Low Back Pain & Radiculopathy



National and International Guidelines

CG88: Low back pain: Early management of persistent non-specific low back pain.

NICE clinical guidelines Issued: May 2009

American Pain Society Clinical Guideline for the Evaluation and Management of Low Back Pain.

Issued: May 2009

European Guidelines for the Management of Chronic Non-specific Low Back Pain.

Issued: Nov 2004

European Guidelines for the Management of Acute Non-specific Low Back Pain in Primary Care.

Issued: 2004

New Zealand Acute Low Back Pain Guideline.

Issued: 2004

Cochrane Review

Red flags to screen for malignancy in patients with low-back pain. 

Henschke N, Maher CG, Ostelo RWJG, de Vet HCW, Macaskill P, Irwig L. Red flags to screen for malignancy in patients withlow-back pain. Cochrane Database of Systematic Reviews 2010, Issue 9.



National and International Guidelines

See 'General' section. 

Cochrane Reviews

Back schools for non-specific low-back pain. 

Heymans MW, van Tulder MW, Esmail R, Bombardier C, Koes BW. CochraneDatabase of Systematic Reviews 2004, Issue 4.


There is moderate evidence suggesting that back schools are more effective for pain and function than other conservative treatments if the patients with chronic low-back pain (LBP) are from the general public, primary or secondary care. There is conflicting evidence whether back schools are more effective than placebo or waiting list controls for pain, function and return-to-work.

There is moderate evidence suggesting that back schools, in an occupational setting, reduce pain, and improve function and return-to-work status, in the short and intermediate-term, compared to exercises, manipulation, myofascial therapy or advice, placebo or waiting list controls, for patients with chronic LBP.

Exercise therapy for treatment of non-specific low back pain.

Hayden J, van Tulder MW, Malmivaara A, Koes BW. Cochrane Database of Systematic Reviews 2005, Issue 3.


Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in populations visiting a healthcare provider. In adults with subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. For patients with acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.

Spinal manipulativetherapy for chronic low-back pain.

Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Cochrane Database of Systematic Reviews 2011, Issue 2.


The results of this review demonstrate that SMT appears to be as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy. However, it is less clear how it compares to inert interventions or sham (placebo) treatment because there are only a few studies, typically with a high risk of bias, which investigated these factors. Approximately two-thirds of the studies had a high risk of bias, which means we cannot be completely confident with their results. Furthermore, no serious complications were observed with SMT. In summary, SMT appears to be no better or worse than other existing therapies for patients with chronic low-back pain.

Exercises for prevention of recurrences of low-back pain.

Choi BKL, Verbeek JH, Tam WWS, Jiang JY. Cochrane Database of Systematic Reviews 2010, Issue 1. 


There was moderate quality evidence that post-treatment exercises can reduce both the rate and the number of recurrences of back pain. However, the results of exercise treatment studies were conflicting.

Adverse (side) effects of exercising were not mentioned in any of the studies. Limitations of this review include the difference in exercises across studies, thus making it difficult to specify the content of such a programme to prevent back pain recurrences.

Massage for low-back pain.

Furlan AD, Imamura M, Dryden T, Irvin E. Cochrane Database of Systematic Reviews 2008, Issue4.


Massage was more likely to work when combined with exercises (usually stretching) and education. The amount of benefit was more than that achieved by joint mobilization, relaxation, physical therapy, self-care education or acupuncture. It seems that acupressure or pressure point massage techniques provide more relief than classic (Swedish) massage, although more research is needed to confirm this.
Massage might be beneficial for patients with subacute (lasting four to 12 weeks) and chronic (lasting longer than 12 weeks) non-specific low-back pain, especially when combined with exercises and education.

Combined chiropractic interventions for low-back pain.

Walker BF, French SD, Grant W, Green S. Cochrane Database ofSystematic Reviews 2010, Issue 4.


The review shows that while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain. Any demonstrated differences were small and were only seen in studies with a high risk of bias. Future research is very likely to change the results and our confidence in them. Well conducted randomised trials are required that compare combined chiropractic interventions to other established therapies for low-back pain.

Spinal manipulative therapy for acute low-back pain. 

Rubinstein SM, Terwee CB, Assendelft WJJ, de Boer MR, van Tulder MW. Cochrane Database of Systematic Reviews 2012, Issue 9.


Overall, we found generally low to very low quality evidence suggesting that SMT is no more effective in the treatment of patients with acute low-back pain than inert interventions, sham (or fake) SMT, or when added to another treatment such as standard medical care. SMT also appears to be no more effective than other recommended therapies. SMT appears to be safe when compared to other treatment options but other considerations include costs of care.

Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica.

Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Cochrane Database of Systematic Reviews 2010, Issue 6


Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed.  However, patients with sciatica experience little or no difference between the two approaches.  Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low quality evidence suggests those patients with or without sciatica experienced little or no difference in pain relief or function, regardless of whether they received advice to stay active, exercises or physiotherapy. Further research is very likely to have an important impact on the estimate of effect and is likely to change our confidence in it.

Physical conditioning programs for improving work outcomes in workers with back pain.

Schaafsma F, Schonstein E, Whelan KM, Ulvestad E, Kenny DT, Verbeek JH. Cochrane Database of Systematic Reviews 2010, Issue 1.


Results showed that light physical conditioning programs have no significant effect on sickness absence duration for workers with subacute or chronic back pain. We found conflicting results for intense physical conditioning programs for workers with subacute back pain. Further analysis suggested a positive effect on sick leave when the workplace was involved in the intervention. Physical conditioning programs probably have a small effect on return-to-work for workers with chronic back pain. We found conflicting results for intense physical conditioning programs compared to other exercise therapy in the first two years of sick leave. No difference in effect was found between a light or an intense physical conditioning program. We found that cognitive behavourial therapy probably has no value as an alternative therapy, or in addition to physical conditioning programs.

Traction for low-back pain with or without sciatica.

Clarke JA, van Tulder MW, Blomberg SEI, de Vet HCW, van der Heijden GJ, Brønfort G, Bouter LM. Cochrane Database of Systematic Reviews 2007, Issue 2.


In studies involving patients with a mix of symptoms (i.e., where some but not all had sciatica), results consistently showed that traction (continuous or intermittent) as a single treatment for LBP was not more effective than placebo, sham treatment or other treatments. For patients with sciatica, there is conflicting evidence on many of the comparisons, but moderate evidence that continuous or intermittent traction is not more effective than other treatments.



National and International Guidelines

See 'General' section. 

Cochrane Reviews

Multidisciplinary biopsychosocial rehabilitation for subacute low-back pain among working age adults.

Karjalainen KA, Malmivaara A, van Tulder MW, Roine R, Jauhiainen M, Hurri H, Koes BW. Cochrane Database of Systematic Reviews 2003, Issue 2.


Prolonged low back pain can lead to a combination of physical, psychological, occupational and social impairment. For that reason, physical rehabilitation can also include psychological, behavioural and educational interventions. This kind of "biopsychosocial multidisciplinary rehabilitation" is available as outpatient rehabilitation, or in pain clinics and rehabilitation centres. The review found moderate evidence of effectiveness from trials of this type of rehabilitation for working age adults. Although the trials showed some benefit from multidisciplinary rehabilitation which includes workplace visits, more research on effectiveness and cost-effectiveness is needed.

Behavioural treatment for chronic low-back pain.

Henschke N, Ostelo RWJG, van Tulder MW, Vlaeyen JWS, Morley S, Assendelft WJJ, Main CJ. Cochrane Database of Systematic Reviews 2010, Issue 7.


For pain relief, there was moderate quality evidence that:

(i) operant therapy was more effective than waiting list controls in the short-term,

(ii) there was little or no difference between operant therapy, cognitive therapy; or a combination of behavioural therapies in the short- or intermediate-term, and

(iii) behavioural treatment was more effective than usual care (which usually consists of physical therapy, back school and/or medical treatments) in the short-term.

Over a longer term, there was little or no difference between behavioural treatment and group exercise for pain relief or reduced depressive symptoms. The addition of behavioural therapy to inpatient rehabilitation did not appear to increase the effect of inpatient rehabilitation alone. For most of the other comparisons, there was only low or very low quality evidence, which was based on the results of only two or three small trials. There were only a few studies which provided information on the effect of behavioural treatment on functional disability or return to work. Further research is very likely to have an important impact on the results and our confidence in them.



National and International guidelines

See 'General' section.

Cochrane Reviews

Manual material handling advice and assistive devices for preventing and treating back pain in workers.

Verbeek JH, Martimo KP, Karppinen J, Kuijer PPFM, Viikari-Juntura E, Takala EP. Cochrane Database of Systematic Reviews 2011, Issue 6.


In conclusion, training workers in proper material handling techniques or providing them with assistive devices are not effective interventions by themselves in preventing back pain. Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Individual patient education for low back pain. 

