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Dutch physiotherapy guidelines for low back

pain
ARTICLE FEBRUARY 2003
DOI: 10.1016/S0031-9406(05)60579-2

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82

Key Words
Low back pain, physiotherapy,
clinical guidelines, evidencebased healthcare.

Dutch Physiotherapy
Guidelines for Low Back
Pain

by G E Bekkering
H J M Hendriks
B W Koes
R A B Oostendorp
R W J G Ostelo
J M C Thomassen
M W van Tulder

Summary Many guidelines for the management of low

back pain in primary care have been published during recent
years, but guidelines for physiotherapy do not yet exist.
Therefore, physiotherapy guidelines have been developed,
reflecting the consequences of the current state of
knowledge of effective and appropriate physiotherapy for
low back pain. They aim to improve the efficiency and
effectiveness of physiotherapeutic care for patients with low
back pain.
The guidelines were constructed on the basis of the phases
of the physiotherapy process, using the Dutch method of
developing physiotherapy guidelines. Scientific evidence
of systematic reviews was used as the basis for the
recommendations. A computerised literature search of
Medline, Cinahl, the Cochrane Database of Systematic
Reviews and the Database of the Dutch National Institute of
Allied Health Professions was conducted to identify relevant
systematic reviews. If no evidence was available, consensus
between experts was obtained.
The guidelines were pilot tested among one hundred
physiotherapists and reviewed by an external multidisciplinary panel.
The guidelines recommend that the diagnostic process
should focus on disability and participation problems
resulting from back pain. The treatment should consist of an
active approach, in which the patients learn to take control
over their back pain. For patients with a normal course,
where activities and participation gradually increase,
reassurance, adequate information and advice to stay active
are the most important recommendations. For patients with
an abnormal course, where activities and participation do not
increase, exercise therapy should also be provided, with a
behavioural approach if necessary.
These are the first national physiotherapy guidelines for low
back pain. The recommendations are largely in line with
other primary care guidelines for low back pain.
Implementation will be a major challenge for the near future.

Physiotherapy February 2003/vol 89/no 2

Introduction
Evidence-based healthcare has received
increased attention during the last decade
and is important to monitor and improve
quality of care. Guidelines are useful
tools in this process aiming at changing
behaviour of healthcare professionals, if
needed. Low back pain is a good example
of a field where evidence has been provided by many randomised trials and
summarised in many systematic reviews.
At least 12 guidelines for low back pain in
primary care have been published, but
none of them specifically for physiotherapy (Koes et al, 2001). However,
physiotherapy management of low back
pain also needs to move forward in the
mainstream of evidence-based healthcare.
The need for an evidence-based and more
uniform approach is signalled by the
variation in treatment of low back pain,
both nationally (van der Valk et al, 1995)
and internationally (Foster et al, 1999; Li
and Bombardier, 2001) and the lack of
evidence-based guiding principles.
The Dutch physiotherapy guidelines for
low back pain presented in this paper
embody the physiotherapeutic diagnostic
and therapeutic process in patients with
low back pain. Manual therapy is not
included in these guidelines because
these techniques demand specific knowledge and skills. For this reason, separate
guidelines for manual therapy are being
developed in the Netherlands.
In the Netherlands, patients do not
have open access to a physiotherapist;
they need a referral from a general
practitioner or another physician.
Consequently, these guidelines focus on
patients with low back pain who are
referred for physiotherapy.
Their aim is to improve the efficiency
and effectiveness of physiotherapy management in patients with low back pain

Guidelines

by translating research findings into

clinically relevant recommendations, by
explicitly describing the role of physiotherapists in the care for patients with
low back pain, and by improving collaboration with other primary care providers.
Definition of Low Back Pain
The concept of 'low back pain' in these
guidelines refers to 'non-specific low back
pain', defined as low back pain without a
specified physical cause, eg nerve root
compression (radicular syndrome),
trauma, infection or tumour. In an
estimated 90% of patients with low back
pain no specific medical diagnosis is made
(Nachemson, 1992). Recurrent back pain
is defined as several episodes of back pain
within one year, the total duration of
which amounts to less than six months
(Von Korff, 1994). The duration of a low
back pain episode can be classified as
acute (0-6 weeks), sub-acute (7-12 weeks)
or chronic (longer than 12 weeks).
Size of the Problem
Of the total population, 60% to 90% will
experience an episode of low back pain at
some time, the annual incidence of being
5% (Frymoyer, 1988). For physiotherapists in the Netherlands, low back pain is
a common referral diagnosis; 27% of all
patients referred to a physiotherapist have
low back pain (Van Ravensberg et al,
1995).
Impairments, Disabilities and
Participation Problems
Physiotherapists describe the health
problems of patients with low back pain in
terms of impairments, disabilities and
participation difficulties.
Impairments are manifestations of a
disorder referring to body structure
or physiological and psychological
function, for example decreased
muscle strength, pain, sensory
impairments or fear of movement.
Disabilities refer to problems in the
performance of activities such as
bending, reaching or walking.
Participation problems refer to
problems an individual may have in
relation to his social life, for example
work.
These concepts are derived from the
International Classification of Human

83

Functioning, Disability and Health

(WHO, 2001). Their use is meant to
promote uniformity in the rehabilitation
professions.
Bio-psychosocial Model
In the traditional (biomedical) model
pain is a direct consequence of underlying pathology. The symptoms will diminish if the pathology is removed. This
model cannot easily explain chronic
complaints, like chronic low back pain,
because there is no clear correlation between symptoms and pathology. Therefore, the current approach to chronic
low back pain tends to be increasingly
inspired by the bio-psychosocial perspective. In this perspective (low back)
pain is the result of the interaction
between biological, psychological and
social factors (Waddell, 1987, 1992, 1998).
Psychosocial factors in particular are
supposed to become more important in
the transition from acute to chronic and
in chronic low back pain.
Prognosis and Course
In an open population the prognosis is
usually favourable; in an estimated 75% to
90% of patients back pain disappears
spontaneously within four to six weeks
(Waddell, 1998). In patients visiting a
general practitioner because of their back
pain, the prognosis is a little less favourable; 65% are free of symptoms after
12 weeks (Van de Hoogen et al, 1998).
Low back pain often recurs; 75% of
patients who seek help from their general
practitioner suffer at least one relapse
within the year (Van de Hoogen et al,
1998). The persistence of back pain does
not necessarily indicate a less favourable
prognosis. There is growing consensus
that the extent of disability is the most
important predictor of outcome in low
back pain (Von Kor ff and Saunders,
1996).
Linton (2000) performed a systematic
review regarding the relationship between
psychological factors and neck and back
pain. The review included 36 prospective
studies. Based on several clinically relevant and methodologically sound studies,
Linton concluded that psychological
factors 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 C
and van Tulder, M W
(2003). Dutch
physiotherapy
guidelines for low
back pain,
Physiotherapy, 89,
2, 82-96.

