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Dutchphysiotherapyguidelinesforlowbackpain

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IntroductionEvidence-based healthcare has receivedincreased attention during the last decadeand is important to monitor and improvequality of care. Guidelines are useful tools in this process aiming at changingbehaviour of healthcare professionals, ifneeded. Low back pain is a good exampleof a field where evidence has been pro-vided by many randomised trials andsummarised in many systematic reviews.At least 12 guidelines for low back pain inprimary care have been published, butnone of them specifically for physio-therapy (Koes et al, 2001). However,physiotherapy management of low backpain also needs to move forward in themainstream of evidence-based healthcare.The need for an evidence-based and moreuniform approach is signalled by thevariation in treatment of low back pain,both nationally (van der Valk et al, 1995)and internationally (Foster et al, 1999; Liand Bombardier, 2001) and the lack ofevidence-based guiding principles.

The Dutch physiotherapy guidelines forlow back pain presented in this paperembody the physiotherapeutic diagnosticand therapeutic process in patients withlow back pain. Manual therapy is notincluded in these guidelines becausethese techniques demand specific know-ledge and skills. For this reason, separateguidelines for manual therapy are beingdeveloped in the Netherlands.

In the Netherlands, patients do nothave open access to a physiotherapist;they need a referral from a generalpractitioner or another physician.Consequently, these guidelines focus onpatients with low back pain who arereferred for physiotherapy.

Their aim is to improve the efficiencyand effectiveness of physiotherapy man-agement in patients with low back pain

Dutch PhysiotherapyGuidelines for Low BackPain

Summary Many guidelines for the management of lowback pain in primary care have been published during recentyears, but guidelines for physiotherapy do not yet exist.Therefore, physiotherapy guidelines have been developed,reflecting the consequences of the current state ofknowledge of effective and appropriate physiotherapy forlow back pain. They aim to improve the efficiency andeffectiveness of physiotherapeutic care for patients with lowback pain.

The guidelines were constructed on the basis of the phasesof the physiotherapy process, using the Dutch method ofdeveloping physiotherapy guidelines. Scientific evidence of systematic reviews was used as the basis for therecommendations. A computerised literature search ofMedline, Cinahl, the Cochrane Database of SystematicReviews and the Database of the Dutch National Institute ofAllied Health Professions was conducted to identify relevantsystematic reviews. If no evidence was available, consensusbetween experts was obtained.

The guidelines were pilot tested among one hundredphysiotherapists and reviewed by an external multi-disciplinary panel.

The guidelines recommend that the diagnostic processshould focus on disability and participation problemsresulting from back pain. The treatment should consist of anactive approach, in which the patients learn to take controlover their back pain. For patients with a normal course,where activities and participation gradually increase,reassurance, adequate information and advice to stay activeare the most important recommendations. For patients withan abnormal course, where activities and participation do notincrease, exercise therapy should also be provided, with abehavioural approach if necessary.

These are the first national physiotherapy guidelines for lowback pain. The recommendations are largely in line withother primary care guidelines for low back pain.Implementation will be a major challenge for the near future.

Key WordsLow back pain, physiotherapy,clinical guidelines, evidence-based healthcare.

by G E BekkeringH J M HendriksB W KoesR A B OostendorpR W J G OsteloJ M C ThomassenM W van Tulder

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by translating research findings intoclinically relevant recommendations, byexplicitly describing the role of physio-therapists in the care for patients with low back pain, and by improving collab-oration with other primary care providers.

Definition of Low Back PainThe concept of 'low back pain' in theseguidelines refers to 'non-specific low backpain', defined as low back pain without aspecified physical cause, eg nerve rootcompression (radicular syndrome),trauma, infection or tumour. In anestimated 90% of patients with low backpain no specific medical diagnosis is made(Nachemson, 1992). Recurrent back painis defined as several episodes of back painwithin one year, the total duration ofwhich amounts to less than six months(Von Korff, 1994). The duration of a lowback pain episode can be classified asacute (0-6 weeks), sub-acute (7-12 weeks)or chronic (longer than 12 weeks).

Size of the ProblemOf the total population, 60% to 90% willexperience an episode of low back pain atsome time, the annual incidence of being5% (Frymoyer, 1988). For physiothera-pists in the Netherlands, low back pain isa common referral diagnosis; 27% of allpatients referred to a physiotherapist havelow back pain (Van Ravensberg et al,1995).

Impairments, Disabilities andParticipation ProblemsPhysiotherapists describe the healthproblems of patients with low back pain interms of impairments, disabilities andparticipation difficulties.

� Impairments are manifestations of adisorder referring to body structure or physiological and psychologicalfunction, for example decreasedmuscle strength, pain, sensoryimpairments or fear of movement.

� Disabilities refer to problems in theperformance of activities such asbending, reaching or walking.

� Participation problems refer toproblems an individual may have inrelation to his social life, for examplework.

These concepts are derived from theInternational Classification of Human

Functioning, Disability and Health(WHO, 2001). Their use is meant topromote uniformity in the rehabilitationprofessions.

Bio-psychosocial ModelIn the traditional (biomedical) modelpain is a direct consequence of under-lying pathology. The symptoms will dim-inish if the pathology is removed. Thismodel cannot easily explain chroniccomplaints, like chronic low back pain,because there is no clear correlation bet-ween symptoms and pathology. There-fore, the current approach to chronic low back pain tends to be increasinglyinspired by the bio-psychosocial per-spective. In this perspective (low back)pain is the result of the interactionbetween biological, psychological andsocial factors (Waddell, 1987, 1992, 1998).Psychosocial factors in particular aresupposed to become more important inthe transition from acute to chronic andin chronic low back pain.

Prognosis and CourseIn an open population the prognosis isusually favourable; in an estimated 75% to90% of patients back pain disappearsspontaneously within four to six weeks(Waddell, 1998). In patients visiting ageneral practitioner because of their backpain, the prognosis is a little less fav-ourable; 65% are free of symptoms after12 weeks (Van de Hoogen et al, 1998).

Low back pain often recurs; 75% ofpatients who seek help from their generalpractitioner suffer at least one relapsewithin the year (Van de Hoogen et al,1998). The persistence of back pain doesnot necessarily indicate a less favourableprognosis. There is growing consensusthat the extent of disability is the mostimportant predictor of outcome in lowback pain (Von Korff and Saunders,1996).

Linton (2000) performed a systematicreview regarding the relationship betweenpsychological factors and neck and backpain. The review included 36 prospectivestudies. Based on several clinically rel-evant and methodologically sound studies,Linton concluded that psychologicalfactors are strongly associated with the change from acute to chronic pain,and with disability. Also, it becomes clear that psychosocial factors generally have a bigger impact on disabilities than

Bekkering, G E,Hendriks, H J M,Koes, B W,Oostendorp, R A B,Ostelo, R W J G,Thomassen, J M Cand van Tulder, M W(2003). ‘Dutchphysiotherapyguidelines for lowback pain’,Physiotherapy, 89, 2, 82-96.

