 1059-67.
8. Karppinen J, Ohinmaa A, Malmivaara A, Kurunlahti M, Kyllonen E, Pienimaki T,
Nieminen P, Tervonen O, Vanharanta H (2001b) Cost effectiveness of periradicular
infiltration for sciatica: subgroup analysis of a randomized controlled trial. Spine,
26(23): 2587-95.
9. Koes BW, Scholten RJ, Mens JM, Bouter LM (1995) Efficacy of epidural steroid
injections for low-back pain and sciatica: a systematic review of randomized clinical
trials. Pain, 63(3): 279-88.
10. Koes BW, Scholten RJPM, Mens JMA, Bouter LM (1999) Epidural Steroid
Injections for low back and sciatica: an updated systematic review of randomized
clinical trials. Pain Digest, 9: 241-7.
11. Kraemer J, Ludwig J, Bickert U, Owczarek V, Traupe M (1997) Lumbar epidural
perineural injection: a new technique. Eur Spine J, 6(5): 357-61.
12. Lutze M, Stendel R, Vesper J, Brock M (1997) Periradicular therapy in lumbar
radicular syndromes: methodology and results. Acta Neurochir (Wien), 139(8): 71924.
13. McQuay HJ, Moore RA, Eccleston C, Morley S, Williams AC (1997) Systematic
review of outpatient services for chronic pain control. Health Technol Assess, 1(6): iiv, 1-135.
14. Nelemans PJ, de Bie RA, de Vet HC, Sturmans F (2004) Injection therapy for
subacute and chronic benign low back pain. In: The Cochrane Library, Issue 3. John
Wiley & Sons, Ltd: Chichester, UK.
15. Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, Goette K (2000)
The effect of nerve-root injections on the need for operative treatment of lumbar
radicular pain. A prospective, randomized, controlled, double-blind study. J Bone
Joint Surg Am, 82-A(11): 1589-93.
16. Rozenberg S (1998) Glucocorticoid therapy in common lumbar spinal disorders.
Rev Rhum Engl Ed, 65(11): 649-55.
17. Tonkovich-Quaranta LA, Winkler SR (2000) Use of epidural corticosteroids in low
back pain. Ann Pharmacother, 34(10): 1165-72.
18. Vad VB, Bhat AL, Lutz GE, Cammisa F (2002) Transforaminal epidural steroid
injections in lumbosacral radiculopathy: a prospective randomized study. Spine,27(1): 11-6.
19. Watts RW, Silagy CA (1995) A meta-analysis on the efficacy of epidural
corticosteroids in the treatment of sciatica. Anaesth Intensive Care, 23(5): 564-9.
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Adrenal suppression following epidural corticosteroid administration for discogenic
pain: influence of injection site. Eur J Anaesthesiol, 9: 36-7.

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C11 (B2) Facet Injections
Definition of procedure
Facet block injections consist of the precise instillation of local anaesthetic and/or
corticosteroid into a facet joint or around its nerve supply (ramus medialis of theramus dorsalis). Fluoroscopic monitoring is necessary to check the position of theneedle. Sometimes CT is used for this purpose. If a joint is anaesthetized through its
nerve supply, at least two nerves (rami dorsales) should be blocked for each joint.
Result of search
Systematic review
Only one high quality review (Nelemans et al 2000) was retrieved and considered
suitable for formulating these recommendations, although an additional low quality
review (Manchikanti 1999) was considered to be of possible clinical value.
The Nelemans’ review included three RCTs (Carette et al 1991, Lilius et al 1989,
Marks et al 1992).
Additional RCTs
None were retrieved
Quality assessment of the evidence
Systematic review
The included SR was of high quality (Nelemans et al 2000). Two of the trials it
included were of high quality (Carette et al 1991, Marks et al 1992) and one was oflow quality (Lilius et al 1989).
From the clinical point of view:a) One of the high methodological quality studies accepted a >50% reduction inpain after one single diagnostic block for applying the diagnosis of “pain comingfrom the facet joint” (Carette et al 1991). Since there is a false positive rate of
25%-36% with single blocks (Manchikanti 1999, Schwarzer et al 1994), this may
have led to the inclusion of patients with pain that did not really derive any
benefit from the facet joint.
b) The low quality study (Lilius et al 1989) did not use diagnostic blocks to establish
the suspected diagnosis of facet pain and injected a volume of 8 ml, which ishigher than recommended (Manchikanti 1999, Schwarzer et al 1994).
Effectiveness
Effectiveness versus sham procedures (intra-articular saline)
The high quality study in which one single diagnostic block was accepted forestablishing the origin of pain (Carette et al 1997) compared intra-articular saline andintra-articular methylprednisolone. They did not find any significant difference
between groups at the 1 and 3 month follow-up assessments. However, at six
months the percentage of patients with notable improvement was significantly higher
in the methylprednisolone group. Despite this latter finding the study concluded thatthe effectiveness of facet joint injections is small, because 11 of the 22 patients in thesteroid group who reported substantial improvement at 6 months after injection
reported no benefit at earlier evaluations. No pharmacological or biologicalexplanation could be offered for the results.
The low quality study (Lilius et al 1989) compared three modes of injection: intraarticular injections with corticosteroid and local anaesthetic, intra-articular injection
with saline only and pericapsular injection of corticosteroid and local anesthetic. They
reported that mean scores for pain relief with methylprednisolone and/or bupivacaine
were not superior to those for placebo (saline) injections.

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Effectiveness versus other treatments
One high quality study (Marks et al 1992) compared intra-articular facet joint
injections with facet nerve blocks, in each case using local anaesthetic (lidocaine)and steroid (methylprednisolone). There was no significant difference in theimmediate response. The duration of response after facet joint injection was
marginally longer than after facet nerve block (p< 0.05 1 month after infiltration), but
for both groups the response was usually short-lived; by 3 months only 2 patients
continued to report complete pain relief. The authors concluded that facet joint
injections and facet nerve blocks may be of equal value as diagnostic tests, butneither is a satisfactory treatment for chronic back pain.
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetyThere is one report on septic facet joint arthritis (Levy et al 1993), but the rate of suchan event is unknown and seems likely to be rare.
Subjects (indications)
There is no clear indication of the patients for whom the procedure would be useful.
An important difficulty is the uncertainty surrounding the clinical definition (diagnosis)
of facet joint syndrome and the necessity for confirming its existence before theinjection is indicated. This cannot be proven by the clinical investigation.
Comments
1. Several possible causes of pain within the facet joints have beenreported (Dreyfuss et al 1995). However, according to some authors (Schwarzer
et al 1994), the reported prevalence of facet joint pain (ranging from 8% to 94%)
seems to be a function of the size of the sample and the belief of the author.
Within the context of these guidelines, facet joint pain is considered as one
possible source for non-specific low back pain and not as a specific diagnosis.
2. Clinical practice does not usually meet recommended criteria. One study reported
that the factors found to be predictive of a response to facet joint anaesthesia(defined as 75% decrease in pain severity), which can be viewed as a gold
standard diagnostic test for facet joint syndrome, were different from the criteria
generally used for the clinical diagnosis of this condition (Revel et al 1998).
3. Facet joint syndrome is very difficult to define clinically and facet nerve blocks
have a very high placebo effect (Schwarzer et al 1994), so it is very difficult inpractice to reliably select patients with indications for a facet joint injection.
4. It has not yet been determined whether the mechanism by which facet joint
injection may alleviate pain involves a local anti-inflammatory effect of the
glucocorticoid, the introduction of fluid into the joint space, or the puncture holemade in the joint capsule.
5. Intra-articular injections and nerve blocks are considered almost the equivalent
for diagnostic and therapeutic purposes and the result is short-lived for bothtechniques.
6. There is moderate evidence that intraarticular corticosteroids are not effective inpatients with pain of facet joint origin (level B).
Summary of evidence

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There is no evidence for the effectiveness of intraarticular injections of steroids or
facet nerve blocks in patients with non-specific low back pain (level D).
Recommendation
We cannot recommend the use of intraarticular injections of steroids or facet nerve
blocks in patients with non-specific chronic low back pain.
References
1. Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, Truchon R,
Parent F, Levesque J, Bergeron V, Montminy P, Blanchette C (1997) Epidural
corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J
Med, 336(23): 1634-40.
2. Carette S, Marcoux S, Truchon R, Grondin C, Gagnon J, Allard Y, Latulippe M(1991) A controlled trial of corticosteroid injections into facet joints for chronic low
back pain. N Engl J Med, 325(14): 1002-7.
3. Dreyfuss PH, Dreyer SJ, Herring SA (1995) Lumbar zygapophysial (facet) joint
injections. Spine, 20(18): 2040-7.
4. Levy J, Gaudin P, Pieyre C, al. e (1993) Arthrites septique articulaires posterieureslombaires. In Pathologie iatrogene du rachis., L. Siomon, M. Revel and C. Herisson,
Editors. Masson: Paris. 58-68.
5. Lilius G, Laasonen EM, Myllynen P, Harilainen A, Gronlund G (1989) Lumbar facet
joint syndrome. A randomised clinical trial. J Bone Joint Surg Br, 71(4): 681-4.
6. Manchikanti L (1999) Facet Joint Pain and the Role of Neural Blockade in Its
Management. Curr Rev Pain, 3(5): 348-58.
7. Marks RC, Houston T, Thulbourne T (1992) Facet joint injection and facet nerve
block: a randomised comparison in 86 patients with chronic low back pain. Pain,
49(3): 325-8.
8. Nelemans PJ, de Bie RA, de Vet HC, Sturmans F (2000) Injection therapy for
subacute and chronic benign low back pain. Cochrane Database Syst Rev, (2):CD001824.
9. Revel M, Poiraudeau S, Auleley GR, Payan C, Denke A, Nguyen M, Chevrot A,
Fermanian J (1998) Capacity of the clinical picture to characterize low back pain
relieved by facet joint anesthesia. Proposed criteria to identify patients with painful
facet joints. Spine, 23(18): 1972-6; discussion 7.
10. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1994) The falsepositive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints.
Pain, 58(2): 195-200.

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C11 (B3) Intradiscal Injections
Definition of procedure
Intradiscal injections (discography) are normally used to diagnose discogenic
nonradicular pain (see section on Diagnosis for further details). In some studies
intradiscal injections of steroids have been used to treat discogenic pain. The
injection is applied by a posterior-lateral extradural approach. The rationale for the
glucocorticoid intradiscal injection is the reduction of inflammation in the disc. The
rationale for intradiscal glycerol for the treatment of so-called discogenic pain is thedenervation of intradiscal nerve fibers (chemical neurolysis).
Result of search
Systematic Reviews
One systematic review (Nelemans et al 2000) included one study (Simmons et al1992) of intradiscal injection of methylprednisolone for non-specific chronic LBP.
Additional RCTs
Two additional RCTs were retrieved (Khot et al 2004, Kotilainen et al 1997).
Quality assessment of the evidence
One of the additional RCTs was of high quality (Khot et al 2004). The RCT includedin the systematic review (Simmons et al 1992) and one additional RCT (Kotilainen etal 1997) were of low quality.
Effectiveness
Effectiveness versus a sham procedure:
Unknown (no studies were found on this issue)
Effectiveness vs. other procedures
One small, low quality study compared intradiscal injections of methylprednisolone
and of bupivacaine in patients with and without sciatica (with internal disc disruption
or nonsequestered prolapsed discs; total N=25 patients) (Simmons et al 1992).
There was no difference between the groups for short-term (after 14 days) pain relief.
In one high quality study (Khot et al 2004) patients with chronic (nonradicular)
discogenic pain (N=120) were randomized to intradiscal saline or methyprednisolone
injection. There was no significant difference in outcome (pain and Oswestry
disability) between the groups at the 12- month follow-up (p=0.71).
The other small (total N=15 patients), low quality study compared intradiscal
injections of glycerol and bupivacaine in patients with chronic low back pain in which
discography had suggested one symptomatic disc (Kotilainen et al 1997). 73% of thepatients showed clinical signs and symptoms of segmental instability of the lumbar
spine. There was a good immediate response after the injection and after 14 days
(self evaluation questionnaires), but after one month the effects had disappeared inboth groups.
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetyIntradiscal injections can be potentially dangerous (infection: discitis or
spondylodiscitis). The rate of occurrence of this event is unknown.
Intradiscal glucocorticoids bring about a progressive degeneration of the disc that ismilder than that occurring after chemonucleolysis (Kato et al 1993).