Physiotherapy February 2003/vol 89/no 2

84

Authors
G E Bekkering MSc is
a researcher at the
Dutch National
Institute of Allied
Health Professions,
Amersfoort, and the
Institute for Research
in Extramural
Medicine, VU
University Medical
Centre, Amsterdam.
H J M Hendriks PhD
PT is leader of the
physiotherapy
guidelines
programme at the
Dutch National
Institute of Allied
Health Professions,
Amersfoort. He is
employed by the
Department of
Epidemiology,
Maastricht University.
B W Koes PhD is
professor of general
practice, at Erasmus
University, Rotterdam.
RAB Oostendorp PhD
PT MT is a professor
at the University
Medical Centre,
Centre of Quality of
Care Research,
Nijmegen, and at the
Faculty of Medicine
and Pharmacology,
Postgraduate
Education Manual
Therapy, Free
University of Brussels,
Belgium, and director
of the Dutch National
Institute of Allied
Health Professions,
Amersfoort.
R W J G Ostelo PhD
PT is a researcher at
the Institute for
Research in
Extramural Medicine,
VU University Medical
Centre, Amsterdam.
J M C Thomassen PT
is a physiotherapist at
the Institute for
Rehabilitation and
Rehabilitation
Research,
Hoensbroek,
The Netherlands.

biomedical and biomechanical factors.

Aspects such as attitudes and emotions of
the patient are important: passive coping
strategies, perceptions about pain, and
emotions such as depression or fear
are highly associated with pain and
disabilities. Also, there is moderate to
strong evidence that these psychosocial
factors may, in the long term, predict
pain and disabilities.
Waddell and Waddell (2000) conducted
a systematic review on the influence of
social factors on back and neck pain.
They conclude that the studies
investigated are of poor methodological
quality, although there are many indications that social factors may be related
to back and neck pain.
The only social factors which show
consistent findings, in either one systematic review or in more than two methodologically sound studies, are lower
social class, and lower work satisfaction.
The authors emphasise that social factors
are not a risk factor for the development
of back or neck pain, but that they may
well influence it, and also the way in
which patients cope with their complaints.
Coping Strategy
Patients may cope with their complaints
either adequately or inadequately. This is
called active or passive coping (Folkman
and Lazarus, 1980).
Active coping means that people undertake actions by themselves to control the
pain (for example by looking for distraction, or by moving). Low back pain
patients who manage to adjust their activities appropriately have an active (or
adequate) coping strategy. Passive coping
refers to the adoption of a passive attitude
(resting or using medication), or depending on others as a way of controlling pain
(Jensen et al, 1991). Patients who restrict
their movements because of low back
pain, who persist in avoiding certain
activities or rest a lot to relieve the pain,
have passive (or inadequate) coping
strategies. Active coping is associated with
better functioning, while passive coping is
associated with worse functioning (Jensen
et al, 1991).
The way in which a person copes with
his complaints will be determined by
patient characteristics (significance and
sense of control), as well as by the
interactions between the person and his
personal environment.

Physiotherapy February 2003/vol 89/no 2

Patient Characteristics
The significance which people attach to
symptoms is based on the subjective
perception and interpretation of stimuli.
If significance does not seem to correspond with an objective reality, a logical
error is being made. A common logical
error is to catastrophise, which means
that the pain, and the situation in which
the pain presents, are being considered a
serious threat, a catastrophe.
The extent to which patients feel that
they have control over the pain is
also important. They may feel that their
health is mainly controlled by themselves
(internal locus of control), or by other
people or circumstances (external locus
of control: patients give other people, for
example physiotherapists, control over
their health -- Hrkp et al, 1996). An
internal locus of control is often related
to active coping and, subsequently, to a
better way of dealing with the pain
(Jensen et al, 1991).
Both the significance attached to the
pain and the perceived sense of control
may determine movement behaviour. For
instance, when pain is considered as a
signal of possible injury (catastrophe), the
chances will be high that this will result in
fear of movement. Fear of movement is
the fear that movement will result in
(new) pain or (re)injury, which will, in
turn, lead to avoidance (Vlaeyen et al,
1995). Also when, based on previous
experiences, patients expect certain
activities to increase the pain and that
they have no control over this (low level
of control), the chances are that this
situation will be avoided.
Interaction between Patient and
Surroundings
The interaction between patients and
their environment (social factors) also
plays a role in their coping strategy. Very
protective partners, but also contradictory
information and recommendations by
different healthcare providers, may
frighten patients and influence their
coping strategy negatively. Physiotherapists attitudes may also play a role,
for example paying too much attention to
pain and not encouraging patients
independence may affect the course in a
negative way.

Guidelines

Method of Guideline Development

These guidelines are systematically
developed according to the method of
Physiotherapy Guidelines Development in the
Netherlands (Hendriks et al, 2000b).
The members of the working group
(authors) of the Low Back Pain Guidelines are all either experienced physiotherapists in low back pain or researchers in physiotherapy and low back
pain. An external group of ten experts
from relevant disciplines (a general
practitioner, an occupational physician, a
rehabilitation physician, an orthopaedic
surgeon, an orthopaedic physician, two
psychologists, one physiotherapist working in a pain clinic, and two teachers
at schools of physiotherapy) reviewed
the draft version of the guidelines. The
members of the working group and the
external members have declared that they
have no conflict of interest.
A group of 100 randomly chosen
physiotherapists, all members of the Royal
Dutch Society for Physiotherapy, were
asked to comment on the draft version of
the guidelines by filling in a structured
form evaluating their quality. The
comments were discussed with the
working group and, if needed, the guidelines were adjusted. An update of the
guidelines is scheduled within three
to five years after publication or sooner
if new evidence alters the recommendations.
Literature Search
A computer-aided search for published
systematic reviews or meta-analyses
investigating the efficacy of physiotherapy
interventions in patients with low back
pain was undertaken. The databases of
Medline (1982-September 2000), Cinahl
(1982-September 2000), the Cochrane
Library (2000, number 3) and the
databases of the Dutch Institute of Allied
Health Professions (up to September
2000) were searched, using the following
key words: back pain, physiotherapy,
physical therapy, behavioural therapy,
massage, education, mobilisation, electrotherapy, 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 with
non-specific low back pain; interventions