Engers AJ, Jellema P, Wensing M, van der Windt DAWM, Grol R, van Tulder MW. Cochrane Database of Systematic Reviews 2008, Issue 1.


People with low-back pain who received an in-person patient education session lasting at least two hours in addition to their usual care had better outcomes than people who only received usual care. Shorter education sessions, or providing written information by itself without an in-person education session, did not seem to be effective.

People with chronic (long-term) low-back pain were less likely to benefit from patient education than people with acute (short-term) pain.

Patient education was no more effective than other interventions such as cognitive behavioural group therapy, work-site visits, x-rays, acupuncture, chiropractic, physiotherapy, massage, manual therapy, heat-wrap therapy, interferential therapy, spinal stabilisation, yoga, or Swedish back school. One study found that patient education was more effective than exercises alone for some measures of function.

Studies that compared different types of patient education did not find clear results on which type was most effective. Some studies found that written information was just as effective as in-person education.

There appeared to be no harmful effects of patient education. Although there were 24 studies included in the review, most treatments were only tested by one or two studies. More research is needed to confirm these results, and to find out which types of patient education are the most effective.



National and International Guidelines

Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain.

American Society of Interventional Pain Physicians. Issued 2009

Cochrane Review

Injection therapy for subacute and chronic low-back pain.

Staal JB, de Bie R, de Vet HCW, Hildebrandt J, Nelemans P. Cochrane Database of Systematic Reviews 2008, Issue 3.


Authors identified 18 randomized controlled trials (RCTs; 1179 participants) that looked at injections with a variety of drugs compared to a placebo drug or other drugs. The injections were given into the epidural space (between the vertebrae of the back and outside the coverings that surround the spinal cord), the facet joints (the joints of two vertebrae), or tender spots in the ligaments or muscles.
The review authors concluded that there is no strong evidence for or against the use of any type of injection therapy for individuals with subacute or chronic low-back pain.

Botulinum toxin injections for low-back pain and sciatica.

Waseem Z, Boulias C, Gordon A, Ismail F, Sheean G, Furlan AD. Cochrane Database of Systematic Reviews 2011, Issue 1.


This review looked at botulinum toxin injections for patients with non-specific low-back pain - i.e., back pain without an obvious underlying cause, with or without sciatica - i.e., pain that shoots down the back into the buttocks, leg and often into the foot. It included three randomised controlled clinical trials involving 123 individuals with long-term back pain, sciatica or both.

Because of the way these trials were designed and carried out, the review concluded that the evidence in favour of botulinum toxin injections is only of low or very low quality. This means that at best, further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Radiofrequency denervation for neck and back pain.

Niemisto L, Kalso EA, Malmivaara A, Seitsalo S, Hurri H. CochraneDatabase of Systematic Reviews 2003, Issue 1.


The review found that radiofrequency denervation can provide short-term pain relief for a small proportion of people with specific joint problems in the neck. There is conflicting evidence about effects for low-back joint pain, and some evidence that it does not relieve pain from low-back disc problems.

Acupuncture and dry-needling for low back pain.

Furlan AD, van Tulder MW, Cherkin D, Tsukayama H, Lao L, Koes BW, Berman BM. Cochrane Database of Systematic Reviews 2005, Issue 1.


Thirty-five RCTs covering 2861 patients were included in this systematic review. There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. The results also show that for chronic low-back pain, acupuncture is more effective for improving function than no treatment, in the short-term. Acupuncture is not more effective than other conventional and "alternative" treatments. When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain.



National and International Guidelines

See 'General' section. 

Cochrane Reviews

Antidepressants for non-specific low back pain.

Roland M, van Tulder MW. Urquhart DM, Hoving JL, Assendelft WJJ, Cochrane Database of Systematic Reviews 2008, Issue 1


The review could find no convincing evidence that antidepressants relieve back pain or depression more effectively than placebo. Antidepressants did not result in any other apparent benefits in the treatment of back pain.

Antidepressants did cause side-effects, however, adequate information about these was not provided in the trials.

Patients with significant depression should not avoid antidepressants based on this review, as they continue to play an important role in the treatment of clinical depression. There is also evidence that antidepressants can help patients with other specific types of pain.

The review cautions that existing studies do not provide adequate evidence regarding antidepressants for low-back pain. There is a need for larger and more sophisticated studies to confirm the conclusions of this review. In the meantime, antidepressants should be regarded as an unproven treatment for non-specific low-back pain.

Non-steroidal anti-inflammatory drugs for low back pain.

