People with LBP are not offered:
Chou, R., Baisden, J., Carragee, E.J., Resnick, D.K., Shaffer, W.O. and Loeser, J.D., 2009. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine, 34(10), pp.1094-1109.
Jacobs, W.C., van Tulder, M., Arts, M., Rubinstein, S.M., van Middelkoop, M., Ostelo, R., Verhagen, A., Koes, B. and Peul, W.C., 2011. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. European Spine Journal, 20(4), pp.513-522.
Peul, W.C., van den Hout, W.B., Brand, R., Thomeer, R.T. and Koes, B.W., 2008. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ, 336(7657), pp.1355-1358
Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M etal. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2017 Apr 20. doi: 10.1007/s00586-017-5099-2. [Epub ahead of print]
Extraforaminal glucocorticoid injection in the lumbar nerve root area should only be offered to patients with recent onset lumbar nerve root compression upon due consideration, since the beneficial effect is probably short-lived and very low
NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE Guideline [NG59] November 2016. Available at: https://www.nice.org.uk/guidance/NG59
Do not offer belts or corsets for managing low back pain with or without sciatica.
Do not offer foot orthotics for management low back pain with or without sciatica.
Do not offer rocker sole shoes for managing low back pain with or without sciatica.
Do not offer traction for managing low back pain with or without sciatica.
Do not offer acupuncture for managing low back pain with or without sciatica.
Do not offer ultrasound for managing low back pain with or without sciatica.
Do not offer percutaneous electrical nerve simulation (PENS) for managing low back pain with or without sciatica.
Do not offer transcutaneous electrical nerve simulations (TENS) for managing low back pain with or without sciatica.
Do not offer interferential therapy for managing low back pain with or without sciatica.
Do not offer spinal injections for managing low back pain.
Do not allow a person's BMI, smoking status or psychological distress to influence the decision to refer them for a surgical opinion for sciatica.
Do not offer spinal fusion for people with low back pain unless as part of a randomised controlled trial.
Do not offer disc replacement in people with low back pain.
NHMRC Australian Acute Musculoskeletal Pain Guidelines Group 2003. Evidence-based Management of Acute Musculoskeletal Pain. Available at: https://www.nhmrc.gov.au/
There is insufficient evidence that acupuncture (dry-needling) is effective compared to injection therapy in acute low back pain.
Adverse effects of acupuncture are rare but potentially serious.
There is insufficient evidence that back school is more effective in reducing pain compared to active and passive therapies and to placebo in acute low back pain.
There is insufficient evidence that back school is more effective in reducing pain compared to placebo and other treatments in mixed populations with low back pain.
There is insufficient evidence demonstrating the effectiveness of injection therapy (facet joint, epidural or soft tissue) in the treatment of acute low back pain.
Adverse effects of injection therapy are rare but serious.
There are no controlled studies on the effect of lumbar supports in acute low back pain.
No Level I or II Evidence
There are no controlled studies testing the effectiveness of electromyographic biofeedback in acute low back pain.
There is insufficient evidence that lumbar supports are effective in reducing pain compared to spinal manipulation, exercises, massage, TENS and simple analgesia in mixed populations with low back pain.
There are no controlled studies on the effect of traction for acute low back pain.
There is insufficient evidence that traction is effective compared to placebo and compared to other treatments in mixed populations with low back pain.
Adverse effects from traction have been reported, including reduced muscle tone, bone demineralisation, thrombophlebitis.
There are no controlled studies on the effect of TENS in acute low back pain.
There is insufficient evidence for the effectiveness of TENS compared to exercises, back books, massage, corset use and simple analgesia in mixed populations with low back pain.
Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, Johnson K, Kramer C, Mueller B, Peterson S, Setterlund L, Timming R. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 2012.
Clinicians should not prescribe or recommend traction for the treatment of acute low back pain.
Acupuncture may be used as an adjunct treatment for subacute low back pain
Agency for Healthcare Research and Quality / National Guidelines Clearinghouse 2012. Low back pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Available at: http://www.guideline.gov/
INTERVENTIONS – TRACTION: There is conflicting evidence for the efficacy of intermittent lumbar traction for patients with low back pain. There is preliminary evidence that a subgroup of patients with signs of nerve root compression along with peripheralization of symptoms or a positive crossed straight leg raise will benefit from intermittent lumbar traction in the prone position. There is moderate evidence that clinicians should not utilize intermittent or static lumbar traction for reducing symptoms in patients with acute or subacute, nonradicular low back pain or patients with chronic low back pain. (Recommendation based on conflicting evidence.)
TOP 2015. Toward Optimised Practice - Evidence-Informed Primary Care Management of Low Back Pain: Clinical Practice Guidelines. 3rd Edition. December 2015. Institute of Health Economics, Alberta, Canada.
DO NOT recommend shoe insoles/orthoses for preventing low back pain.