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biomedical and biomechanical factors.Aspects such as attitudes and emotions ofthe patient are important: passive copingstrategies, perceptions about pain, andemotions such as depression or fear are highly associated with pain anddisabilities. Also, there is moderate tostrong evidence that these psychosocialfactors may, in the long term, predict pain and disabilities.

Waddell and Waddell (2000) conducteda systematic review on the influence ofsocial factors on back and neck pain.They conclude that the studiesinvestigated are of poor methodologicalquality, although there are many indic-ations that social factors may be related to back and neck pain.

The only social factors which showconsistent findings, in either one syst-ematic review or in more than two meth-odologically sound studies, are lowersocial class, and lower work satisfaction.The authors emphasise that social factorsare not a risk factor for the developmentof back or neck pain, but that they maywell influence it, and also the way inwhich patients cope with their complaints.

Coping StrategyPatients may cope with their complaintseither adequately or inadequately. This iscalled ‘active or passive coping’ (Folkmanand Lazarus, 1980).

Active coping means that people under-take actions by themselves to control thepain (for example by looking for dis-traction, or by moving). Low back painpatients who manage to adjust their act-ivities appropriately have an active (oradequate) coping strategy. Passive copingrefers to the adoption of a passive attitude(resting or using medication), or depend-ing on others as a way of controlling pain(Jensen et al, 1991). Patients who restricttheir movements because of low backpain, who persist in avoiding certainactivities or rest a lot to relieve the pain,have passive (or inadequate) copingstrategies. Active coping is associated withbetter functioning, while passive coping isassociated with worse functioning (Jensenet al, 1991).

The way in which a person copes withhis complaints will be determined bypatient characteristics (significance andsense of control), as well as by theinteractions between the person and hispersonal environment.

Patient Characteristics The significance which people attach tosymptoms is based on the subjectiveperception and interpretation of stimuli.If significance does not seem to cor-respond with an objective reality, a logicalerror is being made. A common logicalerror is ‘to catastrophise’, which meansthat the pain, and the situation in whichthe pain presents, are being considered aserious threat, ‘a catastrophe’.

The extent to which patients feel thatthey have control over the pain is also important. They may feel that theirhealth is mainly controlled by themselves(‘internal locus of control’), or by otherpeople or circumstances (‘external locusof control’: patients give other people, forexample physiotherapists, control overtheir health -- Härkäpää et al, 1996). Aninternal locus of control is often relatedto active coping and, subsequently, to abetter way of dealing with the pain(Jensen et al, 1991).

Both the significance attached to thepain and the perceived sense of controlmay determine movement behaviour. Forinstance, when pain is considered as asignal of possible injury (catastrophe), thechances will be high that this will result infear of movement. Fear of movement isthe fear that movement will result in(new) pain or (re)injury, which will, inturn, lead to avoidance (Vlaeyen et al,1995). Also when, based on previousexperiences, patients expect certainactivities to increase the pain and thatthey have no control over this (low levelof control), the chances are that thissituation will be avoided.

Interaction between Patient andSurroundingsThe interaction between patients andtheir environment (social factors) alsoplays a role in their coping strategy. Veryprotective partners, but also contradictoryinformation and recommendations bydifferent healthcare providers, mayfrighten patients and influence theircoping strategy negatively. Physio-therapists’ attitudes may also play a role,for example paying too much attention topain and not encouraging patients’independence may affect the course in anegative way.

Authors

G E Bekkering MSc isa researcher at theDutch NationalInstitute of AlliedHealth Professions,Amersfoort, and theInstitute for Researchin ExtramuralMedicine, VUUniversity MedicalCentre, Amsterdam.

H J M Hendriks PhDPT is leader of thephysiotherapyguidelinesprogramme at theDutch NationalInstitute of AlliedHealth Professions,Amersfoort. He isemployed by theDepartment ofEpidemiology,Maastricht University.

B W Koes PhD isprofessor of generalpractice, at ErasmusUniversity, Rotterdam.

RAB Oostendorp PhDPT MT is a professorat the UniversityMedical Centre,Centre of Quality ofCare Research,Nijmegen, and at theFaculty of Medicineand Pharmacology,PostgraduateEducation ManualTherapy, FreeUniversity of Brussels,Belgium, and directorof the Dutch NationalInstitute of AlliedHealth Professions,Amersfoort.

R W J G Ostelo PhDPT is a researcher atthe Institute forResearch inExtramural Medicine,VU University MedicalCentre, Amsterdam.

J M C Thomassen PTis a physiotherapist atthe Institute forRehabilitation andRehabilitationResearch,Hoensbroek, The Netherlands.

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Method of Guideline DevelopmentThese guidelines are systematicallydeveloped according to the method ofPhysiotherapy Guidelines Development in theNetherlands (Hendriks et al, 2000b).

The members of the working group(authors) of the Low Back Pain Guide-lines are all either experienced phys-iotherapists in low back pain or re-searchers in physiotherapy and low backpain. An external group of ten expertsfrom relevant disciplines (a generalpractitioner, an occupational physician, arehabilitation physician, an orthopaedicsurgeon, an orthopaedic physician, twopsychologists, one physiotherapist work-ing in a pain clinic, and two teachers at schools of physiotherapy) reviewed the draft version of the guidelines. Themembers of the working group and theexternal members have declared that theyhave no conflict of interest.

A group of 100 randomly chosenphysiotherapists, all members of the RoyalDutch Society for Physiotherapy, wereasked to comment on the draft version ofthe guidelines by filling in a structuredform evaluating their quality. Thecomments were discussed with theworking group and, if needed, the guide-lines were adjusted. An update of theguidelines is scheduled within three to five years after publication or sooner if new evidence alters the recommend-ations.

Literature SearchA computer-aided search for publishedsystematic reviews or meta-analysesinvestigating the efficacy of physiotherapyinterventions in patients with low backpain was undertaken. The databases ofMedline (1982-September 2000), Cinahl(1982-September 2000), the CochraneLibrary (2000, number 3) and thedatabases of the Dutch Institute of AlliedHealth Professions (up to September2000) were searched, using the followingkey words: back pain, physiotherapy,physical therapy, behavioural therapy,massage, education, mobilisation, electro-therapy, laser, ultrasound, thermo therapy,systematic review and meta-analysis.

The search yielded 188 publications.Inclusion criteria were: articles in English,German, French or Dutch language;systematic review or a meta-analysis;treatment interventions for patients withnon-specific low back pain; interventions

which are part of the Dutch professionaldomain of physiotherapy, and outcomemeasures relating to the physicalfunctioning of patients. Thirteen reviewswere included (Ernst, 1999; Hagen et al,2000; Hilde and Bo, 1998; Turner, 1996;Van der Heijden et al, 1995; Van Tulder etal, 1997, 1999, 2000a b; Waddell et al,1997). Five additional reviews were con-sidered on the effectiveness of electro-therapeutical applications in patients withmusculoskeletal disorders, becausesystematic reviews of these applicationsspecifically for low back pain were notidentified (De Bie et al, 1998; Gam andJohannsen, 1995; Gam et al, 1993; Van derHeijden et al, 1999; Van der Windt et al,1999).

