Saanichton Physical Therapy Blog

The Do, The Do not do, and the Do not know of Low Back Pain!

The Do, The Do not do, and the Do not know of Low Back Pain!

Major Recommendations for Evidence Based treatment for Low Back Pain

Toward Optimized Practice. Guideline for the evidence-informed primary care management of low back pain. Edmonton (AB): Toward Optimized Practice; 2011. p.37

The criteria used to determine the categorization of the recommendations (Do, Do Not Do, and Do Not Know) are defined at the end of the “Major Recommendations” field. In addition, an explanation of the evidence source (i.e., types of evidence and corresponding “seed” guidelines) are also available.

Note: Statements in italics relate to harm. These statements were sourced from the recommendations or elsewhere in the “seed” guidelines. An * indicates a recommendation was revised or a new recommendation was added since the previous version of the guideline. It is recognized that not all recommended treatment options are available in all communities.

Prevention of Occurrence and Recurrence of Low Back Pain

Recommendation Evidence Source
Do Patient Education

Practitioners should provide information or patient education material on back pain prevention and care of the healthy back that emphasizes patient responsibility and workplace ergonomics (see the patient brochures in the “Patient Resources” field).

Practitioners should emphasize that acute low back pain is nearly always benign and generally resolves within 1 to 6 weeks.

There is insufficient evidence to determine what quantity, intensity, or media is optimal for delivering this information (see the patient information sheets: “What You Should Know About Acute Low Back Pain” and “What You Should Know About Chronic Low Back Pain” and patient booklets: “Acute Low Back Pain: So Your Back Hurts … Learn what works, what doesn’t and how to help yourself” and “Chronic Low Back Pain: So Your Back Hurts … Learn what works, what doesn’t and how to help yourself” [see the “Patient Resources” field]).

Patient information and educational material based on a biomedical or biomechanical model (anatomical and “traditional” posture information) can convey negative messages about back pain and is not recommended.

SR (G2, G5)
Do Physical Activity

Physical activity is recommended. There is insufficient evidence to recommend for or against any specific kind of exercise, or the frequency/intensity of training.

SR (G5)
Do Not Do Shoe Insoles/Orthoses

The use of shoe insoles or orthoses is not recommended for prevention of low back pain.

RCT (G5)
Do Not Do Lumbar Supports*

The use of lumbar supports is not recommended for the prevention of low back pain.

RCT (G3) + SR (IHE Database)
Do Not Know Spinal Manipulative Therapy or Spinal Mobilization

No evidence was found to support recommending regular manipulative treatment for the prevention of low back pain.

RCT (G5)
Do Not Know Risk Factor Modification

Although overweight/obesity and smoking are associated with the increased prevalence of low back pain, there is insufficient evidence to recommend modifying these risk factors for the prevention of low back pain. There is insufficient evidence to recommend reducing alcohol consumption for the prevention of low back pain.

SR (G3, IHE Database)
Do Not Know There is insufficient evidence to recommend for or against the following interventions for preventing low back pain:
Any specific type of mattress RCT (G5)
Any specific type of chair CS (G5)

Acute and Subacute Low Back Pain

Recommendation Evidence Source
Do Diagnostic Triage

The first qualified practitioner with the ability to do a full assessment (i.e., history-taking, physical and neurological examination, and psychosocial risk factor assessment) should assess the patient and undertake diagnostic triage. (See Appendix A in the original guideline document for summary of red and yellow flags and “Clinical assessment for psychosocial yellow flags” and “What can be done to help somebody who is at risk?” [see the “Availability of Companion Documents” field].)

If serious spinal pathology is excluded, manage as non-specific low back pain as per the reassessment and treatment recommendations below.

SR (G2, G4)
Do Ankylosing Spondylitis*

Consider a diagnosis of ankylosing spondylitis, particularly in younger adults who, in the absence of injury, present with a history of needing to get out of bed at night and reduced side bending.