Roelofs PDDM, Deyo RA, Koes BW, Scholten RJPM, van Tulder MW. Cochrane Database of Systematic Reviews 2008, Issue 1.


The review authors conclude that NSAIDs are slightly effective for short-term symptomatic relief in patients with acute and chronic low-back pain without sciatica (pain and tingling radiating down the leg). In patients with acute sciatica, no difference in effect between NSAIDs and placebo was found.

The review authors also found that NSAIDs are not more effective than other drugs (paracetamol/acetaminophen, narcotic analgesics, and muscle relaxants). Placebo and paracetamol/acetaminophen had fewer side effects than NSAIDs, though the latter has fewer side effects than muscle relaxants and narcotic analgesics. The new COX-2 NSAIDs do not seem to be more effective than traditional NSAIDs, but are associated with fewer side effects, particularly stomach ulcers. However, other literature has shown that some COX-2 NSAIDs are associated with increased cardiovascular risk.

The review noted a number of limitations in the studies. Only 42% of the studies were considered to be of high quality. Many of the studies had small numbers of patients, which limits the ability to detect differences between the NSAID and the control group. There are few data on long term results and long-term side effects.

Muscle relaxants for non-specific low-back pain.

vanTulder MW, Touray T, Furlan AD, Solway S, Bouter LM. CochraneDatabase of Systematic Reviews 2003, Issue 4


Muscle relaxants are effective for short-term symptomatic relief in patients with acute and chronic low back pain. However, the incidence of drowsiness, dizziness and other side effects is high. Muscle relaxants must be used with caution and it must be left to the discretion of the physician to weigh the pros and cons and to determine whether or not a specific patient is a suitable candidate for a course of muscle relaxants. Large high quality trials are needed that directly compare muscle relaxants to analgesics or NSAIDs and future studies should focus on reducing the incidence and severity of side effects.

Opioids for chronic low-back pain.

Deshpande A, Furlan AD, Mailis-Gagnon A, Atlas S, Turk D. Cochrane Database ofSystematic Reviews 2007, Issue 3.


There still remains little evidence in the medical literature to address the concerns of physicians and patients regarding the effect of opioids on pain intensity, improved function and risk of drug abuse. The trials that do exist suggest that a weak opioid reduces pain but has minimal effect on function. Side effects were more common with opioids but not life-threatening. The results of these trials should be regarded with caution and may not be appropriate in all clinical settings. More high quality studies are needed to address the benefits and risks of long-term opioid use in chronic LBP, their relative effectiveness compared with other treatments and to better understand which patients may be most suitable for this type of intervention.



National and International Guidelines

See 'General' section

Cochrane Reviews

Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain.


In summary, the review authors found conflicting evidence regarding the benefits of TENS for chronic LBP, which does not support the use of TENS in the routine management of chronic LBP.



National and International Guidelines

See 'General' section. 

Cochrane Reviews

Surgical interventions for lumbar disc prolapse

Gibson JNA, Waddell G. Cochrane Database of Systematic Reviews 2007, Issue 2.

This updated review considers the relative merits of different forms of surgical treatments by collating the evidence from 40 randomized trials and two quasi-randomized controlled trials (5197 participants) on:

(i) Discectomy - surgical removal of part of the disc

(ii) Microdiscectomy - use of magnification to view the disc and nerves during surgery

(iii) Chemonucleolysis - injection of an enzyme into a bulging spinal disc in an effort to reduce the size of the disc

Despite the critical importance of knowing whether surgery is beneficial, only three trials directly compared discectomy with non-surgical approaches. These provide suggestive rather than conclusive results. Overall, surgical discectomy for carefully selected patients with sciatica due to a prolapsed lumbar disc appears to provide faster relief from the acute attack than non-surgical management. However, any positive or negative effects on the lifetime natural history of the underlying disc disease are unclear. Microdiscectomy gives broadly comparable results to standard discectomy. There is insufficient evidence on other surgical techniques to draw firm conclusions.

Trials showed that discectomy produced better outcomes than chemonucleolysis, which in turn was better than placebo. For various reasons including concerns about safety, chemonucleolysis is not commonly used today to treat prolapsed disc.

Many trials provided limited information on complications, but generally included recurrence of symptoms, need for additional surgery and allergic reactions (chemonucleolysis).

Many of the trials had major design weaknesses that introduced considerable potential for bias. Therefore, the conclusions of this review should be read with caution.

Future trials should be designed to reduce potential bias. Future research should explore the optimal timing of surgery, patient-centred outcomes, costs and cost-effectiveness of treatment options, and longer-term results over a lifetime perspective.