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Subjects (indications)
Not having shown effectiveness, it is impossible to define indications for local
intradiscal injections. In addition, it is very difficult to diagnose discogenic low backpain.
Summary of evidence
There is moderate evidence that local intradiscal injections (glucocorticoid or
glycerol) are not effective for chronic low back pain (level B).
Recommendation
We cannot recommend the use of intradiscal injections for the treatment of chronic
low back pain.
References
1. Kato F, Mimatsu K, Kawawami N, Ando T (1993) Changes after the intervertebral
disc after discography with intradiscal injection of corticosteroids observed bymagnetic resonance imaging (MRI). J Neurol Orthop Med Surg, 14: 210-6.
2. Khot A, Bowditch M, Powell J, Sharp D (2004) The use of intradiscal steroid
therapy for lumbar spinal discogenic pain: a randomized controlled trial. Spine, 29(8):833-6; discussion 7.
3. Kotilainen E, Muittari P, Kirvela O (1997) Intradiscal glycerol or bupivacaine in thetreatment of low back pain. Acta Neurochir (Wien), 139(6): 541-5.
4. Nelemans PJ, de Bie RA, de Vet HC, Sturmans F (2000) Injection therapy for
subacute and chronic benign low back pain. Cochrane Database Syst Rev, (2):CD001824.
5. Simmons JW, McMillin JN, Emery SF, Kimmich SJ (1992) Intradiscal steroids. A
prospective double-blind clinical trial. Spine, 17(6 Suppl): S172-5.

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C11 (B4) Intramuscular Injections of Botulinum Toxin
Definition of procedure:
Normally, intramuscular injection of Botulinum toxin is indicated in patients withdystonia or spasticity, and serves to reduce muscle tension and pain. Botulinum toxin
not only inhibits the release of acetylcholine but also of neuropeptides such as
substance P, which is known to have a key function in pain generation.
Result of search
Systematic Reviews.
No systematic reviews were retrieved.
Additional RCTs
One additional RCT was found (Foster et al 2001).
Quality assessment of the evidence
The study was of low quality.
Effectiveness
Effectiveness of Botulinum toxin vs. a sham procedure (injection with saline)
The study compared the injection of 200 units Botulinum toxin (40 units/site at five
paravertebral intramuscular levels on the side of most discomfort) (N=15 patients)
with the injection of saline at the same site (N=16 patients) (Foster et al 2001). The
results for VAS pain and Oswestry disability showed that Botulinum toxin was
superior to placebo at three and eight weeks after injection, but the statisticalanalysis was insufficient (p=0.009 for pain relief and p=0.011 for Oswestry score).
There is limited evidence (level of evidence C) showing the short-term effectivenessof Botulinum toxin in chronic low back pain.
Effectiveness of Botulinum toxin vs. other procedures
Unknown (no studies were found on this issue)
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetyBotulinum toxin can weaken the muscles if repeated injections are given over a long
period of time (Foster et al 2001).
Subjects (indication)
Not having shown evidence of effectiveness, it is not possible to define indications forthe use of botulinum toxin.
Comments
The mechanism of pain relief in patients with low back pain is unclear.
Botulinum toxin is expensive and has side effects.
For these reasons, and in spite of the positive results on effectiveness derived from alow quality RCT vs. placebo, botulinum toxin cannot be recommended for chronic low
back pain. Further studies are needed.

168Summary of evidence
There is limited evidence that Botulinum toxin is effective for the treatment of chronic
low back pain (level C)
Recommendation
We cannot recommend the use of Botulinum toxin for the treatment of chronic nonspecific low back pain.
References
1. Foster L, Clapp L, Erickson M, Jabbari B (2001) Botulinum toxin A and chronic low
back pain: a randomized, double-blind study. Neurology, 56(10): 1290-3.

169C11 (B5) Sacroiliac Joint Injections
Definition of procedure
Sacroiliac joint injections consist of the infiltration of local anaesthetic and/or
corticosteroids into the sacroiliac joint. They can be performed without x-ray control,
under CT-guidance or with fluoroscopic control. A controlled study of clinically guided
injection (with no image guidance) showed that an intra-articular approach wasachieved in only 22% of cases (Rosenberg et al 2000).
Result of search
Systematic review
No systematic reviews were retrieved.
Additional RCTs
Two randomized controlled studies were found (Luukkainen et al 2002, Maugars et al1996). One of these was excluded, as it dealt specifically with sacroiliitis (Maugars et
al 1996).
Quality assessment of the evidence
The remaining RCT was of low quality (Luukkainen et al 2002, Maugars et al 1996).
Effectiveness
Effectiveness of sacroiliac joint injections vs. a sham procedure (saline
injection)
The one RCT compared “blind” peri-articular injections of lidocaine and isotonic
sodium chloride vs. lidocaine and methylprednisolone (Luukkainen et al 2002). Theirresults showed that the injections containing corticosteroid were more effective in
reducing pain one month after the injection.
Effectiveness of sacroiliac joint injections vs. other procedures
Unknown (no studies were found on this issue)
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (Indication)
The study stated that it included patients with sacroiliac pain. However, it is difficult todefine such patients, as there are currently no reliable clinical tests available toconfirm such a diagnosis (Dreyfuss et al 1996).
Comments
1. The sacroiliac joint can definitely be a source of low back pain. Stimulation of thejoint by injection in subjects without pain produces pain in the buttock, theposterior thigh, the groin and the knee (Dreyfuss et al 1996) (see also Guidelines
for Pelvic Girdle Pain).
2. Intra-articular injection can be given in the lower part of the joint with fluoroscopic
guidance only. However, even at this location an accurate intra-articular injection,
confirmed by contrast medium, is often difficult. It is not clear whether intraarticular spread is necessary to achieve effectiveness. Further, it is not clear if
joint injections with corticosteroids are successful only in joints that are inflamed,or also in other conditions.

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3. There is some suggestion that more reliable diagnostic tests for sacroiliac joint
pain have been developed in recent years (Kokmeyer et al 2002, van der Wurff et
al 2000)
Summary of evidence
There is limited evidence that injection of the sacroiliac joint with corticosteroids
relieves sacroiliac pain of unknown origin for a short time (level C).
Recommendation
We cannot recommend the use of sacroiliac joint injections with corticosteroids forthe treatment of non-specific chronic low back pain.
References
1. Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N (1996) The value of
medical history and physical examination in diagnosing sacroiliac joint pain. Spine,21(22): 2594-602.
2. Kokmeyer DJ, Van der Wurff P, Aufdemkampe G, Fickenscher TC (2002) The
reliability of multitest regimens with sacroiliac pain provocation tests. J Manipulative
Physiol Ther, 25(1): 42-8.
3. Luukkainen RK, Wennerstrand PV, Kautiainen HH, Sanila MT, Asikainen EL(2002) Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in nonspondylarthropathic patients with chronic low back pain in the region of the sacroiliac
joint. Clin Exp Rheumatol, 20(1): 52-4.
4. Maugars Y, Mathis C, Berthelot JM, Charlier C, Prost A (1996) Assessment of theefficacy of sacroiliac corticosteroid injections in spondylarthropathies: a double-blind
study. Br J Rheumatol, 35(8): 767-70.
5. Rosenberg JM, Quint TJ, de Rosayro AM (2000) Computerized tomographic
localization of clinically-guided sacroiliac joint injections. Clin J Pain, 16(1): 18-21.
6. van der Wurff P, Meyne W, Hagmeijer RH (2000) Clinical tests of the sacroiliac
joint. Man Ther, 5(2): 89-96.

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C11 (B6) Prolotherapy (Sclerosant Injections)Definition of procedure
Prolotherapy consists of injecting sclerosing substances into the ligaments of thelumbar spine (such as the supraspinous, intraspinous, posterior iliosacral andiliolumbar ligaments) and lumbodorsal fascia and apophysial joint capsules. Today,
the most commonly used solution for these injections is a mixture of glucose,
glycerine and phenol.
The rationale for their use is based on two premises: firstly, that laxity of theligaments and fascia supporting the lumbar motion segments may be responsible forsome cases of chronic low back pain and secondly, that the injection of substances
which initiate an inflammatory response will strengthen these ligaments andconsequently reduce back pain.
Result of search
Systematic Reviews
One SR (Nelemans et al 2000) included one study with sclerosants injected into
ligaments (Ongley et al 1987).
Additional RCTs
Two additional RCTs were found (Dechow et al 1999, Klein et al 1993). These two
papers referred to injections of sclerosants into ligaments, fascia and joint capsulesof the back.
Quality assessment of the evidence
The study included in the SR was of low quality (Ongley et al 1987).
The two additional RCTs were of high quality (Dechow et al 1999, Klein et al 1993).
Effectiveness
Effectiveness versus a sham procedure (injection with lidocaine and saline)
One high quality RCT (Dechow et al 1999) compared the effects of three, onceweekly injections of either dextrose-glycerine-phenol or saline plus lidocaine into theligaments of the L4-5 and L5-S1 lumbar motion segments. There were no differences
between the groups (for McGill pain questionnaire, VAS pain, pain drawing, modified
somatic perception questionnaire, modified Zung depression inventory, Oswestry
disability scale, or physical investigation) at 1, 3 and 6 months.
The other high quality RCT (Klein et al 1993) compared a similar regimen of
injections. 79 patients who failed to respond to previous conservative care wererandomly assigned to receive a double blind series of six, once-weekly injections ofeither xylocaine/saline solution or xylocaine/proliferants (dextrose, 25%, glycerine,
25%, phenol, 2.4%) into the posterior sacroiliac and interspinous ligaments, fascia,
and joint capsules of the low back from L4 to the sacrum. After 6 months, no relevant
differences between the groups were observed for the improvement in Roland andMorris disability score, VAS pain, pain grid score, range of motion, or lumbar function
assessed with the B-200 triaxial dynamometer (both groups improved to a similar
extent).
Effectiveness vs. other procedures
The low quality study (Ongley et al 1987) compared a treatment involving forcefulspinal manipulation and injection of dextrose-glycerine-phenol proliferant (six, onceweekly injections of 20 ml in 40 patients), with a treatment involving less extensive
initial local anaesthesia and manipulation, and substitution of saline for proliferant (41patients). The first group showed better results than the control group (Roland andMorris scale, Waddell scale, VAS pain, pain grid score) in all parameters (p=0.001)

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after 1, 3, and 6 months, although with the combined treatments it was not possible
to ascertain what the “active ingredient” was (manipulation or proliferant).
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (indication)
Not having shown evidence of effectiveness, it is not possible to define indications forthe use of sclerosants. It appears to be difficult to accurately identify patients withinstability of the spine and pelvis or laxity of the ligaments.
Summary of evidence
There is strong evidence that local injections with sclerosants (prolotherapy) in theligaments of the back are not effective for non-specific chronic low back pain (levelA).
Recommendation
We do not recommend the injection of sclerosants (prolotherapy) for the treatment of
non-specific chronic low back pain.
References
1. Dechow E, Davies RK, Carr AJ, Thompson PW (1999) A randomized, doubleblind, placebo-controlled trial of sclerosing injections in patients with chronic low backpain. Rheumatology (Oxford), 38(12): 1255-9.
2. Klein RG, Eek BC, DeLong WB, Mooney V (1993) A randomized double-blind trialof dextrose-glycerine-phenol injections for chronic, low back pain. J Spinal Disord,6(1): 23-33.
3. Nelemans PJ, de Bie RA, de Vet HC, Sturmans F (2000) Injection therapy for
subacute and chronic benign low back pain. Cochrane Database Syst Rev, (2):CD001824.
4. Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ (1987) A new approach to
the treatment of chronic low back pain. Lancet, 2(8551): 143-6.

