RRS Education Research Reviews DATABASE

Research Review By Dr. Joshua Plener©

Audio:

Download MP3

Date Posted:

February 2021

Study Title:

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

Authors:

Kreiner S, Matz P, Bono C et al.

Author's Affiliations:

Barrow Neurological Institute, Phoenix AZ, USA; Advantage Orthopedics and Neurosurgery, Casper WY, USA; Massachusetts General Hospital, Boston MA, USA (and others)

Publication Information:

The Spine Journal 2020; 20(7): 998-1024.

Background Information:

The Low Back Pain Working Group of the North American Spine Society (NASS) created an evidence-based clinical guideline on nonspecific low back pain. This guideline provides a comprehensive overview of the diagnosis and treatment of nonspecific low back pain in adult patients.

This guideline sets out to provide recommendations to key clinical questions, and assign a grade based on the quality of the evidence.

Summary:

Overall, 82 clinical questions were addressed in this guideline. A total of 119 recommendations and two working group consensus statements were also issued.

 
Summary of Recommendations
 
Recommendations Related to the Diagnosis of Nonspecific Low Back Pain (LBP)

 
Grade A Recommendations:
  • Psychosocial factors and workplace factors need to be assessed as they are prognostic factors for the transition of acute to chronic LBP (1).
  • Pain severity and functional impairments can be used to stratify the risk of conversion from acute to chronic LBP (2).
Grade B Recommendations:
  • A potential predictor for the recurrence of LBP is a previous history of LBP (3).
  • Prior LBP episodes are considered prognostic factors for the conversion of acute to chronic LBP (2).
Grade C Recommendations:
  • A non-structural cause of LBP may be considered in patients with diffuse LBP and tenderness (4).
Grade I Recommendations – some clinical practice aspects that have insufficient evidence include:
  • The use of body mass index as a potential predictor of LBP recurrence (3).
  • The assessment of sleep quality as a prognostic factor to predict recovery from acute LBP (5).
  • The use of smoking, and/or obesity as a prognostic factor for acute LBP transitioning to chronic LBP (6).
  • Obtaining laboratory tests to assess for inflammatory disease in patients with sacroiliac joint pain (7).
Work Group Consensus Statement:
In the absence of reliable evidence supporting an absolute indication for advanced imaging based upon the history and physical examination, it is the work group’s opinion that in patients with severe and intractable pain syndromes who have failed medical and/or interventional treatment, advanced imaging may be indicated. Subgroups of patients have been shown to have a higher or lower incidence of radiographic abnormalities based upon their acuity of LBP, tenderness to palpation, and provocation maneuvers; however, the utility of these findings in guiding treatment is not clear (8-11).

 
Recommendations Related to the Use of Imaging in Nonspecific Low Back Pain

No Grade A, B, or C recommendations were provided for the use of imaging in nonspecific low back pain.

 
Grade I Recommendations – some clinical practice aspects that have insufficient evidence include:
  • Making a recommendation for or against an association between LBP and spondylosis using routine radiography (12).
  • Making a recommendation for or against obtaining imaging in the absence of red flags (13).
  • Using imaging findings to correlate with a patient’s presentation of LBP (14).
Recommendations Related to the Medical and Psychological Treatment of Nonspecific Low Back Pain
 
 
 
Grade A Recommendations:
  • Antidepressants are not recommended for the treatment of LBP (15).
  • Topical capsicum is recommended for LBP on a short term basis (< 3 months) (16).
  • Compared to physical therapy alone, cognitive behavioural therapy is recommended in combination with physical therapy to improve pain levels in patients with LBP for greater than 12 months (17).
  • Compared with physical therapy alone, treatments targeting fear avoidance beliefs combined with physical therapy is recommended to improve LBP in the first six months (18).
Grade B Recommendations:
  • NSAIDs are suggested as a possible treatment for LBP (19).
  • Oral or IV steroids are not effective for the treatment of LBP (20).
  • For the treatment of LBP, the use of opioid pain medications should be restricted to short-term duration only (21).
  • Compared to physical therapy alone, cognitive behavioural therapy in combination with physical therapy is suggested to improve disability and return to work in patients with LBP (17).
  • Kinesiophobia is a negative prognostic factor for predicting a patient’s response to LBP treatment (22).
Grade I Recommendations – some clinical practice aspects that have insufficient evidence include:
  • Recommendations for or against the use of anticonvulsants for the treatment of LBP (23).
  • The use of cognitive behavioural therapy for improving depression or anxiety in LBP patients.
  • Recommendations for or against the use of patient education to improve treatment compliance and outcomes such as the duration of pain, intensity of pain, functional outcomes, anxiety, depression and return to work status (24).
Recommendations Related to Physical Medicine and Rehabilitation of Nonspecific Low Back Pain
 
