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Danish Health Technology Assessment 1999; 1(1)

Frequency, Management
and Prevention from
an HTA perspective

Danish Institute for

Health Technology Assessment
Low-Back Pain
Frequency, Management
and Prevention from
an HTA perspective

Danish Institute for

Health Technology Assessment
Frequency, Management and Prevention
from an HTA perspective

Prepared by a working group for Danish Institute for Health Technology Assessment
Published by Danish Institute for Health Technology Assessment

©Danish Institute for Health Technology Assessment

National Board of Health
13, Amaliegade
P.O. Box 2020
1012 Copenhagen, Denmark

ISBN: 87-90765-82-6
ISSN: 1399-0330

This report should be referenced as follows:

Danish Institute for Health Technology Assessment:
Low-Back Pain. Frequency, Management and Prevention from an HTA perspective
Danish Health Technology Assessment 1999; 1(1)

Layout: Peter Dyrvig Grafisk Design

Print: P.J. Schmidt A/S,Vojens
Production: Danish Committee for Health Education

Series Title:
Danish Health Technology Assessment 1999; 1(1)
Series Editorial Board:
Finn Børlum Kristensen, Mogens Hørder, Leiv Bakketeig
Editorial Manager:
Peter Bo Poulsen
Editorial Committee:
The Scientific Board, Danish Institute for Health Technology Assessment:
Mogens Hørder (chairman), Finn Borum,Thomas Gjørup,Torben Jørgensen,
Finn Kamper-Jørgensen, Mette Madsen, Frede Olesen, Jes Søgaard, Helle Timm

Printed witout solvents, using only natural vegetable colours,

on environmentally approved paper.


Low-back pain is one of the most frequent reasons for contact with
the health care system. Low-back pain includes different conditions,
and treat-ment should, therefore, be individualised. However, it is
today acknowledged that the individual diagnosis and treatment
offered to patients with low-back pain, is very varied. This variation
is not always and only an expression of the fact that diagnostic and
treatment are adapted to the individual patient.
On this background a number of national and international
research projects have been made using a Health Technology Assess-
ment (HTA) approach with the perspective to manifest today’s know-
ledge on the problem and the most rational way to handle it.
In 1996, the Health Technology Assessment Committee of the
Danish National Board of Health published “The National Strategy
for Health Technology Assessment”. One important strategy element

“Denmark will ensure, that international HTA initiatives are monitored

and the results applied to the Danish National Health Service.”

The background of the present report is to adapt international health

technology assessments (HTA) into Danish conditions. The report
consists of to volumes, where volume 1 is a survey of the extent of the
problem in Denmark, and volume 2 is an evidence-based evaluation
of different treatment methods and evidence-based recommendations
for prevention diagnostics and treatment.
The report was made by a multidisciplinary working group,
representing relevant professions in the Health Care sector.
DIHTA finds it of great value, that the multidisciplinary wor-
king group was able to agree both on a proposal for clinical guide-
lines for diagnosing patients suffering from low-back pain and re-
commendations on a number of different treatments and prevention.
It is DIHTA’s hope, that the report will be well received and
used by the different professions responsible for treatment as well as
by the authorities with the managerial and economic responsibility
for the health service in Denmark.

Statens Institut for Medicinsk Teknologivurdering
Januar 1999

Finn Børlum Kristensen


DITHA’s summary and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . i-iv

Members of the panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Health Technology Assessment and sources/references . . . . . . . . . . . . . . . . . . . . . 10

1. What is “low-back” pain? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Incidence of low-back pain in the historical perspective. . . . . . . . . . . . . . . . . . . . . 16
The prevalence of low-back pain in Denmark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Established causes of low-back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Social and Economic Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

2. Illness Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3. Risk factors (indicators) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4. Diagnostics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Diagnoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

5. Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
The clinical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Imaging (X-ray, CT and MRI-scans) and spine diagnosis . . . . . . . . . . . . . . . . . . . . . 34
Bloodtests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

6. How do we address the low-back problem

from an organisational standpoint? . . . . . . . . . . . . . . . . . . . . . . . . . . 37
The present health care system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Suggestions for the future organisation of low-back pain assessment
and treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Acute low-back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Chronic low-back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

7. Summary and suggested areas of focus. . . . . . . . . . . . . . . . . . . . . . . 43

Waiting times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Increased inter-disciplinary co-operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Individual patient information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Public information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
X-ray examination of the spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Hospitalisation/amubulatory treatment/multi-disciplinary teams . . . . . . . . . . . 45
Quality control: databases & reference programs . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Teaching/research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Increased knowledge of the course of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . 47
The overall co-ordination of efforts/professional fee schedules . . . . . . . . . . . . . . 48

1. The various Danish health professions that treat patients
with “low-back pain” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Co-operation between health care providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

2. The LPB-group’s analytical method . . . . . . . . . . . . . . . . . . . . . . . . . . 55

HTA-blueprint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
The panel’s evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Grading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Costs that are associated with the utilisation of the technology . . . . . . . . . . . . . . 58
The panel’s recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

3. Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Documented treatment effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Active or passive treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Treatment strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Patient information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
The hta-evaluated treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

4. Treatments which can generally be recommended . . . . . . . . . . . . . 63

Manual therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Back school/group training/ergonomics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Pain relieving medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Exercise therapy according to mckenzie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Exercise therapy/fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