SR (G1)
Do Emergent Cases

Patients with red flags (see Appendix A in the original guideline document for red flag definitions) indicating a high likelihood of serious underlying pathology should be referred for immediate evaluation and treatment to an appropriate resource depending on what is available in your region (e.g., emergency room, relevant specialist.)

EO (G2)
Do Cases Requiring Further Evaluation

Schedule an urgent appointment with a physician if any of the red flags are present. (See Appendix A in the original guideline document for red flag definitions.)

EO (G2)
Do Referral to a Spinal Care Specialist

Patients with disabling back or leg pain or significant limitation of function including job related activities should be referred within 2-6 weeks to a trained spinal care specialist such as a physical therapist, chiropractor, osteopathic physician or physician who specializes in musculoskeletal medicine.

EO (G2)
Do Referral for Magnetic Resonance Imaging (MRI) and Possible Surgical Opinion for Radiculopathy*

If the patient has radiculopathy (leg-dominant pain) that persists after 6 weeks of conservative treatment, consider referral for MRI. If clinical and imaging findings correlate, consider referral to a spinal surgeon.

CS (G8)
Do Laboratory Testing

If cancer or infection is suspected, order the appropriate blood tests. In the absence of red flags, no laboratory tests are recommended.

EO (G2)
Do Psychosocial Risk Factors

Primary care evaluation should include assessment for psychosocial risk factors (“yellow flags”) and a detailed review if there is no improvement (see Appendix A in the original guideline document for summary of yellow flags and “Clinical assessment for psychosocial yellow flags” and “What can be done to help somebody who is at risk?” [see the “Availability of Companion Documents” field]). Psychosocial risk factors (yellow flags) include fear, financial problems, anger, depression, job dissatisfaction, family problems, or stress.

SR (G2, G4)
Do Reassessment of Patients Whose Symptoms Fail to Resolve

Reassess patients whose symptoms are not resolving. Follow-up in 1 week if pain is severe and has not subsided. Follow-up in 3 weeks if moderate pain is not improving. Follow-up in 6 weeks if not substantially recovered. If serious pathology (red flag) is identified, consider further appropriate management. Identify psychosocial risk factors (yellow flags) and address appropriately (see Appendix A in the original guideline document for definitions of red and yellow flags and “Clinical assessment for psychosocial yellow flags” and “What can be done to help somebody who is at risk?” for chronicity and increased disability [see the “Availability of Companion Documents” field]).

G (G2, G4)
Do Information and Reassurance

Educate the patient and describe the benign long-term course of low back pain.

Provide education materials that are consistent with your verbal advice, to reduce fear and anxiety and emphasize active self-managements (see “What you should know about acute low back pain” and “Acute low back pain – so your back hurts … Learn what works, what doesn’t and how to help yourself” [see the “Patient Resources” field]).

Other methods for providing self-care education, such as e-mail discussion groups and videos, are not well studied, but may also be beneficial (see http://www.ihe.ca/research/lbpvideo/ External Web Site Policy).

SR (G1)
Do Advice to Stay Active

Patients should be advised to stay active and continue their usual activity, including work, within the limits permitted by the pain. Physical exercise is recommended.

Patients should limit/pace any activity or exercise that causes spread of symptoms (peripheralization). Self-treating with an exercise program not specifically designed for the patient may aggravate symptoms.

SR (G1, G2, G4)
Do Return to Work

Encourage early return to work.

Refer workers with low back pain beyond 6 weeks to a comprehensive return-to-work rehabilitation program. Effective programs are typically multidisciplinary and involve case management, education about keeping active, psychological or behavioral treatment and participation in an exercise program.

Working despite some residual discomfort poses no threat and will not harm patients.

SR (G1, G2)
Do Heat or Cold Packs

Superficial heat (application of heating pads or heated blankets) is recommended for the short term relief of acute low back pain. Clinical experience supports a role for superficial cold packs and alternating heat and cold as per patient preference.

Heat or cold should not be applied directly to the skin, and not for longer than 15 to 20 minutes. Use with care if lack of protective sensation.

