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International Guidelines For Low Back Pain

When it comes to low back pain it seems like everyone has some piece of advice. “Don’t get a massage”, “rest in bed”, “seeing a chiropractor will make it worse”. So how do you know what advice is good advice?

Generally speaking, treatments that have clinical data to back them up are probably going to be more reliable, but unfortunately not all clinical studies are created equally.

Some studies require very careful reading to see how many people they studied, who sponsored the study, and what was the result? Was it significant? But honestly, if you aren’t a professional researcher, who has time for that sort of bedtime reading?

LivaFortis's latest blog looks at some of the international guidelines surrounding low back pain.

Who Can We Trust?

When it comes to research on the best practices for treating low back pain, fortunately there are some professionals that we can turn to, who have taken the time to thoroughly investigate all of the treatment options available and who have extensively examined the research behind them. These professionals come in the form of workgroups and professional medical organizations such as the American Academy Of Family Physicians (AAFP) and the World Health Organization (WHO).

How Do The Recommendations Work?

If we are looking at research and recommendations, these professional medical organizations (who are not affiliated with any privately held companies) have recommendations either for, or against treatments. The recommendations weigh up the desirable and undesirable outcomes. If there is a recommendation against a therapy it means that the undesirable consequences outweigh the desirable ones. If there is insufficient evidence to either promote or discourage a practice, then they will often say that the evidence is inconclusive at the moment.

LivaFortis looks at guidelines from the WHO, European guidelines, VA guidelines and AAFP and found that they are all fairly similar in treatment recommendations for chronic low back pain.

Who is Included?

Clinical guidelines from 11 different countries were used in the World Health Organization’s (WHO) recommendations. They found that the content of those guidelines from the different countries were quite similar in many aspects. They did have a few discrepancies on different treatment options, so, with that in mind, we decided to go through some of the more common approaches to treating low back pain, and let you know which guidelines were for them, and which ones did not think they were worthwhile. We are going to look at the AAFP, Veterans Administration, European, UK and WHO guidelines on chronic low back pain.

Hopefully this article will give you a starting point to save you some time and research, but if you disagree with how a guideline has rated a treatment then you might want to do some more research on it yourself. Of course, you can always save yourself some time and wait for another of our blogs to come out. We love doing research! So, with that in mind, let’s check out some of the popular treatments and see where they stand.

Education around low back pain issues is a key recommendation for all guidelines.


Almost every set of guidelines starts with education. Knowing what causes low back pain, what it means, and how to avoid it in future is key. Since most cases of low back pain resolve on their own it is good to know that there are some simple things that you can do to reduce back pain or prevent it from occurring again.

Learning that it is important to stay active and avoiding the common myth that resting is good for low back pain is one of the first things to know about low back pain. It is important for sufferers to know that they should try to return to normal activities as soon as possible. It is also important to know how to bend and reach in a proper way so as to not cause future or further injuries. All of the guidelines are in agreement on educating individuals around their condition first and foremost.

Except for NSAIDs, most of the guidelines recommend trying to reduce or refrain from using medication to treat low back pain.


When it comes to low back pain there is a big shift in moving away from using medication to manage the condition. The United States prescribed opioids at two to three times the rate that European countries do. When used for the treatment of low back pain, there is actually very little evidence that opioids are effective at reducing pain. Opioids have not shown any use in speeding up the return to work for injured workers, and they have not shown any major efficacy in improving functional outcomes, either.

When researchers look at the benefits of opioids compared to their side effects, it doesn’t seem like opioids have much to offer. Complications from opioid use give rise to addiction and overdoses, often resulting in death. The side effects aren’t much better and include constipation, nausea, sedation, as well as depression and sexual dysfunction. Almost all the guidelines, with the exception of the AAFP are strongly against opioids for the long term treatment of chronic low back pain.

Benzodiazepines are a class of drugs that the VA, European Guidelines, AAFP, UK and the WHO are all strongly against.

Benzodiazepines are a class of drugs that the VA, European Guidelines, AAFP, UK and the WHO are all strongly against. Systemic corticosteroids and steroid injections are also not highly recommended.

So, what medications do they recommend? All of the guidelines advise to treat low back pain with NSAIDs, but these are not always tolerated (see our blog on medications for low back pain). If you really need to use medication for low back pain for a limited time, then the VA does weakly recommend muscle relaxants. Generally speaking, however, all of the guidelines recommend treating low back pain without medication and trying other treatments instead.

All of the international guidelines for the treatment of low back pain recommend some form of exercise.