5. Treatment methods that can be recommended in

certain conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Injections in the muscles, joints, and ligaments and in close
approximation to nerves, including acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . 73
injections in trigger points, muscles and ligaments. . . . . . . . . . . . . . . . . . . . . . . . . 74
Facet and sacroiliac joint injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Epidural injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Massage and heat/cold therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Back surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Spinal stenosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Stabilising back surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Bed rest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Transcutaneous nerve stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

6. Treatments that cannot be recommended . . . . . . . . . . . . . . . . . . . . 85

Corsets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Traction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Ultra sound, laser, short-wave therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

7. Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Primary prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Secondary/tertiary prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Social assistance programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

8. Economics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Costs of the singular activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Box economic analysis of a course of treatment for “low-back pain” . . . . . . . . . . 93
Savings if “recommended treatment courses” are carried out . . . . . . . . . . . . . . . . 94
Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
How can these savings be achieved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Concluding comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Appendix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

DIHTA’s summary and conclusions
The purpose of this HTA is to adjust international technology assess-
ments, already published on diagnosis, treatment and prevention of
low-back pain, into Danish conditions, in order to improve a better
decision making in the health care system.

A broadly composed working group of relevant professionals made
this report as a result of a systematic consensus process based on a
thorough evaluation of published scientific evidence and clinical ex-
In the first place the quality of the scientific basis of using each
individual technology was assessed – carefully guided by equivalent
foreign HTA-reports. Based on scientific documentation the state-
ments regarding the technology was evaluated on a 4-step scale.
Based on estimates a graduation in three degrees was made of the ex-
pected economic consumption of resources that the use of each single
technology would release.
In addition, the group suggested a recommendation/non-
recommendation of future use of the individual technology. Explana-
tions are linked to each recommendation, so it is clear under which
circumstances the recommendation is valid.

A thorough examination carried out at the very first visit is the most
important activity in the handling of the low-back pain patient. The
main purpose of the clinical examination is to make a specific diag-
nosis and to exclude the existence of serious back diseases. Further-
more, it forms the basis for preparation of the most suitable pro-
gramme of examination- and treatment for the patient concerned.
The past ten years’ science has clearly shown that a patient
activating treatment strategy, both for the acute and the chronic low-
back pain patient is of great importance to ensure a stable effect of the
treat-ment. For a successful treatment result a motivated participa-
tion chosen by the patient is important.

Interdisciplinary agreements exist among the experts upon the fol-
lowing general principles on the organisation of care in the low-back
pain area:

Irrespective of how the patient chooses to contact the health
care system, it is important that examination and treatment procedu-
res are the same.
All treatment should, if possible, take place in the primary sec-
tor and in the patient’s own area. This is important in order to avoid
unnecessary labelling of the patient and to avoid needless costs for the
patient and/or to the health care system, as for example long trans-
Referral to specialist care or to a specialist centre should gene-
rally not occur before other relevant diagnosis/treatment in the pri-
mary sector has been tried.
Referral to specialist care or a specialist centre is recommended
at once if alarming symptoms of back disease appear or if the patient
does not recover within 4 weeks in spite of regular treatment in the
primary sector.
Normally, patients with acute low-back pains are recommen-
ded not to consult emergency wards, as most of the emergency wards
are unable to carry out a thorough evaluation of the problem.
In suspicion of bone fracture after trauma the patient is re-
commended to contact the emergency services.
Hospitalisation of patients with low-back pain is not recom-
mended. Hospitalisation causes unnecessary labelling of the patient
and often also a feeling of inactivity and loss of self-determination.
If serious back disease occurs e.g. bad pains, hospitalisation
will often be necessary.
During the treatment course a close co-operation is important
among the relevant professionals in primary care, for exchange of no-
tes from case records (after permission from the patient is obtained),
x-rays, treatment results etc.
Individual patient information during the diagnosis-/treatment
efforts should always be a key activity.
The formal and informal routes of referrals should in general
be kept unchanged.
The organisation of care should enable a division of work,
which derives from professions’ – by authorisation – defined business
areas. This prevents or minimises the occurrence of multiple parallel
episodes of care.
It should be ensured that the content of the individual treat-
ment course is homogenous, irrespective if the patient consults his or
hers general practitioner or chiropractor. Similarity in information

given to the patient should be ensured, irrespective of the kind of
practitioner that evaluates, informs and advises the patient.

Implementation of improved care programmes, besides causing
savings at the budget in the health care system, will also bring about
savings of public costs in areas such as transfer payments (sickness
benefits and pensions). Overall factors in obtaining savings are:

❖ To avoid costly waiting time.

❖ To obtain the best possible communication and co-ordination
between professionals involved and with other parties e.g.
especially the social authorities.
❖ To avoid that unnecessary or needless diagnosis- and treatment
procedures are carried out.