85

which are part of the Dutch professional

domain of physiotherapy, and outcome
measures relating to the physical
functioning of patients. Thirteen reviews
were included (Ernst, 1999; Hagen et al,
2000; Hilde and Bo, 1998; Turner, 1996;
Van der Heijden et al, 1995; Van Tulder et
al, 1997, 1999, 2000a b; Waddell et al,
1997). Five additional reviews were considered on the effectiveness of electrotherapeutical applications in patients with
musculoskeletal disorders, because
systematic reviews of these applications
specifically for low back pain were not
identified (De Bie et al, 1998; Gam and
Johannsen, 1995; Gam et al, 1993; Van der
Heijden et al, 1999; Van der Windt et al,
1999).
For several interventions the reviews of
Van Tulder et al (1997, 1999) have been
used. These reviews use four levels of
scientific evidence based on the number
of randomised controlled trials, their
methodological quality and the consistency of their results (table 1).
Table 1: Levels of scientific evidence
(source: Van Tulder et al, 1997, 1999)
Level of evidence

Description

Strong

Consistent findings in
several high quality
randomised controlled
trials

Moderate

Consistent findings in one

high quality randomised
controlled trial and one
or several low quality
randomised controlled
trials

M W van Tulder PhD

is a senior investigator
at the Institute for
Research in
Extramural Medicine
and the Department
of Clinical
Epidemiology and
Biostatistics, VU
University Medical
Centre, Amsterdam.
This article was
received on
November 2, 2001,
and accepted on
July 2, 2002.
Address for
Correspondence
G E Bekkering, Dutch
National Institute of
Allied Health
Professions,
PO Box 1161,
3800 BD Amersfoort,
The Netherlands.
E-mail
Bekkering@
paramedisch.org.nl

Limited/contradictory One randomised

controlled trial (high
or low quality), or
inconsistent findings
between several
randomised controlled
trials
None

No randomised controlled
trials

In addition to the scientific literature,

recent professional developments (for
example the active approach in low back
pain) and other considerations (such as
practical issues) have played a role in the
construction of these guidelines, which
have also been aligned with recommendations made in other Dutch national
guidelines such as the guidelines of
the Royal Dutch Association of General
Physiotherapy February 2003/vol 89/no 2

86

Practitioners (Faas et al, 1996), the

Association of Occupational Practitioners
(NVAB, 1999), and international low back
pain guidelines (Bigos et al, 1994; Waddell
et al, 1996; ACC, 1997; Abenhaim et al,
2000).
Definitions:
Normal and Abnormal Course
A long episode of low back pain does
not necessarily imply an unfavourable
prognosis. However, when an episode of
low back pain is associated with longlasting disabilities and participation
problems, prognosis is poor. Because of
this, these guidelines emphasise the
course of disabilities and participation
problems.
Over time, the course of disabilities and
participation problems can be called
normal or abnormal. In a normal course,
activities and participation gradually
increase over time (to the level prior to
the low back pain episode) and symptoms
decrease. This does not necessarily mean
that the low back pain will disappear
completely, but that it will no longer
restrict normal activities and participation. A normal course is to be expected
for most patients with low back pain.
An abnormal course is present when
disabilities and participation problems
do not decrease over time, but stay at the
same level or even increase. In most patients persisting or worsening complaints
will accompany this. An abnormal course
may be seen in patients with either acute
or chronic low back pain. There was
consensus among the guideline working
group that the course should be defined
as abnormal when activities and participation have not increased within three
weeks.
Diagnostic Process
The process of problem solving is central
to methodical physiotherapeutic management. This comprises the elements of
referral, history taking, physical examination, 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 process
is to assess the severity and type of low
back pain and its consequences, and to
evaluate to what extent physiotherapy can
influence the problem. In patients with
Physiotherapy February 2003/vol 89/no 2

non-specific low back pain it is often not

possible to find impairments in anatomical structures causing the complaints.
Even possibly identified impairments will
not usually provide enough explanation
for the development or continuation of
the complaints. Therefore, the diagnostic
interventions should focus on the relevant
disabilities and participation problems.
Referral
Important referral data are patients'
needs and expectations, reason for
referral, the course of disability and
participation problems, and information
about additional diagnostic procedures
and prognosis. The physiotherapist
should contact the referring physician
if the referral does not contain enough
data.
The starting point of these guidelines is
that the referring physician has excluded
a specific cause of low back pain. If the
physiotherapist suspects that there is a
specific cause, he or she should contact
the referring physician.

History Taking
The physiotherapist tries to get a clear
picture of the patients health problem.
What does the patient expect and prefer,
what is the most important complaint,
what are the consequences of this
complaint on daily life, which factors
increase, decrease or maintain the
complaint, and how does the patient feel
about his complaint and its consequences? (Hendriks et al, 2000a).
Key points of history taking are listed in
table 2. In cases of recurrent low back
pain, the physiotherapist specifically
examines possible causes for these
repeated episodes (eg changes in work
load or activities), the total duration of
the complaints and the time between
episodes of low back pain. The physiotherapist will also ask about the use of
ergonomic adjustments and compliance.
These guidelines recommend the use of
two instruments to assess and evaluate
functional status. The first instrument is
for the patient-specific complaints to
assess the patients functional status
(Beurskens et al, 1996). To date, there
are no studies on the reliability of this
instrument, although the questionnaire
has proved to be useful for patients with

Guidelines

Table 2: Key points of history taking of patients

with low back pain
Identification of patients needs and
expectations/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 time
Present state: severity and nature of
symptoms (impairments, disabilities and
participation problems)
Course of complaints (normal/abnormal)
Previous diagnostic procedures, treatment
interventions and results
Previous information obtained (content of
information, given by whom)
Coping strategy
What significance does the patient attach
to his symptoms?
Does the patient have control over his
symptoms?
Additional information
Co-morbidity
Current treatment: medication/other
treatment/advice/medical aids
Work-related aspects

low back pain (Schoppink et al, 1996).

The second instrument is the Quebec
back pain disability scale that identifies
disabilities and participation problems.
This questionnaire has been shown to be
valid, reliable and revealing (Schoppink et
al, 1996).
Physical Examination
It is recommended that the examination
of low back patients should be focused on
abilities and participation, instead of
finding a physical cause for the back pain.
This recommendation is based on the
assumption that the referring physician
has excluded a specific cause for the back
pain (Faas et al, 1996), and that the
patient was referred six weeks after onset
of the back pain because his or her
functioning did not improve (Faas et al,
1996). It is also based on the evidence of
previous research, which showed limited
reliability and validity of diagnostic tests,
by physiotherapists, in low back pain
(Moons and Van der Graaf, 2000; Potter
and Rothstein, 1985).
The physiotherapist assesses patients
disabilities (eg when maintaining a sitting
position or picking up an object from
the floor) and participation problems
(eg with work or housekeeping) that

87

were identified during history taking.