For several interventions the reviews ofVan Tulder et al (1997, 1999) have beenused. These reviews use four levels ofscientific evidence based on the numberof randomised controlled trials, theirmethodological quality and the con-sistency of their results (table 1).

In addition to the scientific literature,recent professional developments (forexample the active approach in low backpain) and other considerations (such aspractical issues) have played a role in theconstruction of these guidelines, whichhave also been aligned with recomm-endations made in other Dutch nationalguidelines such as the guidelines of the Royal Dutch Association of General

M W van Tulder PhDis a senior investigatorat the Institute forResearch inExtramural Medicineand the Departmentof ClinicalEpidemiology andBiostatistics, VUUniversity MedicalCentre, Amsterdam.

This article wasreceived onNovember 2, 2001,and accepted on July 2, 2002.

Address forCorrespondence

G E Bekkering, DutchNational Institute ofAllied HealthProfessions, PO Box 1161, 3800 BD Amersfoort, The Netherlands.

E-mail Bekkering@paramedisch.org.nl

Table 1: Levels of scientific evidence (source: Van Tulder et al, 1997, 1999)

Level of evidence Description

Strong Consistent findings inseveral high qualityrandomised controlledtrials

Moderate Consistent findings in onehigh quality randomisedcontrolled trial and one or several low qualityrandomised controlledtrials

Limited/contradictory One randomisedcontrolled trial (high or low quality), orinconsistent findingsbetween severalrandomised controlledtrials

None No randomised controlledtrials

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Practitioners (Faas et al, 1996), theAssociation of Occupational Practitioners(NVAB, 1999), and international low backpain guidelines (Bigos et al, 1994; Waddellet al, 1996; ACC, 1997; Abenhaim et al,2000).

Definitions:Normal and Abnormal CourseA long episode of low back pain does not necessarily imply an unfavourableprognosis. However, when an episode oflow back pain is associated with long-lasting disabilities and participationproblems, prognosis is poor. Because ofthis, these guidelines emphasise thecourse of disabilities and participationproblems.

Over time, the course of disabilities andparticipation problems can be callednormal or abnormal. In a normal course,activities and participation graduallyincrease over time (to the level prior tothe low back pain episode) and symptomsdecrease. This does not necessarily meanthat the low back pain will disappearcompletely, but that it will no longerrestrict normal activities and particip-ation. A normal course is to be expectedfor most patients with low back pain.

An abnormal course is present whendisabilities and participation problems do not decrease over time, but stay at thesame level or even increase. In most pat-ients persisting or worsening complaintswill accompany this. An abnormal coursemay be seen in patients with either acuteor chronic low back pain. There wasconsensus among the guideline workinggroup that the course should be definedas abnormal when activities and part-icipation have not increased within threeweeks.

Diagnostic ProcessThe process of problem solving is centralto methodical physiotherapeutic man-agement. This comprises the elements ofreferral, history taking, physical exam-ination, analysis (including formulation of the physiotherapeutic diagnosis),treatment plan, treatment, evaluation,conclusion, and the written final report(Hendriks et al, 2000a).

The objective of the diagnostic processis to assess the severity and type of lowback pain and its consequences, and toevaluate to what extent physiotherapy caninfluence the problem. In patients with

non-specific low back pain it is often notpossible to find impairments in ana-tomical structures causing the complaints.Even possibly identified impairments willnot usually provide enough explanationfor the development or continuation ofthe complaints. Therefore, the diagnosticinterventions should focus on the relevantdisabilities and participation problems.

ReferralImportant referral data are patients'needs and expectations, reason forreferral, the course of disability andparticipation problems, and informationabout additional diagnostic proceduresand prognosis. The physiotherapistshould contact the referring physician if the referral does not contain enoughdata.

History TakingThe physiotherapist tries to get a clearpicture of the patient’s health problem.What does the patient expect and prefer,what is the most important complaint,what are the consequences of thiscomplaint on daily life, which factorsincrease, decrease or maintain thecomplaint, and how does the patient feelabout his complaint and its consequ-ences? (Hendriks et al, 2000a).

Key points of history taking are listed intable 2. In cases of recurrent low backpain, the physiotherapist specificallyexamines possible causes for theserepeated episodes (eg changes in workload or activities), the total duration ofthe complaints and the time betweenepisodes of low back pain. The physio-therapist will also ask about the use ofergonomic adjustments and compliance.

These guidelines recommend the use oftwo instruments to assess and evaluatefunctional status. The first instrument isfor the patient-specific complaints toassess the patient’s functional status(Beurskens et al, 1996). To date, there are no studies on the reliability of thisinstrument, although the questionnairehas proved to be useful for patients with

The starting point of these guidelines isthat the referring physician has excludeda specific cause of low back pain. If thephysiotherapist suspects that there is aspecific cause, he or she should contactthe referring physician.

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low back pain (Schoppink et al, 1996).The second instrument is the Quebecback pain disability scale that identifiesdisabilities and participation problems.This questionnaire has been shown to bevalid, reliable and revealing (Schoppink etal, 1996).

Physical ExaminationIt is recommended that the examinationof low back patients should be focused onabilities and participation, instead offinding a physical cause for the back pain.This recommendation is based on theassumption that the referring physicianhas excluded a specific cause for the backpain (Faas et al, 1996), and that thepatient was referred six weeks after onsetof the back pain because his or herfunctioning did not improve (Faas et al,1996). It is also based on the evidence ofprevious research, which showed limitedreliability and validity of diagnostic tests,by physiotherapists, in low back pain(Moons and Van der Graaf, 2000; Potterand Rothstein, 1985).

The physiotherapist assesses patients’disabilities (eg when maintaining a sittingposition or picking up an object from the floor) and participation problems (eg with work or housekeeping) that

were identified during history taking. The physiotherapist will also ident-ify impairments (eg decreased musclestrength of the back extensors, decreasedmobility of the lumbar spine, decreasedphysical fitness) which may be related tothe disability and participation problems.The purpose of the physical examinationis to identify factors that may hamper orfacilitate management, and to assess pat-ients’ level of physical fitness and funct-ioning.

AnalysisBased on the systematic process of col-lecting patient data, patients’ healthproblems will be defined. The physio-therapist describes the most imp-ortant disabilities and participationproblems, the relevant impairments(which are related to the patients’disabilities or participation problems),and whether the back pain follows a normal or an abnormal course.Indications for an abnormal course are,for example, the number of daily periodsof rest increase, the use of analgesicspersists or increases, no return to activitiesor participation. These indications arerelated to the duration of three weeks andto the patients’ level of activities.

If the course is abnormal, the physio-therapist describes the present physical,psychological and social factors maint-aining or aggravating the complaints. Thisincludes co-morbid problems. Finally thephysiotherapist decides whether thehealth problem could be improved byphysiotherapy.

If the physiotherapist determines thatphysiotherapeutic intervention is likely to be effective, the physiotherapist sets atreatment plan.

If there is no indication for physio-therapy, patients are referred back to thephysician. Physiotherapists should contactthe referring physician if they think that bio-psychosocial factors and/or im-pairment, disability and participationproblems cannot be treated by physiother-apy (only).