DO NOT recommend lumbar supports for preventing low back pain.
There is insufficient evidence to recommend for or against the following interventions for preventing low back pain
DO NOT use traction. Traction has been associated with significant adverse events. Passive treatment modalities such as traction should be avoided as mono-therapy and not routinely be used because they may increase the risk of illness behavior and chronicity. Adverse effects from traction include reduced muscle tone, bone demineralization, and thrombophlebitis.
DO NOT use therapeutic ultrasound for acute or subacute low back pain.
DO NOT use TENS for acute low back pain.
DO NOT use epidural steroid injections for acute low back pain in the absence of radiculopathy.
There is inconclusive evidence to recommend for or against epidural steroid injections in the presence of radiculopathy. Image-guided epidural steroid injections may be helpful for some patients with lumbar radicular pain for longer than six weeks who have not responded to non-interventional treatments. Clinical experience suggests that patients who have responded favourably (improved function and pain relief) to an epidural steroid injection may benefit from a follow-up injection after three months. Adverse effects are infrequent and include headache, fever, and subdural penetration; rare but catastrophic events, including epidural abscess and paralysis, can occur.
No evidence was found to recommend interdisciplinary rehabilitation for acute low back pain (pain less than four weeks).
There is inconclusive evidence to recommend for or against the following interventions for acute or subacute low back pain:
Recommend acupuncture as a short-term therapy or as an adjunct to a broader active rehabilitation program. No serious adverse events were reported in the clinical trials. The incidence of minor adverse events was 5%.
DO NOT use motorized traction for chronic low back pain.
DO NOT use prolotherapy as a sole treatment for chronic low back pain.
DO NOT use TENS as a sole treatment for chronic low back pain.
DO NOT order diagnostic SNRBs in primary care. There is evidence to support their use in specialty services to assist in diagnosis when multiple levels may be involved; they require specialist follow-up to interpret.
There is inconclusive evidence to recommend for or against diagnostic lumbar facet joint nerve blocks.
There is insufficient evidence to recommend for or against diagnostic sacroiliac joint blocks.
There is inconclusive evidence to recommend for or against spinal manipulative treatment for chronic low back pain.
There is inconclusive evidence to recommend for or against spinal mobilization for chronic low back pain.
Prolotherapy may be useful for carefully selected and monitored patients who are participating in an appropriate program of therapeutic exercise and/or manipulation or mobilization.
TENS may be useful as an adjunct in select patients for pain control to reduce the need for medications. A short trial (two to three treatments) using different stimulation parameters should be sufficient to determine if the patient will respond to this modality.
There is insufficient evidence to recommend for or against the use of therapeutic ultrasound for chronic low back pain. Based on expert opinion, this modality is overused relative to any potential therapeutic benefit.
There is inconclusive evidence to recommend for or against epidural steroid injections. For patients with leg pain, image-guided epidural steroid injections may be effective in providing short-term and occasional long-term pain relief. Clinical experience suggests that patients who have responded favourably (improved function and pain relief) to an epidural steroid injection may benefit from a follow-up injection after three months. Adverse effects are infrequent and include headache, fever, and subdural penetration; rare but catastrophic events, including epidural abscess and paralysis, can occur.
There is insufficient evidence to recommend for or against conventional radiofrequency neurotomy with or without appropriate diagnostic evaluation by controlled lumbar facet joint blocks. The most commonly reported adverse events include increased pain (usually temporary) due to neuritis and cutaneous dysaesthesias.
There is insufficient evidence (no evidence from SRs) to recommend for or against the following interventions for acute or subacute low back pain
· Craniosacral massage/therapy
· Interferential current therapy
· Manual therapy – spinal mobilization
· Modified work duties for facilitating return to work
· Shock-wave treatment
· Tapentadol (Nucynta®)
· Touch therapies
· Yoga therapy
There is inconclusive evidence to recommend for or against the following interventions for chronic low back pain:
· Gravity tables (inversion/inverted traction, self-traction, gravitational traction)
· Low-level laser therapy
· Mindfulness-based meditation
· Shock-wave treatment
· Spa therapy
· Trigger point injections
There is insufficient evidence (no evidence from SRs) to recommend for or against the following interventions for chronic low back pain
· Back belts, corsets, non-motorized traction, or over-the-counter TENS
· Buprenorphine Transdermal system
· Craniosacral massage/therapy
· Intramuscular stimulation
· Interferential current therapy
· Tapentadol (Nucynta®)
· Topical NSAIDs
· Touch therapies
Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen WM, et al. Clinical Practice Guideline: Chiropractic Care for Low Back Pain. J Manipulative Physiol Ther 2016;39:1-22
The use of therapeutic modalities (ie, ultrasonography, electrical stimulation, etc) in isolation, their use as part of a passive-to-active care multimodal approach to LBP management may be warranted based on clinician judgment and patient preferences.