The physiotherapist will also identify impairments (eg decreased muscle
strength of the back extensors, decreased
mobility of the lumbar spine, decreased
physical fitness) which may be related to
the disability and participation problems.
The purpose of the physical examination
is to identify factors that may hamper or
facilitate management, and to assess patients level of physical fitness and functioning.
In patients with non-specific low back
pain, impairments often do not offer
enough explanation for the
dysfunctioning. Therefore, diagnostic
procedures should focus on the level of
(dis)ability and participation (problems).

Analysis
Based on the systematic process of collecting patient data, patients health
problems will be defined. The physiotherapist describes the most important disabilities and participation
problems, 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 periods
of rest increase, the use of analgesics
persists or increases, no return to activities
or participation. These indications are
related to the duration of three weeks and
to the patients level of activities.
If the course is abnormal, the physiotherapist describes the present physical,
psychological and social factors maintaining or aggravating the complaints. This
includes co-morbid problems. Finally the
physiotherapist decides whether the
health problem could be improved by
physiotherapy.
If the physiotherapist determines that
physiotherapeutic intervention is likely
to be effective, the physiotherapist sets a
treatment plan.
If there is no indication for physiotherapy, patients are referred back to the
physician. Physiotherapists should contact
the referring physician if they think
that bio-psychosocial factors and/or impairment, disability and participation
problems cannot be treated by physiotherapy (only).
Physiotherapy February 2003/vol 89/no 2

88

Table 3: Summary of effectiveness of treatment modalities

(Sub)acute low back pain
Strong evidence
of effectiveness

Advice to stay active

Limited/moderate
evidence of effectiveness
Effectiveness unclear

Chronic low back pain

Exercise therapy

Behavioural therapy

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

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

Moderate evidence
of ineffectiveness

Specific exercises,
traction

Biofeedback

Strong evidence
of ineffectiveness

Advice to take bed rest

Traction

Treatment Plan
The main objective of the treatment for
low back pain is a return to the highest
(or desired) level of activities and participation and the prevention of chronic
complaints and recurrences.
As most patients with a normal course
will return to their normal level of activities and participation, irrespective of
treatment, one or two treatment sessions
to coach these patients will often be
enough. The main intervention is patient
education, aimed at patients continuing
their self-management.
In patients with an abnormal course the
sub-goals of the treatment are to increase
their knowledge and understanding and
change inadequate behaviour, if needed;
gradually to increase activities and participation; 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 be
associated with chronic low back pain and
which are within the scope of physiotherapy. The main treatment interventions are systematic patient education and
exercise therapy aimed at functioning.
The physiotherapist will pursue an
active policy, in which patients also take
responsibility for the results of the
treatment.

The physiotherapist uses an active

approach towards patients with low back
pain. The most important interventions
are patient education and exercise
therapy.

Physiotherapy February 2003/vol 89/no 2

Treatment
Evidence from Systematic Reviews
First the findings of the systematic reviews
are summarised (table 3), followed by a
description of the therapeutic process.
This is based on the distinction between
patients with low back pain with a normal
and those with an abnormal course.
Advice to Stay Active
It is useful to advise (sub)acute patients
with low back pain to stay active.

Two reviews describe the effects of advice

to stay active to patients with (sub)acute
low back pain (Van Tulder et al, 1999;
Waddell et al, 1997). Both reviews
included the same eight trials. Both
reviews conclude that advice to stay active
results in a faster return to work, fewer
chronic disabilities and fewer recurrence
problems, and so the advice to stay active
is useful in the management of (sub)
acute low back pain.
Advice against Bed Rest
Bed rest is not useful in acute low back
pain. If bed rest is unavoidable, it should
be for a short period (a maximum of two
days).

Three systematic reviews describe the

effects of bed rest in acute patients with
low back pain (Hagen et al, 2000; Van
Tulder et al, 1999; Waddell et al, 1997).
The most recent review included nine
trials, five of which had a high methodological quality. The findings and
conclusions of all reviews are consistent
and show that bed rest is not a useful
treatment for acute low back pain and
may even cause delay in recovery.
Exercise Therapy
Exercise therapy has no added value in
acute patients with low back pain
(< 6 weeks). Exercise therapy is useful in
the treatment of chronic patients with
low back pain (> 12 weeks). It is not clear
which exercises are best.

The systematic review by Van Tulder et al

(2000a) included 39 randomised controlled trials on the effectiveness of
exercise therapy for low back pain in
primary care health settings.

Guidelines

In patients with acute low back pain

there is strong evidence that exercise
therapy has no better results than
placebo, inactive or any other active
treatments. In chronic low back pain
there is strong evidence that exercise
therapy is equally effective compared with
physiotherapy (usually a combination of
some of the following modalities:
hotpacks, massage, traction, mobilisation,
shortwave therapy, ultrasound, stretching exercises, mobilisation exercises,
improving co-ordination, and electrotherapy) and there is strong evidence that
exercise therapy is more effective than
the standard care provided by general
practitioners.
Hilde and Bo (1998) conclude that it is
not clear if the methodological quality,
the dosage or the type of exercise
influence the results of exercise therapy
in chronic low back pain. It remains
unclear which type of exercises are best.
Behavioural Treatment
In chronic low back pain behavioural
treatment principles may be useful.

Van Tulder et al (2000b) conducted a

meta-analysis on the effectiveness of
behavioural treatment for chronic nonspecific low back pain. The analysis
included 21 studies.
Results show that there is strong
evidence that behavioural treatment
(compared to no treatment, waiting list or
placebo) has a moderately positive effect
on pain intensity, and small positive
effects on general functional status and
behavioural outcomes in patients with
chronic low back pain.
The effectiveness of behavioural treatment compared to other treatments is not
clear. There is no evidence that any one
of the modalities of behavioural treatment
is more effective than another. There is
moderate evidence that the addition of a
behavioural component to a normal
treatment programme for chronic low
back pain (standard physiotherapy, back
school, multi-disciplinary treatment,
medical treatment) has a small short-term
effect on functional status. No short-term
effects were seen on the intensity of pain
or on behavioural outcomes, but there is
moderate evidence for small long-term
effects on functional status and on
behavioural outcomes.

89

Turner (1996) included 14 publications

in her meta-analysis on the effectiveness
of cognitive and behavioural interventions
in patients with low back pain in primary
care health settings. Turner concludes
that cognitive and behavioural treatments have better effects than control
treatments (such as waiting lists) on pain
behaviour and disabilities. No differences
were found between cognitive or behavioural treatments or other active treatments.
Traction
Traction does not seem useful in acute
low back pain (< 6 weeks). Traction is
not useful in chronic low back pain
(> 12 weeks).