If the documentation and recommendations of this report are fol-
lowed, a range of treatments will definitively disappear from the
health care system’s handling of low-back pain, and more effective
patient episodes of care will represent far a bigger fraction of cases.
In crucial areas implementation of the results of the report
should go through interdisciplinary formed reference programmes
and clinical guidelines. One obvious subject could be a reference pro-
gramme with guidelines for the work out of “correct x-ray proce-
dures”of the low back, carried out in co-operation with radiologists,
surgeons, chiropractors, reumatologists, general practitioners etc. In
addition reference programmes describing in which cases blood tests
are necessary, should be worked out.
Economic aspects influence practice behaviour, and changes in
collective agreements and contracts may cause great effect.
Broad implementation strategies that form a combination of
printed material, (local, small-group based) problem oriented educa-
tion, collegiate influence from opinion leaders, audit-feed back of
actual treatment activity and visit by colleagues to the clinic is best
suited in order to obtain changes in clinical behaviour. The working
group was not asked to deal with future division of work between the
caregivers. There is, however, a need for such a clarification, which
could be made through discussions and negotiations with public
agreement parties such as Sygesikringens Forhandlingsudvalg (The
Board of Public Health Insurance).

It is important that the patient early in the treatment course
takes an active part by receiving a thorough information. Informa-
tion about the problem and treatment is most often repeated several
times before the patient gets full insight into the matter. Individual
information is recommended and should be based on the individual
situation and need. A strengthened individual information effort
towards the patient – both in the primary-and in the secondary sector
– is an important aspect for the strengthening of future efforts. The
collective agreements’ possibility to promote this information effort
should be analysed critically.
A shared patient record and electronic communication should
be developed and tested so that the practitioners can share informa-
tion about diagnosis and treatment already carried out.
Common and improved training of physicians, chiropractors
and physiotherapists should be developed so the professions get
a more equal approach to the individual patient and a technical lan-
guage that is more common than it is today. These courses should
also include other relevant professional groups such as teachers of
relaxation and psychologists. Relevant professional academic envi-
ronments should support the training.
Particular courses for social-/rehabilitation staff should be
given higher priority than it is in the care today. The newest well-
documented professional know how should also form the basis for
decisions about social measures for patients with low-back problems.
The professional groups’ thorough work has revealed a big
need for a broad scientific effort in the field of clinical science research
and health services research. Methodological competence at high
levels is necessary for valid and reliable results. There is, therefore, a
need for supporting academic centres, which are willing to undertake
education of scientists and methodology advisers.
The evidence basis for decisions on treatment is regularly chan-
ged. Thus, the low-back pain-report must be updated after four years
at the latest, in order to preserve its relevance.

Members of the panel

This manuscript is the result of work carried out by a panel which

was appointed by the Health Technology Assessment Committee of
The Danish National Board of Health. The manuscript was compi-
led by Claus Manniche.

Professor, Chief Physician Claus Manniche MD, (Chairman)*

Economic Affairs Anni Ankjær-Jensen*
Assistant manager Anni Olsen*
Relaxation Therapist Anni Fog
Danish Relaxation Therapists.
Physiotherapist Kirsten Williams
Danish Physiotherapy Aassociation
Chief Physician Finn Biering-Sørensen, MD
Danish Epidemiologic Society
Peter Kryger-Baggesen, DC
Danish Chiropractors Association
Chief Physician Claus Mosdal, MD
Danish Society of Neurosurgeons
Hospital Director, Chief Physician Hans Christian Thyregod, MD
Danish Society of Orthopaedic Surgery
Chief Physician Erik Martin Jensen, MD
Danish Rheumatological Society
Niels-Frederik Pedersen, MD
Danish Society of General Medicine
Chief Physician Svend Lings, MD
Danish Society for Occupational and Environmental Medicine
Chief Physician Lars Remvig, MD
Danish Society for Musculoskeletal Medicine
Professor, Chief Physician Tom Bendix, MD
The Arthritis Association
* Members appointed by the Health Technology Assessment Committee of The Danish
National Board of Health.

Protocol records:
Per Bülow, MD
Kim Upperup, of the Center for Health Services Research and Social Politics, University of
Odense, has participated in the production of the Appendix and Appendices A,B, and C.

In the spring of 1995 the Health Technology Assessment Committee
of The Danish National Board of Health (HTA) appointed a working
group which was called the “Low-back pain group” (LBP-group).
The task of the LBP-group was to adapt published international HTA
reports regarding the diagnosis, treatment and prevention of “low-
back pain” to Danish conditions.
Low-back pain has such a high prevalence in the general po-
pulation that an episode should almost be classified as a normal oc-
currence. Every fifth Dane will experience low-back pain during a
fourteen-day period. This result in a great utilisation of treatment,
sick-leave, and in many cases health related disability pensions.
The LBP-group was comprised of individuals representing the
different professional associations that deal with low-back pain and
also included a representative from a musculoskeletal patient associ-
ation. Individuals with expertise in administrative and economical af-
fairs related to the hospital sector were also included. The scientific
societies from different medical specialties that are involved with the
examination and treatment of low-back pain each appointed a re-
presentative to the LBP-group.
In the fall of 1996 the LBP-group delivered the report entitled
“Low-back pain- a delineation of the problem, prevalence and sug-
gestions for its management” to the committee, whereupon it was
published by the National Board of Health. In this manuscript the ini-
tial report will be termed Low-back pain Volume 1. This report has
been sent out to those responsible for political decisions, health pro-
fessional organisations as well as their members in the Danish health
care sector. The first volume was published in 8000 copies.
In 1997 the Danish Institute for Health Technology Assess-
ment was formed, and the responsibility for concluding the work was
placed here. The LBP-group continued its work until the present
report was completed after holding 31 meetings until August 1998.
The LBP-group has carried out its work in an objective man-
ner and has demonstrated a willingness to look closely at the entire
area under investigation without political interference. The LBP-

group has reached agreement on all important issues. There has been
some divergence of opinion as regards a few minor details. The report
is written without the use of too many professionals’ terms, as was
the case with Low-back Pain, Volume 1. The LBP-group has attemp-
ted to write a report that can inspire both politicians and professio-
nal decision-makers that are associated with the health care sector.
With the publication of this report, the LBP-group’s work as-
signment according to the original commission is completed.