In patients with non-specific low backpain, impairments often do not offerenough explanation for thedysfunctioning. Therefore, diagnosticprocedures should focus on the level of(dis)ability and participation (problems).

Table 2: Key points of history taking of patientswith low back pain

Identification of patients’ needs andexpectations/evaluation of problem

Identification of symptoms at onset Situation before start of symptoms (levels of activities and participation)Development of symptoms

Evaluation of course over timePresent state: severity and nature of symptoms (impairments, disabilities andparticipation problems) Course of complaints (normal/abnormal)Previous diagnostic procedures, treatmentinterventions and resultsPrevious information obtained (content ofinformation, given by whom)

Coping strategyWhat significance does the patient attach to his symptoms?Does the patient have control over hissymptoms?

Additional informationCo-morbidity Current treatment: medication/othertreatment/advice/medical aids Work-related aspects

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Treatment PlanThe main objective of the treatment forlow back pain is a return to the highest(or desired) level of activities and part-icipation and the prevention of chroniccomplaints and recurrences.

As most patients with a normal coursewill return to their normal level of act-ivities and participation, irrespective oftreatment, one or two treatment sessionsto coach these patients will often beenough. The main intervention is patienteducation, aimed at patients continuingtheir self-management.

In patients with an abnormal course thesub-goals of the treatment are to increasetheir knowledge and understanding andchange inadequate behaviour, if needed;gradually to increase activities and part-icipation; to improve relevant functions(eg muscle strength, flexibility, stability);to promote an adequate coping style; and to influence any other physical or psychosocial factors which may beassociated with chronic low back pain andwhich are within the scope of physio-therapy. The main treatment intervent-ions are systematic patient education andexercise therapy aimed at functioning.

The physiotherapist will pursue anactive policy, in which patients also takeresponsibility for the results of thetreatment.

TreatmentEvidence from Systematic ReviewsFirst the findings of the systematic reviewsare summarised (table 3), followed by adescription of the therapeutic process.This is based on the distinction betweenpatients with low back pain with a normaland those with an abnormal course.

Advice to Stay Active

Two reviews describe the effects of adviceto stay active to patients with (sub)acutelow back pain (Van Tulder et al, 1999;Waddell et al, 1997). Both reviewsincluded the same eight trials. Bothreviews conclude that advice to stay activeresults in a faster return to work, fewerchronic disabilities and fewer recurrenceproblems, and so the advice to stay activeis useful in the management of (sub)acute low back pain.

Advice against Bed Rest

Three systematic reviews describe theeffects of bed rest in acute patients withlow back pain (Hagen et al, 2000; VanTulder et al, 1999; Waddell et al, 1997).The most recent review included ninetrials, five of which had a high meth-odological quality. The findings andconclusions of all reviews are consistentand show that bed rest is not a usefultreatment for acute low back pain andmay even cause delay in recovery.

Exercise Therapy

The systematic review by Van Tulder et al(2000a) included 39 randomised con-trolled trials on the effectiveness ofexercise therapy for low back pain inprimary care health settings.

It is useful to advise (sub)acute patientswith low back pain to stay active.

Bed rest is not useful in acute low backpain. If bed rest is unavoidable, it shouldbe for a short period (a maximum of twodays).

Exercise therapy has no added value inacute patients with low back pain (< 6 weeks). Exercise therapy is useful inthe treatment of chronic patients withlow back pain (> 12 weeks). It is not clearwhich exercises are best.

The physiotherapist uses an activeapproach towards patients with low backpain. The most important interventionsare patient education and exercisetherapy.

Table 3: Summary of effectiveness of treatment modalities

(Sub)acute low back pain Chronic low back pain

Strong evidence Advice to stay active Exercise therapyof effectiveness

Limited/moderate Behavioural therapyevidence of effectiveness

Effectiveness unclear Ultrasound, Ultrasound,electrotherapy, laser, electrotherapy, laser,transcutaneous electrical transcutaneous nerve stimulation, electrical nerve massage stimulation, massage

Moderate evidence Specific exercises, Biofeedbackof ineffectiveness traction

Strong evidence Advice to take bed rest Tractionof ineffectiveness

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In patients with acute low back painthere is strong evidence that exercisetherapy has no better results thanplacebo, inactive or any other activetreatments. In chronic low back painthere is strong evidence that exercisetherapy is equally effective compared withphysiotherapy (usually a combination ofsome of the following modalities:hotpacks, massage, traction, mobilisation,shortwave therapy, ultrasound, stretch-ing exercises, mobilisation exercises,improving co-ordination, and electro-therapy) and there is strong evidence thatexercise therapy is more effective than the standard care provided by generalpractitioners.

Hilde and Bo (1998) conclude that it isnot clear if the methodological quality,the dosage or the type of exerciseinfluence the results of exercise therapyin chronic low back pain. It remainsunclear which type of exercises are best.

Behavioural Treatment

Van Tulder et al (2000b) conducted ameta-analysis on the effectiveness ofbehavioural treatment for chronic non-specific low back pain. The analysisincluded 21 studies.

Results show that there is strongevidence that behavioural treatment(compared to no treatment, waiting list orplacebo) has a moderately positive effecton pain intensity, and small positiveeffects on general functional status andbehavioural outcomes in patients withchronic low back pain.

The effectiveness of behavioural treat-ment compared to other treatments is notclear. There is no evidence that any oneof the modalities of behavioural treatmentis more effective than another. There ismoderate evidence that the addition of abehavioural component to a normaltreatment programme for chronic lowback pain (standard physiotherapy, backschool, multi-disciplinary treatment,medical treatment) has a small short-termeffect on functional status. No short-termeffects were seen on the intensity of painor on behavioural outcomes, but there ismoderate evidence for small long-termeffects on functional status and onbehavioural outcomes.

Turner (1996) included 14 publicationsin her meta-analysis on the effectivenessof cognitive and behavioural interventionsin patients with low back pain in primarycare health settings. Turner concludesthat cognitive and behavioural treat-ments have better effects than controltreatments (such as waiting lists) on painbehaviour and disabilities. No differenceswere found between cognitive or behav-ioural treatments or other active treat-ments.

Traction

In 1995 Van der Heijden et al performed asystematic review on the effectiveness oftraction in neck and back pain. In thisreview 17 randomised controlled trials areincluded, 14 of which were on the efficacyof lumbar traction. The authors con-cluded that the methodological quality ofthe studies was too low to be able to drawconclusions about the effectiveness oftraction in low back pain.

A more recent systematic review by Van Tulder et al (1999) shows a completeoverlap with the above-mentioned review,with the exception of one randomisedcontrolled trial, which was published in1995. The newly added trial is of highmethodological quality and compares theeffectiveness of traction with placebo-traction in patients with chronic low backpain. The study does not demonstrate anyeffects on general improvement, pain orfunctional status. Van Tulder et al con-clude that there is strong evidence thattraction is not an effective treatment inchronic low back pain.

Biofeedback

In the systematic review by Van Tulder etal (1999) five studies on the effectivenessof biofeedback in patients with chroniclow back pain were included. All trialswere of low methodological quality. Theauthors conclude that there is moderateevidence against the effectiveness ofbiofeedback in these patients.