Lumbar supports (bracing/taping/orthoses) are not recommended for routine use
Low Back Pain: Medical Treatment Guidelines. July 2007. Department of Labor and Employment, State of Colorado, USA.
Electromyography (EMG), Nerve Conduction Studies (NCS): These are generally accepted, well-established, and widely used diagnostic procedures. EMG and NCS, when performed and interpreted by a trained physician/electrophysiologist, may be useful for patients with suspected neural involvement whose symptoms are persistent or unresponsive to initial conservative treatments.
Zygapophyseal (Facet) Injection -
This is an accepted intra-articular or pericapsular injection of local anesthetic and corticosteroid with very limited uses. There is no justification for a combined facet and medial branch block. A high quality meta-analysis provides good evidence against the use of lumbar facet or epidural injections for relief of non-radicular low back pain. Facet injections have very limited use.
Iontophoresis: There is no proven benefit for this therapy in the low back. Not recommended due to lack of evidence in the lumbar spine.
Low Level Laser: Not recommended as there is no proven benefit for this intervention due to lack of studies of sufficient quality.
Manipulation under General Anesthesia (MUA): Refers to manual manipulation of the lumbar spine in combination with the use of a general anesthetic or conscious sedation. It is intended to improve the success of manipulation when pain, muscle spasm, guarding, and fibrosis appear to be limiting its application in patients otherwise suitable for their use. There have been no high-quality studies to justify its benefits given the risks of general anesthetic and conscious sedation. It is not recommended.
Manipulation under Joint Anesthesia (MUJA): Refers to manipulation of the lumbar spine in combination with a fluoroscopically guided injection of anesthetic, with or without corticosteroid agents, into the facet joint at the level being manipulated. There are no controlled clinical trials to support its use. It is not recommended.
An accepted treatment that involves the use of equipment that exposes soft tissue to a magnetic or electrical field. Indications include enhanced collagen extensibility before stretching, reduced muscle guarding, reduced inflammatory response, and enhanced re-absorption of hemorrhage/hematoma or edema. Best practice suggests that this modality be accompanied by active therapy.
Traction – Manual: This is an accepted treatment and an integral part of manual manipulation or joint mobilization.
Traction – Mechanical: There is good evidence that mechanical traction is not useful for low back pain patients with sciatica nor those with low back pain without radicular symptoms. Therefore, it is not recommended in this population.
Transcutaneous Electrical Nerve Stimulation (TENS): Interferential squared wave with microcurrent, usually with four channels. A generally accepted treatment. TENS should include at least one instructional session for proper application and home use.
Ultrasound (including phonophoresis) There is no proven benefit for this therapy in the low back. Not recommended due to lack of evidence in the lumbar spine.
Vertebral Axial Decompression (VAX-D)/DRX, 9000: Motorized traction devices that purport to produce non-surgical disc decompression by creating negative intradiscal pressure in the disc space; included are devices with the trade names VAX-D and DRX 9000. There are no quality randomized studies to support their use. They are not recommended.
BIOFEEDBACK: Biofeedback is a form of behavioural medicine that helps patients learn self-awareness and self-regulation skills for the purpose of gaining greater control of their physiology, such as muscle activity, brain waves, and measures of autonomic nervous system activity.
INJECTIONS – SPINAL THERAPEUTIC: Therapeutic spinal injections have not been proven to change the long-term course of most patients with spinal pain. They have a limited role in treatment and should be used in only a small subset of patients where the criteria below have been clearly met.
INJECTIONS – OTHER (INCLUDING RADIO FREQUENCY): The following are in alphabetical order:
Botulinum Toxin Injections:
it is not recommended for use for low back pain or other myofascial trigger points
Epiduroscopy and Epidural Lysis of Adhesions Epiduroscopy-directed steroid injections are also not recommended because there is no evidence to support an advantage in using an epiduroscope with steroid injections.
The use of prolotherapy for low back pain is generally not recommended, as the majority of patients with SI joint dysfunction will do well with a combination of active therapy and manipulation and not require prolotherapy.
Radio Frequency Ablation - Dorsal Nerve Root Ganglion: Due to the combination of possible adverse side effects, time limited effectiveness, and mixed study results, this treatment is not recommended.
Cooled radiofrequency is generally not recommended due to current lack of evidence.
Radio Frequency Denervation - Sacro-iliac (SI) Joint Cooled: This procedure requires neurotomy of multiple nerves, L5 dorsal ramus, and lateral branches of S1-S3 under C-arm fluoroscopy. There is good evidence that cooled RF neurotomy performed in a highly selected population
Transdiscal Biacuplasty It is not recommended due to lack of published data demonstrating effectiveness.
Lumbar Corsets and Back Belts: There is insufficient evidence to support their use. They are an accepted treatment with limited application.