In 1995 Van der Heijden et al performed a

systematic review on the effectiveness of
traction in neck and back pain. In this
review 17 randomised controlled trials are
included, 14 of which were on the efficacy
of lumbar traction. The authors concluded that the methodological quality of
the studies was too low to be able to draw
conclusions about the effectiveness of
traction in low back pain.
A more recent systematic review by
Van Tulder et al (1999) shows a complete
overlap with the above-mentioned review,
with the exception of one randomised
controlled trial, which was published in
1995. The newly added trial is of high
methodological quality and compares the
effectiveness of traction with placebotraction in patients with chronic low back
pain. The study does not demonstrate any
effects on general improvement, pain or
functional status. Van Tulder et al conclude that there is strong evidence that
traction is not an effective treatment in
chronic low back pain.
Biofeedback
The administration of biofeedback does
not seem useful in chronic patients with
low back pain (>12 weeks).

In the systematic review by Van Tulder et

al (1999) five studies on the effectiveness
of biofeedback in patients with chronic
low back pain were included. All trials
were of low methodological quality. The
authors conclude that there is moderate
evidence against the effectiveness of
biofeedback in these patients.
Physiotherapy February 2003/vol 89/no 2

90

Massage

Electrotherapy

It is unknown whether or not massage is

useful in patients with low back pain.

It is unknown whether or not

electrotherapy is useful in low back pain.

Ernst (1999) conducted a review on the

effectiveness of massage in patients with
low back pain. Four randomised trials
were included. All studies used massage
as a control treatment instead of an
experimental intervention. Also, the
methodological construct of all studies
was weak. In conclusion, it can be stated
that the evidence on the effectiveness of
massage in low back pain is contradictory.

In a review by Van der Heijden et al

(1999) 11 trials were included on the
effectiveness of electrotherapy in low
back pain. Electrotherapy encompasses
direct current therapy (diadynamic and
ultrareiz) and alternating current therapy
(transcutaneous electrical nerve stimulation and interferential). The authors
conclude that there is not enough
evidence in favour of electrotherapy
compared with placebo, and also in
comparison with a pragmatic treatment
such as other modalities of electrotherapy,
combined modalities of electrotherapy,
or an active approach.

Transcutaneous Electrical Nerve

Stimulation
It is unknown whether or not
transcutaneous electrical nerve
stimulation is useful in patients with
low back pain.

The review by van Tulder et al (1999) on

the effectiveness of transcutaneous
electrical nerve stimulation contains two
trials studying acute patients with low
back pain, of which one was of high
methodological quality; and four studies,
of which three were of high methodological quality; comparing transcutaneous electrical nerve stimulation with
placebo in chronic patients with low back
pain. In conclusion, the evidence on the
effectiveness of transcutaneous electrical
nerve stimulation in low back pain is
contradictory.
Ultrasound
It is unknown whether or not ultrasound
is useful in low back pain.

Van der Windt et al (1999) produced a

systematic review of 38 studies of
ultrasound in musculoskeletal disorders.
Only one study related to the effectiveness
of ultrasound in patients with degenerative rheumatic disorders (including
those in the low back). The authors
conclude that there is little evidence in
favour of the effectiveness of ultrasound
in the management of musculoskeletal
disorders. This conclusion is in agreement
with the conclusion from a previously
per formed meta-analysis by Gam and
Johannsen (1995) on the effectiveness of
ultrasound in musculoskeletal disorders.
Physiotherapy February 2003/vol 89/no 2

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

Gam et al (1993) per formed a metaanalysis on the effectiveness of low level

laser therapy in patients with musculoskeletal disorders. Twenty-three randomised controlled trials were included, of
which one was on patients with low back
pain. The authors conclude that laser
therapy has no effect on pain resulting
from musculoskeletal disorders.
De Bie et al (1998) did a systematic
review on the effectiveness of laser
therapy (904 nm laser) in patients with
musculoskeletal disorders. A total of 25
trials were found, of which two were
studies on patients with low back pain.
Neither study was able to prove the
effectiveness of laser.
Process
Treatment of Patients with Low Back
Pain with a Normal Course
The starting point is that patients cope
adequately with their symptoms. One
treatment session in which the physiotherapist gives education and exercise
therapy, if needed, should therefore be
sufficient. If necessary, a second appointment may be made, in order to
evaluate the course of disability and
participation problems.
Patient Education
The physiotherapist reassures the patients

Guidelines

and explains that low back pain usually

has a favourable course, and discusses the
relation between load and load-bearing
capacity. The message should be that
gradually increasing activities is beneficial
and not harmful for the back.
The physiotherapist coaches patients
and encourages them to continue current
activities and to build up to a full level of
activities and participation. Physiotherapist and patient will evaluate
potential barriers in this process and
together they will seek solutions.
Exercise Therapy
To support the information and advice
the physiotherapist may allow patients to
experience that moving or being active
is not harmful. Patients get positive
experiences by practising movements
that are necessary for daily activities.
Subsequently they may be able to carry
these experiences over to other activities
in daily life.
Treatment of Patients with Low Back
Pain with an Abnormal Course
The most important interventions in the
treatment of patients with low back pain
with an abnormal course are patient
education and exercise therapy.
Patient Education
The physiotherapists main contribution
in the treatment of patients with low
back pain is coaching. The objective is
to enable them to regain control with
respect to function and activities. To
achieve this objective the physiotherapist
will provide information about the nature
and course of the back pain, the relation
between load and load-bearing capacity
and the importance of an active lifestyle.
Patients should be told that low back
pain is usually not harmful and that an
increase of back pain does not necessarily
imply that structures in the back have
been damaged. Coaching may include
(re)activation, reassurance and motivation of patients, determination of progress and rewarding by giving positive
feedback.
Effective education requires knowledge
and educational skills, and some
behavioural techniques. Van der Burgt
and Verhulst (1996) present a patient
education model for allied health
professional practice, in which it is
hypothesised that the readiness to change

91

behaviour is determined by an interplay

between attitude (how does the person
perceive the change of behaviour?), social
influence (how do others perceive the
change of behaviour?) and self efficacy
(will it work or not?) The model consists
of six steps 'being open', 'understanding',
' wanting' and 'doing', 'being able' and
'keep on doing' (table 4). The history
taking provides attention points for
education. To increase self-management it
may be necessary to influence coping,
cognition and fear.
Table 4: Illustration of the six steps in the process of patient education
1. Being open
The physiotherapist will try to meet the experiences, expectations,
questions and worries of the patient.
2. Understanding
The information must be offered in such a way that the patient is able to
understand and remember the information.
3. Wanting
The physiotherapist evaluates what drives (does not drive) the patient to
show certain behaviour. The physiotherapist offers support and provides
information about possibilities and alternatives. Agreements should be
feasible.
4. Being able
The patient must be able to perform the desired behaviour.
Functional activities need to be practised.
5. Doing
The 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 whether
or not the patient thinks that he will be able to show and maintain the new
behaviour. If there are problems, solutions must be sought.