SR (G1)
Do Analgesia

Prescribe medication, if necessary, for pain relief preferably to be taken at regular intervals. First choice acetaminophen; second choice non-steroidal anti-inflammatory drugs (NSAIDs).

Only consider adding a short course of muscle relaxant (benzodiazepines, cyclobenzaprine, or antispasticity drugs) on its own, or added to NSAIDs, if acetaminophen or NSAIDs have failed to reduce pain.

Serious adverse effects of NSAIDs include gastrointestinal complications (e.g., bleeding, perforation and increased blood pressure). Drowsiness, dizziness, and dependency are common adverse effects of muscle relaxants (see Medication Table in Appendix B of the original guideline document).

SR (G1, G2b, G4, G7, IHE Database)
Do Spinal Manipulation

Patients who are not improving may benefit from referral for spinal manipulation provided by a trained spinal care specialist such as a physical therapist, chiropractor, osteopathic physician or physician who specializes in musculoskeletal medicine.

Risk of serious complication after spinal manipulation is low (estimated risk: cauda equina syndrome, less than 1 in one million). Current guidelines contraindicate manipulation in people with severe or progressive neurological deficit.

SR (G1, G4)
Do Multidisciplinary Treatment Programs for Subacute Low Back Pain*

For subacute low back pain (duration 4 to 8 weeks), intensive interdisciplinary rehabilitation (defined as an intervention that includes a physician consultation coordinated with a psychological, physical therapy, social, or vocational intervention) is moderately effective.

Functional restoration with a cognitive-behavioral component reduces work absenteeism due to subacute low back pain in occupational settings.

SR (G1)
Do Not Do Bed Rest

Do not prescribe bed rest as a treatment.

If the patient must rest, bed rest should be limited to no more than 2 days. Prolonged bed rest for more than 4 days is not recommended for acute low back problems. Bed rest for longer than two days increases the amount of sick leave compared to early resumption of normal activity in acute low back pain.

There is evidence that prolonged bed rest is harmful.

SR (G2, G4, G7)
Do Not Do Diagnostic Imaging

For acute low back pain (no red flags), diagnostic imaging tests, including X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) are not indicated.

In the absence of red flags, routine use of X-rays is not justified due to the risk of high doses of radiation and lack of specificity.

SR (G1, G4, G8)
Do Not Do Traction

Do not use traction. Traction has been associated with significant adverse events.

Passive treatment modalities such as traction should be avoided as monotherapy and not routinely be used because they may increase the risk of illness behavior and chronicity.

The following adverse effects from traction were reported: reduced muscle tone, bone demineralization, and thrombophlebitis.

SR (G1, G4, G7)
Do Not Do Therapeutic Ultrasound*

Do not use therapeutic ultrasound for acute or subacute low back pain.

RCT (G1) + SR (IHE database)
Do Not Do Transcutaneous Electrical Nerve Stimulation (TENS)

TENS is not recommended for the treatment of acute non-specific low back pain.

SR (G1, G4)
Do Not Do Oral Steroids

Do not use oral steroids for acute low back pain.

EO (G2)
Do Not Do Systemic Steroids*

Systemic corticosteroids (intramuscular injection) are not effective for the treatment of patients with acute low back pain and a negative result on a straight-leg-raise test.

RCT(G1)
Do Not Do Epidural Steroids in the Absence of Radiculopathy

Do not use epidural steroid injections for acute low back pain without radiculopathy.

SR (G4)
Do Not Know Epidural Steroids in the Presence of Radiculopathy*

It may be helpful to use epidural steroid injections for patients with radicular pain for longer than 6 weeks who have not responded to first line treatments.

Fluoroscopy improves/verifies accuracy. Even in the most experienced hands, epidural injections can be misplaced.

Adverse effects are infrequent and include headache, fever, subdural penetration and more rarely epidural abscess and ventilatory depression.