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C11 (B7) Trigger Point Injections
Definition of procedure
Myofascial trigger points are defined as hyperirritable loci within a taut band ofskeletal muscle. Trigger points are located in the muscle or its associated fascia.
They are painful on compression and can evoke a reliable, characteristic referredpain with or without autonomic response.
It is proposed that an “active” trigger point causes pain, while a “latent” trigger point
may restrict movement and weaken the affected muscle. The latent trigger point
persists for years after recovering from injury (or in connection with degenerative
disease of the joints and spine) and predisposes to acute exacerbation, fatigue,
reaction to cold and damp surroundings, and emotional upset (Lou and Racz 1998).
The rationale or hypothetical mechanism for injection in the trigger points is theselective destruction of mature myocytes by local anaesthetic, saline infiltration or dry
needling, or the “breaking of the reflex mechanism” of the pain, probably mainly bymuscle relaxation.
Result of search
Systematic reviews
One systematic review was found (Nelemans et al 2000), which included 5 papers on
trigger point injections (Collee et al 1991, Frost et al 1980, Garvey et al 1989,
Hameroff et al 1981, Sonne et al 1985): three of these dealt with local injections into
muscles (Frost et al 1980, Garvey et al 1989, Hameroff et al 1981), and two into
ligaments (Collee et al 1991, Sonne et al 1985).
One of these studies concerned acute pain (Frost et al 1980) and another examinedboth lumbar and cervical triggerpoints (Hameroff et al 1981). These two were
therefore not considered further.
Additional RCTs
No additional trials were found.
Quality assessment of the evidence
All studies were of low quality.
Effectiveness
Effectiveness versus a sham procedure (injection with saline)
One study (Collee et al 1991) compared trigger point injections (lig. iliolumbale) with
5 ml of lidocaine or isotonic saline, in patients with iliac crest pain. When both
treatment groups were compared at day 14, the pain score was slightly but
significantly lower in the lidocaine treated group and more patients in this group felt
improvement (but this was not significant). Among those who improved withlidocaine, the beneficial effect continued for at least 2 months in more than 80% of
patients.
One study that examined triggerpoint injections into a ligament (Sonne 1985) (lig.
ileo-lumbale) included subacute and chronic LBP patients: 30 patients wererandomly allocated to one of two treatment groups: (i) 5 ml lidocaine 1% mixed withmethylprednisolone acetate, or (ii) isotonic saline. A maximum of three injections
were given at one-week intervals. Pain (VAS), movement, and the patient’s selfassessment were measured 14 days after treatment. Significant improvement s inpain (p<0.01) and patient self-assessment (p<0.05) but no changes in movement
were recorded in the lidocaine/methylprednisolone group; no significant changes
were recorded in the control group.

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Effectiveness vs. other procedures
One study dealt with patients with subacute pain of 4 weeks duration (N=63) (Garvey
et al 1989). Injection therapy into several myofascial tender points was of four
different types: lidocaine, lidocaine combined with a steroid, acupuncture in thetriggerpoint, and vapocoolant spray with acupressure. Results indicated that therapy
without injected medication (63% improvement rate) was at least as effective as
therapy with drug injection (42% improvement rate) (p=0.09 for the difference). The
acupressure group showed the greatest response, but the difference was not
significant. The authors concluded that direct mechanical stimulus to the trigger-point
seemed to give symptomatic relief equal to that of treatment with various types of
injected medication.
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (indications)Patients with trigger points in the back and pelvic muscles, or localized pain of
muscular origin.
Comments
It has not yet been determined whether the mechanism by which intramuscular
injection may alleviate pain involves the needling effect, the local anaesthetic, or the
local anti-inflammatory effect of a glucocorticoid.
Summary of evidence
There is conflicting evidence for the short-term effectiveness of local intramuscular or
ligament (lig. ilio-lumbale) infiltration with anaesthetics in chronic low back pain (level
C).
Recommendation
We cannot recommend the use of trigger point injections in patients with chronic low
back pain.
References
1. Collee G, Dijkmans BA, Vandenbroucke JP, Cats A (1991) Iliac crest pain
syndrome in low back pain. A double blind, randomized study of local injection
therapy. J Rheumatol, 18(7): 1060-3.
2. Frost FA, Jessen B, Siggaard-Andersen J (1980) A control, double-blind
comparison of mepivacaine injection versus saline injection for myofascial pain.
Lancet, 1(8167): 499-500.
3. Garvey TA, Marks MR, Wiesel SW (1989) A prospective, randomized, doubleblind evaluation of trigger-point injection therapy for low-back pain. Spine, 14(9): 9624.
4. Hameroff SR, Crago BR, Blitt CD, Womble J, Kanel J (1981) Comparison ofbupivacaine, etidocaine, and saline for trigger-point therapy. Anesth Analg, 60(10):752-5.
5. Lou L, Racz GB (1998) Examinations of trigger points that produce myofascialpain syndrome. Pain Digest, 8: 364-75.
6. Nelemans PJ, de Bie RA, de Vet HC, Sturmans F (2000) Injection therapy for
subacute and chronic benign low back pain. Cochrane Database Syst Rev, (2):CD001824.

175

7. Sonne M, Christensen K, Hansen SE, Jensen EM (1985) Injection of steroids andlocal anaesthetics as therapy for low-back pain. Scand J Rheumatol, 14(4): 343-5.

176

C11 (C) Neuro-Reflexotherapy
Definition of the procedure
Neuro-reflexotherapy intervention (NRT) is defined as the temporary implantation of
epidermal devices (surgical staples (up to 90 days) and small metallic burins (which fall
off after about 2 weeks)) in trigger points in the back at the site of clinically involved
dermatomes in each case, and in referred trigger points located in the ear. The trigger
points used in NRT are defined by their innervation and by physical examination anddiffer from those used for trigger point therapy injections (Kovacs et al 1993, Kovacs etal 1997, Kovacs et al 2002, Urrutia et al 2004). NRT is performed without anaesthesia,
on an outpatient basis.
NRT interventions are not related to acupuncture. The zones of the skin chosen for the
implants are defined by their innervation. They do not coincide with the points describedin Chinese acupuncture texts or with the migration pathways of some radioactive
tracers (as is typically the case for acupuncture points) (Kovacs et al 1993, Kovacs et al
1997, Kovacs et al 2002, Urrutia et al 2004). Similar to TENS, the purpose of NRT is to“deactivate” neurons assumed to be involved in the persistence of pain, neurogenic
inflammation, and muscle dysfunction and contracture (Kovacs et al 1993, Kovacs et al
1997, Kovacs et al 2002, Urrutia et al 2004).
Results of search
Three papers (Kovacs et al 1993, Kovacs et al 1997, Kovacs et al 2002) and a
Cochrane review (Urrutia et al 2004) were retrieved.
All three papers were RCTs. Two were double-blind randomized controlled clinical
trials of NRT versus a sham procedure, consisting of the implantation of epidermal
devices up to 5cm away from the appropriate target zones. Both studies focused on
the effect of NRT for treating exacerbations of low back pain and had a short-term
follow-up (up to 45 days) (Kovacs et al 1993, Kovacs et al 1997). The third study wasa cluster randomized controlled trial in which physicians (i.e. clusters) wererandomized, and which compared the standard GP treatment protocol with such a
protocol supplemented with NRT. Its follow-up period for pain and disability was 60days and for subsequent healthcare utilisation, one year (Kovacs et al 2002).
Approximately 50% of the patients examined had had LBP for less than 17.5 days
(control group) and 48 days (experimental group), indicating that many of patientswere not strictly chronic according to the definition given in the introduction. All threestudies were led by the same senior author, and were conducted in different
Hospitals and Primary Care Centers belonging to the Spanish National HealthService.
Quality assessment of the evidence
The systematic review and the three RCTs were of high quality.
Effectiveness
Effectiveness vs. sham procedures
Two high quality studies showed a statistically significant reduction in the severity ofpain, whether local or referred, in the NRT group, at the end of the follow-up period(30 and 45 days, respectively) (Kovacs et al 1993, Kovacs et al 1997). Quality of life
was only assessed in one study, and showed a slightly more favourable result in theintervention group for the subscale "change in quality of life" of the COOP
charts (Kovacs et al 1997) (N.B. this data is wrongly reported in the tables of both theoriginal study (Kovacs et al 1997) and the Cochrane review (Urrutia et al 2004); datafor control and intervention groups have been reversed.) There were no differences
found for the variables "overall health" and "overall quality of life" (Kovacs et al 1997).
One study did (Kovacs et al 1993) and one study did not (Kovacs et al 1997) findsignificant differences between the two groups in their ability to perform activities of177daily living (possibly because of the different ways used to assess this variable). In
one study, the mean numbers of days off work due to an episode of LBP duringfollow-up was significantly lower in the NRT group (Kovacs et al 1993). A reduction in
the consumption of drug treatment was observed in one RCT (Kovacs et al 1993) but
not in the other (Kovacs et al 1997), possibly because in the latter its consumption
was low at baseline.
Effectiveness vs. other treatments
One high quality study showed that the addition of NRT to standard medical care
improved low back pain, referred pain, disability and return to work at 60 days followup. Additionally, it was associated with a reduction in the subsequent use of healthresources (cost of drug treatment, visit to primary care physicians, and referral toseveral diagnostic procedures and to physiotherapy) over the year following
treatment. No differences in quality of life –as measured by the EuroQolquestionnaire- were found between groups (Kovacs et al 2002).
Cost/effectivenessOne high quality RCT studied the cost/effectiveness of adding NRT to standard
medical care. Its results show that such an addition improves the cost/effectivenessof the management of low back pain (Kovacs et al 2002).
Cost/effectiveness ratios for low back pain, referred pain, disability, and quality of life
were more favorable (not significant) for the NRT-treated group. A sensitivity
analsysis showed that differences in favor of the NRT group persisted in the threeassumptions of the best case, the worst case, and the average case. In addition, thecost-effectiveness ratio for lumbar pain and disability in the NRT group was better
even when the worst-case assumption in this group was compared with the bestcase assumption in the control group (Kovacs et al 2002).
SafetyIn the RCTs in which NRT was compared to a sham procedure (Kovacs et al 1993,
Kovacs et al 1997), adverse events included transient cutaneous discomfort (itching,irritation and redness) after insertion of the surgical staples in 4% to 13% of cases(7% to 11% in the sham group), and limited dermal infection in 0% to 2% of cases(0% to 3% in the sham group). Dermal infection was successfully treated with anantibiotic cream in less than 48 hours in all cases, and none of the patients required
extraction of the staples before they were planned to be removed (Kovacs et al 1993,
Kovacs et al 1997).
In the cluster randomized RCT, in which NRT was added to standard medical care,adverse events were enquired about and none were reported (Kovacs et al 2002).
Subjects (indications).
All of the RCTs included chronic patients with low back pain, with or without referredpain (Kovacs et al 1993, Kovacs et al 1997, Kovacs et al 2002), and two of them also
included patients with acute (defined in the COST guidelines project as lasting for 6
weeks or less) and subacute LBP (6 weeks – 3 months). Only patients with a VAS
pain score ≥ 3 were included.
Comments
All three RCTs were conducted in Spain. Availability of the procedure outside Spainis unknown. No data are available on the ease and time-frame needed to achieve thenecessary level of expertise, although various different physicians participated in the
Spanish RCTs, indicating that the administration of NRT can be learnt with adequate
training. At present, the results are only valid where physicians with a special training
in NRT are available.