 
 
Grade A Recommendations:
  • Back school is recommended to provide improvements in pain and function when compared with general medical care, modality care or a simple handout at 6 to 12 months follow-up for chronic LBP (25).
  • Ultrasound is not recommended to improve functional outcomes (26).
  • Laser acupuncture provides no short-term or medium-term benefit over sham treatment for patients with chronic LBP (27).
  • For subacute or chronic LBP, traction is not recommended to provide clinically significant improvements in pain or function (28).
  • The addition of acupuncture to usual care is recommended for short term improvement in pain and function compared with usual care alone for chronic LBP patients (28).
  • For acute LBP, SMT results in similar outcomes to no treatment, medication or modalities. Occasionally, short term improvement is statistically better but clinical significance is uncertain (24).
Grade B Recommendations:
  • The use of heat for acute LBP results in short-term pain improvements (29).
  • The combination of laser therapy with exercise provides better short-term relief of pain than either exercise or laser therapy alone (30).
  • In the long-term, the addition of massage to an exercise program provides no benefit compared to an exercise program alone.
  • In mild LBP patients, yoga may offer medium-term improvement in pain and function compared with usual care. However, these improvements are not clinically meaningful due to the low baseline of pain and/or disability (31).
  • A specific stabilization exercise program is equivalent to a general exercise program (32).
  • The addition of exercise to SMT results in similar outcomes compared to SMT alone (33).
  • In acute LBP, individuals who exercise more at baseline and use exercise to facilitate recovery are predicted to have better functional outcomes over time than patients who do not exercise or use bed rest to help with recovery (34).
  • In acute LBP, it is suggested that advice to remain active within the patient’s pain tolerance compared with short periods of bed rest for 3 to 7 days result in similar outcomes in pain and function at short and medium-term follow-up (35).
Grade C Recommendations:
  • For acute and chronic LBP, SMT is an option to improve pain and function (24).
  • The Mckenzie method is an option for the treatment of chronic LBP (36).
  • Work hardening may be considered to improve a worker’s return to work in LBP patients (37).
Grade I Recommendations – some clinical practice aspects that have insufficient evidence include::
  • A self-directed McKenzie exercise program for acute LBP results in different outcomes compared with usual medical care (37).
  • Acupuncture provides improvements in pain and function as compared with sham acupuncture (38).
  • The use of TENS results in improvement in pain or function at short to medium term follow-up (39).
  • Recommendations for or against the use of lumbar stabilization exercises in patients with chronic LBP (40).
  • The use of Mackenzie exercises results in different outcomes when compared with a dynamic strengthening program for the treatment of chronic LBP (36).
  • The use of work hardening produces different results compared to an active therapeutic exercise program or guideline based therapy (36)
Work Group Consensus Statement:
In the absence of reliable evidence for patients with non-specific back pain, it is the work group’s opinion that remaining active is preferred and likely results in better short-term outcomes than bed rest.

 
Recommendations Related to Interventional Treatment for Nonspecific Low Back Pain
 
 
 