Health Technology Assessment is a thorough, systematic evaluation
of the indications and consequences of utilising medical technology.
Technology refers to any method used in arriving at a diagnosis, treat-
ment or prevention. HTA includes an evaluation of a series of ele-
ments which can be classified into the following 4 headings:
Technology (treatment method),
The patient
Organisation and

The LPB-group has at certain times retrieved literature in order to

clarify certain areas but has for the most part used the following
national and international Consensus -/HTA-reports as the basis for
its recommendations.

❖ Back pain- causes, diagnosis and treatment (pages 1-122).

Statens Beredning för Utvärdering (SBU), Stockholm 1992, Alf
Nachemson, report nr. 108, pp 1 – 122. This publication was a
thorough review of the entire subject including the documenta-
tion of different treatments as well as future strategies.

❖ Acute low back problems in adults Agency for Health Care Policy
and Research, Public Health Service, Rockville, U.S. 1994. This
project included a thorough and systematic review of the available
literature regarding treatment. The report has been published in a
user-friendly fashion and can be used as a reference text. The dif-
ferent treatments have been graded according to scientific docu-
mentation so that the reasoning behind their recommendations is
❖ Musculo and Skeletal disease in Denmark. Danish Institute for

Clinical Epidemiology (DICE), 1995. The report is a population
based survey of the frequency of musculo and skeletal diseases in
Denmark. The survey is based on interviews with 4818 danes
between September 1990 and May 1991.

❖ Report on Back Pain. The Clinical Standards Advisory Group,

London, 1994, pp. 1-47. The epidemiological review is particu-
larly thorough.

❖ Consensus report: Low back pain. The Danish Society of Inter-

nal Medicine, Ugeskrift for Læger;1996:suppl 4; 1-18. This
report is a concise and systematic review of the subject. The em-
phasis was on diagnosis and treatment of the most common
acute and chronic low back diseases

❖ Clinical guidelines for the management of acute low-back pain.

Royal College of General Practitioners, London 1996, pages 1-
35. Organisations contributing to this report included: general
practitioners, physiotherapists and chiropractors. The report
includes practical guidelines based upon the “Report of back
pain”, see above.

❖ Conservative treatment of acute and chronic non-specific low-

back pain. Van Tulder MW et at. Spine 1997;18:2128-56. This
“evidence based” medical evaluation of the most commonly used
treatment forms for low-back pain was written by a research team
from the University of Amsterdam.

If another source has been used this will be referred to in the text.
Figures and Tables are always given with references. As far as was
possible reference material representative of the adult Danish popu-
lation was used.

Low-Back Pain
Volume 1

What is “low-back pain”?
In this report, “low-back pain” is defined as tiredness, discomfort, or
pain in the low back region, with or without radiating symptoms to the
leg or legs. In the remainder of this text these symptoms will be referred
to as low-back pain. The definition does not take into consideration
either the duration or the degree of symptoms. Anatomically the low
back is to be considered the area from the lowest rib and downward to
the bottom of the sitting muscles as illustrated in Figure 1.


The upper region

of the low-back

The lower region

of the low-back

Kilde: Standardised Nordic questionnaires for the analysis of muscoloskeletal symptoms, 1987.

This definition does not differ markedly from those used in

other international HTA-reports. The British report only recognises
symptoms of more than 24 hours duration.
Diagnoses commonly used in clinical practice include: lum-
bago, facet syndrome, sciatica, disc herniation, muscle tension, crooked
or curved spine, degenerative arthritis, osteoporosis, and so forth.
These “diagnoses” may cover a specific condition (osteoporosis or
disc herniation) but for the most they cover a range of symptoms.
The report includes data on people with low-back symptoms
of shorter or longer duration. The term acute symptom is to be un-
derstood as symptoms lasting less than three months. All symptoms
lasting more than three months are considered as chronic symptoms.

In accordance with the international HTA-reports we do not use the
term sub-acute symptoms in this report. This term is difficult to limit
in terms of time and has no particular diagnostic or treatment rele-