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Summary of evidence• There is strong evidence that NRT is more effective than a sham procedure inproviding pain relief up to 30-45 days (level A)• There is limited evidence that NRT is more effective than a sham procedure in
improving return to work (level C).
• There is limited evidence that the addition of NRT to standard medical careprovides better outcomes than standard care alone with respect to short-term (upto 60 days) pain relief and disability, and for subsequent drug treatment,
healthcare utilisation and sick leave up to 1 year later (level C).
• Only minor and rare adverse events have been reported.
Recommendation
Consider NRT for patients with moderate or severe (≥3 points on a VAS) low back
pain.
References
1. Kovacs FM, Abraira V, Lopez-Abente G, Pozo F (1993) [Neuro-reflexotherapy
intervention in the treatment of non specified low back pain: a randomized,
controlled, double-blind clinical trial]. Med Clin (Barc), 101(15): 570-5.
2. Kovacs FM, Abraira V, Pozo F, Kleinbaum DG, Beltran J, Mateo I, Perez de Ayala
C, Pena A, Zea A, Gonzalez-Lanza M, Morillas L (1997) Local and remote sustained
trigger point therapy for exacerbations of chronic low back pain. A randomized,
double-blind, controlled, multicenter trial. Spine, 22(7): 786-97.
3. Kovacs FM, Llobera J, Abraira V, Lazaro P, Pozo F, Kleinbaum D (2002)
Effectiveness and cost-effectiveness analysis of neuroreflexotherapy for subacuteand chronic low back pain in routine general practice: a cluster randomized,
controlled trial. Spine, 27(11): 1149-59.
4. Urrutia G, Burton AK, Morral A, Bonfill X, Zanoli G (2004) Neuroreflexotherapy for
non-specific low-back pain. Cochrane Database Syst Rev, (2): CD003009.

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C11 (D) Percutaneous electrical nerve stimulation (PENS)
Definition of the procedure
Percutaneous electrical nerve stimulation (PENS) can be described as an analgesic
therapy which uses acupunture-like needle probes positioned in the soft tissues
and/or muscles to stimulate peripheral sensory nerves at the dermatomal levels
corresponding to the local pathology (Ghoname et al 1999a). PENS treatments mayvary with respect to location, frequency and duration of the electrical stimulation.
Results of search
Systematic reviews
No systematic reviews were found on the effectiveness of PENS as a treatment forchronic low back pain.
Additional RCTs
Seven RCTs were found. Four of these were randomized crossoverstudies (Ghoname et al 1999a, Ghoname et al 1999b, Hamza et al 1999, White et al2001) and the other three were parallel group RCTs (Hsieh and Lee 2002, Weiner et
al 2003, Yokoyama et al 2004).
Three of the randomized crossover studies examined the effects of different
treatment durations (Hamza et al 1999), different frequencies of electrical stimulation(Ghoname et al 1999b), and different montages (i.e. patterns of stimulation) (White etal 2001). The fourth one compared PENS with TENS and with flexion-extension
exercises (Ghoname et al 1999a). The three parallel group RCTs compared theeffects of PENS with TENS (Yokoyama et al 2004), one-shot PENS withTENS (Hsieh and Lee 2002) and PENS plus physical therapy with sham-PENS plus
physical therapy (Weiner et al 2003).
Quality assessment of the evidence
One RCT was rated as high quality (Weiner et al 2003), and the others as low
quality (Ghoname et al 1999a, Ghoname et al 1999b, Hamza et al 1999, Hsieh andLee 2002, White et al 2001, Yokoyama et al 2004).
Effectiveness
Effectiveness of PENS vs sham/placebo procedures
One high quality RCT (Weiner et al 2003) and three low quality randomised crossover studies (Ghoname et al 1999a, Ghoname et al 1999b, Hamza et al 1999) madea comparison of the effects of PENS and sham-PENS. The three studies showedsignificant effects on pain in favour of PENS compared with sham-PENS. The study
population of the high quality RCT (Weiner et al 2003) consisted of adults aged 65
years and older, which somewhat limits the generalisability of the results to otherpopulations and settings.
There is moderate evidence that PENS is more effective than sham PENS in thetreatment of chronic low back pain (level B).
Effectiveness of PENS vs. other treatments
Three low quality studies compared PENS with TENS (Ghoname et al 1999a, Hsiehand Lee 2002, Yokoyama et al 2004). One study showed that PENS was significantly
more effective for pain relief than TENS (Yokoyama et al 2004). Another compared
one-shot treatment of PENS plus medication with one-shot treatment TENS plus
medication and found no differences in effects (Hsieh and Lee 2002). The third
compared PENS with TENS and with flexion-extension exercises and showed that
PENS was significantly more effective in decreasing pain than either TENS or
flexion-extension exercises (Ghoname et al 1999a).

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There is conflicting evidence that PENS is more effective than other treatments in thetreatment of chronic low back pain (level C).
Relative effectiveness of different modes of PENS application (duration,
frequency, location)
Three low quality randomised cross-over studies compared differing modes of PENS
application. One study compared electrical stimulation for four different time intervals(0, 15, 30 and 45 minutes) (Hamza et al 1999). The 30-minute and 45-minutedurations of electrical stimulation produced similar hypoalgesic effects and weresignificantly more effective than either the 15-minute or 0-minute durations ofelectrical stimulation. Another study compared the use of different frequencies of
PENS applied for 30 minutes, three times a week for 2 weeks: 4 Hz, alternating 15
Hz and 30 Hz, 100 Hz and sham-PENS (0 Hz) (Ghoname et al 1999b). Alternating
15 Hz and 30 Hz was the most effective PENS frequency for the reduction of pain.
The third study compared PENS treatments with four different patterns of stimulation(montages) (White et al 2001). In all groups, patients received 30 minutes’ PENS
treatment with an alternating stimulation frequency of 15 and 30 Hz, which wasapplied three times a week for 2 consecutive weeks. The study showed that
stimulation of the lower back and buttock along the involved nerve roots at thedermatomal levels corresponding to the patients’ pain symptoms was more effective
than stimulation at locations closer to the spinal column.
There is conflicting evidence that PENS treatments with 30 minutes stimulation
duration, with an alternating frequency of 15 and 30 Hz, and with needle probes
positioned along the involved nerve roots at dermatomal levels corresponding to thepatients’ pain symptoms are more effective than PENS treatments with othertreatment characteristics (level C).
Cost-effectiveness
Unknown (no studies were found on this issue)
SafetyPotential side effects for PENS are fainting, bleeding, wound infection, or evenpneumothorax (Hsieh and Lee 2002). It is not clear how often these side effects
occur as a result of PENS treatments. For obvious reasons PENS should preferably
be applied by skilled and experienced physicians.
Subjects (indications)
Symptomatic pain relief in patients with non-specific low back pain.
Summary of evidence• There is moderate evidence that PENS is more effective than sham PENS in thetreatment of chronic low back pain (level B).
• There is conflicting evidence that PENS is more effective than other treatmentsin the treatment of chronic low back pain (level C).
• There is conflicting evidence that PENS treatments with 30 minutes duration ofelectrical stimulation, with an alternating frequency of 15 and 30 Hz, and withneedle probes positioned along the involved nerve roots at dermatomal levels
corresponding to the patients’ pain symptoms are more effective than PENS
treatments with other treatment characteristics (level C).
Recommendation
Consider PENS for symptomatic pain reduction in patients with chronic non-specific
low back pain.

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References
1. Ghoname EA, Craig WF, White PF, Ahmed HE, Hamza MA, Henderson BN,
Gajraj NM, Huber PJ, Gatchel RJ (1999a) Percutaneous electrical nerve stimulation
for low back pain: a randomized crossover study. Jama, 281(9): 818-23.
2. Ghoname ES, Craig WF, White PF, Ahmed HE, Hamza MA, Gajraj NM, Vakharia
AS, Noe CE (1999b) The effect of stimulus frequency on the analgesic response topercutaneous electrical nerve stimulation in patients with chronic low back pain.
Anesth Analg, 88(4): 841-6.
3. Hamza MA, Ghoname EA, White PF, Craig WF, Ahmed HE, Gajraj NM, Vakharia
AS, Noe CE (1999) Effect of the duration of electrical stimulation on the analgesic
response in patients with low back pain. Anesthesiology, 91(6): 1622-7.
4. Hsieh RL, Lee WC (2002) One-shot percutaneous electrical nerve stimulation vs.
transcutaneous electrical nerve stimulation for low back pain: comparison oftherapeutic effects. Am J Phys Med Rehabil, 81(11): 838-43.
5. Weiner DK, Rudy TE, Glick RM, Boston JR, Lieber SJ, Morrow LA, Taylor S(2003) Efficacy of percutaneous electrical nerve stimulation for the treatment ofchronic low back pain in older adults. J Am Geriatr Soc, 51(5): 599-608.
6. White PF, Ghoname EA, Ahmed HE, Hamza MA, Craig WF, Vakharia AS (2001)
The effect of montage on the analgesic response to percutaneous neuromodulation
therapy. Anesth Analg, 92(2): 483-7.
7. Yokoyama M, Sun X, Oku S, Taga N, Sato K, Mizobuchi S, Takahashi T, Morita K(2004) Comparison of percutaneous electrical nerve stimulation with transcutaneouselectrical nerve stimulation for long-term pain relief in patients with chronic low backpain. Anesth Analg, 98(6): 1552-6.

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Chapter 11 (E) Radiofrequency denervation andelectrothermal denervation proceduresRadiofrequency procedures, first introduced in 1975 (Shealy 1975), involve theapplication of current flow from an active electrode to a dispersive ground plate. The
body’s tissue completes the circuit, creating an electrical field. This electrical field
and ionic motion leads to the creation of frictional heat dissipation, causing local
tissue heating.
Recently this procedure has been questioned and another RF-technique, called“pulsed RF (PRF)”, has been introduced to avoid damage to nerve fibres. However,the latter is not included in this review since to date no RCTs are available for thisprocedure.
The rationale for the use of radiofrequency (RF) procedures and also for intradiscal
electrothermal therapy in low back pain is the assumption that these treatments canrelieve pain by destroying the nerves innervating the relevant structures causing thepain (joints and discs, or the spinal ganglion itself).