Grade A Recommendations:
  • Provocative discography is correlated with pain reproduction in the presence of moderate to severe disc degeneration on MRI and/or CT discography (41).
  • Provocative discography correlates with the presence of endplate abnormalities on MRI imaging (42).
Grade B Recommendations:
  • In patients selected for facet joint procedures using diagnostic criteria of a physical exam and a response to a single diagnostic intra-articular injection of 50% pain relief, it is suggested that an intra-articular injection of steroids provides no clinically meaningful improvement at 6 months (43).
  • Thermal radiofrequency ablation is suggested as a treatment for patients with LBP arising from the zygapophyseal joints. The outcomes of this procedure become more reliable when more stringent diagnostic criteria are used. The clinical relief from these ablations can last for at least six months following the procedures (44).
  • Intradiscal steroids are suggested to provide short-term improvements in pain and function in patients with modic changes (45).
  • Intradiscal electrothermal annuloplasty is suggested to provide improvements in pain and function for up to 2 years. This treatment is limited in its effectiveness with roughly half of patients receiving a 50% reduction in pain (46).
Grade C Recommendations:
  • Intra-articular steroid joint injections may be considered in patients with suspected SI joint pain (47).
  • Cooled radiofrequency ablation of the sacral lateral branch nerves and dorsal ramus of L5 may be considered in patients with sacroiliac joint pain diagnosed through a dual diagnostic block (48).
  • Bony vibration provocation may correlate with the presence of pain in patients who have pain on provocation discography (49).
  • Biacuplasty (radiofrequency ablation) is an option to produce clinically and statistically significant improvements in pain at 6 months in patients with discogenic LBP (50).
Grade I Recommendations – some clinical practice aspects that have insufficient evidence include:
  • The beneficial use of interlaminar epidural steroid injections in patients with LBP (51).
  • The beneficial use of steroid injections for zygapophyseal joint pain in patients with chronic back pain and a physical exam suggestive of facet-mediated pain (52).
  • Using spinal cord stimulation as a treatment for LBP (53).
Recommendations Related to the Surgical Treatment of Nonspecific Low Back Pain

No Grade A, B, or C recommendations were provided for the use of surgical intervention in nonspecific low back pain.

 
Grade I Recommendations – some clinical practice aspects that have insufficient evidence include:
  • Recommending a particular fusion technique for the treatment of LBP (54).
Recommendations Related to the Cost Utility of Treatments for Nonspecific Low Back Pain
 
 
 
Grade B Recommendation:
  • Acupuncture-based therapy in the management of LBP is suggested to be more cost effective when compared with other medical and/or interventional treatments (56).
Grade I Recommendations – some clinical questions that have insufficient evidence include:
  • The cost effectiveness for the use of routine ordering of lumbar spine radiographs for LBP lasting greater than 6 months in the absence of red flags (57).
  • The cost effectiveness of physical therapy in the management of LBP versus other medical and/or interventional treatments (58).
  • The cost effectiveness of SMT for the treatment of LBP (58).
  • The cost effectiveness of cognitive or psychological-based therapy in the management of LBP (59).
  • The cost effectiveness of surgical management (including fusion, lumbar disc replacement and spinal cord stimulators) for patients with LBP compared to medical and/or interventional treatments (60).

Clinical Application & Conclusions:

This paper outlines an evidence-based clinical guideline for the diagnosis and treatment of low back pain that can be used by many stakeholders. This guideline can be used as an educational tool for both clinicians and patients to assist practitioners who provide treatment to adult patients with non-specific low back pain. In addition, this guideline provides a rating based on the quality of the scientific data, allowing clinicians to have a working knowledge of the most current evidence related to nonspecific LBP in adult patients. Furthermore, this guideline can assist researchers in identifying knowledge gaps in the literature to recognize where further research is required.

Study Methods:

A multidisciplinary working group of spine care specialists (primary care, psychology, neurosurgery, chiropractic, physical therapy etc.) was formed in order to determine a set of clinical questions to address low back pain in individuals 18 years of age or older. Low back pain is defined as pain of musculoskeletal origin extending from the lowest rib to gluteal fold and may extend to the thigh above the knee.

 
The following low back pain conditions were excluded from this guideline:
  • Low back pain due to tumour, infection, metabolic disease, inflammatory arthritis, fracture
  • Patient with a diagnosed deformity including spondylolisthesis, spondylolysis and scoliosis
  • Pain experienced below the knee
  • Extraspinal conditions (i.e. visceral, vascular, genitourinary)
  • Patients who have undergone prior lumbar surgery
  • Presence of neurological deficit
  • Back pain associated with widespread multisite pain (> 2 sites)
  • Pregnancy
The literature was searched in consultation with medical librarians in order to answer the specific clinical questions posed. Relevant studies were summarized, strengths and weaknesses were identified, and the level of evidence was classified according to the NASS Levels of Evidence for Primary Research Question Scale.