Discomfort and pain in the low-back was first described on paper in
1500 BC by Edwin Smith’s papyrus writings. Prior to the 19th cen-
tury the possible relationship between the facet joints, the discs, and
nerve irritation and low-back pain was unknown. However, the rela-
tionship between fractures and deformities had been known for a
long time.
In the 20th century it was quickly established that the nervous
system could be involved in the development of low-back pain and
later on it was widely accepted that low-back pain was possibly cau-
sed by an “irritation” of the nervous system. Due to the difficulty in
establishing a physical cause many of the symptoms were considered
to be of an hysterical (psychological) nature. The most commonly
held belief was that symptoms were a result of an irritated nervous
system and research focused on this area.
In conjunction with the development of the British railway
system (1800-1850) a relationship between heavy work and damage
to the back was acknowledged. Prior to this time low-back pain was
never seen in association to an injured spine. The term “wear and tear
of the back” became accepted and individuals were entitled to com-
pensation in some instances. Research activity in this field increased
markedly but it was still not possible to establish a direct cause and
effect relationship.
During this time, the medical speciality orthopaedic surgery
was developed. As regards low-back pain, bed rest was the most com-
monly prescribed treatment. Low-back pain was not treated with bed
rest in earlier times, but was considered to be a valid treatment in this
period as symptoms appeared to improve in many patients. The use
of bed rest was not based upon scientific documentation but rather
on empirical evidence (experience). Current knowledge dictates that
it is both wrong and clinically ineffective to treat almost all low-back
ailments with bed rest of up to several weeks’ duration.
In 1934 it became clear that the bulging of discal material
could result in pressure on the spinal nerves which could in turn
result in loss of muscular function and sensory disturbances. This

groundbreaking new knowledge regarding the pathoanatomical rela-
tionships of spinal structures unfortunately led many physicians
to believe that all spinal problems were discal in origin. Many were
therefore of the opinion that surgery would be the answer for most
back ailments. As great advances were being made in anaesthetics
and surgical specialities during this period many low-back pain
patients underwent surgery; many of them up to several times. The
tendency to overutilise a newly developed treatment modality for a
period of time has also been seen in other areas of medical science.
The use of long-term bed rest resulted in increased illness be-
haviour for low-back patients, which also resulted in physical de-con-
ditioning. Many patients became worse off due to bed rest than they
would have been otherwise. Additionally, many patients underwent
surgery in spite of uncertain pathoanatomical findings. These and
other factors may have led patients with ordinary low-back pain on
a journey ending with severe disabilities.
During the past 30 years much energy has been focused upon
reducing workloads as a result of the increased number of low-back
pain episodes occurring at the work place.
Many preventative measures have been undertaken in order to
prevent repetitive work and heavy lifting at the workplace. In spite of
these measures the incidence of low-back episodes at the work place
continues to rise. This development underscores the multi-factorial
nature of low-back pain, which includes socio-economic factors as
well as work conditions.


Low-back pain is among the most common painful conditions
in the Danish population. If questioned directly, thirty-five per cent of
the population will report that they have experienced low-back pain
(either short-lived or persistent) during the past year while twenty-
one per cent will have experienced back pain during the past fourteen
days (Table1). Females report a greater frequency of low-back pain
than males however the percentage of disc herniations and long-term
low-back disability is very similar for both genders.
As far as age in concerned there is a weak increase in frequency
from ages 16 to 67 whereupon a decrease in frequency takes place for
both genders, but the decrease is not as great for females. In all likel-
ihood this is due to osteoporosis which is commonly observed in
females of this age group.

Percentage of males and females with various low-back problems in different age groups
Males Females
16-24 25-44 45-66 67+ Total 16-24 25-44 45-66 67+ Total M+F
Percent with:
- Back pain within
the past year *) 34 42 40 24 38 41 42 45 37 42 40
- Low-back pain
during the past year 27 36 35 22 33 34 36 41 34 37 35
- Daily back pain
during the past year *) 2 6 11 11 8 6 8 15 20 12 10
- Back pain during
the past 14 days *) 12 19 21 16 18 18 21 26 27 23 21
- Disc herniation
during the past year - 1 3 1 2 - 1 3 3 2 2
- Other back diseases
during the past year 9 15 19 9 15 11 11 21 16 15 15
- Long-term disease 3 7 11 7 8 4 5 15 9 8 8
# of interviewed people 378 923 693 311 2305 388 947 738 440 2513 4818
*) Back pain in this row is to be considered as both upper and/or lower back pain but not neck pain. Ref. DIKE 1991.

The British “Report of back pain” documents that the number

of sick-leave days due to low-back pain has increased three-fold du-
ring the past fifteen years. The newest data from Denmark also point
to a further increase compared to the data used in this manuscript.
The most frequently reported painful region of the spine is the
low-back (28%), while pain in the upper spine or both the upper and
lower regions of the spine are not as common (Table 2). There is no
difference between genders as far as spinal pain localisation is con-
cerned (Table 2.)


In this section “causes” should be considered as objective fin-
dings such as; x-ray findings and blood tests which may explain the
symptoms. Factors such as heavy lifting or repetitive work (external
factors) are not considered even though they may influence low-back
symptom development.
We are aware of a wide variety of diseases/conditions, which
can contribute to or cause low-back pain but even after a thorough
examination it is not possible to make an accurate diagnosis in 70-
80% of patients. In the remaining 20-30% a diagnosis can be made
on the basis of objective findings which cannot be found in healthy

The percentage of males and females with back pain during the previous year
Males Females
16-24 25-44 45-66 67+ Total 16-24 25-44 45-66 67+ Total M+F
Pain only in the upper region
of the back 8 6 4 2 5 7 7 5 3 6 5
Pain only in the lower region
of the back 23 33 30 17 28 28 29 30 24 28 28
Pain in both the upper and
lower regions of the spine 4 6 6 4 5 9 6 10 9 8 7
No spinal pain 66 55 61 77 61 57 58 14 63 58 59
Back pain in this Table is either pain in the lower and/or upper back but not the neck. Ref. DIKE 1991.

individuals. There is however an element of uncertainty with this lat-

ter group as well. It has been demonstrated scientifically (CT-scan-
ning) for example, that between 25% and 75% of healthy individu-
als have positive findings suggestive of disc herniations. Degenerative
changes in the spine as seen on plain x-rays should be considered as
a part of the natural ageing process. Approximately fifty per cent of
all people over fifty years of age have degenerative changes but the
incidence of low-back pain is equivalent in people either with or
without spinal degeneration.