Traction does not seem useful in acutelow back pain (< 6 weeks). Traction isnot useful in chronic low back pain (> 12 weeks).

The administration of biofeedback doesnot seem useful in chronic patients withlow back pain (>12 weeks).

In chronic low back pain behaviouraltreatment principles may be useful.

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Massage

Ernst (1999) conducted a review on the effectiveness of massage in patients withlow back pain. Four randomised trialswere included. All studies used massage as a control treatment instead of an experimental intervention. Also, themethodological construct of all studieswas weak. In conclusion, it can be statedthat the evidence on the effectiveness ofmassage in low back pain is contradictory.

Transcutaneous Electrical NerveStimulation

The review by van Tulder et al (1999) onthe effectiveness of transcutaneouselectrical nerve stimulation contains twotrials studying acute patients with lowback pain, of which one was of highmethodological quality; and four studies,of which three were of high method-ological quality; comparing transcutan-eous electrical nerve stimulation withplacebo in chronic patients with low backpain. In conclusion, the evidence on theeffectiveness of transcutaneous electricalnerve stimulation in low back pain iscontradictory.

Ultrasound

Van der Windt et al (1999) produced asystematic review of 38 studies ofultrasound in musculoskeletal disorders.Only one study related to the effectivenessof ultrasound in patients with degen-erative rheumatic disorders (includingthose in the low back). The authorsconclude that there is little evidence infavour of the effectiveness of ultrasoundin the management of musculoskeletaldisorders. This conclusion is in agreementwith the conclusion from a previouslyperformed meta-analysis by Gam andJohannsen (1995) on the effectiveness ofultrasound in musculoskeletal disorders.

Electrotherapy

In a review by Van der Heijden et al(1999) 11 trials were included on theeffectiveness of electrotherapy in low back pain. Electrotherapy encompassesdirect current therapy (diadynamic andultrareiz) and alternating current therapy(transcutaneous electrical nerve stim-ulation and interferential). The authorsconclude that there is not enoughevidence in favour of electrotherapycompared with placebo, and also incomparison with a pragmatic treatmentsuch as other modalities of electrotherapy,combined modalities of electrotherapy, or an active approach.

Laser

Gam et al (1993) per formed a meta-analysis on the effectiveness of low levellaser therapy in patients with musculo-skeletal disorders. Twenty-three random-ised controlled trials were included, ofwhich one was on patients with low backpain. The authors conclude that lasertherapy has no effect on pain resultingfrom musculoskeletal disorders.

De Bie et al (1998) did a systematicreview on the effectiveness of lasertherapy (904 nm laser) in patients withmusculoskeletal disorders. A total of 25trials were found, of which two werestudies on patients with low back pain.Neither study was able to prove theeffectiveness of laser.

Process Treatment of Patients with Low BackPain with a Normal CourseThe starting point is that patients copeadequately with their symptoms. Onetreatment session in which the physio-therapist gives education and exercisetherapy, if needed, should therefore besufficient. If necessary, a second app-ointment may be made, in order toevaluate the course of disability andparticipation problems.

Patient Education The physiotherapist reassures the patients

It is unknown whether or notelectrotherapy is useful in low back pain.

It is unknown whether or not laser isuseful in low back pain.

It is unknown whether or nottranscutaneous electrical nervestimulation is useful in patients with low back pain.

It is unknown whether or not ultrasoundis useful in low back pain.

It is unknown whether or not massage isuseful in patients with low back pain.

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and explains that low back pain usuallyhas a favourable course, and discusses therelation between load and load-bearingcapacity. The message should be thatgradually increasing activities is beneficialand not harmful for the back.

The physiotherapist coaches patientsand encourages them to continue currentactivities and to build up to a full level ofactivities and participation. Physio-therapist and patient will evaluatepotential barriers in this process andtogether they will seek solutions.

Exercise TherapyTo support the information and advicethe physiotherapist may allow patients toexperience that moving or being active is not harmful. Patients get positiveexperiences by practising movements that are necessary for daily activities.Subsequently they may be able to carrythese experiences over to other activitiesin daily life.

Treatment of Patients with Low BackPain with an Abnormal Course The most important interventions in thetreatment of patients with low back painwith an abnormal course are patienteducation and exercise therapy.

Patient EducationThe physiotherapist’s main contributionin the treatment of patients with low back pain is coaching. The objective is to enable them to regain control withrespect to function and activities. Toachieve this objective the physiotherapistwill provide information about the natureand course of the back pain, the relationbetween load and load-bearing capacityand the importance of an active lifestyle.Patients should be told that low back pain is usually not harmful and that anincrease of back pain does not necessarilyimply that structures in the back havebeen damaged. Coaching may include(re)activation, reassurance and motiv-ation of patients, determination of prog-ress and rewarding by giving positivefeedback.

Effective education requires knowledgeand educational skills, and somebehavioural techniques. Van der Burgtand Verhulst (1996) present a patienteducation model for allied healthprofessional practice, in which it ishypothesised that the readiness to change

behaviour is determined by an interplaybetween attitude (how does the personperceive the change of behaviour?), socialinfluence (how do others perceive thechange of behaviour?) and self efficacy(will it work or not?) The model consistsof six steps 'being open', 'understanding',' wanting' and 'doing', 'being able' and'keep on doing' (table 4). The historytaking provides attention points foreducation. To increase self-management itmay be necessary to influence coping,cognition and fear.

Promoting AdherenceTo bring about a beneficial effect on thecomplaints, it is important that patientsadhere to the treatment. Various factorsmay decrease adherence:

1. Problems which patients experience in their attempts to adhere to theexercises and instructions given by the physiotherapist,

2. Lack of positive feedback.

3. Degree of 'helplessness' (if patientsthink that exercise will not help).

4. Bad prognosis.

5. Not feeling much hindered by thedisorder (Sluijs, 1991).

Physiotherapists should explore care-fully the extent to which patients are ableto adhere to the prescribed exercises and

Table 4: Illustration of the six steps in the process of patient education

1. Being openThe physiotherapist will try to meet the experiences, expectations,questions and worries of the patient.

2. UnderstandingThe information must be offered in such a way that the patient is able tounderstand and remember the information.

3. Wanting The physiotherapist evaluates what drives (does not drive) the patient toshow certain behaviour. The physiotherapist offers support and providesinformation about possibilities and alternatives. Agreements should befeasible.

4. Being ableThe patient must be able to perform the desired behaviour. Functional activities need to be practised.

5. DoingThe physiotherapist makes clear, concrete and feasible agreements with the patient and sets concrete targets.

6. Keep doing During the treatment episode there must be communication about whetheror not the patient thinks that he will be able to show and maintain the newbehaviour. If there are problems, solutions must be sought.

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advice, and seek solutions together withthe patient (Sluijs, 1991).

Exercise TherapyBehavioural Approach The behaviouralapproach focuses on the prevention offurther disablement of patients (Vlaeyenet al, 1996). Treatment may focus on pain behaviour (operant approach), onthe recognition of tension (respondentapproach), or on the expectations andideas of the patient (cognitive approach).The operant approach is best suited tothe physiotherapist’s professional domain.The purpose of the operant approach isto increase the level of activities and todecrease pain behaviour in such a waythat patients are able to perform theactivities they want to do despite the pain (Vlaeyen et al, 1996). Characteristicbehavioural principles are active part-icipation and time contingent manage-ment.

