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WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settingsWHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings.ISBN 978-92-4-008178-9(electronic version)ISBN 978-92-4-008179-6(print version)World Health Organization 2023Some rights reserved.This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence(CC BY-NC-SA 3.0 IGO;https:/creativecommons.org/licenses/by-nc-sa/3.0/igo).Under the terms of this licence,you may copy,redistribute and adapt the work for non-commercial purposes,provided the work is appropriately cited,as indicated below.In any use of this work,there should be no suggestion that WHO endorses any specific organization,products or services.The use of the WHO logo is not permitted.If you adapt the work,then you must license your work under the same or equivalent Creative Commons licence.If you create 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licensing,see https:/www.who.int/copyright.Third-party materials.If you wish to reuse material from this work that is attributed to a third party,such as tables,figures or images,it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder.The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user.General disclaimers.The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country,territory,city or area or of its authorities,or concerning the delimitation of its frontiers or boundaries.Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned.Errors and omissions excepted,the names of proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by WHO to verify the information contained in this publication.However,the published material is being distributed without warranty of any kind,either expressed or implied.The responsibility for the interpretation and use of the material lies with the reader.In no event shall WHO be liable for damages arising from its use.WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settingsWHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settingsContentsiiiContentsAcknowledgements viiAbbreviations and acronyms xiGlossary xiiiExecutive summary xix1.Introduction 12.Methods 72.1.Contributors to guideline development 72.2.Declarations of interests by external contributors 92.3.Identifying priority questions and outcomes 92.4.Evidence search,retrieval and syntheses 142.5.Formulating recommendations:Evidence-to-decision(EtD)approach 15 2.6.Document preparation and peer review 22 3.Guiding principles:Management of chronic primary low back pain in adults 23 4.Evidence and recommendations 29 4.1.Clinical practice considerations relevant across recommendations 30 4.2.Qualitative evidence synthesis findings relevant across interventions 314.3.Evidence and recommendations for each intervention 34 Intervention class A:Structured and standardized education 40A.1 Structured and standardized education and/or advice 40 Intervention class B:Physical interventions 47B.1 Structured exercise therapies or programmes 47B.2 Needling therapies(traditional Chinese medicine acupuncture and other dry needling modalities)61B.3 Spinal manipulative therapy 66B.4 Massage 70B.5 Traction 74B.6 Therapeutic ultrasound 78B.7 Transcutaneous electrical nerve stimulation 81B.8 Assistive products:lumbar braces,belts and/or supports and mobility assistive products 84 Intervention class C:Psychological interventions 90C.1 Operant therapy 94C.2 Respondent therapy 97C.3 Cognitive therapy 100C.4 Cognitive behavioural therapy 103C.5 Mindfulness-based stress reduction therapy 107WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settingsivIntervention class D:Medicines 111D.1.Systemic pharmacotherapies 115 D.1.1 Opioid Analgesics 120 D.1.2 Non-steroidal anti-inflammatory drugs(NSAIDs)123D.1.3 Serotonin and noradrenaline reuptake inhibitor(SNRI)antidepressants 127D.1.4 Tricyclic antidepressants 130D.1.5 Anticonvulsants 133D.1.6 Skeletal muscle relaxants 136D.1.7 Glucocorticoids 138D.1.8 Paracetamol(acetaminophen)141D.1.9 Benzodiazepines 142D.2 Cannabis-related pharmaceutical preparations for therapeutic use 143D.3 Injectable local anaesthetics 144D.4 Herbal medicines 149D.4.1 Topical Cayenne pepper Capsicum Frutescens 153D.4.2 Devils claw Harpagophytum Procumbens 154D.4.3 White willow Salix Spp.156D.4.4 Topical Brazilian arnica Solidago Chilensis 158D.4.5 Ginger