Table 1 Clinical guidelines recommendations regarding diagnosis of low back pain
2078
Country Patient population Diagnostic classification
123
Australia (2003) Acute (\3 months) Non-specific low back pain
(divided into acute,
subacute and chronic)
Specific low back pain
Austria (2007) Acute (0–6 week), Non-specific LBP
subacute (6–12 week) Specific LBP (based on list
chronic ([12 week), of red flags)
and recurrent
Including high-grade
spondylolisthesis, facet
arthrosis, severe
degenerative disc disease
Canada (2007) Acute, subacute and Simple back pain
persistent Back pain with
neurological involvement
Back Pain with suspected
serious pathologies
All divided into acute,
subacute and persistent
Europe (2006) Acute (\6 weeks) and Serious spinal pathology
subacute (6– Nerve root pain/radicular
12 weeks) LBP pain
Non-specific low back pain
Europe (2006) Chronic LBP Specific spinal pathology
([12 weeks) Nerve root pain/radicular
pain
Non-specific low back pain
Physical examination
Conduct physical examination
to assess for the presence of
serious conditions
Neurological examination in
case it is suspected. (Physical
examination such as
inspection, range of motion
and posture may have low
reliability and validity and
should be used with caution)
Inspection, palpation, range of
motion testing of lumbar
spine, neurological screening
(strength, reflexes,
sensibility, SLR)
Physical examination in
patients with back pain and
neurological involvement
includes SLR, motor,
sensitivity, reflex signs
Physical assessment including
neurological screening when
appropriate
Diagnostic triage, neuro-
screening
‘We cannot recommend spinal
palpatory and range of
motion tests in the diagnosis
of chronic low back pain’
Imaging Psychosocial factors
Not recommended unless Yellow flags associated with the
alerting features of progression from acute to
serious conditions are chronic should be assessed early
present to facilitate intervention
Not useful in the first Evaluate psychosocial factors in
4 weeks of an episode patients who do not show
After 4–6 weeks may be improvement over time (with
indicated in search for a recommended treatment) and in
specific cause patients with recurrent LBP
Not recommended for Assess patients’ perceived
simple low back pain but disability and probability to
recommended for pain return to usual activity after
with neurological 4 weeks of disability or at first
involvement and consultation if patient has a
suspected serious history of long-lasting back-
pathology. MRI and CT related disability (Symptom
scans recommended if Check List Back Pain Prediction
surgery is in question Model)
Diagnostic imaging tests Assess for psychosocial factors
(including X-rays, CT and and review them in detail if there
MRI) are not routinely is no improvement
indicated for non-specific
low back pain
No radiographic imaging ‘We recommend the assessment of
MRI in case of red flags prognostic factors (yellow flags)
in patients with chronic low back
X-ray in case of suspected
pain’
structural deformities
Eur Spine J (2010) 19:2075–2094
 Table 1 continued
Country Patient population Diagnostic classification Physical examination Imaging Psychosocial factors

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

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

123
 Table 1 continued
Country Patient population Diagnostic classification
123
New Zealand (2004) Acute LBP (\3 months) Non-specific LBP
Specific pathologic change
Norway (2007) Acute and subacute Non-specific LBP
(\3 months) Radicular pain
Chronic ([3 months)
Serious pathologies/acute
neurological conditions
(Cauda equina syndrome)
Spain (2005) Non-specific acute, Specific spinal pathology
subacute and chronic Nerve root pain/radicular
pain
Non-specific low back pain
The Netherlands (2003) Acute (0–12 week) and Non-specific LBP
chronic ([12 week) Specific LBP (based on a
LBP list of red flags)
United Kingdom (2008) Acute \6 weeks, sub Non-specific low back pain:
acute 6–12 weeks, Mechanical low back pain
chronic [3 months Inflammatory low back pain
and stiffness
Serious pathology
United States (2007) Acute and chronic LBP Non-specific LBP
LBP due to specific causes
LBP-Radiculopathy/Spinal
Stenosis
Physical examination
Neurological screening
Establish degree of functional
limitation caused by the pain
Inspection, posture, deformity,
Spinal mobility, including
finger-to-floor distance,
Neurological screening
(SLR/Lasegue) if radicular
pain is suspected
Clinical history, red flags. Do
not recommend palpation and
tests of intervertebral
mobility
SLR-test, neurological
inspection; loss of motor
control, sensibility, miction.
Palpation of spine, Inspection
of lumbar kyphosis or
flattened lumbar lordosis
Rule out serious pathology
(identify red flags)
Confirm pain is in the lower
back, is mechanical, not
inflammatory
Neurological screening
(including SLR, strength,
reflexes, sensory symptoms)
2080
Imaging Psychosocial factors
Investigations in first Screen for yellow flags with the
4–6 weeks do not provide Acute Low Back Pain Screening
clinical benefit unless Red Questionnaire, and if at risk,
Flags present clinical assessment
There are risks associated
with unnecessary
radiology
Not recommended in acute, A list of yellow flags is presented
subacute chronic LBP and as risk factors for chronicity, sick
radicular pain in the leave
absence of red flags,
Recommended in case of
red flag
First choice is MRI
Not useful in non-specific Assess psychological factors in 2–
LBP; X-rays, CT and 6 weeks after treatment if not
MRI use only in case of improving. Assess physiological
red flags factors as prognostic factor only
Not useful in non-specific Assessment of psychosocial
acute LBP factors (yellow flags) is
recommended. These include
emotional reaction, cognitions
and behaviour
Does not inform Recognise and manage
management of non- psychosocial barriers (yellow
specific low back pain but flags) to recovery
may be indicated to rule
in/out serious pathologies
Only where progressive Assessment of psychosocial risk
neurological or serious factors strongly recommended
pathology is suspected
Discouraged for non-
specific LBP
Recommended for
radiculopathy or spinal
stenosis only if patients
are potential candidates
for further intervention
Eur Spine J (2010) 19:2075–2094
Eur Spine J (2010) 19:2075–2094 2081