Increasing Activities Using a Time Con-tingent Approach Activities are incr-eased step by step, based on stepspreviously agreed, rather than on the pain(graded activity, see example in table 5).The objective is to increase the level ofactivity and to learn to cope with one’sown physical capacity. In order to fit thepatients’ needs as closely as possible, theywill be asked which activities are the mostlimited and which activities they considerthe most important. These activities willbe the points of departure for treatment.

First, the baseline of the activities to bepractised will be set. This is done byasking patients to perform the activitiesfor as long, or as frequently, as possible. It is preferable to perform the measure-ments repeatedly in order to produce amore reliable estimate of the startinglevel. Based on the written parameters(time, duration, weight/heaviness,frequency) the mean can be calculatedfor every activity: the baseline per activity.During the baseline measurement thephysiotherapist will pay attention to thequality of movement.

Subsequently, a feasible goal is agreedfor each activity. The physiotherapist willgrade the activities, starting some waybelow the baseline level, and progressingto the projected outcome level, carefullybalancing between the load and thepatient’s load-bearing capacity.

The way the programme is built up (the

size and number of steps) depends on thedifference between the starting level andthe projected outcome level, and on theindividual’s load-bearing capacity. Thephysiotherapist must make an estimate of this. It is important that the presence of pain does not obstruct the exerciseassignments. During the programmepatients will exercise no less, but also nomore, than was mutually agreed for thatday. Patients will also exercise at homeand keep a record of their progress.

Other Interventions Biofeedback andtraction are not recommended becausethese interventions have not been shownto be effective. It is not clear whethermassage, electrotherapy (includingtranscutaneous neuromuscular nervestimulation), ultrasound or laser areeffective in low back pain. On the basis ofindividual circumstances (eg strongpatient preferences) physiotherapists mayconsider the use of these interventions,but they should be a subordinate com-ponent of the treatment regime and onlybe used for a short time and in support ofthe active approach.

Traction and biofeedback are not usefulin chronic patients with low back pain. It is unclear whether massage,electrotherapy (including transcutaneouselectrical nerve stimulation), ultrasoundor laser are useful in patients with lowback pain. The guideline recommendsusing these interventions reservedly andonly in support of the active approach.

Table 5: Practical example of pain and timecontingent treatment

Pain contingentA patient walks with the therapist. After 100metres the patient mentions that he is in pain.They sit down for a while. During the rest theychat, until ‘it’s better’ and the walking isresumed.What happened is this: the walking seems to bepunished by pain (so walking will be reduced),the pain seems to be rewarded by a rest (soresting will be increased), resting seems to berewarded with social talk (so resting willincrease).

Time contingentThe patient walks with the therapist. They agreebeforehand to walk to a particular corner with abench. There they will sit down for five minutes,before walking back. It may be difficult andpainful, or it may be easy and perhaps they couldhave gone further. But they stick to theiragreement and do no more and no less.After the walk the physiotherapist will givepositive feedback on the progress made.

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EvaluationThe physiotherapist evaluates the treat-ment results regularly and systematicallyby setting them against the treatmentobjectives. On the basis of this evalua-tion, the treatment plan may be mod-ified. The physiotherapist may use the measuring instruments mentionedpreviously in the diagnostic process. Toevaluate the outcomes of the informationand advice given, the physiotherapistshould ask: ‘Does the patient know whathe needs to know?’ and ‘Does the patientcope the way he should?’ If the treatmentdoes not improve a patient’s functioningwithin three weeks, the physiotherapistshould contact the referring physician.

Treatment Conclusion and ReportAt the end of the treatment the effects of the intervention should be evaluatedand reported to the referring physician.The written report should include thetreatment objectives, the improvements infunctioning, perceived quality of life andthe reason for concluding the treatment(Hendriks et al, 2000a).

DiscussionIn the Netherlands seeking care for lowback pain usually starts with consulting a general practitioner (primary carephysician), who decides if and whichtreatment is necessary. The Dutch generalpractice guidelines favour a wait-and-seepolicy in acute patients with low back painand do not recommend a referral tophysiotherapy within the first six weeks(Faas et al, 1996). In practice, however,general practitioners refer patients withinsix weeks (Schers et al, 2001).

The physiotherapy guidelines arelargely in line with the general practiceguidelines; if the course of symptoms isnormal the physiotherapist supports thewait-and-see policy. Patients with anabnormal course, who do not increaseactivities and participation within threeweeks, may be at risk of developing chron-ic complaints. Therefore intervention isnecessary in order to prevent transition tothe chronic stage.

The guidelines recommend adequateeducation and exercise therapy for thesepatients, although they may still be in theacute stage of their back pain, in whichthere is no evidence for the effectivenessof exercise therapy. However, based onprinciples of early activation which is

shown to prevent chronic complaints, weargued that it may not be beneficial forthese patients to wait for treatment untilsix weeks have passed. Although this cut-off point of six weeks is frequently used in efficacy literature, there is hardly anyevidence in favour for this in practice.

The Dutch physiotherapy guidelinesrecommend only one or two treatmentcounselling sessions in patients with anormal course. Usually this concerns theacute stage of back pain. This recomm-endation is based on the findings that theadvice to stay active has better results than any treatment in the acute stage(Van Tulder et al, 1999; Waddell et al,1997). Most patients have a good prog-nosis and will get better within a few days or weeks, regardless of treatment.Furthermore, if we intervene too much ortoo early, patients might attach too muchsignificance to their back pain or get thefeeling that they cannot control the backpain themselves.

This recommendation has been care-fully discussed by the working groups as we were aware that it will probably becontroversial for many physiotherapists. Itis important to realise that in a healthcaresystem such as that of the Netherlands,where patients do not have direct accessto physiotherapy but have to be referred,only a small minority of patients who visit a physiotherapist will have a normalcourse. It is the responsibility of thereferring physician to refer only patientswith an abnormal course. However, in healthcare systems where patients have direct access to physiotherapy it isthe responsibility of the physiotherapist to avoid over-treatment and/or over-medicalisation.

The cut-off point of three weeks todefine a normal and abnormal course isbased on consensus and is arbitrary. Thispoint has been set, after careful discussionwith both working groups, to meet theneeds of physiotherapists working in thefield, who were not able to distinguish anormal from an abnormal course withouta time-frame.

Recently Dutch multi-disciplinaryguidelines for low back pain have beendeveloped. Our mono-disciplinary guide-lines have added value, as the primarygoal of our guidelines is to improve thequality of physiotherapeutic treatment forlow back pain. They also define clearly theposition and tasks of physiotherapists

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treating patients with low back pain inprimary care. Multidisciplinary guidelinestend to focus more on evidence and lesson the treatment process and which pro-fession should perform certain manage-ment activities.