Zingiber Officinale Roscoe 159D.4.6 Topical white lily Lilium Candidum 160D.4.7 Topical combination herbal compress Zingiber Cassumunar Roxb.Rhizomes,Curcuma Longa L.Rhizomes,Cymbopogon Citratus(Dc.),Stapf Leaves And leaf Sheaths,Croton Roxburghii N.p.balakr.leaves,Tamarindus Indica L.leaves,Citrus Hystrix Dc.peels,Blumea Balsamifera(L.)Dc.leaves,Vitex Trifolia L.leaves And Camphor 161D.4.8 Topical combination transdermal diffusional patch Oleum Thymi,Oleum Limonis,Oleum Nigra,Oleum Rosmarini,Oleum Chamomilla And Oleum Lauri Expressum 162 Intervention class E:Multicomponent interventions 164E.1 Weight management 165E.2 Multicomponent biopsychosocial care 1715.Implementation considerations 1766.Research implications 1807.Dissemination 1868.Monitoring and evaluating the impact of the recommendations 1879.Updating the guideline 18810.References 19011.Annex 1:GRADE definitions 20412.Annex 2:Characteristics of medicines trials 20613.Annex 3:Summaries of judgements across ETD domains 215ContentsvList of tablesList of annex tablesTable 1 WHO recommendations for the non-surgical management of CPLBP in adults in community and primary care settings.xxiiiTable 2 Overview of the guideline structure 10Table 3 EtD domains that informed the direction and strength of a recommendation 16Table 4 Operational definitions for developing recommendations 20Table 5 Definitions for supporting contextual commentaries used throughout the guideline 36Table 6 Number of trials including specific topics as part of a structured education and/or advice intervention 42Table 7 Summary of outcomes for pain and function by exercise modality compared to sham(20182022 evidence)51Table 8 Summary of outcomes for pain and function by exercise modality compared to no intervention,or where the effect of exercise could be isolated(20182022 evidence)53Table 9 Summary of outcomes for pain and function by exercise modality compared to usual care(20182022 evidence)55Table 10 Number of psychological therapy trials by intervention and comparator 92Table 11 Summary of trials by medicine and comparator for short and long treatment duration 116Table 12 Summary of trials of herbal medicines and combination medicines 150Table 13 Summary of trials by comparator for weight loss interventions 166Table A1 Definitions of GRADE evidence certainty criteria 204Table A2 Definitions of GRADE certainty ratings 206Table A3 Definitions of GRADE-CERQual confidence ratings 205Table B1 Characteristics of trials by systemic pharmacotherapy agent.All agents were administered orally,unless indicated otherwise 206Table B2 Characteristics of trials by herbal medicine agent 211Table C1 Summary of judgements for intervention class A:Structured and standardized education(intervention A.1)215Tables C2-9 Summary of judgements for interventions class B:Physical interventions(interventions B.1-B.8.1)216WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settingsviWeb AnnexesWeb Annex A:Contributors to the guidelineWeb Annex B:Protocols for evidence synthesesWeb Annex C:Evidence profile for the qualitative evidence synthesisWeb Annex D:Evidence-to-Decision summaries Web Annex E:List of trials by interventionTables C10-14 Summary of judgements for intervention class C:Psychological interventions(interventions C.1-C.5)224Tables C15-25 Summary of judgements for intervention class D:Medicines (interventions D.1.1-D.4.3)229Tables C26-C28 Summary of judgements for intervention class E:Multicomponent interventions(interventions E.1.1-E.2)240ContentsviiAcknowledgementsThe WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings was coordinated by the Ageing and Health Unit,Department of Maternal,Newborn,Child and Adolescent Health and Ageing(MCA)at WHO headquarters under the leadership of Anshu Banerjee.Andrew Briggs and Yuka Sumi led the preparation of this document as the secretariat.WHO extends sincere thanks the 25 members of the Guideline Development Group(GDG):-Deborah Alperovitch-Najenson,Ben-Gurion University of the Negev,Israel.-Annette Becker,University of Marburg,Germany.-Joletta Belton,Global Alliance of Partners for Pain Advocacy,Task Force of the International Association for the Study of Pain,United States of America.-Rachelle Buchbinder,Monash University,Australia.-Eniola Olubukola Cadmus,University of Ibadan,Nigeria.