C11 (E1) Radiofrequency Facet-Denervation
Definition of procedureRadiofrequency facet joint procedure (neurotomy) consists of applying an RFprocedure to the facet joint in order to destroy the nerves that supply it.
The rationale for this procedure is based on the assumption that cutting the nerve
supply to the facet joints at special target points (junction between superior border of
the transverse process and the lateral aspect of the superior articular process) will
alleviate the pain
Result of search
Systematic Review
Two systematic reviews of RCTs on radiofrequency facet denervation were retrieved(Geurts et al 2001, Niemisto et al 2003).
The Cochrane review (Niemisto et al 2003) was used to formulate theserecommendations, as it was the more recent of the two SRs (including studies up to
April 2002, and all those considered in the previous review).
The Cochrane review included 4 studies of facet denervation (Gallagher et al 1994,
Leclaire et al 2001, Sanders and Zuurmond 1999, van Kleef et al 1999).
Additional RCTs
No additional trials were found.
Quality assessment of the evidence
The included SR (Niemisto et al 2003) was of high quality.
Among the three considered RCTs, two were of high quality (Leclaire et al 2001, vanKleef et al 1999) and two were of low quality (Gallagher et al 1994, Sanders andZuurmond 1999).
Effectiveness
Effectiveness of radiofrequency facet-denervation versus sham procedures
One study investigated 15 patients with facet denervation (lesion of rami dorsales L3L5) and a control group (16 patients) (van Kleef et al 1999). The control group
received the same procedure but without use of radiofrequency current. Patientswere selcted for neurotomy procedure after positive (at least 50% pain reduction)
ramus dorsali diagnostic block with lidocaine. Before treatment and 8 weeks after the183treatment VAS pain, Waddell impairment scale, number of analgesics, Oswestry
scale, quality of life and globalperceived effect (7-point scale) were monitored. The
rate of success (reduction in VAS pain) was higher in the lesion group (odds ratio ofeffect was 3.33 unadjusted to the effect of a previous diagnostic nerve block and9.53 adjusted to it). The difference between the adjusted and unadjusted odds ratios
was mainly caused by controlling for outcome after the diagnostic block: patients who
were pain free after a diagnostic block had better results. There was a significant(p<0.01 for adjusted difference, p<0.05 for unadjusted difference) reduction in theOswestry scale and in the global perceived effect (p<0.05). The other scales didn’tchange significantly.
A similar study design was used in another study to investigate 41 patients (30patients neurotomy, 11 sham lesion) who had firstly undergone a diagnostic block(“in and around the joints followed by pain relief for 10 hours”) (Gallagher et al 1994).
They reported a minor change (p=0.05) in patients in the facet neurotomy group withrespect to pain (VAS) after one and 6 months and with respect to the McGill score
only one month after the lesion.
One study investigated 70 patients (36 neurotomy, 34 placebo lesion) who had had asuccessful intraarticular diagnostic block (“significant pain reduction for 24 hours”)
with lidocaine/Triamcinolone (Leclaire et al 2001). Minor (p=0.05) positive and shortterm (4 weeks) improvements were observed for disability (Roland and Morris scale),but there was no effect on pain (VAS) and Oswestry scale. After 12 weeks neither
functional disability nor pain showed any improvement.
There is conflicting evidence that RF denervation of the facet joints is more
successful than placebo for eliciting short-term or long-term improvements in pain orfunctional disability in mechanical chronic low back pain (level C). Proper selection of
the patients (successful diagnostic blocks) and an optimal technique may be importat
to achieve better results.
Effectiveness of radiofrequency facet-denervation versus other treatments
In one study, two types of facet denervation were compared: intra-articular (PIFD;
N=17 patients) and extra-articular (PEFD; N=17 patients) (Sanders and Zuurmond1999). Before and 3 months after the lesion, VAS pain, functional health(COOP/WONCA) and Oswestry disability (function) were recorded. The VAS scores
before and after treatment were respectively: PIFD, 6.3 (2.0) and 1.5 (1.7); andPEFD, 5.7 (2.3) and 3.9 (2.8) (difference between groups for reduction in pain,
p<0.01). The two functional scores were also significantly better (p<0.01) after PIFD
than PEFD.
There is limited evidence that intra-articular denervation of the facet joints is more
effective than extra-articular denervation (level C).
Cost effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)

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Subjects (indications)Patients with chronic facet pain. However, in practical terms, these patients are very
difficult to define because there are no clinical tests of facet joint pain and there are ahigh proportion of positive results to placebo from the prognostic blocks.
Patients selected for facet denervation should firstly have a diagnostic block, twice,with a very low volume of anaesthetic (0.5 ml) at the target location; they should
show consistent results with at least 80 % pain relief (Dreyfuss et al 2000).
Comments
1. Facet denervation may be indicated for cervical pain more than for lumbar pain.
In contrast to RF procedures at the cervical facets, it seems that technicalproblems limit denervation of the lumbar facets because it is difficult to place theelectrode parallel to the nerve, as needed for denervation in the lumbar area.
Additionally, lumbar mechanical pain is seldom of pure facet origin.
2. A non-randomized study has suggested that there must be at least 80% pain
relief from a diagnostic block before permanent denervation is indicated, andselection has to be strict in order to get really good results (Dreyfuss et al 2000).
This was not done in one of the trials included in formulating theseguidelines (Leclaire et al 2001).
3. There is a need for further high quality RCTs with larger patient samples, careful
pre-selection of patients with diagnostic blocks, longer follow-ups, and meaningful
standardized outcomes.
Summary of evidence• There is conflicting evidence that RF denervation of the facet joints is more
successful than placebo for eliciting short-term or long-term improvements in painor functional disability in mechanical chronic low back pain (level C). Proper
selection of the patients (successful diagnostic blocks) and an optimal technique
may be importat to achieve better results.
• There is limited evidence that intra-articular denervation of the facet joints is more
effective than extra-articular denervation (level C).
Recommendation
We cannot recommend RF facet denervation for patients with non-specific chronic
low back pain.
References
1. Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N (2000) Efficacy
and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain.
Spine, 25(10): 1270-7.
2. Gallagher J, Periccione die Vadi PL, Wedley JR, Hamann W, Ryan P, Chikanza I,
Kirkham B, Price, Watson RMS, Grahame R, Wood S (1994) Radiofrequency facet
joint denervation in the treatment of low back pain: a prospective controlled doubleblind study to assess its efficacy. Pain Clin, 7: 193-98.
3. Geurts JW, van Wijk RM, Stolker RJ, Groen GJ (2001) Efficacy of radiofrequency
procedures for the treatment of spinal pain: a systematic review of randomized
clinical trials. Reg Anesth Pain Med, 26(5): 394-400.
4. Leclaire R, Fortin L, Lambert R, Bergeron YM, Rossignol M (2001)
Radiofrequency facet joint denervation in the treatment of low back pain: a placebocontrolled clinical trial to assess efficacy. Spine, 26(13): 1411-6; discussion 7.
5. Niemisto L, Kalso E, Malmivaara A, Seitsalo S, Hurri H (2003) Radiofrequency
denervation for neck and back pain: a systematic review within the framework of thecochrane collaboration back review group. Spine, 28(16): 1877-88.

185

6. Sanders M, Zuurmond WWA (1999) Percutaneous intraarticular lumbar facet joint
denervation in the treatment of low back pain: a comparison with percutaneous
extraarticular lumbar facet denervation. Pain Clin, 11: 329-35.
7. Shealy CN (1975) Percutaneous radiofrequency denervation of spinal facets.
Treatment for chronic back pain and sciatica. J Neurosurg, 43(4): 448-51.
8. van Kleef M, Barendse GA, Kessels A, Voets HM, Weber WE, de Lange S (1999)
Randomized trial of radiofrequency lumbar facet denervation for chronic low backpain. Spine, 24(18): 1937-42.

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C11 (E2) Intradiscal Radiofrequency Thermocoagulation (IRFT) andIntradiscal Electrothermal Therapy (IDET)
Definition of procedureRadiofrequency (RF) lesions not only target the rami dorsales to relieve facet pain,
but also aim to reduce the nociceptive input from painful intervertebral discs.
Percutaneous intradiscal radiofrequency thermocoagulation (IRFT) has been used
for this purpose. In this procedure a RF cannula is placed in the center of the discand a lesion is then made here.
Intradiscal electrothermal therapy (IDETTM) consists of heating the outer annulus of
the intervertebral disc. A flexible intradiscal catheter with a temperature controlled
thermal resistive coil is passed through a trocar into the annulus of the disc and isheated to a temperature of 70 degrees centigrade. This procedure has beendeveloped as an alternate treatment to spinal fusion for patients with unremitting pain
hypothesised to be caused by internal disc disruption (IDD). Much controversy
surrounds the diagnosis of IDD (Biyani et al 2003, Carragee and Hannibal 2004,
Wetzel et al 2002) (also see Diagnosis).
The biological effect of IDET is not well understood (Bono et al 2004, Freeman et al
2003a, Kleinstueck et al 2003, Wetzel et al 2002). The aims of the procedure are todestroy nociceptors and induce modulation and shrinkage of collagen in the outerannulus.
To date, there is no clear consensus regarding the effects on neuronal
deafferentation, collagen modulation, or spinal stability. One study on cadaveric
specimens (Kleinstueck et al 2003) showed that, except for a very limited margin (1.2mm) around the catheter, the temperature does not reach the required level to
induce collagen shrinkage within the disc. Temperatures sufficient to ablate nerves
were developed in some areas but were not reliably produced in clinically relevant
regions, such as the posterior annulus. These results suggest that beneficial clinicaloutcomes may be critically dependent on probe placement or other unknown factors.
Another study on human cadaveric specimens (Bono et al 2004) detected
temperatures sufficient for collagen denaturation and nociceptive ablation at
distances greater than those reported in the study of Kleinstueck (Kleinstueck et al2003). A further study investigated intradiscal electrothermal therapy (IDET) in an
ovine model in which posterolateral annular tears were induced
experimentally (Freeman et al 2003a). IDET delivered at 90° C consistently heatedthe posterior annulus and the nucleus to a temperature normally associated withcoagulation of nociceptors and collagen contraction. However, IDET did not
denervate the posterior annular lesion. Thermal necrosis was observed within the
inner annulus and the adjacent nucleus from 6 weeks after IDET. The authors
concluded that the reported benefit from IDET appear to be related to factors otherthan denervation and repair.
Results of search
Systematic reviews
No systematic reviews were found.
Additional studies
Three RCTs were retrieved (Barendse et al 2001, Ercelen et al 2003, Pauza et al2004).
One prospective cohort study of IDETwith historical or non-interventional groups ascontrols (Karasek and Bogduk 2000) and three retrospective cohort studies (Cohenet al 2003, Davis et al 2004, Saal and Saal 2002) were also identified. The latter187

studies, although uncontrolled, provided useful information to consider in forming
these recommendations, but they were not considered in arriving at the level ofevidence.
One RCT on radiofrequency denervation of the ramus communicans nerve forchronic discogenic pain was found (Oh and Shim 2004).
Quality assessment,
Three RCTs (Barendse et al 2001, Ercelen et al 2003, Pauza et al 2004) were ofhigh quality and one (Oh and Shim 2004) was of low quality.
Effectiveness
Effectiveness of IRFT or IDET vs. a sham procedure
One RCT compared the effects of IRFT denervation (N=13 patients) and sham IRFT
(same procedure but without the use of radiofrequency current ; N=15) on short-term
pain relief physical impairment, disability and quality of life (Barendse 2001). There
were no differences in outcome between the groups (no relevant improvements ineither group). A later study sought to examine different durations of radiofrequency
thermocoagulation (120s vs 360s) in an attempt to examine their influence on theeffectiveness of this method (Ercelen et al 2003). The authors found no significant
difference between the application of lesioning for two different time periods (bothmethods were associated with a significant reduction in pain 1 month after treatment,with the effect disappearing in each group by 6 months).
The other RCT compared the effects of intradiscal electrothermal therapy (IDET)(N=37 patients) with sham IDET (same procedure without heating) (N=27patients) (Pauza et al 2004). Patients in both groups exhibited improvements in VAS
pain, Oswestry disability and quality of life (SF-36); improvements in pain anddisability were slightly but significantly better in the IDET group. The number needed
to treat with IDET to achieve 75% relief of pain was five. 50% of patients experienced
no appreciable benefit.
There is conflicting evidence that procedures aimed at reducing the nociceptive input
from painful intervertebral discs using either IRFT or IDET, in patients withdiscogenic low back pain pain, are not more effective than sham treatments (level C).
Effectiveness of IRFT or IDET vs. other treatments
One study investigated the effectiveness of a different method for causing discdenervation in patients suffering from chronic discogenic back pain, namely RF
lesioning of the ramus communicans, which innervates the posterior part of thedisc (Oh and Shim 2004). The lesion group (n=26 patients with one symptomaticlevel) received RF thermocoagulationand the control group (n=23), a lidocaine
injection at the same side. Both groups were failed IDET patients. 4 months after
treatment, the improvement in pain was significantly greater in the RF lesion groupthan in the control group.
There is limited (level C) evidence that RF lesioning of the ramus communicans iseffective in reducing pain up to 4 months after treatment.
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetySome complications have been reported: burning sensations in the legs, which
resolved after several weeks; herniation of a disc treated with the procedure anddevelopment of radicular pain, numbness and paresis, which resolved after several
weeks (Cohen et al 2003); and discitis (Davis et al 2004).