 
The NASS Levels of Evidence are as follows:
  • Grade A: Level I studies with consistent findings.
  • Grade B: Level II or III studies with consistent findings.
  • Grade C: Level IV or V studies.
  • Grade I: Insufficient or conflicting evidence not allowing for a recommendation.

Study Strengths / Weaknesses:

Strengths:
  • This guideline is a very comprehensive assessment of the nonspecific low back pain literature.
  • Stakeholders from different professions were included in the working group to formulate this guideline.
Weaknesses:
  • Due to the nature of this guideline, statements are provided with an evidence grade, however there is not an elaborate discussion of the articles used that guides the recommendations. Nevertheless, a document that elaborates on this guideline can be found on the NASS website which expands on the recommendations provided.

Additional References:

  1. Matsudaira K, Konishi H, Miyoshi K, et al. Potential risk factors of persistent low back pain developing from mild low back pain in urban Japanese workers. PLoS ONE 2014;9(4):e93924.
  2. Coste J, Lefrancois G, Guillemin F, et al. Prognosis and quality of life in patients with acute low back pain: insights from a comprehensive inception cohort study. Arthritis Care Res 2004;51(2):168–76.
  3. Heuch I, Heuch I, Hagen K, et al. Body mass index as a risk factor for developing chronic low back pain: a follow-up in the Nord-Trondelag Health Study. Spine 2013;38(2):133–9.
  4. Jensen OK, Nielsen CV, Stengaard-Pedersen K. Low back pain may be caused by disturbed pain regulation: a cross-sectional study in low back pain patients using tender point examination. Eur J Pain 2010;14(5):514–22. 519p.
  5. Alsaadi SM, McAuley JH, Hush JM, et al. Poor sleep quality is strongly associated with subsequent pain intensity in patients with acute low back pain. Arthritis Rheumatol 2014;66(5):1388–94.
  6. Bakker EWP, Verhagen AP, Lucas C, et al. Spinal mechanical load: a predictor of persistent low back pain? A prospective cohort study. Eur Spine J 2007;16(7):933–41.
  7. Gupta AD. Sacroiliac joint pathologies in low back pain. J Back Musculoskel Rehabil 2009;22(2):91–7..
  8. Elgafy H, Semaan HB, Ebraheim NA, et al. Computed tomography findings in patients with sacroiliac pain. Clin Orthop 2001(382):112–8.
  9. Graves JM, Fulton-Kehoe D, Jarvik JG, et al. Early imaging for acute low back pain: one-year health and disability outcomes among Washington State workers. Spine 2012;37(18):1617–27.
  10. Kumar N, Wijerathne SI, Lim WWJ, et al. Resistive straight leg raise test, resistive forward bend test and heel compression test: novel techniques in identifying secondary gain motives in low back pain cases. Eur Spine J 2012;21(11):2280–6.
  11. Mainka T, Lemburg SP, Heyer CM, et al. Association between clinical signs assessed by manual segmental examination and findings of the lumbar facet joints on magnetic resonance scans in subjects with and without current low back pain: a prospective, single-blind study. Pain 2013;154(9):1886–95.
  12. Nemoto O, Kitada A, Tsuda Y, et al. A longitudinal study of radiological changes in the lumbar spine in asymptomatic Japanese military young adults. Eur Orthop Traumatol 2012;3(2):135–9.
  13. Lakadamyali H, Tarhan NC, Ergun T, et al. STIR sequence for depiction of degenerative changes in posterior stabilizing elements in patients with lower back pain. AJR Am J Roentgenol 2008;191(4):973–9.
  14. Atkinson JH, Slater MA, Wahlgren DR, et al. Effects of noradrenergic and serotonergic antidepressants on chronic low back pain intensity. Pain 1999;83(2):137–45.
  15. Frerick H, Keitel W, Kuhn U, et al. Topical treatment of chronic low back pain with a capsicum plaster. Pain 2003;106(1-2):59–64.
  16. Bendix AF, Bendix T, Ostenfeld S, et al. Active treatment programs for patients with chronic low back pain: a prospective, randomized, observer-blinded study. Eur Spine J 1995;4 (3):148–52.
  17. George SZ, Fritz JM, Bialosky JE, et al. The effect of a fearavoidance- based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. Spine 2003;28(23):2551–60.