In these guidelines best evidence hasbeen used as basis for the recom-mendations. However, the evidence re-garding the physiotherapeutic diagnosticprocess was very sparse and concernedmainly the psychometric quality ofquestionnaires. Therefore, the diagnosticprocess was primarily constructed on theprocess of clinical reasoning. Clinicalreasoning requires a systematic process ofdiagnosis and concurrent evaluationduring the process of treatment for theidentification of a patient’s problem andresponse to treatment (Hendriks et al,2000a). This systematic approach makesthe considerations, arguments andactivities underlying certain clinicaldecisions explicit and may increase theeffectiveness and efficiency of treatment.More, and methodologically sound,research on (physiotherapeutic) diagn-ostic tests and procedures with respect tolow back pain are urgently needed.

These guidelines describe the state-of-the-art with respect to physiotherapy forlow back pain. How far these principlesare already used in practice is not known.Field testing, a phase of developmentwhen physiotherapists could comment onthe draft guidelines, showed that there is a gap between these guidelines andcurrent practice. Implementation ofguidelines is crucial in trying to changethe behaviour of physiotherapists. Eachset of Dutch physiotherapy guidelines isaccompanied by a separate implem-entation plan, directed specifically at thetopic of the guidelines. These low backpain guidelines are promulgated in theNetherlands mainly by publication(Bekkering et al, 2001) and disseminatingthem to all members of the Royal DutchSociety for Physiotherapy, together withforms facilitating implementation.Probably a more active approach isnecessary to encourage changes inpractice. At the moment experiments aregoing on in the Netherlands, comparingthe cost-effectiveness of the standardimplementation strategy versus a moreintensive implementation strategy. Theresults are expected in 2003.

AcknowledgementThese guidelines were issued by the RoyalDutch Society for Physiotherapy andfunded by the Government Department ofPublic Health, Sciences and Sports.

For the production of these guidelines,special words of gratitude to the multi-disciplinary working committee are inorder. Many thanks to (in alphabeticalorder): P F van Akkerveeken PhD(orthopaedic surgeon, Back Advice CentreNederland), R M Bakker-Rens MSc(occupational physician, Dutch Society forOccupational Practice), A J Engers PT MSc(psychologist / human movement scientist,Centre of Care Research, Medical Centre St Radboud, Nijmegen), L Göeken PhD(rehabilitation physician, Dutch Society forRehabilitation Physicians), J Mens MSc(orthopaedic surgeon, Spine and Joint

Centre), H H C F M van Maasakkers PT(Rugcentrum Uden), A C M RomeijndersMSc (general practitioner, DutchAssociation for General Practice), M A Schmitt PT (School of Physiotherapy,Utrecht), J W S Vlaeyen PhD (psychologist,University of Maastricht) and A de Wijer PTPhD (School of Physiotherapy, Utrecht).

Also we would like to thank allphysiotherapists who have co-operated in the field tests, and N E Knibbe MSc(human movement scientist, locomotion), Y F Heerkens PhD and E M H M Vogels MSc(both from the National Dutch Institute ofAllied Health Professions) for theircontribution to the guidelines.

Finally we gratefully acknowledge R V M Chadwick-Straver for translatingthese guidelines.

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References

Abenhaim, L, Rossignol, M, Valat, J, Nordin, M, Avouac, B, Blotman, F, Charlot, J,Dreiser, R L, Legrand, E, Rozenberg, S andVautravers, P (2000). ‘The role of activity inthe therapeutic management of back pain:Report of the international Paris Task Forceon Back Pain’, Spine, 25, 1s-33s.

ACC (Accident Rehabilitation andCompensation Insurance Corporation) andNational Health Committee (1997). NewZealand Acute Low Back Pain Guide, Wellington,New Zealand.

Bekkering, G E, Hendriks, H J M, Koes, B W,Oostendorp, R A B, Ostelo, R W J G,Thomassen, J and Van Tulder, M W (2001).‘KNGF (Koninglijk Nederlands Genootschapvoor Fysiotherapie)-richtlijn Lage-rugpijn’,Nederlands Tijdschrift voor Fysiotherapie, 111, 3,supplement.

Beurskens, A J H M, Vet, H C W and Köke, A J A(1996). ‘Responsiveness of functional status inlow back pain: A comparison of differentinstruments’, Pain, 65, 71-76.

Bigos, S, Bowyer, O, Braen, G et al (1994).Acute Low Back Problems in Adults: Assessmentand Treatment, Clinical practice guidelinenumber 14, Department of Health andHuman Services, Pub 95-0643, Agency forHealth Care Policy and Research.

De Bie, R A, Verhagen, A P, Lenssen, A F, De Vet, H C W, Van de Wildenberg, F A J M,Kootstra, G and Knipschild, P G (1998).‘Efficacy of 904 nm laser therapy in themanagement of musculosketal disorders: A systematic review’, Physical Therapy Reviews, 3, 59-72.

Ernst, E (1999). ‘Massage therapy for low backpain: A systematic review’, Journal of Pain andSymptom Management, 17, 65-69.

Faas, A, Chavannes, A W, Koes, B W, Hoogen, J M M, Mens, J M A, Smeele, L J M,Romeijnders, A C M and Van der Laan, J R(1996). ‘NHG (Nederlands Huisartsengenootschap)-Standaard Lage-Rugpijn’,Huisarts and Wetenschap, 39, 18-31.

Folkman, S and Lazarus, R S (1980). ‘An analysis of coping in a middle-agedcommunity sample’, Journal of Health and Social Behaviour, 21, 219-239.

Foster, N E, Thompson, K A, Baxter G D andAllen, J M (1999). ‘Management of non-specific low back pain by physiotherapists inBritain and Ireland’, Spine, 24, 13, 1332-42.

Frymoyer, J W (1988). ‘Medical progress: Back pain and sciatica’, New England Journal ofMedicine, 318, 291-300.

Gam, J N and Johannsen, J (1995).‘Ultrasound therapy in musculoskeletaldisorders: A meta-analysis’, Pain, 63, 85-91.

Gam, A N, Thorzen, H and Lonnberg, F (1993).‘The effect of low-level laser therapy on musculo-skeletal pain: A meta-analysis’, Pain, 52, 63-66.

Hagen, K B, Hilde, G, Jamtvedt, G andWinnem, M (2000). Bed Rest for Acute Low BackPain and Sciatica (Cochrane Review), TheCochrane Library, no 3, Update Software,Oxford.

Härkäpää, K, Järvikoski, A, Vakkari, T (1996).‘Association of locus of control beliefs withpain coping strategies and other pain-relatedcognitions in back pain patients’, BritishJournal of Health Psychology, 1, 1, 51-63.

Hendriks, H J M, Oostendorp, R A B,Bernards, A T M, Van Ravensberg, C D,Heerkens, Y F and Nelson, R M (2000a). ‘The diagnostic process and indication forphysiotherapy: A prerequisite for treatmentand outcome evaluation’, Physical TherapyReviews, 5, 29-47.

Hendriks, H J M, Bekkering, G E, Brandsma, J W et al (2000b). ‘Developmentand implementation of national practiceguidelines: A prospect for continuous qualityimprovement in physiotherapy: Anintroduction to the method of guidelinedevelopment’, Physiotherapy, 86, 535-547.

