Education

Most guidelines suggest education and advice as a key intervention strategy^{[1][2][3][4][5][6][7]}.  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, progressively increase their activity levels and return to work as soon as possible.  This is particularly relevant for patients with acute back pain who are low risk of disbaility.

The NICE Guidelines^[1] summarise many of the available guidelines and state the following:

• Provide people with advice and information to promote self-management of their low back pain.
• Offer educational advice that includes information on the nature of non-specific low back pain and encourages the person to be physically active and continue with normal activities as far as possible.
• Include an educational component consistent with this guideline as part of other interventions, but do not offer stand-alone formal education programmes.
• Take into account the person’s expectations and preferences when considering recommended treatments, but do not use their expectations and preferences to predict their response to treatments.
• Advise people with low back pain that staying physically active is likely to be beneficial.
• Advise people with low back pain to exercise.

The STarT Back Approach also has some advice for us when educating individuals with LBP:

Language and labels

• Use functional explanations for pain (sprained back, non-serious back pain). Example: “Many people have back pain from time to time but it is rare for this to be caused by a specific problem. Mostly all that is needed is to get your back moving again and things will settle down.
• ”Avoid “spondylitis, degeneration, crumbling” etc.
• Can be more specific sometimes, for example sciatica, if this leads to specific management.
• Avoid investigating in the first place unless it is specifically indicated. However if you do so be aware that the technical terms used in reports often alarm patients. Translate appropriately, examples: “normal for your age ”, “ the changes seen on your scan are like getting grey hair or wrinkles as you get older”

Dealing with distress

• Suspend pre-judgment
• Listen carefully / summarize points
• Plan to address points
• Care with language and labels
• Be honest and realistic
• Do not criticize the opinions of other clinicians who have seen the patient.
• Provide information

Activity promotion

• Activity promotion: beneficial, hurt doesn’t equal harm, minimise bed rest
• Pacing: short, frequent bouts of activity rather than overdoing things and then regretting it the next day, rests between activity, do less than maximal capabilities and increase as tolerated.
• Return to work as soon as possible, prolonged absence likely to lead to loss of employment. Use fit notes to support return to work and communicate suggestions to the employer. Help the patient negotiate an early return to work if at all possible.

Exercise Therapy

There is now relatively large consensus across the various guidelines that specific back exercises (as opposed to the advice to stay active, including for example walking, cycling) are not recommended for patients with acute low back pain^[3].  There are now also more firm recommendations in favour of exercise therapy in patients with subacute and chronic low back pain^[3] but there is no evidence that one form of exercise is superior to another^[8].  

NICE Guidelines^[1] recommend offering a structured exercise programme tailored to the person. Exercise programmes may include aerobic activity, movement instruction, muscle strengthening, postural control and& stretching.  They should comprise up to a maximum of eight sessions over a period of up to 12 weeks, a group supervised exercise programme in a group of up to 10 people or one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.

Delitto ^[4]et al suggest that clinicians should consider:

• utilizing trunk coordination, strengthening, and endurance exercises to reduce low back pain and disability in patients with sub-acute and chronic low back pain with movement coordination impairments and in patients post lumbar microdiscectomy. 
• utilizing repeated movements, exercises, or procedures to promote centralization to reduce symptoms in patients with acute low back pain with related (referred) lower extremity pain. Clinicians should consider using repeated exercises in a specific direction determined by treatment response to improve mobility and reduce symptoms in patients with acute, subacute, or chronic low back pain with mobility deficits. 
• flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking, for reducing pain and disability in older patients with chronic low back pain with radiating pain.
• utilizing lower-quarter nerve mobilization procedures to reduce pain and disability in patients with subacute and chronic low back pain and radiating pain.
• moderate- to high-intensity exercise for patients with chronic low back pain without generalized pain
• incorporating progressive, low-intensity, submaximal fitness and endurance activities into the pain management and health promotion strategies for patients with chronic low back pain with generalized pain.

Manual Therapy

Manual Therapy refers to spinal manipulation (a low-amplitude, high-velocity movement at the limit of joint range that takes the joint beyond the passive range of movement), spinal mobilisation (joint movement within the normal range of motion) and massage (manual manipulation or mobilisation of soft tissues).

The recommendations regarding spinal manipulation continue to show some variation and systematic reviews have demonstrated marginal treatment effects across heterogeneous groups of patients with low back pain^[9][10]. In some guidelines manipulation is recommended, or presented as a therapeutic option, usually for short-term benefit, but others do not recommend it^[3].  The reason for these differences is probably that the underlying evidence is not strong enough to result in similar recommendations regarding manipulation across all guidelines, leaving more room for interpretation.  There may also be local and political reasons involved.  Recent research has demonstrated that spinal manipulative therapy is effective for subgroups of patients and as a component of a comprehensive treatment plan, rather than in isolation^[4]. Clinical prediction rules can be used to identify patients that will benefit form thrust manipulation^{[11][12][13][14]}.