SR (G4)
Do Not Know Narcotic Analgesics (Opioids)*

There is insufficient evidence to recommend the use of opioids in the treatment of acute low back pain. However clinical experience suggests the use of opioids may be necessary to relieve severe musculoskeletal pain. If used, opioids are preferable for only short term intervention. Ongoing need for opioids is an indication for reassessment.

In general, opioids and compound analgesics have a substantially increased risk of side effects compared with acetaminophen alone.

SR (G1, G2b, G7, IHE Database)
Do Not Know Therapeutic Exercise

There is insufficient evidence to recommend for or against any specific kind of exercise, or the frequency/intensity of training. Clinical experience suggests that supervised or monitored therapeutic exercise may be useful following an individualized assessment by a spine care specialist. For patients whose pain is exacerbated by physical activity and exercise, refer to a physical therapist, chiropractor, osteopathic physician, or physician who specializes in musculoskeletal medicine for therapeutic exercise recommendations.

Patients should discontinue any activity or exercise that causes spread of symptoms (peripheralization). Self-treating with an exercise program not specifically designed for the patient may aggravate symptoms.

SR (G2, G4, IHE Database)
Do Not Know Multidisciplinary Treatment Programs for Acute Low Back Pain*

No evidence was found to support recommending interdisciplinary rehabilitation for acute low back pain (pain <4 weeks).

SR (G1)
Do Not Know There is insufficient evidence to recommend for or against the following interventions for acute or subacute low back pain:
Acupuncture SR (G7, IHE Database)
Adjuvant therapies: antidepressants and anticonvulsants* EO (G1)
Back schools* SR (G1)
Herbal medicine* SR (IHE Database)
Low-level laser therapy* RCT (G1) + SR (IHE database)
Massage therapy* SR (G1, IHE Database)
Modified work duties for facilitating return to work* RCT (G1)
Operant conditioning provided by a physiotherapist* SR (IHE Database)
Short-wave diathermy* RCT (G1) + SR (IHE database)
Topical NSAIDs* SR (IHE Database)
No evidence from SR(s) was found to support recommending the following interventions for acute or subacute low back pain:
Interferential current therapy* EO (GDG)
Touch therapies* EO (GDG)
Yoga therapy* EO (GDG)

Chronic Low Back Pain

Recommendation Evidence Source
Do Diagnostic Tests

In chronic low back pain, X-rays of the lumbar spine are very poor indicators of serious pathology. Hence, in the absence of clinical red flags spinal x-rays are not encouraged. More specific and appropriate diagnostic imaging should be performed on the basis of the pathology being sought (e.g., dual energy X-ray absorptiometry [DEXA] scan for bone density, bone scan for tumors and inflammatory diseases). However, lumbar spine X-rays may be required for correlation prior to more sophisticated diagnostic imaging, for example prior to a magnetic resonance imaging (MRI) scan. In this case, the views should be limited to standing anterior-posterior (AP) and lateral in order to achieve better assessment of stability and stenosis. Oblique views are not generally recommended. Computed tomography (CT) scans are best limited to suspected fractures or contraindication to MRI.

In the absence of red flags, radiculopathy, or neurogenic claudication, MRI scanning is generally of limited value.

Oblique view X-rays are not recommended; they add only minimal information in a small percentage of cases, and more than double the patient’s exposure to radiation.

EO (GDG)
Do Laboratory Testing

If cancer or infection is suspected, order the appropriate blood tests. In the absence of red flags, no laboratory tests are recommended.

EO (GDG)
Do Physical Exercise

Patients should be encouraged to initiate gentle exercise and gradually increase their exercise level within their pain tolerance.

Sophisticated equipment is not necessary. Low cost alternatives include unsupervised walking and group exercise programs such as those offered though chronic disease management programs. The peer support of group exercise is likely to result in better outcomes, giving patients improved confidence and empowering them to manage with less medical intervention.

When exercise exacerbates the patient’s pain, the exercise program should be assessed by a qualified physical therapist or exercise specialist.

If exercise persistently exacerbates their pain, patients should be further assessed by a physician to determine if further investigation, medication, treatment, or consultation is required.