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Subjects (indications)
At this stage, it is impossible to define patients in whom the procedure would beindicated, since it has no proven effectiveness; further, the patient selection
procedures are unclear.
Comments
1. A second, randomized, double blind, placebo controlled trial (with a similar design
to that described above (Pauza et al 2004)) was recently published in the form ofa peer-reviewed abstract (Freeman et al 2003b) after presentation at the Annual
Conference of the Spine Society of Europe. The study reported no difference
between IDET and sham IDET with respect to the number of patients showing aclinically relevant improvement in pain or disability (no significant improvementsin either group). Although the study appeared to be of high quality, since it has
not yet been published as a full paper, it is impossible to formally rate it.
2. Three retrospective studies on IDET revealed good results after 6 months (Cohenet al 2003), 6 and12 months (Karasek and Bogduk 2000) and 24 months (Saaland Saal 2002). However, a more recent study revealed particularly poor results
for the procedure, with only 39% patients reporting less pain 1 year after theprocedure compared with their pre-IDET status; 50% were dissatisfied with theiroutcome and the percentage of patients on disability remained constant (Davis et
al 2004).
Summary of evidence• There is conflicting evidence that procedures aimed at reducing the nociceptive
input from painful intervertebral discs using either IRFT or IDET, in patients withdiscogenic low back pain pain, are not more effective than sham treatments (levelC).
• There is limited evidence that RF lesioning of the ramus communicans is effective
in reducing pain up to 4 months after treatment (level C).
Recommendation
We cannot recommend the use of intradiscal radiofrequency, electrothermal
coagulation or radiofrequency denervation of the rami communicans for thetreatment of either non-specific or “discogenic” low back pain.
References
1. Barendse GA, van Den Berg SG, Kessels AH, Weber WE, van Kleef M (2001)
Randomized controlled trial of percutaneous intradiscal radiofrequency
thermocoagulation for chronic discogenic back pain: lack of effect from a 90-second
70 C lesion. Spine, 26(3): 287-92.
2. Biyani A, Andersson GB, Chaudhary H, An HS (2003) Intradiscal electrothermal
therapy: a treatment option in patients with internal disc disruption. Spine, 28(15Suppl): S8-14.
3. Bono CM, Iki K, Jalota A, Dawson K, Garfin SR (2004) Temperatures within the
lumbar disc and endplates during intradiscal electrothermal therapy: formulation of apredictive temperature map in relation to distance from the catheter. Spine, 29(10):1124-9; discussion 30-1.
4. Carragee EJ, Hannibal M (2004) Diagnostic evaluation of low back pain. Orthop
Clin North Am, 35(1): 7-16.
5. Cohen SP, Larkin T, Abdi S, Chang A, Stojanovic M (2003) Risk factors for failureand complications of intradiscal electrothermal therapy: a pilot study. Spine, 28(11):1142-7.
6. Davis TT, Delamarter RB, Sra P, Goldstein TB (2004) The IDET procedure forchronic discogenic low back pain. Spine, 29(7): 752-6.

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7. Ercelen O, Bulutcu E, Oktenoglu T, Sasani M, Bozkus H, Cetin Saryoglu A, Ozer F(2003) Radiofrequency lesioning using two different time modalities for the treatmentof lumbar discogenic pain: a randomized trial. Spine, 28(17): 1922-7.
8. Freeman BJ, Walters RM, Moore RJ, Fraser RD (2003a) Does intradiscal
electrothermal therapy denervate and repair experimentally induced posterolateralannular tears in an animal model? Spine, 28(23): 2602-8.
9. Freeman BJC, Fraser RD, Cain CMJ, Hall DJ (2003b) A randomised, double-blind,
controlled efficacy study: intradiscal electrotheraml therapy (IDET) versus placebo forthe treatment of chronic discogendic low back pain. Eur Spine J, 12(Suppl 1): S23.
10. Karasek M, Bogduk N (2000) Twelve-month follow-up of a controlled trial of
intradiscal thermal anuloplasty for back pain due to internal disc disruption. Spine,25(20): 2601-7.
11. Kleinstueck FS, Diederich CJ, Nau WH, Puttlitz CM, Smith JA, Bradford DS, Lotz
JC (2003) Temperature and thermal dose distributions during intradiscal
electrothermal therapy in the cadaveric lumbar spine. Spine, 28(15): 1700-8;
discussion 9.
12. Oh WS, Shim JC (2004) A randomized controlled trial of radiofrequency
denervation of the ramus communicans nerve for chronic discogenic low back pain.
Clin J Pain, 20(1): 55-60.
13. Pauza KJ, Howell S, Dreyfuss P, Peloza JH, Dawson K, Bogduk N (2004) A
randomized, placebo-controlled trial of intradiscal electrothermal therapy for thetreatment of discogenic low back pain. Spine J, 4(1): 27-35.
14. Saal JA, Saal JS (2002) Intradiscal electrothermal treatment for chronic
discogenic low back pain: prospective outcome study with a minimum 2-year followup. Spine, 27(9): 966-73; discussion 73-4.
15. Wetzel FT, McNally TA, Phillips FM (2002) Intradiscal electrothermal therapy
used to manage chronic discogenic low back pain: new directions and interventions.
Spine, 27(22): 2621-6.

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C11 (E3) Radiofrequency Lesioning of Dorsal Root Ganglion
Definition of the procedure
Percutaneous radiofrequency consists of partially lesioning the dorsal root ganglion,
in order to destroy nerves responsible for chronic refractory radicular pain. This
procedure was developed as an alternative to surgical rhizotomy.
Results of search
Only one RCT was retrieved (Geurts et al 2003).
Quality assessment of the evidence
The RCT was of high quality.
Effectiveness
Effectiveness vs. a sham procedure
One high quality RCT showed that, after 3 months, there was no difference between
groups receiving either radiofrequency lesions of the dorsal root ganglion (n=45) or
sham radiofrequency lesions (identical procedure, but without current) (n=38) for the
primary outcome “success” or “failure” (as measured by changes in VAS leg pain,changes in daily physical activities and changes in use of analgesics) or for any
secondary outcomes (pain intensity, daily physical activities, use of analgesics,
quality of life). Treatment was “successful” in seven of 44 patients (16%) who
received the radiofrequency lesion compared with nine (25%) of 36 who received
control treatment (difference p=0.43) (Geurts et al 2003).
Effectiveness vs. other treatments
Unknown (no studies were found on this issue)
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (indications)This procedure was not shown to be effective, so it is impossible to define
indications. In theory, its use would only make sense for patients with radicular pain.
Summary of evidence
There is limited evidence that radiofrequency lesions of the DRG are not effective inthe treatment of chronic LBP (level C).
Recommendation
We cannot recommend the use of RF lesioning of the dorsal root ganglion to treat
chronic low back pain.
References
1. Geurts JW, van Wijk RM, Wynne HJ, Hammink E, Buskens E, Lousberg R, Knape
JT, Groen GJ (2003) Radiofrequency lesioning of dorsal root ganglia for chronic
lumbosacral radicular pain: a randomised, double-blind, controlled trial. Lancet,
361(9351): 21-6.

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C11 (F) Spinal Cord Stimulation (SCS)
Definition of procedure
SCS consists of implanting epidural electrodes transcutaneously and connecting
them to a generator, which is internalized during a second procedure if the test
stimulation is successful.
SCS has been used for treatment of postoperative back pain (so-called failed backsurgery syndrome; FBSS) for more than 30 years, mainly to treat chronic radicular
pain (Burchiel et al 1996).
Result of search
Systematic reviews
No systematic reviews on SCS for non-specific chronic LBP were retrieved by thesearch.
Additional studies
No additional trials were found.
Effectiveness
Effectiveness vs. a sham procedure
Unknown (no studies were found on this issue)
Effectiveness vs other treatments
Unknown (no studies were found on this issue)
Cost/effectiveness
Unknown (no studies were found on this issue)
SafetyUnknown (no studies were found on this issue)
Subjects (indications)
Not having shown evidence of effectiveness, it is not possible to define indications forspinal cord stimulation.
Comments
1) One high quality systematic review on the effectiveness of spinal cord stimulation(SCS) in relieving pain and improving function in patients with failed back surgery
syndrome or complex regional pain syndrome (CRPS) was found (Turner et al 2004).
It contained three (uncontrolled) prospective case series studies of SCS for failed
back surgery syndrome (Dario et al 2001, Kumar et al 2002, Ohnmeiss et al 1996),
which were all of low quality.It concluded that the literature on SCS for FBSS is too
sparse to be able to make definitive statements about its effectiveness in reducing
physical disability, work disability, and medication consumption in chronic LBP.
2) Two case-series studies (20 patients with a follow up 24-84 months (Dario et al2001) and 40 patients with a follow up 12 and 24 months (Ohnmeiss et al 1996))
concluded that patients with FBSS improve significantly after SCS with regard to leg
pain, but not back pain (NRS) and disability.
3) The review reported a complication rate of 34.3% (mean across all studies withSCS for CRPS or FBSS) (Turner et al 2004). Superficial infection was reported at a
rate of 4.5%; equipment failure, 10.2%; stimulator revision, 23.1%; and stimulator
removal, 11.0%. The most common adverse event was a stimulator revision(additional operation), most frequently due to a need to reposition the electrodes.
Battery replacement was another reason for stimulator revision, but not mentioned ascomplication. Serious side effects were not reported.

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4) One low quality study examined the cost-effectiveness of SCS (Kumar et al2002). Patients who were referred for SCS but did not undergo electrodeinternalisation were used as controls. This group was treated with conservative pain
therapy. The surgical group consisted of 60 patients and the control group of 40
patients. The authors reported cumulative costs for SCS over a five-year period of$29.123 compared with $38.029 for medical therapy. The type of medical therapy
administered was not mentioned.
5) There is clearly a need for trials on SCS versus modern multidisciplinary pain
management or versus opioid treatment in patients with chronic LBP due to FBSS.
Summary of evidence
There is no evidence on the effectiveness of spinal cord stimulation in patients with
non-specific chronic low back pain (level D).
Recommendation
We cannot recommend the use of spinal cord stimulation for the treatment of chronic
non-specific LBP.
References
1. Burchiel KJ, Anderson VC, Brown FD, Fessler RG, Friedman WA, Pelofsky S,
Weiner RL, Oakley J, Shatin D (1996) Prospective, multicenter study of spinal cord
stimulation for relief of chronic back and extremity pain. Spine, 21(23): 2786-94.
2. Dario A, Fortini G, Bertollo D, Bacuzzi A, Grizzeti C, Cuffari S (2001) Treatment offailed back surgery syndrome. Neuromodulation, 19: 1201-6.
3. Kumar K, Malik S, Demeria D (2002) Treatment of chronic pain with spinal cord
stimulation versus alternative therapies: cost-effectiveness analysis. Neurosurgery,
51(1): 106-15; discussion 15-6.
4. North RB, Kidd DH, Piantadosi S (1995) Spinal cord stimulation versus
reoperation for failed back surgery syndrome: a prospective, randomized study
design. Acta Neurochir Suppl (Wien), 64: 106-8.
5. Ohnmeiss DD, Rashbaum RF, Bogdanffy GM (1996) Prospective outcome
evaluation of spinal cord stimulation in patients with intractable leg pain. Spine,
21(11): 1344-50; discussion 51.
6. Turner JA, Loeser JD, Deyo RA, Sanders SB (2004) Spinal cord stimulation forpatients with failed back surgery syndrome or complex regional pain syndrome: asystematic review of effectiveness and complications. Pain, 108(1-2): 137-47.