There are no specific data regarding the influence of social and eco-
nomic factors and low-back pain for the individual but musculoske-
letal disease is the most common cause of decreased daily activity,
sick-leave and disability pensions (Table 3).

The relative contributions (percentages) of various diseases that result in activity decreases, change of work
or loss of work, and disability pensions
Activity - long-term- - short-term- job change/ -job change- -job loss health related
limitations loss disability pension
Musculoskeletal disease 38 47 21 45 47 43 33
Heart/vascular disease 6 9 1 9 5 13 14
Nervous system disease 5 6 4 6 5 8 11
Respiratory disease 20 9 39 5 5 5 5
Injuries 10 7 14 8 10 5 6
Psychological illness 2 2 1 7 6 8 8
Other diseases 19 19 21 20 22 7 22
The numbers are given as percentages of all disease groups. Back disease represents approximately 50% of all musculoskeletal disease. Ref. DIKE 1991.

Number of hospitalisation days for chosen diagnoses in Denmark 1994.
Diagnosis Discharged # of days at hospital Discharged # of days at hospital
÷ operation ÷ operation + operation + operation
Lumbar disc herniation 4778 43566 2880 26828
Degeneration of discs or
bones in the low-back 1682 16938 498 5709
Low-back pain without signs
of disc herniation 2696 25319
Reference: National patient registry, Ministry of Health 1995

The lower back is the most frequent problem area of the entire
musculoskeletal system, and as such we can use the data from the en-
tire group. Similar data can be found from other Western countries
which we normally compare ourselves.
In Denmark, more than 120,000 hospital days as a result of
disc and other vertebral lesions were documented (Table 4). In addi-
tion to this, a large patient group exists with more diffuse symptoms
such as osteoporosis, or referred pain from other organs. According
to the Ministry of Health’s figures from 1993 the total number of
hospital days due to somatic disease in Denmark was 7.5 million. The
group including spinal disease, disc herniation, osteoarthritis as well
as other related illnesses was calculated to be 330,000 days per year.
This number equals the yearly hospital day capacity of one of the lar-
gest hospitals in Denmark.
The number of hospital days used for back illness has remained
fairly constant from 1983 to 1993 in spite of the fact that it has been
shown that hospitalisation for most back conditions has been shown
to be unnecessary or even contributory regarding the promotion of
illness behaviour. At present there are no separate numbers as regards
costs regarding low-back pain patients as opposed to the overall
group of musculoskeltal patients. The possibility of arriving at precise
public health costs associated with low-back disease is made difficult
by the fact that certain disease costs are not classified singularly. For
example, services provided in the primary health care sector are not
registered systematically (how many patients, what type of treatment,
which diagnoses?). It is also difficult to calculate the exact public costs
associated with sick-leave and disability pensions directly related to
low-back disease alone, because many patients are unable to work
for differing periods of time due to several competing diseases which

Social costs for 13 diseases in Denmark calculated according to the cost-of – illness method. Figures are presented as millions of DKK
(1992 price index).
Direct costs1) Indirect costs2) Costs
Disease Hospital Primary3) Total s%4) r%5) Sick-leaver6) Pension7) Death Total s%4) r%5) Total s%4) Rank
Musculoskeletal disease 1.848 1.295 3.143 8,4 14,8 5.127 12.891 112 18.130 17,7 85,2 21.273 15,2 2
Cancer 3.234 485 3.719 9,9 23,1 953 3.320 8.088 12.361 12,0 76,9 16.080 11,5 4
Respiratory disease 1.617 1.145 2.762 7,4 39,5 847 2.310 1.079 4.236 4,1 60,5 6.998 5,0 7
Injuries/accidents 2.772 578 3.350 9,0 27,1 4.067 2.339 2.615 9.021 8,8 72,9 12.371 8,8 5
Diseases of the digestive tract 1.848 680 2.528 6,8 36,7 1.907 909 1.538 4.354 4,2 63,3 6.882 4,9 8
Nutritional and metabolic diseases 924 400 1.324 3,5 40,7 0 1.265 668 1.933 1,9 59,3 3.257 2,3 10
Psychiatric disease 3.446 736 4.182 11,2 14,4 2.224 22.122 540 24.886 24,2 85,6 29.068 20,7 1
Diseases of the nervous system,eyes,ears 924 978 1.902 5,1 28,0 1.144 3.249 503 4.896 4,8 72,0 6,798 4,9 9
Diseases of the urinary tract and
reproductive organs 924 605 1.529 4,1 60,3 634 281 91 1.006 1,0 39,7 2.535 1,8 12
Infectious diseases 693 242 935 2,5 38,3 212 860 432 1.504 1,5 61,7 2.439 1,7 13
Heart and vascular disease 4.620 1.305 5.925 15,8 33,2 1.843 4.457 5.595 11.895 11,6 66.8 17.820 12,7 3
Diseases related to pregnancy 1.617 550 2.167 5.8 81,5 4.87 3 3 493 0,5 18,5 2.660 1,9 11
Other diseases8) 2.078 1.866 3944 10,5 33.1 1.697 1.105 5.169 7.971 7,8 66,9 11.915 8,5 6
Total 26.545 10.865 37.410 100 26,7 21.142 55.111 26.433 102.686 100 73,3 140.096 100
1) BTreatment costs included only resources used in the health care sector as defined in Denmark. In other words, costs related to handicap dwellings and other social costs are not included
2) The present value of production loss, discounted by a factor of 4%.
3) Includes only general practitioners, specialist practices, physiotherapeutic treatment, chiropractic, and the usage of medicine outside of the hospital sector. Costs include both public health insurance costs
as well as the direct costs paid by the individual patients. The diagnostic classification is the one used in 1989
4) Column percentages, in other words, disease specific costs in relation to total column costs.
5) Row percentages, in other words, the disease specific distribution of costs of both direct and indirect costs
6) Of non-permanent character, the disease distribution is from 1981
7) Permanently reduced ability to work or total loss of ability to work; disease distribution is the average of 1989-91.
8) Includes production costs of 2.3 billion Danish DKK related to suicide, which is not included under injuries/accidents or under psychiatric diseases.
Source: Nastra Recommendations nr. 1284, 1995.