US) the measurement of yellow

recommended at a much earlier

In a few guidelines (Netherlands,

recommended. In Germany the

Summary of Common Recommendations for Diagnosis of Low back

flags are now more strongly

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

assessments is now
Psychosocial factors

* Screen for serious pathology using red flags.

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

Therapeutic recommendations
and MRI
Imaging

Table 2 compares therapeutic recommendations given in

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

with the previous review, the current guidelines increas-

Physical examination

Almost no change in

ingly mention early return to work (despite having low

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

cases where paracetamol is not sufficient. There is some

Diagnostic classification

used in the guidelines

variation between guidelines with regard to recommen-

Almost no change in

dations for opioids, muscle relaxants, steroids, antide-

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

discouraged as a treatment for low back pain. Some

includes subacute and
recommendations for
More countries (UK,

guidelines state that if bed rest is indicated because of

US) now include
Patient population

chronic LBP in

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

recurrent LBP
Germany now

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

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

sciatica but does clearly describe how major sciatica differs

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

gramme (as distinct from encouraging resumption of nor-

Addition of guidelines

Spain and a unified

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

Table 1 continued

one from Europe

Austria, Canada,

Those guidelines that consider subacute and chronic low

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

The European guideline advises against exercise that

requires expensive training and machines. The one area of

123
 Table 2 Clinical guidelines recommendations regarding treatment of low back pain
Country Education Medication
123
Australia (2003) [8] Provide information, First choice paracetamol,
assurance and advice second choice NSAIDs,
to resume normal third choice oral opioids
activity (stay active) Not recommended:
anticonvulsants,
antidepressants, muscle
relaxants
Austria (2007) [9] Acute LBP: expect a Acute LBP: (1)
favourable course; Paracetamol; (2) NSAIDs
maintain normal daily 3) muscle relaxants or weak
activities opioids as last option
Chronic LBP: Options:
NSAIDs/Coxibs; Opioids;
Antidepressant; muscle
relaxants; Anti-
convulsion medication
(for radicular pain),
Capsaicin
Only for short periods: (1)
paracetamol, (2) tramadol
or NSAID, (3) opioids
Canada (2007) [10] Reassurance and advice NSAIDs, muscle relaxants
to return to work and and analgesics for acute.
usual activities Low evidence for
NSAIDs and analgesics
for subacute pain
Europe (2006) Reassure and advise Prescribe medication, if
(acute) [11] patients to stay active necessary for pain relief;
and continue normal Preferably to be taken at
daily activities regular intervals; first
including work if choice paracetamol,
possible second choice NSAIDs.
Third choice consider
short course of muscle
relaxants on its own or
added to NSAIDs
2082
Exercises Manipulation Bed rest Referral to specialist
There is conflicting Conflicting evidence of Not advisable When alerting features (red
evidence of the effect spinal manipulation flags) or serious
of exercises but versus placebo in first conditions are present
evidence shows that it 2–4 weeks
is no better than usual
care
Acute LBP: Acute LBP: Acute LBP: In case of suspected specific
Not specifically Optional for patients Avoid bedrest LBP; Surgery is optional
mentioned in the who do not return to only after 2 years of
(but if necessary,
guideline normal level of recommended
only for a short
activity within the first conservative treatment,
Chronic LBP: period)
weeks persisting complaints and
Exercise therapy with a surgical indication
recommended as Chronic LBP:
monotherapy or in Optional for patients
combination with back with persistent
school, massage problems with
performing daily
activities
Strengthening exercises, Recommended for Not recommended Refer patients with
extension exercises short- term pain neurological signs or
and specific exercises reduction for acute. symptoms if functional
are not recommended Recommended with deficits are persistent or
for acute but low evidence for deteriorating after
recommended for subacute and chronic 4 weeks
subacute and chronic
with no superior form
of exercise
Do not advise specific Consider (referral for) Do not prescribe bed Refer patients with
exercises (for example spinal manipulation rest as a treatment neurological symptoms
strengthening, for patients who are such as cauda equina
stretching, flexion, and failing to return to syndrome
extension exercises) normal activities
for acute low back
pain
Eur Spine J (2010) 19:2075–2094
 Table 2 continued
Country Education Medication
Europe (2006) Advice and reassurance Recommend use of NSAID
(chronic) [12] to return to normal for short term pain relief
