Chapter 4 - European guidelines for the management of chronic nonspecific low back pain

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 nonspecific CLBP unless a specific cause is strongly suspected. MRI is the best imaging procedure for use in diagnosing patients with radicular symptoms, or for those in whom discitis or neoplasm is suspected. Plain radiography is recommended for the assessment of structural deformities. Electromyography: We cannot recommend electromyography for the diagnosis of nonspecific CLBP. Prognostic factors We recommend the 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 in the assessment of patients with nonspecific CLBP. Summary of the concepts of treatment of chronic lowback pain (CLBP) Conservative treatments: Cognitive behavioural therapy, supervised exercise therapy, brief educational interventions, and multidisciplinary (bio-psycho-social) treatment can each be recommended for nonspecific CLBP. Back schools (for short-term improvement), and short courses of manipulation/mobilisation can also be considered. The use of physical therapies (heat/cold, traction, laser, ultrasound, short wave, interferential, massage, corsets) cannot be recommended. We do not recommend TENS. Pharmacological treatments: The short term use of NSAIDs and weak opioids can be recommended for pain relief. Noradrenergic or noradrenergic-serotoninergic antidepressants, muscle relaxants and capsicum plasters can be considered for pain relief. We cannot recommend the use of Gabapentin. Invasive treatments: Acupuncture, epidural corticosteroids, intra-articular (facet) steroid injections, local facet nerve blocks, trigger point injections, botulinum toxin, radiofrequency facet denervation, intradiscal radiofrequency lesioning, intradiscal electrothermal therapy, radiofrequency lesioning of the dorsal root ganglion, and spinal cord stimulation cannot be recommended for nonspecific CLBP. Intradiscal injections and prolotherapy are not recommended. Percutaneous electrical nerve stimulation (PENS) and neuroreflexotherapy can be considered where available. Surgery for nonspecific CLBP cannot be recommended unless 2 years of all other recommended conservative treatments - including 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 with maximum 2-level degenerative disc disease. 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 with very 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 nonspecific CLBP. In cases of low impairment and disability, simple evidence-based therapies (i.e. exercises, brief interventions, and medication) may be 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 nonspecific low back pain, the following 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 best delivered to specific target groups. More research is required to develop tools to improve the classification and, identification of specific clinical sub-groups of CLBP patients. Good quality RCTs are then needed to determine the effectiveness of specific interventions aimed at these specific risk/target groups. More research is required to develop relevant assessments of physical capacity and functional performance in CLBP patients, in order to better understand the relationship between self-rated disability, physical capacity and physical impairment. 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 commonly used by physical therapists, by comparing their individual and combined use. The combination of certain passive physical treatments for symptomatic pain relief with more active treatments aimed at reducing disability (e.g. massage, hot packs or TENS together with exercise therapy) should be further investigated. The application of cognitive behavioural principles to physiotherapy in general needs to be evaluated. 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 be further researched, as should the issue of individual versus 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 behavioural principles to the prescription of exercises needs to be further evaluated. Back schools, brief education The type of advice and information provided, the method of delivery, and its relative effectiveness all need to be further evaluated, in particular 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, in order to identify subgroups of patients who will benefit most from cognitive-behavioural therapy and in whom components of pain persistence need addressing. Promising predictors of outcome of behavioural treatment have been suggested and need further assessment, such as treatment credibility, stages of change, expectations regarding outcome, beliefs (coping resources, fear-avoidance) and catastrophising. The use of cognitive behavioural principles by professionals not trained in clinical psychology should be investigated, to find out how the latter can best be educated to provide 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 the right 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 have examined the effects of long term NSAIDs use in the treatment of chronic low back pain; 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 longer-term 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 and electrothermal denervation procedures. Surgery Newly emerging surgical methods should be firstly examined within the confines of high 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 surgical indications and diagnostic procedures. Methods not able to be recommended It is possible that many of the treatments that 'we cannot recommend' in these guidelines (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 the execution of carefully designed studies to establish whether the further use of such methods 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 considered in these guidelines.