  18. Birbara CA, Puopolo AD, Munoz DR, et al. Treatment of chronic low back pain with etoricoxib, a new cyclo-oxygenase-2 selective inhibitor: improvement in pain and disability−a randomized, placebo-controlled, 3-month trial. J Pain 2003;4(6):307–15.
  19. Eskin B, Shih RD, Fiesseler FW, et al. Prednisone for emergency department low back pain: a randomized controlled trial. J Emerg Med 2014;47(1):65–70.
  20. Buynak R, Shapiro DY, Okamoto A, et al. Efficacy and safety of tapentadol extended release for the management of chronic low back pain: results of a prospective, randomized, double-blind, placebo- and active-controlled Phase III study.[Erratum appears in Expert Opin Pharmacother. 2010 Nov;11 (16):2773]. Expert Opin Pharmacother 2010;11(11):1787–804.
  21. Gremeaux V, Benaım C, Poiraudeau S, et al. Evaluation of the benefits of low back pain patients’ education workshops during spa therapy. Joint Bone Spine 2013;80(1):82–7.
  22. Muehlbacher M, Nickel MK, Kettler C, et al. Topiramate in treatment of patients with chronic low back pain: a randomized, double-blind, placebo-controlled study. Clin J Pain 2006;22(6):526–31.
  23. Cherkin DC, Deyo RA, Battie M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 1998;339(15):1021–9.
  24. Durmus D, Unal M, Kuru O. How effective is a modified exercise program on its own or with back school in chronic low back pain? A randomized-controlled clinical trial. J Back Musculoskelet Rehabil 2014;27(4):553–61. 5-1431.
  25. Durmus D, Alayli G, Goktepe AS, et al. Is phonophoresis effective in the treatment of chronic low back pain? A single-blind randomized controlled trial. Rheumatol Int 2013;33(7):1737–44.
  26. Glazov G, Schattner P, Lopez D, et al. Laser acupuncture for chronic non-specific low back pain: a controlled clinical trial. Acupunct Med 2009;27(3):94–100.
  27. Haake M, Muller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups.[Erratum appears in Arch Intern Med. 2007 Oct 22;167(19):2072]. Arch Intern Med 2007;167(17):1892–8.
  28. Dehghan M, Farahbod F. The efficacy of thermotherapy and cryotherapy on pain relief in patients with acute low back pain, a clinical trial study. J Clin Diag Res 2014;8(9):LC01–4.
  29. Alayat MS, Atya AM, Ali MM, et al. Long-term effect of high-intensity laser therapy in the treatment of patients with chronic low back pain: a randomized blinded placebo-controlled trial. Lasers Med Sci 2014;29(3):1065–73.
  30. Aboagye E, Karlsson ML, Hagberg J, et al. Cost-effectiveness of early interventions for non-specific low back pain: a randomized controlled study investigating medical yoga, exercise therapy and self-care advice. J Rehabil Med 2015;47(2):167–73.
  31. Aluko A, DeSouza L, Peacock J. The effect of core stability exercises on variations in acceleration of trunk movement, pain, and disability during an episode of acute nonspecific low back pain: a pilot clinical trial. J Manip Physiol Ther 2013;36(8). 497-504.e491-493.
  32. Hsieh CY, Adams AH, Tobis J, et al. Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial. Spine 2002;27(11):1142–8.
  33. Oleske DM, Neelakantan J, Andersson GB, et al. Factors affecting recovery from work-related, low back disorders in autoworkers. Arch Phys Med Rehabil 2004;85(8):1362–4.
  34. Hagen EM, Eriksen HR, Ursin H. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain. Spine 2000;25(15):1973–6.
  35. Petersen T, Kryger P, Ekdahl C, et al. The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain: a randomized controlled trial. Spine 2002;27(16):1702–8.
  36. Bendix T, Bendix A, Labriola M, et al. Functional restoration versus outpatient physical training in chronic low back pain: a randomized comparative study. Spine 2000;25 (19):2494–500.
  37. Carlsson CP, Sjolund BH. Acupuncture for chronic low back pain: a randomized placebo-controlled study with long-term follow-up. Clin J Pain 2001;17(4):296–305.