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Chapter 11 (G) Surgery
Definition of procedure
The rationale for the use of surgery in chronic low back pain is the assumption thatspinal segments demonstrating degenerative changes on imaging can lead tomechanical pain.
Usually surgeons tend to reject the global definition of non-specific chronic low-backpain and attempt to identify subgroups in the CLBP group of patients with presumed,
and in part clinically defined, symptoms elicited by a degenerated segment, often
described as segmental pain, often the sequelae of a disc herniation. Definitions
such as degenerative disc disease, facet joint degeneration, spinal instability —which are not universally recognized as diagnostic entities — were therefore
acknowledged in searching for evidence to formulate these recommendations, as
was the term used for the Cochrane review, “degenerative lumbar
spondylosis” (Gibson et al 1999). Surgery performed for more specific conditions(tumours, trauma, radicular and myelopathic syndromes) was not taken into
consideration.
The surgical procedures are usually aimed at obtaining a solid fusion between two or
more vertebral segments. This can be performed with a posterior, anterior, or
combined approach. The surgeon can also use different types of commerciallyavailable instrumentation (spacers, cages, screws, hooks and rods), andsupplemental bone from the same patient or others, or, more recently, synthetic boneand growth factors, to promote bone formation and the achievement of solid fusion(arthrodesis). As in other fields of medicine, in recent years there has been a trend
towards minimally invasive spine surgery, and some of the new techniques havebeen considered in other sections of the guidelines; many other variants will no doubt
be presented in the near future, but they will need to firstly undergo the same
rigorous scientific scrutiny as the traditional ones. Another type of surgery that is
potentially indicated in degenerative disc disease, and hence worthy of considerationin this review on non-specific LBP, is disc replacement surgery.
Result of search
Systematic Reviews
One systematic review on surgery for back pain was found (Gibson et al 1999). The
review included 16 trials, none comparing any form of surgery for degenerative
lumbar spondylosis with natural history, placebo, or conservative treatment. Most of
the trials also included patients with specific conditions that were simply grouped
together because of the surgical technique (fusion). Another systematic review (deKleuver et al 2003) investigated the rationale for total disc replacement or disc
prosthesis (searched Medline (1966 to January 2002), Cochrane, Current Contents
and Cinahl). It included nine case series with a total of 564 arthroplasties in 411
patients. As the review did not identify any controlled trials, it was not consideredfurther in summarising the evidence for these guidelines.
Additional RCTs
27 additional studies, reporting 15 RCTs, were identified from the search and theworking group’s knowledge of the literature.
Three RCTs, written up in 4 papers compared surgery for CLBP with conservative
treatment (Brox et al 2003, Fairbank et al 2004, Fritzell et al 2001, Keller et al 2004);
two of these also addressed the comparison of three different surgical techniques for
CLBP (Fritzell et al 2003, Fritzell et al 2002) or evaluated cost-effectiveness oflumbar fusion vs. nonsurgical treatment for CLBP (Fairbank et al 2004, Fritzell et al2004).

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Two RCTs comparing lumbar artificial disc replacement with fusion were reported in
6 studies (Delamarter et al 2003, Geisler et al 2004, McAfee et al 2003a, b, Zigler
2003, Zigler et al 2003).
The remaining 13 articles reporting on 10 RCTs addressed the comparison ofdifferent surgical techniques to achieve a spinal fusion (Andersen et al 2003, Bodenet al 2002, Boden et al 2000, Burkus et al 2002a, Burkus et al 2002b, Christensen etal 2002b, Johnsson et al 2002, Ma et al 2001, Madan and Boeree 2003, McAfee et al
2002, Sasso et al 2004, Thomsen et al 1997, Zhao et al 2002).
Quality assessment of the evidence
Systematic reviews
The systematic review was a Cochrane Review and methodologically of highquality (Gibson et al 1999). None of the trials included in the review compared any
form of surgery with natural history, placebo, or conservative treatment. Therefore,
none of the RCTs included in the review are useful for the scope of this chapter.
Additional trials
The three RCTs comparing surgery with conservative treatment (Brox et al 2003,
Fairbank et al 2004, Fritzell et al 2004, Fritzell et al 2001, 2002, Keller et al 2004)
were of high methodological quality, although minor flaws (or at least reasons forconcern) could be found in all three. The inclusion/exclusion criteria and the control
groups used differed somewhat and these studies were therefore addressed
separately in the effectiveness section.
The trials on disc replacement (Delamarter et al 2003, Geisler et al 2004, McAfee etal 2003a, b, Zigler 2003, Zigler et al 2003) were of low methodological quality, had
several methodological flaws, and constituted — to a certain extent — the repeatedpublication of the same material.
The surgical fusion trials compared: 360° fusion vs. posterior fusion in 1 high quality
study (Christensen et al 2002b); 2 types of 360° fusion in 1 low quality study (Sasso
et al 2004); anterior vs. posterior fusion in 1 study (Ma et al 2001) (in Chinese, only
abstract could be evaluated); instrumented vs. uninstrumented fusion in 1 highquality longer follow-up (Andersen et al 2003, Christensen et al 2002a) of apreviously reported study (Thomsen et al 1997); BMP vs. autograft bone in 3 highquality studies (Boden et al 2002, Boden et al 2000, Johnsson et al 2002) and 1 low
quality study (Burkus et al 2002a, Burkus et al 2002b); 1 vs. 2 BAK cages in 1 low
quality study (Zhao et al 2002); GRAFT ligamentoplasty vs. anterior fusion in 1 low
quality study (Madan and Boeree 2003); complete vs. partial discectomy prior tofusion in 1 low quality study (McAfee et al 2002).
Effectiveness of surgery vs natural history, ineffective or sham treatment(placebo)
None of the systematic reviews or the additional trials directly addressed theeffectiveness of surgery in comparison with natural history, ineffective or
sham/placebo treatments. However, we considered the Swedish Lumbar Spine
Study (Fritzell et al 2001) in this section, because it explicitly used as a control grouppatients who were treated with different kinds of physical therapy that were notspecifically designed for this kind of patient, but rather reflected the non-surgicaltreatment policy at the time. Moreover, as one of the inclusion criteria for the study
was “unsuccessful non-surgical treatment efforts”, assignment to a control group thatinvolved further use of these previously unsuccessful non-surgical treatments could
only at best be considered a placebo treatment (and at worst, a nocebo). We
therefore considered this treatment to reflect the “natural treatment history” of thecondition.

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In the Swedish Lumbar Spine Study, at the 2-year follow-up 289 of 294 (98%)
patients, including 25 who had changed groups, were examined (Fritzell et al 2001).
Back pain was reduced in the surgical group by 33% (64 to 43), compared with 7%(63 to 58) in the non-surgical group (P=0.0002). Pain improved most during the first 6
months and then gradually deteriorated. Different indices of disability were used:
Oswestry scores reduced by 25% (47 to 36) in the surgical group compared with 6%(48 to 46) in the non-surgical group (P=0.015); Million index scores by 28% (64 to 46)
and 8% (66 to 60) (P=0.004) respectively, and General Function Scores by 31% (49to 34) and 4% (48 to 46) (P=0.005) respectively. ZUNG depressive scores werereduced by 20% (39 to 31) in the surgical group compared with 7% (39 to 36) in the
non-surgical group (P=0.123). In the surgical group, 63% (122/195) rated themselves
as "much better" or "better" compared with 29% (18/62) in the non-surgical group(P<0.0001). The "net back to work rate" was significantly in favour of surgicaltreatment: 36% vs. 13% in the non-surgical group (P=0.002).
Effectiveness of surgery vs conservative treatment
In the Norwegian study (N=64), at the 1-year follow-up, 97% of the patients were
examined, including 6 who had either not attended treatment or had changed groups(four patients randomised to lumbar fusion did not have surgery, and two patientsrandomised to cognitive/exercises did not attend treatment (Brox 2003). The
Oswestry Disability Index was significantly reduced from 41 to 26 after surgery,compared with 42 to 30 after the cognitive intervention and exercises. The meandifference between groups was 2.3 (-6.7 to 11.4) (P = 0.33). Improvements in backpain, use of analgesics, emotional distress, life satisfaction, and return to work were
not different. Fear-avoidance beliefs and fingertip-floor distance were reduced more
after the conservative treatment, and lower limb pain was reduced more after thesurgical treatment, in each case significantly. The success rate according to anindependent observer was 70% after surgery and 76% after cognitive intervention
and exercises.
In the UK Medical Research Council trial (N=349), at the 2-year follow-up there wasno clinical or statistical difference in outcome (pain, Oswestry disability, quality of life,
SF36 physical or mental components) between spinal fusion and an intensive 3week (15 day) programme of exercise therapy, spine stabilisation exercises andeducation using cognitive-behavioural principals (Fairbank et al 2004). The surgery
results paralleled those reported in the other two trials (Brox 2003, Fritzell et al2001).
Effectiveness of different surgical treatments vs each otherIn the comparison of the three techniques in the Swedish Lumbar Spine
Study (Fritzell et al 2003, Fritzell et al 2002), the following groups were analysed:
Group 1 (posterolateral fusion; n = 73), Group 2 (posterolateral fusion combined withvariable screw placement, an internal fixation device; n = 74), and Group 3(posterolateral fusion combined with variable screw placement and interbody fusion;n = 75). The "circumferential fusion" in Group 3 was performed either as an anterior
lumbar interbody fusion (n = 56) or as a biomechanically similar posterior lumbarinterbody fusion (n = 19). All surgical techniques were found to reduce pain anddecrease disability substantially, but no significant differences were found among thegroups. In all three groups, the patients rated the overall outcome similarly, as did the
independent observer. The more demanding techniques in Groups 2 and 3
consumed significantly more resources in terms of operation time, bloodtransfusions, and days in hospital after surgery. In this high quality trial, there was no
obvious disadvantage in using the least demanding surgical technique of
posterolateral fusion without internal fixation.
In the disc replacement trials, changes in pain and Oswestry Disability Index were
not significantly different between disc replacement and fusion surgery at the mid-196