DISCECTOMY (USUALLY ACCOMPANIED BY PARTIAL LAMINECTOMY): To enter into and partially remove the disc. May be an open procedure or minimally invasive, and usually involves partial laminectomy. Surgical Indications: To include all of the following: specific diagnosis of nerve root compression proven by MRI or CT myelogram and correlated to exam findings, primary radicular symptoms, radiculopathy on exam (Refer to beginning of this section G. for a description of radiculopathy) and failure of 6 weeks of active therapy. In some cases, surgery may need to occur sooner due to an individual’s inability to participate in active therapy. Epidural injections have not been proven to have long-term benefit; however they may be trialed prior to surgery if the patient wishes to try to avoid surgery or is unable to participate in therapy after the first 2 weeks. The purpose of spinal injections, as well as surgery, is to facilitate active therapy by providing short-term relief through reduction of pain. Since most patients with these conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Percutaneous discectomy is indicated only in cases of suspected septic discitis in order to obtain diagnostic tissue. The procedure is not recommended for contained disc herniations or bulges with associated radiculopathy due to lack of evidence to support long-term improvement.
LASER DISCECTOMY: Involves the delivery of laser energy into the center of the nucleus pulposus using a fluoroscopically guided laser fiber under local anesthesia. The energy denatures protein in the nucleus, causing a structural change, which is intended to reduce intradiscal pressure. Its effectiveness has not been shown. Laser discectomy is not recommended.
ARTIFICIAL LUMBAR DISC REPLACEMENT: There is some evidence that disc replacement has a slight advantage over multidisciplinary intensive treatment - 60 hours over 5 weeks.
KYPHOPLASTY: There is good evidence that kyphoplasty provides rapid improvement in function in the initial months after the fracture as compared to non-operative treatment or analgesics alone. There is no clear long-term advantage.
VERTEBROPLASTY: The available information suggests that vertebroplasty may be considered for a selected subgroup of patients with painful vertebral compression fractures if they:
PERCUTANEOUS RADIOFREQUENCY DISC DECOMPRESSION: An investigational procedure that introduces a 17 gauge cannula under local anesthesia and fluoroscopic guidance into the nucleus pulposus of the contained herniated disc, using radiofrequency energy to dissolve and remove disc material. Pressure inside the disc is lowered as a result. There have been no randomized clinical trials of this procedure at this time. Percutaneous radiofrequency disc decompression is not recommended.
NUCLEUS PULPOSUS REPLACEMENT: Involves the introduction of a prosthetic implant into the intervertebral disc, replacing the nucleus while preserving the annulus fibrosus. It is limited to investigational use in the United States at this time. It is not recommended.
LAMINOTOMY/LAMINECTOMY/FORAMENOTOMY/FACETECTOMY FOR CENTRAL OR LATERAL SPINAL STENOSIS:
Surgical Indications include all of the following:
• Radicular symptoms or symptoms of neurogenic claudication, often with clinical evidence of radiculopathy that correlates with the patient’s pain and findings.
• Evidence of nerve root compression generally proven by MRI or CT myelogram.
• Failure of non-surgical care. For patients with stenosis non-surgical active treatment should generally consist of 6 to 12 weeks for an adequate trial. Patients with severe stenosis that correlates with symptoms often do not improve with conservative care.
SPINAL FUSION: A timely decision-making process is recommended when considering patients for possible fusion. The treatment for some patients with lumbar fractures may be immediate fusion. For chronic low back problems, fusion should not be performed within the first five months of symptoms, except for fracture, dislocation, or for some patients with functional loss due to stenosis and instability.
DYNAMIC NEUTRALIZATION SYSTEM: At this time the procedure is not recommended.
SACROILIAC JOINT FUSION: Until the efficacy of this procedure for mechanical low back pain is determined by an independent valid prospective outcome study, this procedure is not recommended for mechanical low back pain.
IMPLANTABLE SPINAL CORD STIMULATORS: Reserved for those low back pain patients with pain, radiculopathy, and failed surgery of greater than six months duration who have not responded to the standard non-operative or operative interventions previously discussed within this document.
INTRADISCAL ELECTROTHERMAL ANNULOPLASTY (IDEA) (MORE COMMONLY CALLED IDET, OR INTRADISCAL ELECTROTHERMAL THERAPY): IDET is an outpatient procedure. A wire is guided into the identified painful disc using fluoroscopy. The wire is then heated at the nuclear annular junction within the disc. Due to lack of evidence indicating benefit from this procedure, it is not recommended.
INTERSPINAL SPACERS: The device is indicated for treatment of patients 50 or older suffering from neurogenic intermittent claudication caused by lumbar spinal stenosis (with X-ray, MRI and/or CT evidence of thickened flavum, narrowed lateral recess and/or central canal narrowing.