Exercise Therapy

Exercise therapy is one of the most widely recommended treatments for low back pain. Exercise is often recommended to patients with LBP because it reduces pain and helps maintain or restore flexibility, strength, and endurance. Since there is quite a lot of evidence around the effectiveness of exercise in treating low back pain, this treatment is unanimously recommended by all of the guidelines and it has strong support behind it. The bit that gets more complicated is what type of exercise therapy do they recommend?

Tai Chi, and yoga are recommended by the AAFP, the VA, and the WHO.

Tai Chi, and yoga are recommended by the AAFP, the VA, and the WHO. The European guidelines do not really specify which exercise types are preferred. The VA also recommends Pilates for chronic low back pain as well as ‘clinician directed exercise’.

Physical Therapy is recommended by the WHO and advocates for the use of heat therapy (strongly recommends) and massage. The UK guidelines and the AAFP also recommend heat therapy and massage.

Exercise programs that involve strengthening and endurance exercises have been proven to reduce low back pain and disability in chronic low back pain patients. Exercises that target core strengthening are recommended.

The UK is one country that does not recommend the use of acupuncture for the treatment of low back pain.


While more data would be helpful to strengthen the recommendation for the use of acupuncture in treating chronic low back pain, systematic reviews have shown that this treatment, used on its own or combined with conventional treatments, has shown short term improvements in pain and function for chronic low back pain sufferers. Based on this evidence, the AAFP and the VA recommend this as a treatment option. The UK, however, does not recommend using acupuncture. There is no recommendation on this from the EU or the WHO.

The international guidelines weakly recommend spinal manipulation for treating low back pain, as the research is not very strong to support it.

Spinal Manipulation

All guidelines apart from the EU recognize the effectiveness of spinal manipulation in the treatment of chronic low back pain. The AAFP recommends it strongly but recognizes that more data is still needed. The VA recommends it weakly. A study that looked at 47 different clinical trials with a total of almost ten thousand patients found that there was moderate evidence suggesting that SMT worked as well as other recommended therapies for short term pain relief, and a small clinical improvement in function.

When it comes to adverse effects, however, it has been documented that almost half of patients who undergo spinal manipulation experience mild to moderate effects such as headache, tiredness and radiating discomfort. It is with this in mind that it is recommended that low back pain sufferers are aware of the risks associated with spinal manipulation.

The psychosocial approach to treating low back pain believes that people's minds and spirits play a role in their physical illnesses, and treating mental health can have real physical benefits.

Psychosocial Approach

The psychosocial approach to low back pain recognizes that people cannot be separated from their condition. Basically, what this means, is that doctors are recognizing that our environment, our mental health, and our social support frame all affect low back pain. Psychological factors like depression and anxiety are considered as risk factors for developing persistent low back pain (LBP) and disability. In fact, LBP and psychosocial distress are two of the most frequent reasons for seeking health care and sickness absence. Psychological factors associated with chronic pain in general often include depression, PTSD, fear avoidance and anxiety.

CBT and mindfulness based stress reduction practices can play a role in reducing low back pain.

When we consider low back pain from a psychological standpoint we discover that therapies such as cognitive behavioral therapy (CBT) and mindfulness based stress reduction (MBSR) are highly effective tools in treating low back pain. CBT is a method that helps manage pain by changing the way a person thinks about it, and therefore changes their behaviour around pain. It is not intended to treat pain, but helps individuals manage their pain in a more positive manner.

MSBR is a treatment that focuses on increasing awareness and acceptance of moment-to-moment experiences which, in this case, would include the physical discomfort and difficult emotions that accompany low back pain. With MSBR people learn how they typically respond to stress or pain and they learn to accept the situation and respond in a manner of their choosing.

Social factors that impact chronic low back pain can include absenteeism from work, social isolation, and our social and economic infrastructures.

Social factors that impact chronic low back pain can include absenteeism from work, social isolation, and our social and economic infrastructures.

All of the guidelines recognize these therapies for the management of low back pain. Learning more about how stress affects the body and how we can manage our stress, thereby reducing low back pain, is an important feature of the psychosocial approach.

As more data emerges, and new products come to market, the guidelines may be reviewed over time.


With chronic low back pain affecting millions of individuals around the world, it is no wonder that research continues to take place in order to find effective treatments to this debilitating condition. Unfortunately there is no one-size fits all treatment for chronic low back pain since pain is so unique and so subjective.

The good news is that new research is constantly being done, and while these guidelines do provide a very comprehensive and evidence-based review of current treatments, there may be new data that emerges over time that will lead to new treatments being included.

What is exciting to see is the recognition of chronic low back pain sufferers as more than just their diagnosis. The new biopsychosocial approach takes a truly holistic approach to the management of this condition and looks at treatments accordingly. This is a very promising outlook for future discoveries.

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