Some studies reported mild negative reactions to the exercise programs, such as increased low back pain and muscle soreness in some patients.

SR (G6)
Do Therapeutic Exercise

A client-specific, graded, active therapeutic exercise program is recommended.

EO (GDG)
Do Therapeutic Aquatic Exercise*

Therapeutic aquatic exercise is recommended for chronic low back pain.

SR (IHE Database)
Do Yoga Therapy*

There is some evidence that Viniyoga and Iyengar types of yoga can be helpful in the treatment of chronic low back pain.

No evidence was found to support recommending other types of yoga.

It is important to find an instructor who has experience in working with individuals who have low back pain to avoid further injury.

SR (IHE Database)
Do Active Rehabilitation

An active rehabilitation program includes:

  • Education about back pain principles
  • Self-management programming (see Self-Management Programs recommendation)
  • Gradual resumption of normal activities (including work and physical exercise as tolerated)
  • Therapeutic exercise (see Therapeutic Exercise recommendation)
EO (GDG)
Do Self-Management Programs

Where available, refer to a structured community-based self-management group program for patients who are interested in learning pain coping skills. These programs are offered through chronic disease management and chronic pain programs. Self-management programs focus on teaching core skills such as self-monitoring of symptoms to determine likely causal factors in pain exacerbations or ameliorations, activity pacing, relaxation techniques, communication skills, and modification of negative ‘self-talk’ or catastrophizing. These programs use goal setting and ‘homework assignments’ to encourage participants’ self confidence in their ability to successfully manage their pain and increase their day-to-day functioning. Most community-based programs also include exercise and activity programming which are also recommended.

Where structured group programs are not available, refer to a trained professional for individual self-management counseling.

G (G6)
Do Massage Therapy

Massage therapy is recommended as an adjunct to an overall active treatment program.

SR (G6)
Do Acupuncture

Acupuncture is recommended as a stand-alone therapy or as an adjunct to an overall active treatment program.

No serious adverse events were reported in the trials. The incidence of minor adverse events was 5% in the acupuncture group.

SR (G6)
Do Acetaminophen and Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)*

Acetaminophen and NSAIDs are recommended. No one NSAID is more effective than another.

A proton pump inhibitor (PPI) should be considered for patients over 45 years of age when offering treatment with an oral NSAID/cyclooxygenase (COX)-2 inhibitor.

NSAIDs are associated with mild to moderately severe side effects such as: abdominal pain, bleeding, diarrhea, edema, dry mouth, rash, dizziness, headache, tiredness. There is no clear difference between different types of NSAIDs (see Medication Table in Appendix B in the original guideline document).

SR (G6, IHE Database)
Do Muscle Relaxants

Some muscle relaxants (e.g., cyclobenzaprine) may be appropriate in selected patients for symptomatic relief of pain and muscle spasm.

Caution must be exercised with managing side effects, particularly drowsiness, and also with patient selection, given the abuse potential for this class of drugs (see Medication Table in Appendix B in the original guideline document).

SR (G6)
Do Antidepressants

Tricyclic antidepressants have a small to moderate effect for chronic back pain, at much lower doses than might be used for depression.

Possible side-effects include drowsiness and anticholinergic effects (see Medication Table in Appendix B in the original guideline document).

SR (G6, IHE Database)
Do Opioids

Long-term use of weak opioids, like codeine, should only follow an unsuccessful trial of non-opioid analgesics. In severe chronic pain, opioids are worth careful consideration. Long-acting opioids can establish a steady state blood and tissue level that may minimize the patient’s experience of increased pain from medication withdrawal experienced with short acting opioids.

Careful attention to incremental changes in pain intensity, function, and side effects is required to achieve optimal benefit. Because little is known about the long-term effects of opioid therapy, it should be monitored carefully.

Opioid side-effects (including headache, nausea, somnolence, constipation, dry mouth, and dizziness) should be high in the differential diagnosis of new complaints.

