Objective: The objective of this study was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments.

Methods: The topic areas were chosen based on an Agency for Healthcare Research and Quality comparative effectiveness review, specific to spinal manipulation as a nonpharmacological intervention. The panel updated the search strategies in Medline. We assessed admissible systematic reviews and randomized controlled trials for each question using A Measurement Tool to Assess Systematic Reviews and Cochrane Back Review Group criteria. Evidence profiles were used to summarize judgments of the evidence quality and link recommendations to the supporting evidence. Using the Evidence to Decision Framework, the guideline panel determined the certainty of evidence and strength of the recommendations. Consensus was achieved using a modified Delphi technique. The guideline was peer reviewed by an 8-member multidisciplinary external committee.

Results: For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises).

Conclusions: A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.

Author keywords: Practice Guideline; Low Back Pain; Chiropractic; Disease Management; Conservative Treatment

Author affiliations: AEB: School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montreal, Québec, Canada;  AEB: Département Chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada; GS: Private Practice, Winnipeg, Manitoba, Canada; Immediate Past President, World Federation of Chiropractic, North American Region, Canada; FA-Z: School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montreal, Québec, Canada; PD, MS: Department of Clinical Education, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; MD: Département des Sciences de l'Activité Physique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada; DH: Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada; CH: Epidemiologist, Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; IP: Département d'anatomie, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada; SP: Faculty of Kinesiology & Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada; JS: Human Health and Nutritional Science, University of Guelph, Guelph, Ontario, Canada; JW: Downsview Chiropractic, Toronto, Ontario, Canada; JO: Health Systems Management, Rush University, Chicago, Illinois

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