term follow-ups (Delamarter et al 2003, Geisler et al 2004, McAfee et al 2003a, b,
Zigler 2003, Zigler et al 2003).
Cost-EffectivenessIn the Swedish Lumbar Spine Study (Fritzell et al 2004), the societal total cost per
patient (with standard deviations in brackets) in the surgical group was significantly
higher than in the non-surgical group: Swedish kroner (SEK) 704,000 (254,000) vs.
SEK 636,000 (208,000). The cost per patient for the healthcare sector was
significantly higher for the surgical group, SEK 123,000 (60,100) vs. 65,200 (38,400)
for the non-surgical group. All treatment effects were significantly better after surgery.
The incremental cost-effectiveness ratios (ICER), illustrating the extra cost per extra
effect unit gained by using fusion instead of non-surgical treatment, were: for overall
improvement, SEK 2,600 (600-5,900); for back pain, SEK 5,200 (1,100-11,500); forOswestry, SEK 11,300 (1,200-48,000); and for return to work, SEK 4,100 (10021,400). The authors concluded that for both the society and the healthcare sectors,
the 2-year costs for lumbar fusion were significantly higher compared with nonsurgical treatment but all treatment effects were significantly in favour of surgery. The
probability of lumbar fusion being cost-effective increased with the value put on extra
effect units gained by using surgery. It most be noted that although different surgical
techniques had different costs, all were grouped together in this article: using thenon-instrumented PLF as a reference, costs increased by 66% when instrumentation
was added, and 103% if an interbody procedure was also performed. The costeffectiveness of interventions for chronic conditions probably requires a longer-term
analysis.
In the MRC trial, at the 2-year follow-up, the treatment costs of the surgery arm wereapproximately twice those of the conservative arm. The costs of conservative
treatment depend on how many patients opt for surgery afterwards (22% in this trial).
SafetyNo information regarding clinically relevant complications was provided in the
Cochrane review.
In the Swedish Lumbar Spine Study (Fritzell et al 2001), the early complication ratein the surgical group was 17%. 7 patients (10%) in the conservative groupsubsequently underwent surgical treatment before the 2-year follow-up. In theanalysis of the three surgical subgroups, the early complication rate was 6% inGroup 1, 16% in Group 2, and 31% in Group 3 (for group definitions see earlier).
There was no association between clinical outcome and complications on a grouplevel. The re-intervention rate was 6% in the PLF group, 22% in the VSP, and 17% in
the "360" group (P=0.020). The odds ratio for requiring a re-intervention after
instrumented fusion compared with non-instrumented fusion was 4.0 (95%
confidence interval, 1.3-11.9).
In the Norwegian study (Brox 2003), the early complication rate in the surgical groupwas 18%.
In the MRC trial (Fairbank et al 2004), no complication rate was reported for thesurgical group.
In one of the disc replacement studies (disc replacement vs fusion), the number ofpatients with major, minor, or other neurological complications was equivalent in thetwo groups (Geisler et al 2004). There was a greater incidence of both major andminor complications in the BAK fusion group at 0 to 42 days postoperatively.
Subjects (indications)
The inclusion criteria for the three RCTs comparing surgery with conservative
treatment were different, in particular regarding the duration for which the patients
had to have shown no response to conservative treatment: in the Swedish Study thiswas 2 years, and in the Norwegian and UK studies, 1 year.

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Some efforts have been made to characterise patients who might ultimately benefit
from a spinal fusion prior to their actually undergoing surgery. Methods used include
external fixators, bracing, provocative injections, pain drawings, dynamic x-rays,
discography and other more common imaging techniques. The usefulness of most ofthese methods remains unproven. There is conflicting evidence on the use of
external fixation (Axelsson et al 1999, 2003, Bednar and Raducan 1996), and thecontradictory results do not therefore allow a formal recommendation on the use ofthis technique. However, given the invasiveness and the non-reversibility of surgicalprocedures, it is strongly encouraged that more studies are performed in thisdirection.
Comments
1. Even though all three RCTs on surgery vs conservative treatment used theOswestry Disability Index (ODI) as the primary outcome measure, combining theresults of the three studies is not directly possible because they used very different
non-surgical comparison groups, and had different selection criteria for indicating
surgery. In fact the Swedish and the MRC study did not exclude previous discsurgery, as the Norwegian did (presented separately, in the form of an abstract (Brox2003)), and the inclusion criteria for the MRC study were procedure-driven (“patients
being considered for surgical stabilisation”), rather than based on a common“diagnosis”. The fact that the Norwegian study reported a significant difference inpost-treatment leg pain in favour of the surgical group is also a reason for concern.
Among other explanations, this might indicate the presence of some specific causeof leg pain that was treated successfully surgically; this might, in turn, indicate aselection bias in a group of patients that were supposed to have non-specific CLBP.
Discrepancies in the power calculations used and in the estimates of clinically
relevant change scores for the ODI are also detectable in the three studies. The
Swedish “non-specific conservative care” may reflect the natural history of thecondition in that country, rather than a specifically designed treatment alternative.
The other two studies used a more extensive combination of cognitive intervention
and exercises for the conservative treatment. The Norwegian study showedsignificant improvements in fear avoidance beliefs and fingertip-floor distance after
non-operative treatment, whilst lower limb pain was better in the surgical group.
2. The trials that addressed the comparison of different surgical fusion techniques
included patients with specific conditions that were grouped together because of thesurgical technique (fusion), rather than the indication. Therefore it was difficult todecide whether they should be included in a review on CLBP. On the other hand,
there is no a priori reason to believe that fusion performed for a specific cause would
have a different technical evolution. As most of the trials of different surgical
techniques are not identified by a systematic search on low back pain, we concedethat the evidence retrieved for this chapter might not be systematic enough to makea definitive statement on the single comparisons. In general, however, high quality
trials failed to demonstrate any positive effect of more demanding and expensive
surgical techniques. The interested reader might look for the next update ofCochrane review, which should be published soon and should incorporate the newtrials with the 11 trials already included in the paper published in 2000 (Gibson et al1999). In the latter review, the authors stated that any attempt to interpret the
combined results must be cautious and tentative, because of the heterogeneity inpatient selection and implants used in the different trials.
3. We are also aware of an ongoing protocol for a Health Technology Assessmenton the same topic (as above) for the Spanish Health authorities, and of a large
multicentre study comparing disc replacement vs. cognitive intervention andexercises, started in May 2004 in Norway. The studies published to date on discreplacement often comprise the same basic material presented in various smaller
papers: the results of multicentre RCTs are split to produce numerous interim andsub-group analyses. This is a cause for concern. Considering that the sample size of198

the originally planned study can be nearly 10 times greater than that of the studies
that are ultimately published, we fear this publication strategy may end up with thewidespread acceptance of this new technology before it has undergone proper
evaluation.
Evidence Summary• There is limited evidence that in selected patients with severe CLBP anddegenerative changes at L4-L5 or L5-S1 level, who have failed to improve withconservative treatment, surgery is successful in relation to improvements infunctional disability (Oswestry) and pain up to 2 years after treatment whencompared to traditional non-specific conservative treatment in Sweden (level C)• There is moderate evidence that surgery is similar to a combined program ofcognitive intervention and exercises provided in Norway or UK in improving
functional disability (Oswestry) (level B)• There is strong evidence that demanding, expensive and higher risk surgical
techniques are not better than the most straightforward and least expensive
surgical technique of posterolateral fusion without internal fixation (level A)• There is conflicting evidence on the cost-effectiveness of surgery: it appeared tobe slightly more cost-effective than (or equal to) traditional non-specificconservative treatment in Sweden, but twice as expensive as a combined
program of cognitive intervention and exercises provided in UK, for which similar
clinical results had been obtained (level C)• The complication rate after surgery has been reported to be around 17-18% (6 to31% depending on technique) with a 6-22% re-intervention rate; however, in thetrials examined, 4-22% of patients allocated to the non-surgical treatment arms
also underwent surgery.
Recommendation
We cannot recommend surgery for CLBP unless 2 years of all other recommended
conservative treatments have failed and combined programs of cognitive intervention
and exercises are not available in the given geographical area. Considering the highcomplication rates of surgery, as well as the costs to society and suffering forpatients with failed back surgery, we strongly recommend that only carefully selectedpatients with severe pain should be considered for this procedure.
References
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2. Axelsson P, Johnsson R, Stromqvist B, Andreasson H (1999) External pedicular
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4. Bednar DA, Raducan V (1996) External spinal skeletal fixation in the managementof back pain. Clin Orthop, (322): 131-9.
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10. Burkus JK, Transfeldt EE, Kitchel SH, Watkins RG, Balderston RA (2002b)
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Appendix
Search strategy for the systematic reviews
Literature search, conducted 11.12.2001
Databases
1. Cochrane
2. Medline
3. Health Star
4. Embase
5. Pascal
6. Psychoinfo
7. Biosis
8. Lilacs
9. IME (Índice Médico Español)
Search Strategy:
1. Cochrane:#·1

Back pain.

2. Medline and Health Star:a) sensitive strategy:#1(back pain) AND systematic[sb]#2(back pain) AND systematic[sb] Field: All Fields, Limits:
Publication Date from 1990b) specific strategy: Adding:#3(back pain) AND systematic[sb] Field: All Fields, Limits:
Publication Date from 1990, Review
3. Embase:

#1
#2
#3
#4
#5

Back pain. De (MESH)
Low back pain. De (MESH)
1 OR 2
Systematic
3 and 4 (Limitado por Review y publicaciones desde1990)

4. Pascal, Psychoinfo and Biosis:#1
Back pain#2
Low back pain
#3
1 OR 2#4
Systematic#5
3 AND 4 (limit to Publication type”Review” andPublication Date since1990)
5. Lilacs:

#1
#2
#3
#4
#5
#6

6.

#1 (dolor de espalda) O lumbago O lumbalgia. [DE]#2 (dolor de espalda) O lumbago O lumbalgia

IME:

dolor de espalda. [DE](lumbago) O lumbalgia. [TI]
(dolor) Y espalda. [TI]
#1 O #2 O #3
(revisión) Y sistemática.
#4 Y #5202#3 revisión sistemática
#4 #1 Y #3
#5 #2 Y #3
RESULTS
Total hits
12

CochraneMedline and Health Star“Specific”:

121“Sensitive”

273

5
20
121
14
10

excluded
redundant
redundant with
Medline specificexcluded
redundant

Embase13

1

redundant

Pascal, Psychoinfo and Biosis

14

2

redundant

Lilacs0

IME0

Typical subgroup search(e.g. results for physical treatments and exercise)
EmbaseNo. Records Request
19163 back pain
274295 randomized trial
3
458 #1 and #2
4
81 exercise and #3
5
44 training and #3
6
14 traction and #3
7
0 bracing and #3
829 manipulation and #3
914 massage and #3
10
8 heat and #3
11
5 cold and #3
12
4 ultrasound and #3
13
7 tens and #3
14
0 electrotherapy and #3
15
3 diathermy and #3
16
4 laser and #3
17
9 manual therapy and #3
18
4 TNS and #3
19
1 interferential therapy and #3* 20
163 #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or#15 or #16 or #17 or #18 or #19

203

Psychinfo
Search History#20 #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or#13 or #14 or #15 or #16 or #17 or #18 or #19 (6 records)#19 interferential therapy and #3 and (PY=1995-2002) (0records)#18 TNS and #3 and (PY=1995-2002) (0 records)#17 laser and #3 and (PY=1995-2002) (0 records)#16 diathermy and #3 and (PY=1995-2002) (0 records)#15 electrotherapy and #3 and (PY=1995-2002) (0 records)#14 manual therapy and #3 and (PY=1995-2002) (0 records)#13 tens and #3 and (PY=1995-2002) (0 records)#12 ultrasound and #3 and (PY=1995-2002) (0 records)#11 cold and #3 and (PY=1995-2002) (0 records)#10 heat and #3 and (PY=1995-2002) (0 records)#9 massage and #3 and (PY=1995-2002) (0 records)#8 manipulation and #3 and (PY=1995-2002) (0 records)#7 bracing and #3 and (PY=1995-2002) (0 records)#6 traction and #3 and (PY=1995-2002) (0 records)#5 training and #3 and (PY=1995-2002) (0 records)#4 exercise and #3 and (PY=1995-2002) (2 records)#3 #1 and #2 (6 records)#2 randomized trial and (PY=1995-2002) (352 records)#1 back pain and (PY=1995-2002) (645 records)

204