Promoting Adherence
To bring about a beneficial effect on the
complaints, it is important that patients
adhere to the treatment. Various factors
may decrease adherence:
1. Problems which patients experience
in their attempts to adhere to the
exercises and instructions given by
the physiotherapist,
2. Lack of positive feedback.
3. Degree of 'helplessness' (if patients
think that exercise will not help).
4. Bad prognosis.
5. Not feeling much hindered by the
disorder (Sluijs, 1991).
Physiotherapists should explore carefully the extent to which patients are able
to adhere to the prescribed exercises and
Physiotherapy February 2003/vol 89/no 2

92

advice, and seek solutions together with

the patient (Sluijs, 1991).
Exercise Therapy
Behavioural Approach The behavioural
approach focuses on the prevention of
further disablement of patients (Vlaeyen
et al, 1996). Treatment may focus on
pain behaviour (operant approach), on
the recognition of tension (respondent
approach), or on the expectations and
ideas of the patient (cognitive approach).
The operant approach is best suited to
the physiotherapists professional domain.
The purpose of the operant approach is
to increase the level of activities and to
decrease pain behaviour in such a way
that patients are able to perform the
activities they want to do despite the
pain (Vlaeyen et al, 1996). Characteristic
behavioural principles are active participation and time contingent management.
Increasing Activities Using a Time Contingent Approach Activities are increased step by step, based on steps
previously agreed, rather than on the pain
(graded activity, see example in table 5).
The objective is to increase the level of
activity and to learn to cope with ones
own physical capacity. In order to fit the
patients needs as closely as possible, they
will be asked which activities are the most
limited and which activities they consider
the most important. These activities will
be the points of departure for treatment.
First, the baseline of the activities to be
practised will be set. This is done by
asking patients to perform the activities
for as long, or as frequently, as possible.
It is preferable to perform the measurements repeatedly in order to produce a
more reliable estimate of the starting
level. Based on the written parameters
(time, duration, weight/heaviness,
frequency) the mean can be calculated
for every activity: the baseline per activity.
During the baseline measurement the
physiotherapist will pay attention to the
quality of movement.
Subsequently, a feasible goal is agreed
for each activity. The physiotherapist will
grade the activities, starting some way
below the baseline level, and progressing
to the projected outcome level, carefully
balancing between the load and the
patients load-bearing capacity.
The way the programme is built up (the
Physiotherapy February 2003/vol 89/no 2

size and number of steps) depends on the

difference between the starting level and
the projected outcome level, and on the
individuals load-bearing capacity. The
physiotherapist must make an estimate
of this. It is important that the presence
of pain does not obstruct the exercise
assignments. During the programme
patients will exercise no less, but also no
more, than was mutually agreed for that
day. Patients will also exercise at home
and keep a record of their progress.
Table 5: Practical example of pain and time
contingent treatment
Pain contingent
A patient walks with the therapist. After 100
metres the patient mentions that he is in pain.
They sit down for a while. During the rest they
chat, until its better and the walking is
resumed.
What happened is this: the walking seems to be
punished by pain (so walking will be reduced),
the pain seems to be rewarded by a rest (so
resting will be increased), resting seems to be
rewarded with social talk (so resting will
increase).
Time contingent
The patient walks with the therapist. They agree
beforehand to walk to a particular corner with a
bench. There they will sit down for five minutes,
before walking back. It may be difficult and
painful, or it may be easy and perhaps they could
have gone further. But they stick to their
agreement and do no more and no less.
After the walk the physiotherapist will give
positive feedback on the progress made.

Other Interventions Biofeedback and

traction are not recommended because
these interventions have not been shown
to be effective. It is not clear whether
massage, electrotherapy (including
transcutaneous neuromuscular nerve
stimulation), ultrasound or laser are
effective in low back pain. On the basis of
individual circumstances (eg strong
patient preferences) physiotherapists may
consider the use of these interventions,
but they should be a subordinate component of the treatment regime and only
be used for a short time and in support of
the active approach.
Traction and biofeedback are not useful
in chronic patients with low back pain.
It is unclear whether massage,
electrotherapy (including transcutaneous
electrical nerve stimulation), ultrasound
or laser are useful in patients with low
back pain. The guideline recommends
using these interventions reservedly and
only in support of the active approach.

Guidelines

Evaluation
The physiotherapist evaluates the treatment results regularly and systematically
by setting them against the treatment
objectives. On the basis of this evaluation, the treatment plan may be modified. The physiotherapist may use
the measuring instruments mentioned
previously in the diagnostic process. To
evaluate the outcomes of the information
and advice given, the physiotherapist
should ask: Does the patient know what
he needs to know? and Does the patient
cope the way he should? If the treatment
does not improve a patients functioning
within three weeks, the physiotherapist
should contact the referring physician.
Treatment Conclusion and Report
At the end of the treatment the effects
of the intervention should be evaluated
and reported to the referring physician.
The written report should include the
treatment objectives, the improvements in
functioning, perceived quality of life and
the reason for concluding the treatment
(Hendriks et al, 2000a).
Discussion
In the Netherlands seeking care for low
back pain usually starts with consulting
a general practitioner (primary care
physician), who decides if and which
treatment is necessary. The Dutch general
practice guidelines favour a wait-and-see
policy in acute patients with low back pain
and do not recommend a referral to
physiotherapy within the first six weeks
(Faas et al, 1996). In practice, however,
general practitioners refer patients within
six weeks (Schers et al, 2001).
The physiotherapy guidelines are
largely in line with the general practice
guidelines; if the course of symptoms is
normal the physiotherapist supports the
wait-and-see policy. Patients with an
abnormal course, who do not increase
activities and participation within three
weeks, may be at risk of developing chronic complaints. Therefore intervention is
necessary in order to prevent transition to
the chronic stage.
The guidelines recommend adequate
education and exercise therapy for these
patients, although they may still be in the
acute stage of their back pain, in which
there is no evidence for the effectiveness
of exercise therapy. However, based on
principles of early activation which is