  38. Herman E, Williams R, Stratford P, et al. A randomized controlled trial of transcutaneous electrical nerve stimulation (CODETRON) to determine its benefits in a rehabilitation program for acute occupational low back pain. Spine 1994;19 (5):561–8.
  39. Moussouli M, Vlachopoulos SP, Kofotolis ND, et al. Effects of stabilization exercises on health related quality of life in women with chronic low back pain. J Phys Act Health 2014;11(7):1295–303.
  40. Chen JY, Ding Y, Lv RY, et al. Correlation between MR imaging and discography with provocative concordant pain in patients with low back pain. Clin J Pain 2011;27(2):125–30.
  41. Weishaupt D, Zanetti M, Hodler J, et al. Painful lumbar disk derangement: relevance of endplate abnormalities at MR imaging. Radiology 2001;218(2):420–7.
  42. Carette S, Marcoux S, Truchon R, et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med 1991;325(14):1002–7.
  43. Lakemeier S, Lind M, Schultz W, et al. A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double-blind trial. Anesth Analg 2013;117 (1):228–35.
  44. Cao P, Jiang L, Zhuang C, et al. Intradiscal injection therapy for degenerative chronic discogenic low back pain with end plate Modic changes. Spine J 2011;11(2):100–6.
  45. Pauza KJ, Howell S, Dreyfuss P, et al. A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J 2004;4(1):27–35.
  46. Chakraverty R, Dias R. Audit of conservative management of chronic low back pain in a secondary care setting − part I: facet joint and sacroiliac joint interventions. Acupunct Med 2004;22 (4):207–13.
  47. Kapural L, Nageeb F, Kapural M, et al. Cooled radiofrequency system for the treatment of chronic pain from sacroiliitis: the first case-series. Pain Practice 2008;8(5): 348–54. 347p.
  48. Yrjama M, Vanharanta H. Bony vibration stimulation: a new, noninvasive method for examining intradiscal pain. Eur Spine J 1994; 3(4):233–5.
  49. Desai MJ, Kapural L, Petersohn JD, et al. A prospective, randomized, multicenter, open-label clinical trial comparing intradiscal biacuplasty to conventional medical management for discogenic lumbar back pain. Spine 2016;41 (13):1065–74.
  50. Lee JW, Shin HI, Park SY, et al. Therapeutic trial of fluoroscopic interlaminar epidural steroid injection for axial low back pain: effectiveness and outcome predictors. AJNR Am J Neuroradiol 2010;31(10):1817–23.
  51. Chaturvedi A, Chaturvedi S, Sivasankar R. Image-guided lumbar facet joint infiltration in nonradicular low back pain. Indian J Radiol Imaging 2009;19(1):29–34.
  52. Vallejo R, Manuel Zevallos L, et al. Is spinal cord stimulation an effective treatment option for discogenic pain? Pain Pract 2012;12(3):194–201.
  53. Madan SS, Boeree NR. Comparison of instrumented anterior interbody fusion with instrumented circumferential lumbar fusion. Eur Spine J 2003;12(6):567–75.
  54. Vamvanij V, Fredrickson BE, Thorpe JM, et al. Surgical treatment of internal disc disruption: an outcome study of four fusion techniques. J Spinal Disord 1998;11(5):375–82.
  55. Witt CM, Jena S, Selim D, et al. Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol 2006;164(5):487–96.
  56. Kvarstein G, Mawe L, Indahl A, et al. A randomized double-blind controlled trial of intra-annular radiofrequency thermal disc therapy−a 12-month follow-up. Pain 2009;145(3):279–86.
  57. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK Beam) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ 2004;329 (7479):1381. Epub 2004 Nov 19.
  58. Lamb SE, Lall R, Hansen Z, et al. A multicentred randomised controlled trial of a primary care based cognitive behavioural programme for low back pain. The Back Skills Training (BeST) trial. Health Technol Assess 2010;14 (41):1–253. iii-iv.
  59. Johnsen LG, Hellum C, Storheim K, et al. Cost-effectiveness of total disc replacement versus multidisciplinary rehabilitation in patients with chronic low back pain: a Norwegian multicenter RCT. Spine 2014;39(1):23–32.

Contact Tech Support  Contact Dr. Shawn Thistle
 
RRS Education on Facebook Dr. Shawn Thistle on Twitter Dr. Shawn Thistle on LinkedIn Find RRS Education on Instagram RRS Education (Research Review Service)