Recommended treatments

Treatments Basis, indications and risk Patient information Postural hygiene Exercise Maintaining level of Activity Bed rest Pharmacological therapy Neuroreflexotherapy (NRT) Spinal column surgery Surgery for Pain and Pain Clinics Vertebral manipulation Behavioral treatment Epidural injections Facet joint infections Trigger point and ligament infections Rhizotomy Corsets and lumbar belts Traction Physical therapy/physiotherapy Electromyografic Feedback TENS: Transcutaneous electrical Nerve Stimulation Shoe insoles and shoe lifts Acupunture Recommended treatments

Experts from the Scientific Department of the Kovacs Foundation have added recommendations to the existing evidence-based ones. These recommendations originate from studies performed since the guidelines were published. They are mentioned in sections on each treatment.

To assess a patient's condition, it is mandatory to perform a physical examination and the clinical interpretation of the collected data. Therefore, only a physician can do this. The following treatment schemes are generic and only a physician can evaluate their application to each specific case.

1. General measures:
   1. Avoid bed rest, if possible.
      Patients must avoid bed rest. Should pain make it unavoidable, bed rest should be as short as possible. Available studies show that bed rest delays recovery or improvement.
   2. Stay as active as possible.
      Patients must maintain their normal daily activities as much as possible. Should they limit their normal activities because of pain, they must try to resume them as soon as possible.
   3. Postural hygiene: Avoid back overload.
      Even when maintaining the rate of activity as normal as possible, patients must avoid back overloading. Patients must be familiar with and follow postural hygiene measures in their postures, and when making movements or efforts.
      After recovery, exercise and postural hygiene decrease the risk of further pain episodes.
   4. Heat or cold application.
      Patients may self-apply heat or cold if relief in the painful area is felt, although there are no scientific studies to assess its efficacy. In general, heat is applied in cases of recurrent chronic pain and cold in acute episodes.
2. Pharmacological treatment.
   1. Phase 1: When pain starts, the use of analgesics is recommended, specially if back pain is not very intense and there is no arm or leg pain radiation.
   2. Phase 2: If analgesics are not effective, substitution by nonsteroideal anti-inflammatory drugs should be considered.
   3. Phase 3: If none of the above is sufficient to control pain, muscle relaxants may be added for a short period of time, usually less than 1 week.
3. Vertebral manipulation.
   In spite of conflicting evidence, some recommendations suggest the consideration of spinal manipulation if an adequately trained professional is available. Vertebral manipulation may be considered, provided that:
   1. Despite administered drugs, the patient continues feeling pain or has not returned to normal daily activities,
   2. - The patient only complains of back pain -no leg or arm radiated pain is present-,
   3. - Pain is of less than 6 weeks' duration (there are no scientific studies that prove the efficacy of manipulation in pain of longer duration).
      Manipulation should be interrupted if it shows no efficacy within 1 month.
4. Neuroreflexotherapy (NRT).
   NRT intervention is indicated in patients who:
   1. - Continue with back pain despite 14 consecutive days of pharmacological treatment, or in instances where drug therapy is contraindicated (for example, during pregnancy).
   2. - Do not present criteria for urgent disc herniation surgery, spinal stenosis or spondylolisthesis.
5. Exercise.
   Patients who have not returned to normal daily activities after 6 weeks should follow an exercise program.
   At the beginning, mild and generic physical activities are recommended, such as walking or swimming, to avoid muscle weakening. More specific back exercises may be started after that.
   After recovery, exercise and postural hygiene decrease the risk of further pain episodes.
6. Surgery.
   It should only be done on patients where specific selection criteria are met, in some cases of disc herniation, spinal stenosis, spondylolisthesis or progressive scoliosis.
   Rhizotomy can be considered in a small subgroup of chronic patients, if they are selected very rigorously under specific criteria.
7. Behavioral Treatment.
   It is indicated for chronic back pain patients, and in those where psychosocial factors may increase the risk of chronicity.