The NICE guidelines recommend offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks in early management of non-specific LBP^[1].  

Delitto et al^[4] suggest that clinicians should consider utilising thrust manipulative procedures to reduce pain and disability in patients with mobility deficits and acute low back and back-related buttock or thigh pain.  Thrust manipulative and nonthrust mobilization procedures can also be used to improve spine and hip mobility and reduce pain and disability in patients with subacute and chronic low back and back-related lower extremity pain.

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^[4][15] and recent guidelines advise against traction as a treatment option^[8].

Electrotherapy

Evidence for efficacy of most electrotherapy modalities in the managment of low back pain is weak or lacking^[16][17].  Guidelines suggest that electrotherapy modalities (laser, interferrential, ultrasound, TENS) are not appropriate for non-specific low back pain^[3][1]  Passive treatment modalities (for example bed rest, massage, ultrasound, electrotherapy, laser and traction) should be avoided as mono-therapy and not routinely be used, because they may increase the risk of illness behaviour and chronicity^[18].

Cognitive Behavioural Therapy

Behavioral education, also known as cognitive behavioral theory, encompasses many aspects of patient education and counseling for patients with low back pain, including:

• Activity pacing
• Attention diversion
• Cognitive restructuring
• Goal setting
• Graded exposure
• Motivational enhancement therapy
• Maintenance strategies
• Problem-solving strategies

Henschke et al^[19] in a recent Cochrane review, concluded there is moderate-quality evidence that operant therapy and behavioral therapy are more effective than waiting-list or usual care for short-term pain relief in patients with chronic low back pain, but no specific type of behavioral therapy is superior to another. In the intermediate to long term, there is no established difference between behavioral therapy and group exercise for management of pain or depressive symptoms in patients with chronic low back pain.

The NICE guidelines^[1] suggest referral for a combined physical and psychological treatment programme that includes a cognitive behavioural approach and exercise, comprising around 100 hours over a maximum of 8 weeks, for people who have received at least one less intensive treatment and have high disability and/or significant psychological distress.

References

1. ↑ ^{1.01.11.21.31.41.5} National Institute for Health and Care Excellence. ↑ Hill J, D Whitehurst, Lewis M, Bryan S, Dunn K, Foster N, Konstantinou, Main C, Mason E, Somerville S, Sowden G, Vohora K, Hay E. A randomised controlled trial and economic evaluation of stratified primary care management for low back pain compared with current best practice: The STarT Back trial.The Lancet, Volume 378, Issue 9802, Pages 1560 – 1571, 29 October 2011
2. ↑ ^{3.03.13.23.33.4} Koes BW, van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C. ↑ 4.0^4.14.24.34.4 Anthony Delitto, Steven Z. George, Linda Van Dillen, Julie M. Whitman, Gwendolyn Sowa, Paul Shekelle, Thomas R. Denninger, Joseph J. Godges. 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. Journal of Orthopaedic and Sports Physical Therapy, 2012, 42(4)
3. ↑ Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 2018; 27: 60-75.
4. ↑ Van Wambeke P, Desomer A, Ailliet L, et al. Summary: ↑ Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017; 166: 514-530.
5. ↑ ^8.08.1 Almeida M, Saragiotto B, Richards B, Maher C. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018; 208 (6): 272-275
6. ↑ Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, hekelle PG. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev. 2004;CD000447.
7. ↑ Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med. 2003;138:871-881
8. ↑ Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila Pa 1976).
9. ↑ Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004;141:920-928.
10. ↑ Cleland JA, Fritz JM, Kulig K, et al. Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial. Spine (Phila Pa 1976).
11. ↑ Hancock MJ, Maher CG, Latimer J, Herbert RD, McAuley JH. Independent evaluation of a clinical prediction rule for spinal manipulative therapy: a randomised controlled trial. Eur Spine J. 2008;17:936-943.
12. ↑ Delitto A, Erhard RE, Bowling RW. ↑ Matthew S Thiese, Matthew Hughes and Jeremy Biggs. Electrical stimulation for chronic non-specific lowfckLRback pain in a working-age population: a 12-weekfckLRdouble blinded randomized controlled trial. BMC Musculoskeletal Disorders 2013, 14:117
13. ↑ GE Bekkering, HJM Hendriks, BW Koes, RAB Oostendorp, RWJG Ostelo, JMC Thomassen, MW van Tulder. ↑ van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, Koes B, Laerum E, Malmivaara A; COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care. Chapter 3. ↑ Henschke N, Ostelo RW, van Tulder MW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010;CD002014