93

shown to prevent chronic complaints, we

argued that it may not be beneficial for
these patients to wait for treatment until
six weeks have passed. Although this cutoff point of six weeks is frequently used
in efficacy literature, there is hardly any
evidence in favour for this in practice.
The Dutch physiotherapy guidelines
recommend only one or two treatment
counselling sessions in patients with a
normal course. Usually this concerns the
acute stage of back pain. This recommendation is based on the findings that the
advice 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 prognosis and will get better within a few
days or weeks, regardless of treatment.
Furthermore, if we intervene too much or
too early, patients might attach too much
significance to their back pain or get the
feeling that they cannot control the back
pain themselves.
This recommendation has been carefully discussed by the working groups
as we were aware that it will probably be
controversial for many physiotherapists. It
is important to realise that in a healthcare
system such as that of the Netherlands,
where patients do not have direct access
to physiotherapy but have to be referred,
only a small minority of patients who
visit a physiotherapist will have a normal
course. It is the responsibility of the
referring physician to refer only patients
with an abnormal course. However,
in healthcare systems where patients
have direct access to physiotherapy it is
the responsibility of the physiotherapist
to avoid over-treatment and/or overmedicalisation.
The cut-off point of three weeks to
define a normal and abnormal course is
based on consensus and is arbitrary. This
point has been set, after careful discussion
with both working groups, to meet the
needs of physiotherapists working in the
field, who were not able to distinguish a
normal from an abnormal course without
a time-frame.
Recently Dutch multi-disciplinary
guidelines for low back pain have been
developed. Our mono-disciplinary guidelines have added value, as the primary
goal of our guidelines is to improve the
quality of physiotherapeutic treatment for
low back pain. They also define clearly the
position and tasks of physiotherapists
Physiotherapy February 2003/vol 89/no 2

94

treating patients with low back pain in

primary care. Multidisciplinary guidelines
tend to focus more on evidence and less
on the treatment process and which profession should perform certain management activities.
In these guidelines best evidence has
been used as basis for the recommendations. However, the evidence regarding the physiotherapeutic diagnostic
process was very sparse and concerned
mainly the psychometric quality of
questionnaires. Therefore, the diagnostic
process was primarily constructed on the
process of clinical reasoning. Clinical
reasoning requires a systematic process of
diagnosis and concurrent evaluation
during the process of treatment for the
identification of a patients problem and
response to treatment (Hendriks et al,
2000a). This systematic approach makes
the considerations, arguments and
activities underlying certain clinical
decisions explicit and may increase the
effectiveness and efficiency of treatment.
More, and methodologically sound,
research on (physiotherapeutic) diagnostic tests and procedures with respect to
low back pain are urgently needed.

These guidelines describe the state-ofthe-art with respect to physiotherapy for

low back pain. How far these principles
are already used in practice is not known.
Field testing, a phase of development
when physiotherapists could comment on
the draft guidelines, showed that there
is a gap between these guidelines and
current practice. Implementation of
guidelines is crucial in trying to change
the behaviour of physiotherapists. Each
set of Dutch physiotherapy guidelines is
accompanied by a separate implementation plan, directed specifically at the
topic of the guidelines. These low back
pain guidelines are promulgated in the
Netherlands mainly by publication
(Bekkering et al, 2001) and disseminating
them to all members of the Royal Dutch
Society for Physiotherapy, together with
forms facilitating implementation.
Probably a more active approach is
necessary to encourage changes in
practice. At the moment experiments are
going on in the Netherlands, comparing
the cost-effectiveness of the standard
implementation strategy versus a more
intensive implementation strategy. The
results are expected in 2003.

Acknowledgement
These guidelines were issued by the Royal
Dutch Society for Physiotherapy and
funded by the Government Department of
Public Health, Sciences and Sports.
For the production of these guidelines,
special words of gratitude to the multidisciplinary working committee are in
order. Many thanks to (in alphabetical
order): P F van Akkerveeken PhD
(orthopaedic surgeon, Back Advice Centre
Nederland), R M Bakker-Rens MSc
(occupational physician, Dutch Society for
Occupational Practice), A J Engers PT MSc
(psychologist / human movement scientist,
Centre of Care Research, Medical Centre
St Radboud, Nijmegen), L Geken PhD
(rehabilitation physician, Dutch Society for
Rehabilitation Physicians), J Mens MSc
(orthopaedic surgeon, Spine and Joint

Centre), H H C F M van Maasakkers PT

(Rugcentrum Uden), A C M Romeijnders
MSc (general practitioner, Dutch
Association for General Practice),
M A Schmitt PT (School of Physiotherapy,
Utrecht), J W S Vlaeyen PhD (psychologist,
University of Maastricht) and A de Wijer PT
PhD (School of Physiotherapy, Utrecht).
Also we would like to thank all
physiotherapists 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 of
Allied Health Professions) for their
contribution to the guidelines.
Finally we gratefully acknowledge
R V M Chadwick-Straver for translating
these guidelines.

Physiotherapy February 2003/vol 89/no 2

Guidelines

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

95

Gam, A N, Thorzen, H and Lonnberg, F (1993).

The effect of low-level laser therapy on musculoskeletal pain: A meta-analysis, Pain, 52, 63-66.
Hagen, K B, Hilde, G, Jamtvedt, G and
Winnem, M (2000). Bed Rest for Acute Low Back
Pain and Sciatica (Cochrane Review), The
Cochrane Library, no 3, Update Software,
Oxford.

ACC (Accident Rehabilitation and

Compensation Insurance Corporation) and
National Health Committee (1997). New
Zealand Acute Low Back Pain Guide, Wellington,
New Zealand.

Hrkp, K, Jrvikoski, A, Vakkari, T (1996).

Association of locus of control beliefs with
pain coping strategies and other pain-related
cognitions in back pain patients, British
Journal of Health Psychology, 1, 1, 51-63.

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 Genootschap
voor Fysiotherapie)-richtlijn Lage-rugpijn,
Nederlands Tijdschrift voor Fysiotherapie, 111, 3,
supplement.

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 for
physiotherapy: A prerequisite for treatment
and outcome evaluation, Physical Therapy
Reviews, 5, 29-47.

Beurskens, A J H M, Vet, H C W and Kke, A J A

(1996). Responsiveness of functional status in
low back pain: A comparison of different
instruments, Pain, 65, 71-76.

Hendriks, H J M, Bekkering, G E,
Brandsma, J W et al (2000b). Development
and implementation of national practice
guidelines: A prospect for continuous quality
improvement in physiotherapy: An
introduction to the method of guideline
development, Physiotherapy, 86, 535-547.

Bigos, S, Bowyer, O, Braen, G et al (1994).