may be present simultaneously. In our group we concluded that it was
impossible to acquire more precise data without initiating several
costly analyses.
Indirect costs can be evaluated by using data from the whole
disease group “musculoskeletal diseases.” Table 5 shows both the
direct and indirect costs of 13 chosen disease groups. Only psychia-
tric diseases are more costly to society than muscoloskeletal disease.
The numbers cover the entire musculoskeletal disease area and as pre-
viously stated low-back disease contribute approximately 50% of the
costs of this disease group. The yearly costs to society are therefore
roughly 10 billion DKK. Note that the direct costs of this group are
less than several of the other groups. However, the large indirect costs
result in the great total costs related to this disease group. We con-
clude that considerable savings will mainly come from reducing the
indirect costs.

Illness Behaviour
Illness behaviour includes all forms of reactions resulting from signs
and symptoms of a disease. Examples include conscious inactivity,
self-treatment, and seeking help from health professionals as well as
from friends and family.
Many individuals (approximately 30%) suffering from mus-
culoskeletal symptoms do not alter their activities of daily living nor
do they seek help in the form of treatment (Table 6, page 24). There
is no data in the DIKE report which deals specifically with low-back
pain, however, it is unlikely that this group differs from individuals
suffering from other forms of musculoskeltal pain.
A large group attempt to tackle their low-back pain problem
by altering work patterns, changing the ergonomics of their work-
stations, or by participating in preventative fitness training programs
(Figure 2, page 25).
Individuals suffering from severe pain or disability will natu-
rally seek help from health professionals at greater rates than others.
(Table 7 page 24). There is therefore, a clear relationship between pain
intensity and treatment although approximately 68% of individuals
suffering from severe pain do not seek treatment even though 88% of
these individuals do not believe that their symptoms will subside.
Twenty-three per cent of individuals suffering from low-back
pain that seek professional help will initially contact their general pra-
ctitioner. A group (12%) will seek help from a chiropractor either
separately or at the same time that they contact their general prac-
titioner. Slightly less than fifty per cent will be referred to a physio-
therapist (9% of all patients seeking help). Only a small percentage
will be examined and treated by a specialist in rheumatology or at a
hospital. The vast majority of treatment is provided in the primary
health care sector by general practitioners, physiotherapists or
chiropractors (Table 8, page 24).
Thirty-seven per cent of individuals suffering from low-back
pain will seek treatment within a year (DIKE 1995). The percentage
of individuals that seek care due to low-back pain related functional
disabilities are greater than those suffering from other diseases of the

Illness behaviour among males and females in different age groups suffering from musculoskeletal
symptoms during the past 14 days given in percentages (%)
Males Females
16-24 25-44 45-66 67+ Total 16-24 25-44 45-66 67+ Total M+F
Has done nothing 42 34 33 42 36 29 21 22 35 25 30
Self-treatment only 44 50 51 47 49 60 62 62 47 58 55
Self-treatment and
sought professional care 9 12 15 7 12 8 14 13 13 13 12
Only sought treatment 4 3 1 4 3 3 2 3 6 3 3
In total 100 100 100 100 100 100 100 100 100 100
Source DIKE 1991

Percentage of differing illness behaviour among people with different types of musculoskeletal symptoms
given in percentages (%).
With severe With reduced Are not capable Have symptoms Tired due to Have had Do not expect
pain activity levels of doing what from several symptoms symptoms that their
what they areas of for a longer symptoms
would like to the body period of time will resolve
Has done nothing 14 20 24 25 21 30 32
Self-treatment only 54 49 52 57 55 56 56
Sought treatment
(and eventually did
something themselves) 33 31 24 18 24 14 12
In total 100 100 100 100 100 100 100
Source DIKE 1991