A history of addiction is a relative contraindication. Consultation with an addictions specialist may be helpful in these cases.

Consult the National Guideline Clearinghouse summary of the National Opioid Use Guideline Group guideline Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, endorsed by the College of Physicians & Surgeons of Alberta (CPSA) (see also Medication Table in Appendix B in the original guideline document).

SR (G6, IHE Database)
Do Herbal Medicine*

The following herbal medicines can be considered as treatment options for acute exacerbations of chronic low back pain:

  • An aqueous extract of Harpagophytum procumbens (also called Devil’s claw, grapple plant, wood spider) at a standardized daily dosage of 50 mg harpagoside
  • A combination of extract of Salix daphnoides and Salix purpurea (also called purple willow, red willow) at a standardized dosage of 240 mg salicin/day
  • A plaster of Capsicum frutescens (also called bird pepper, hot pepper, red chili, spur pepper, Tabasco pepper)

Devil’s claw was associated with the following adverse events: repeated coughs, tachycardia, and gastrointestinal upset. Use of Capsicum frutescens plaster was associated with inflammatory contact eczema, urticaria, minute haemorrhagic spots, vesiculation or dermatitis, sensation of warmth locally and pruritus.

Patients should be advised to read the product ingredients to ensure they are getting the correct amount and correct product mentioned in the recommendation. It is important to be aware that a product could list on the label different extracts of the same active ingredient (e.g., Devil’s claw and wood spider).

Devil’s claw, Salix and Capsicum frutescens are currently regulated by Health Canada.

SR (IHE Database)
Do Behavioral Therapy/Progressive Muscle Relaxation

Where group programs are not available, consider referral for individual cognitive behavioral treatment provided by psychologist or other qualified provider.

SR (G6)
Do Multidisciplinary Treatment Program

Referral to a multidisciplinary chronic pain program is appropriate for patients who are significantly affected by chronic pain and who have failed to improve with adequate trials of first line treatment. Get to know the multidisciplinary chronic pain program in your referral area and use it for selected cases of chronic low back pain.

SR (G6)
Do Injection Therapy*

The following injection therapies may be beneficial for carefully selected patients (see Appendix C in the original guideline document) with a clinical diagnosis of pain originating from the lumbar facet joints:

  • Intra-articular facet joint blocks
  • Medial branch blocks (studies show benefit for up to 6 weeks, and sometimes longer)
  • Medial branch neurotomy (studies demonstrate pain relief lasting longer than 3 months)

The clinical diagnosis of facet joint pain lacks specificity and may be best determined by a trained spinal care specialist.

The most commonly reported adverse events are:

  • Facet joint interventions: haematoma, steroid side effects, accidental dural puncture and infection.
  • Radiofrequency denervation: increased pain (usually temporary) due to neuritis, and cutaneous dysaesthesias.
SR (IHE Database)
Do Epidural Steroid Injections

For patients with leg pain, epidural steroid injections can be effective in providing short-term pain relief.

Fluoroscopy improves/verifies accuracy. Even in the most experienced hands, epidural injections can be misplaced.

Transient minor complications include: headache, nausea, pruritus, increased pain of sciatic distribution, and puncture of the dura.

SR (G6)
Do Referral for Surgical Opinion on Spinal Fusion*

Consider referral for an opinion on spinal fusion for patients who:

  • Have completed an optimal package of care including a combined physical and psychological treatment program (usually 6 months of care); and
  • Still have severe low back pain for which the patient would consider surgery, particularly if related to spinal stenosis with leg pain.

Offer anyone with significant psychological distress appropriate treatment for this before referral for an opinion on spinal fusion.

Refer the patient to a specialist spinal surgical service if spinal fusion is being considered. Give due consideration to the possible risks in that patient. Counsel the patient that surgery may not be an option in his/her case.

EO (GDG)
Do Not Do Selective Serotonin Reuptake Inhibitors (SSRIs)*

Do not offer SSRIs for treating chronic low back pain. They may, however, be indicated for co-morbid depression.