Hilde, G and Bo, K (1998). ‘Effect of exercisein the treatment of low back pain: A systematicreview emphasising type and dose of exercise’,Physical Therapy Reviews, 3, 107-117.

Jensen, M P, Turner, J A, Romano, J M andKaroly, P (1991). ‘Coping with chronic pain: A critical review of the literature’, Pain, 47,249-283.

Koes, B W, Van Tulder, M W, Ostelo, R,Burton, A K and Waddell, G (2001). ‘Clinical guidelines for the management of lowback pain in primary care: An internationalcomparison’, Spine, 26, 2504-13.

Li, L and Bombardier, C (2001). ‘Physical therapy management of low back pain: An exploratory survey of therapistapproaches’, Physical Therapy, 81, 4, 1018-28.

Linton, S J (2000). ‘Psychological factors inneck and low back pain’ in: Nachemson, A Nand Jonsson, E (eds) Neck and Back Pain: The scientific evidence of causes, diagnosis andtreatment, Lippincott, New York.

Moons, K G M and Van der Graaf, Y (2000).‘Evaluatie van de toegevoegde waarde vandiagnostische tests’, Nederlands Tijdschrift voorGeneeskunde, 144, 1256-61.

Nachemson, A L (1992). ‘Newest knowledge oflow back pain: A critical look’, Clinical andOrthopedic Related Research, 279, 8-20.

NVAB Nederlandse Vereniging voor Arbeids -en Bedrijfsgeneeskunde (1999). Richtlijnenvoor het Handelen van de Bedrijfsarts bijWerknemers met Lage-rugklachten.

Physiotherapy February 2003/vol 89/no 2

96

Potter, N A and Rothstein, J M (1985). ‘Inter-tester reliability for selected clinical tests of thesacroiliac joint’, Physical Therapy, 65, 1671-75.

Schers, H, Wensing, M, Huijsmans, Z, Van Tulder, M W and Grol, R (2001).‘Implementation barriers for general practiceguidelines on low back pain: A qualitativestudy’, Spine, 26, 15, E348-E353.

Schoppink, L E M, Van Tulder, M W, Koes, BW, Beurskens, A J H M and De Bie, R A (1996).‘Reliability and validity of the Dutchadaptation of the Quebec back pain disabilityscale’, Physical Therapy, 76, 268-275.

Sluijs, E M (1991). Patient Education in PhysicalTherapy, Nivel, Utrecht.

Turner, J A (1996). ‘Educational andbehavioural interventions for back pain inprimary care’, Spine, 21, 2851-59.

Van de Hoogen, J M M, Koes, B W, Devillé, W,Van Eijk, J T M and Boute, L M (1998). ‘De prognose van de aan de huisartsgepresenteerde lage-rugpijn’, Huisarts andWetenschap, 41, 62-68.

Van den Burgt, M and Verhulst, F (1996). Doen en Blijven Doen: Patiëntenvoorlichting in deparamedische praktijk, Bohn Stafleu VanLoghum, Houten.

Van der Heijden, G J M G, Beurskens, A J H M,Assendelft, W J J, De Vet, H C W and Bouter, LM (1995). ‘The efficacy of traction for backand neck pain: A systematic blinded review ofrandomised clinical trial methods’, PhysicalTherapy, 75, 18-29.

Van der Heijden, G J M G, Torenbeek, M, Van der Windt, D A W M, Hidding, A, Dekker,J and Bouter, L M (1999). ‘Transcutaneouselectrotherapy for musculoskeletal disorders:A systematic review’ in: Gezondheidsraad,Gezondheidsraad, Den Haag.

Van der Valk, R W A, Dekker, J and Van Baar,M E (1995). ‘Physical therapy for patients withback pain’, Physiotherapy, 81, 6, 345-351.

Van der Windt, D A W M, Van der Heijden, G JM G and Berg, S G M (1999). ‘Effectiviteit vanultrageluidbehandeling voor aandoeningenvan het bewegingsapparaat: Een systematischereview’, Nederlands Tijdschrift voor Fysiotherapie,109, 14-23.

Van Ravensberg, C D, Van Klaveren, A A J,Wams, H W A, Elvers, J W H, Oostendorp, R A Band Hendriks H J M (1995). Variabelen inSamenhang met het Aantal BehandelingenFysiotherapie, Paramedisch Instituut,Amersfoort, Nederlands.

Van Tulder, M W, Koes, B W and Bouter, L M(1997). ‘Conservative treatment of acute andchronic non-specific low back pain: Asystematic review of randomised controlledtrials of the most common interventions’,Spine, 22, 2128-56.

Van Tulder, M W, Koes, B W, Assendelft, W J Jand Bouter, L M (1999). The Effectiveness ofConservative Treatment of Acute and Chronic LowBack Pain, EMGO Institute, Amsterdam.

Van Tulder, M W, Malmivaara, A, Esmail, Rand Koes, B W (2000a). Exercise Therapy for LowBack Pain (Cochrane Review), The CochraneLibrary, no 3, Update Software, Oxford.

Van Tulder, M W, Ostelo, R W J G, Vlaeyen, J W S, Linton, S J, Morley, S J andAssendelft, W J J (2000b). BehaviouralTreatment for Chronic Low Back Pain(Cochrane Review), The Cochrane Library, no 3, Update Software Oxford.

Von Korff, M (1994). ‘Studying the naturalhistory of a back pain’, Spine, 19, 2041S-46S.

Von Korff, M and Saunders, K (1996). ‘The course of back pain in primary care’,Spine, 21, 2833-39.

Vlaeyen, J W S, Kole-Snijders, A, Rotteveel, A M, Ruesink, R and Heuts, P(1995). ‘The role of fear of movement(re)injury in pain disability’, Journal ofOccupational Rehabilitation, 5, 235-251.

Vlaeyen, J W S, Kole-Snijders, A M J and Van Eek, H (1996). ‘Chronische pijn enrevalidatie’, Praktijkreeks Gedragstherapie, BohnStafleu Van Loghum, Houten.

Waddell, G (1987). ‘A new clinical model forthe treatment of low back pain’, Spine, 12, 632-644.

Waddell, G (1992). ‘Biopsychosocial analysis oflow back pain’, Bailliere’s Clinical Rheumatology,6, 523-557.

Waddell, G (1998). The Back Pain Revolution,Churchill Livingstone, Edinburgh.

Waddell, G, Feder, G, McIntosh, A, Lewis, Mand Hutchinson, A (1996). Low Back PainEvidence Review, Royal College of GeneralPractitioners, London.

Waddell, G, Feder, G and Lewis, M (1997).‘Systematic reviews of bed rest and advice tostay active for acute low back pain’, BritishJournal of General Practice, 47, 647-652.

Waddell, G and Waddell, H (2000). ‘Socialinfluences on neck and low back pain’ in:Nachemson, A N and Jonsson, E (eds) Neckand Back Pain: The scientific evidence of causes,diagnosis and treatment, Lippincott Williams andWilkins, New York.

World Health Organisation (2001).International Classification of Functioning,Disability and Health: IC, WHO, Geneva.