Evidence-based treatment recommendations for neck and low back pain across Europe

Key points

• This systematic review identified 17 European clinical practice guidelines on neck and low back pain (11 low back, 5 neck, 1 both) from 8 countries; 7 were rated high quality with AGREE II.
• For low back pain, there were strong recommendations for advice and education, remaining active, exercise programmes/therapy and return-to-work programmes.
• For low back pain, there were strong recommendations against traction, electrotherapy, orthoses, anticonvulsants and spinal injections for non-specific low back pain, and a moderate recommendation against paracetamol.
• For neck pain, recommendations were weak or moderate, covering reassurance, advice and education, exercise, manual therapy combined with other treatment, topical medications and oral analgesics.
• Across both conditions, the recommended options were mainly non-pharmacological.

Overview

European guidelines broadly agree on a range of mainly non-pharmacological options for neck and low back pain: reassurance, advice and education, exercise, and manual therapy combined with active treatment, with psychological or multidisciplinary care for specific subgroups. Recommendations were generally stronger for low back pain than for neck pain, and analgesics were supported for neck pain but not for low back pain.

Guidelines reviewed

Searches of thirteen databases covered 1 January 2013 to 4 May 2020 for evidence-based European guidelines on primary care management of neck and low back pain in adults, issued by professional bodies or organisations. The guidelines came from Belgium, Denmark, France, Germany, Italy, the Netherlands, Poland and the UK. Quality was appraised with AGREE II, and the direction and strength of recommendations were synthesised across guidelines with predefined criteria; options recommended in only one guideline were not considered further.

Low back pain

Strong recommendations supported advice and education, remaining active, exercise programmes/therapy and return-to-work programmes. Moderate recommendations supported manual therapy combined with other treatment, group exercise programmes/back schools, psychological therapies combined with exercise, and work-based interventions. Psychological therapies, multidisciplinary treatment and referral for surgery were strongly supported for specific subgroups only. Bed rest (except for a few days in severe or acute cases) and imaging (except with red flags) were strongly recommended against, as were antidepressants and muscle relaxants, with exceptions. Recommendations were inconsistent for NSAIDs, opioids, epidural steroid injections, manual therapy alone, acupuncture and thermotherapy.

Neck pain

Moderate recommendations supported exercise programmes/therapy, exercise or manual therapy combined with other treatment, and topical medications. Weak recommendations supported reassurance, advice and education, remaining active, encouraging exercise, paracetamol, and NSAIDs and opioids including tramadol for short-term use. Psychological therapies and multidisciplinary treatment were weakly supported for specific subgroups. Recommendations were inconsistent or inconclusive for manual therapy alone, traction, electrotherapy, thermotherapy, cervical orthoses, acupuncture/dry needling and imaging. No neck pain option reached a strong recommendation.

Frequently asked questions

Is paracetamol recommended?

For low back pain the guidelines gave a moderate recommendation against paracetamol; for neck pain there was a weak recommendation for it.

When is imaging appropriate for low back pain?

Only with red flags, such as increased risk of fracture, infection, (metastatic) cancer, neurological emergencies including cauda equina syndrome, aortic aneurysm or systemic inflammatory arthritis, or with deterioration of symptoms.

What do neck and low back pain guidelines have in common?

Both support advice and education, reassurance, exercise, manual therapy combined with active treatment and psychological interventions, and both limit imaging to patients with red flags or where it is likely to change management.

Source

Corp N, Mansell G, Stynes S, Wynne-Jones G, Morsø L, Hill JC, et al. Evidence-based treatment recommendations for neck and low back pain across Europe: a systematic review of guidelines. Eur J Pain 2021;25(2):275-295. doi:10.1002/ejp.1679. Publisher licence CC BY-NC 4.0. Summary prepared by Medpresso from the accepted manuscript of the original publication; it is not a substitute for the full text or medical advice.