Acute Low Back Problems in Adults: Assessment
and Treatment, Clinical practice guideline
number 14, Department of Health and
Human Services, Pub 95-0643, Agency for
Health 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 the
management of musculosketal disorders:
A systematic review, Physical Therapy Reviews,
3, 59-72.
Ernst, E (1999). Massage therapy for low back
pain: A systematic review, Journal of Pain and
Symptom 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 Huisartsen
genootschap)-Standaard Lage-Rugpijn,
Huisarts and Wetenschap, 39, 18-31.
Folkman, S and Lazarus, R S (1980).
An analysis of coping in a middle-aged
community sample, Journal of Health and
Social Behaviour, 21, 219-239.
Foster, N E, Thompson, K A, Baxter G D and
Allen, J M (1999). Management of nonspecific low back pain by physiotherapists in
Britain and Ireland, Spine, 24, 13, 1332-42.
Frymoyer, J W (1988). Medical progress:
Back pain and sciatica, New England Journal of
Medicine, 318, 291-300.
Gam, J N and Johannsen, J (1995).
Ultrasound therapy in musculoskeletal
disorders: A meta-analysis, Pain, 63, 85-91.

Hilde, G and Bo, K (1998). Effect of exercise

in the treatment of low back pain: A systematic
review emphasising type and dose of exercise,
Physical Therapy Reviews, 3, 107-117.
Jensen, M P, Turner, J A, Romano, J M and
Karoly, 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 low
back pain in primary care: An international
comparison, Spine, 26, 2504-13.
Li, L and Bombardier, C (2001).
Physical therapy management of low
back pain: An exploratory survey of therapist
approaches, Physical Therapy, 81, 4, 1018-28.
Linton, S J (2000). Psychological factors in
neck and low back pain in: Nachemson, A N
and Jonsson, E (eds) Neck and Back Pain:
The scientific evidence of causes, diagnosis and
treatment, Lippincott, New York.
Moons, K G M and Van der Graaf, Y (2000).
Evaluatie van de toegevoegde waarde van
diagnostische tests, Nederlands Tijdschrift voor
Geneeskunde, 144, 1256-61.
Nachemson, A L (1992). Newest knowledge of
low back pain: A critical look, Clinical and
Orthopedic Related Research, 279, 8-20.
NVAB Nederlandse Vereniging voor Arbeids en Bedrijfsgeneeskunde (1999). Richtlijnen
voor het Handelen van de Bedrijfsarts bij
Werknemers met Lage-rugklachten.
Physiotherapy February 2003/vol 89/no 2

96

Potter, N A and Rothstein, J M (1985). Intertester reliability for selected clinical tests of the
sacroiliac joint, Physical Therapy, 65, 1671-75.
Schers, H, Wensing, M, Huijsmans, Z,
Van Tulder, M W and Grol, R (2001).
Implementation barriers for general practice
guidelines on low back pain: A qualitative
study, Spine, 26, 15, E348-E353.
Schoppink, L E M, Van Tulder, M W, Koes, B
W, Beurskens, A J H M and De Bie, R A (1996).
Reliability and validity of the Dutch
adaptation of the Quebec back pain disability
scale, Physical Therapy, 76, 268-275.
Sluijs, E M (1991). Patient Education in Physical
Therapy, Nivel, Utrecht.
Turner, J A (1996). Educational and
behavioural interventions for back pain in
primary care, Spine, 21, 2851-59.
Van de Hoogen, J M M, Koes, B W, Devill, W,
Van Eijk, J T M and Boute, L M (1998).
De prognose van de aan de huisarts
gepresenteerde lage-rugpijn, Huisarts and
Wetenschap, 41, 62-68.
Van den Burgt, M and Verhulst, F (1996).
Doen en Blijven Doen: Patintenvoorlichting in de
paramedische praktijk, Bohn Stafleu Van
Loghum, Houten.
Van der Heijden, G J M G, Beurskens, A J H M,
Assendelft, W J J, De Vet, H C W and Bouter, L
M (1995). The efficacy of traction for back
and neck pain: A systematic blinded review of
randomised clinical trial methods, Physical
Therapy, 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). Transcutaneous
electrotherapy 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 with
back pain, Physiotherapy, 81, 6, 345-351.
Van der Windt, D A W M, Van der Heijden, G J
M G and Berg, S G M (1999). Effectiviteit van
ultrageluidbehandeling voor aandoeningen
van het bewegingsapparaat: Een systematische
review, 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 B
and Hendriks H J M (1995). Variabelen in
Samenhang met het Aantal Behandelingen
Fysiotherapie, Paramedisch Instituut,
Amersfoort, Nederlands.
Van Tulder, M W, Koes, B W and Bouter, L M
(1997). Conservative treatment of acute and
chronic non-specific low back pain: A
systematic review of randomised controlled
trials of the most common interventions,
Spine, 22, 2128-56.
Physiotherapy February 2003/vol 89/no 2

Van Tulder, M W, Koes, B W, Assendelft, W J J

and Bouter, L M (1999). The Effectiveness of
Conservative Treatment of Acute and Chronic Low
Back Pain, EMGO Institute, Amsterdam.
Van Tulder, M W, Malmivaara, A, Esmail, R
and Koes, B W (2000a). Exercise Therapy for Low
Back Pain (Cochrane Review), The Cochrane
Library, no 3, Update Software, Oxford.
Van Tulder, M W, Ostelo, R W J G,
Vlaeyen, J W S, Linton, S J, Morley, S J and
Assendelft, W J J (2000b). Behavioural
Treatment for Chronic Low Back Pain
(Cochrane Review), The Cochrane Library,
no 3, Update Software Oxford.
Von Korff, M (1994). Studying the natural
history 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 of
Occupational Rehabilitation, 5, 235-251.
Vlaeyen, J W S, Kole-Snijders, A M J and
Van Eek, H (1996). Chronische pijn en
revalidatie, Praktijkreeks Gedragstherapie, Bohn
Stafleu Van Loghum, Houten.
Waddell, G (1987). A new clinical model for
the treatment of low back pain, Spine, 12,
632-644.
Waddell, G (1992). Biopsychosocial analysis of
low back pain, Baillieres Clinical Rheumatology,
6, 523-557.
Waddell, G (1998). The Back Pain Revolution,
Churchill Livingstone, Edinburgh.
Waddell, G, Feder, G, McIntosh, A, Lewis, M
and Hutchinson, A (1996). Low Back Pain
Evidence Review, Royal College of General
Practitioners, London.
Waddell, G, Feder, G and Lewis, M (1997).
Systematic reviews of bed rest and advice to
stay active for acute low back pain, British
Journal of General Practice, 47, 647-652.
Waddell, G and Waddell, H (2000). Social
influences on neck and low back pain in:
Nachemson, A N and Jonsson, E (eds) Neck
and Back Pain: The scientific evidence of causes,
diagnosis and treatment, Lippincott Williams and
Wilkins, New York.
World Health Organisation (2001).
International Classification of Functioning,
Disability and Health: IC, WHO, Geneva.