activities and opioids in case patient
is not responding to other
treatment. Consider the
use of noradrenergic or
noradrenergic-
serotonergic
antidepressants as co-
medication for pain relief
Finland (2008) [13] Benign nature of Acute/Subacute LBP: (1)
condition; prognosis is paracetamol, (2) NSAIDs,
good; continue (3) adding a weak opiate
ordinary daily to paracetamol/NSAID.
activities. Back pain (4) muscle relaxants
may recur but even Antidepressant only if clear
then recovery is depression.
usually good Benzodiazepines not
recommended
Chronic LBP Analgesics
used periodically, be
aware of side effect of
NSAIDs (gastrointestinal,
cardiovascular)
France (2000) [14] Short-term education Acute & Chronic:
about the back, in Regular simple analgesics,
groups, is not non-steroidal anti-
beneficial inflammatory drugs and
muscle relaxants. No
evidence for systemic
corticosteroids
Chronic: Additional
recommendations for:
acetylsalicylic acid, Level
II following failure to
respond to Level I and
Level III (strong opioids)
on a case by case basis.
Tetrazepam, Tricyclic
antidepressants
123
Exercises Manipulation Bed rest Referral to specialist
Supervised exercise Recommend short Discouraged Most invasive treatments
therapy is advisable course of spinal not recommended
specifically manipulation/ Surgery not recommended
approaches that don’t mobilisation unless in carefully
require expensive selected patients, 2 years
training and machines. of all recommended
Cognitive behavioural conservative treatments
approach including including
Eur Spine J (2010) 19:2075–2094
graded activity and multidisciplinary
group therapy are approaches with
advisable combined programmes of
cognitive intervention and
exercises have failed
Acute LBP: Acute LBP: some Avoid bedrest; Immediate referral: Cauda
Active exercises not effectiveness a short period of equina syndrome, sudden
effective in early Similar effectiveness as bedrest may be massive paresis,
stages GP in subacute LBP necessary due to excruciating pain
intense back pain, Referral: serious, non
Light exercises (e.g. Chronic LBP: similar
but bedrest must urgent conditions
walking) can be effectiveness as GP,
not be considered
recommended analgesics, Multidisciplinary (bio-
as a treatment of
Subacute: gradually physiotherapy, etc. psycho-social)
back problems rehabilitation focused on
increasing exercises
improving functional
Chronic: Intensive
capacity
training effective for
pain and function
Acute: Acute & Chronic: Acute and Chronic: Acute:
Flexion exercises have Provides short-term Not recommended No recommendation
been not been shown benefit. No Chronic:
to be of benefit. No recommendation for
Recommended
recommendation on one form of manual
physiotherapy/
extension exercises therapy over another
behavioural therapy/
Chronic: multidisciplinary
Physical exercise is programme if non-
recommended, no response to first-line care
particular type is
advocated
2083
 Table 2 continued
2084

Country Education Medication Exercises Manipulation Bed rest Referral to specialist

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

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

of pain who did not for patients with pain

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

123
 Table 2 continued
Country Education Medication
123
United States (2007) Provide information on Paracetamol, NSAIDs
[22] prognosis, staying recommended as first-line
active, self drugs
management For acute (\4 weeks)—
Self-care education muscle relaxants,
books recommended benzodiazepines,
tramadol, opioids
For subacute or chronic
([4 weeks)—
antidepressants,
benzodiazepines,
tramadol, opioids
Most apparent changes since 2001
The advice to stay No change regarding
active remains similar. recommendation of
Now some guidelines paracetamol and NSAIDs
(european, NZ, as first-line treatments and
Canada, Italy, recommendation
Norway) explicitly regarding muscle
mention continuation/ relaxants
early RTW Now more often explicit
recommendations (for or
against) anti-depressants,
opioids, benzodiazepines
and combinations of
medications
2086
Exercises Manipulation Bed rest Referral to specialist
Not effective for acute For acute LBP if not Even if required for For interdisciplinary
LBP improving severe symptoms, intervention if chronic
Recommended for patients should be If suspicion of significant
subacute or chronic encouraged to nerve root impingement
LBP return to normal or spinal stenosis
activities as soon
as possible
The advice that exercise Recommendations for The The recommendations for
therapy is not useful in spinal manipulation, recommendation referral appear more
acute LBP has not the timing of against bedrest is explicit regarding : (1)
changed application and target fairly consistent immediate referral (cauda
Now more explicit group continue to vary between 2001 and equina syndrome), (2)
recommendations in now medical specialist in case
favour of exercise of red flags, (3) referral
therapy in subacute within primary care
and chronic LBP (physiotherapy/cognitive
behavioural therapy, (4)
multidisciplinary
treatments and (5)
consider surgery if
2 years of recommended
conservative care has
failed
Eur Spine J (2010) 19:2075–2094