-Mary Cardosa,Selayang Hospital and Hospital University Kebangsaan,Malaysia.-Santosh Kumar Chaturvedi,National Institute of Mental Health&Neurosciences,India.-Roger Chou,Oregon Health&Science University,United States of America.-Ben Daitz,University of New Mexico,United States of America.-Mohamed Mohi Eldin,Cairo University Hospitals,Egypt.-Manuela L Ferreira,The University of Sydney,Australia.-Jan Hartvigsen,University of Southern Denmark and Chiropractic Knowledge Hub,Denmark.-Germain Honvo,University of Abomey-Calavi,Benin.-Jae-Young Lim,Seoul National University,Republic of Korea.-Quinette Louw,Stellenbosch University,South Africa.-Christopher Maher,The University of Sydney,Australia.-Geoffrey Outerbridge,Canadian Memorial Chiropractic College,Canada.-T.K.Sundari Ravindran,Sexual and Reproductive Health Matters Journal,India.-Jean-Yves Reginster,University of Lige,Belgium.-Yves Rolland,Grontople de Toulouse,France.-Saniya Sabzwari,Aga Khan University Hospital,Pakistan.-Sakshi Sharma,Central Council for Research in Ayurvedic Sciences,India.-Simone Steyn,Samson Institute for Ageing Research,South Africa.-Martin Underwood,The University of Warwick,United Kingdom of Great Britain and Northern Ireland.-Darong Wu,The Second Affiliated Hospital of Guangzhou University of Chinese Medicine,China.WHO acknowledges Saniya Sabzwari and Martin Underwood who acted as co-chairs for meeting series 1 and 2,Jan Hartvigsen who acted as co-chair on Day 1 of meeting series 2,and Annette Becker who acted as co-chair at meeting series 3.Martin Underwood acted as chair at meeting series 4.WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settingsviiiWHO also thanks the 14 members of the External Review Group:-Hanadi Khamis Mubarak Alhamad,Hamad Medical Corporation,Qatar.-Cyrus Cooper,University of Southampton,United Kingdom.-Pierre Ct,Ontario Tech University,Canada.-Helen Foster,Newcastle University,United Kingdom.-Janet Gunderson,The Arthritis Society and Cochrane Canada,Canada.-Scott Haldeman,World Spine Care,United States of America.-Jaro Karppinen,University of Oulu,Finland.-Bart Koes,Erasmus University Medical Center,Netherlands(Kingdom of the).-Andrew McLachlan,The University of Sydney,Australia.-Seiji Okada,Osaka University,Japan.-Livia Puljak,Catholic University of Croatia,Croatia.-Francois Rannou,Hpital Cochin and Universit Paris Cit,France.-Robyn Speerin,independent consultant,Sydney,Australia.-Steven Vogel,University College of Osteopathy,United Kingdom.WHO sincerely thanks Nandi Siegfried,who acted as the independent guideline methodologist.WHO thanks the authors of the systematic reviews across eight teams.1.Christopher Williams(lead),The University of Sydney,Australia.Team members:Aidan Cashin,Steven Kamper,James McAuley,Zoe Michaleff,Emma Robson,Amanda Tutty.2.Roger Chou(lead),Oregon Health&Science University,United States of America.Team members:Yun Yu,Rochelle(Rongwei)Fu.3.James McAuley(lead),Neuroscience Research Australia,Australia.Team members:Michael Wewege,Matthew Jones,Michael Ferraro,Hayley Leake(on behalf of the ANiMALIA and ANiMAL network meta-analyses groups).4.Sidney Rubinstein(lead),Vrije Universiteit Amsterdam,Netherlands(Kingdom of the).Team members:Alessandro Chiarotto,Tiziano Innocenti,Esther Maas,Raymond Ostelo,Sylvia Pellekooren,Annemarie de Zoete.5.Chiara Arienti(lead),Fondazione Don Carlo Gnocchi,Italy.Team members:Stefano Giuseppe Lazzarini,Silvia Minozzi,Claudio Cordani,Fabio Zaina,Carlotte Kiekens,Stefano Negrini.6.Carol Cancelliere(lead),Ontario Tech University,Canada.Team members:Lisandra Almeida de Oliveira,Nora Bakaa,Geronimo Bejarano Cardenas,Ginny Brunton,Andr Bussires,Kasper Blow,Christine Cedraschi,Gaelan Connell,Cristiano Costa,Benjamin Csiernik,Sophia da Silva-Oolup,Astrid DeSouza,Annemarie de Zoete,Junior Fandim,Martha Funabashi,Douglas Gross,Brett Guist,Shireen Harbin,Jill Hayden,Cesar Hincapi,Lonie Hofstetter,Wilhelmina Ijzelberg,Pedro Isaac,Carsten Juhl,Shazia Kashif,Rahim Lalji,Joyce Lee,Mariana Leite,Silvano Mior,Somayyeh Mohammadi,Fabianna Moraleida,Javier Muoz Laguna,Kent Murnaghan,Danny Myrtos,Margareta Nordin,Rachel Ogilvie,Daniele Pereira,Paulo Pereira,Diego Roger,Andrew Romanelli,Bruno Saragiotto,Heather Shearer,Sareen Singh,Danielle Southerst,Kent Stuber,Maja Stupar,Daphne To,Andrea Tricco,Leslie Vervi
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