SR (IHE Database)
Do Not Do Motorized Traction*

Do not use motorized traction for chronic low back pain.

SR (IHE Database)
Do Not Do Prolotherapy as a Sole Treatment*

Prolotherapy is not recommended as a sole treatment for chronic low back pain.

SR (G6)
Do Not Do Transcutaneous Electrical Nerve Stimulation (TENS) as a Sole Treatment*

TENS is not recommended as a sole treatment for chronic low back pain.

SR (G6)
Do Not Know Lumbar Discography as a Diagnostic Test*

There is insufficient evidence to recommend for or against the use of lumbar discography as a diagnostic test.

SR (IHE Database)
Do Not Know Prolotherapy as an Adjunct Treatment*

Prolotherapy may be useful for carefully selected and monitored patients who are participating in an appropriate program of therapeutic exercise and/or manipulation/mobilization.

The most commonly reported adverse events were temporary increases in back pain and stiffness following injections. Some patients had severe headaches suggestive of lumbar puncture, but no serious or permanent adverse events were reported.

EO (G6)
Do Not Know Transcutaneous Electrical Nerve Stimulation (TENS) as an Adjunct Treatment*

TENS may be useful as an adjunct in select patients for pain control to reduce the need for medications. A short trial (2 to 3 treatments) using different stimulation parameters should be sufficient to determine if the patient will respond to this modality.

Skin irritation is a common adverse event.

EO (G6)
Do Not Know Therapeutic Ultrasound*

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.

SR (IHE Database)
Do Not Know There is insufficient evidence to recommend for or against the following interventions for chronic low back pain:
Low-level laser therapy* SR (IHE Database)
Spa therapy* SR (IHE Database)
Spinal manipulative treatment or spinal mobilization SR (G6, IHE Database)
No evidence from SR(s) was found to support recommending the following interventions for chronic low back pain:
Buprenorphine transdermal system* EO (GDG)
Duloxetine* EO (GDG)
Intramuscular stimulation* EO (GDG)
Interferential current therapy* EO (GDG)
Topical NSAIDs* EO (GDG)
Touch therapies* EO (GDG)

Definitions:

Summary of Criteria to Determine the Categorization of Recommendations

Do
  • The Guideline Development Group (GDG) accepted the original recommendation, which provided a prescriptive direction to perform the action or used the term “effective” to describe it.
  • The GDG supplemented a recommendation or created a new one, based on their collective professional opinion, which supported the action.
  • A supplementary literature search found at least one systematic review presenting consistent evidence to support the action.
Do Not Do
  • The GDG accepted the original recommendation, which provided a prescriptive direction “not” to perform the action; used the term “ineffective” to describe it; or stated that the evidence does “not support” it.
  • The GDG supplemented a recommendation or created a new one, based on their collective professional opinion, which did not support the action.
  • A supplementary literature search found at least one systematic review presenting consistent evidence that did not support the action.
Do Not Know
  • The GDG accepted the original recommendation, which did not recommend for or against the action or stated that there was “no evidence”, “insufficient or conflicting evidence”, or “no good evidence” to support its use.
  • The GDG supplemented a recommendation or created a new one, based on their collective professional opinion, which was equivocal with respect to supporting the action.
  • A supplementary literature search found either no systematic reviews or at least one systematic review presenting conflicting or equivocal results or stating that the evidence in relation to the action was “limited”, “inconclusive”, “inconsistent”, or “insufficient”.

Evidence Source

The Evidence Source provides information on the “seed” guideline(s) that were used to develop the Alberta guideline recommendations and the design of the studies referenced by the seed guideline(s) in support of their recommendations.

Evidence source legend:

  • Systematic review – SR
  • Randomized controlled trial – RCT
  • Case series – CS
  • Guideline – G
  • Expert opinion as cited by the seed guideline(s) – EO
  • Collective EO of the Ambassador Guideline Development Group (GDG) – EO (GDG)
  • Institute for Health Economics – IHE