The number of consultations with health professionals during the past year and the number of treatments
from all individuals suffering from low-back pain.
Percentage with Average number Number of
contact (%) of contacts treatments*
general practitioner 23 3,5 417.000
Physiatrist or rheumatologist in private practice 4 6,5 135.000
Doctor at a hospital department 4 4,0 83.000
Physiotherapist at a hospital 4 8,4 174.000
Physiotherapist in private practice 9 11,7 545.000
Chiropractor 12 6.5 404.000
Total number of treatments 1.758.000
The same person can have received treatment from several health professionals.
*The number of treatments is derived from the fact that there are 4 million Danes over the age of 16, of which 35% have had trouble with back pain during
the past year and 37% of whom have sought treatment.
Source DIKE 1991

The percentage who attempt different things in order to reduce symptoms due to musculoskeletal trouble

Advice from family and friends

Avoid certain work position
Rested more
Hot packs
Alternative (natural) medicines
Fitness centre
Usual physical activity
Increased physical activity
0% 10% 20% 30% 40% 50%
Source DIKE 1995

musculoskeletal system (10-20%). This can be interpreted to mean

that low-back pain related symptomatology is perceived as requiring
more treatment than other diseases of the musculoskeletal system.

◆ 35% of the Danish population report having low-back pain during the
past year
◆ 37% of individuals with low-back pain seek treatment
◆ The number of sick-leave days has been increasing the past 20-30 years
◆ At the present time there is no scientific evidence that low-back trouble
has changed character. The increase in the number of back complaints
must therefore be a result of changed work or psychosocial aspects
◆ Low-back pain results in a total cost to society of over 10 billion DKK

Risk factors (indicators)
Risk factors relates to factors that have a probable influence regarding
the development of as well as the course of low-back pain, but should
not be confused with a cause and effect relationship which requires
secure knowledge regarding a direct relationship between an injury
resulting in low-back pain. The scientific literature in this area is rather
unclear both regarding the clear definition of the involved terms as
well as the statistics employed. For example, many risk factors have
not been examined as far as their relationship to one another is con-
cerned. Utilising the term factors can therefore result in misunderstan-
dings while the term indicators (to be a sign of, to represent, or to
reflect) more accurately describes our concerns. Generally the term
factors is more commonly used in the literature and we will follow
suite in this report.
Our knowledge regarding possible risk factors has been derived
from large population studies where a statistical correlation between
risk factors and low-back pain in the studied population has been
frequently demonstrated. The relationships are very complex due to
the fact that many factors have to be evaluated at the same time. Ad-
ditionally, unknown factors may play a role in the development of
low-back pain as may factors that have not been recorded.
Results from research may present conflicting conclusions.
However, for a number of factors there is solid documentation of a
relationship between exposure and the general development of low-
back pain. The degree and duration of exposure will influence both the
development and the course of low-back pain.
Traditionally, risk factors are divided into individual and exter-
nal groups. Furthermore, there are factors, which contribute to the de-
velopment of chronicity. Individual factors are related to the person in
question, while external factors most often relate to work or social fac-
tors. However, a clear separation of these factors is not always possi-
ble. Similarly, risk factors regarding the development of acute and
chronic low-back pain oftentimes overlap. This can be seen in Figure
3, where there is no clear separation between the different risk factors.
A series of different factors are important as regards the frequ-
ency as well as the duration of low-back pain for the individual per-

son. Oftentimes, several risk factors (both known and unknown)
acting simultaneously will affect the course of low-back pain and it
can be impossible to determine which of the factors is the most im-
In Figure 3 a series of risk factors are presented under the hea-
ding “proven”. These factors are regarded by most experts as being
most frequently involved in the development of low-back pain, but
they should not be regarded as obligatory. At the present time it is not
possible to propose a list, ranking the most important factors.
We cannot for example conclude that “heavy lifting” contri-
butes more frequently to the development of low-back pain than either
“psychological stress or low social status”.
In the future, it will be of great importance to study risk factors
responsible for the development of chronic low-back pain because this
oftentimes results in patients being sick-listed for several years, recei-
ving endless amounts of treatment, and ending with permanent dis-
ability pensions. Risk factors of importance as far as this issue is con-
cerned include: long-term sick-listing, exaggerated illness behaviour,
stress or depression, low levels of job satisfaction, smoking, and on-
going litigation/pension procedures.
During the course of the last twenty years, decision makers as
well as the population at large have been led to believe that back-pain
is most often due to many years of heavy lifting or inappropriate sea-
ting postures. This has logically resulted in preventive measures being
undertaken at the workplace aimed at reducing the pace of work as
well as the number of heavy lifts. During this period, the number of
people suffering from low-back pain has unfortunately increased mar-
kedly. This is in all likelihood due to the fact that only some of the
cases of back-pain are mainly work-related. A great number of low-
back complaints are a result of other social as well as individual factors.
Among the HTA participants there is agreement that “indivi-
dual factors” are at least as important regarding the development of
low-back pain as are the external factors. It is essential that in future
preventive activities, all known risk factors be addressed (both indivi-
dual and external).

◆ Individual risk factors are at least as important regarding the develop-

ment of low-back pain as are external factors
◆ Future preventive measures must address both individual and external

Possible and proven risk factors regarding the development of low-back pain
Possible will be presented in normal font,while proven will be given in bold type.

Individual risk factors External risk factors

Age (1) Previous back pain Sedentary work

Poor general health
Radiating pain
to the leg
Poor physical health Many aggrevating twisting
Genetic disposition Depression
Personal problems (3)

Long term Poor job

Psychological stress (2) sick-listing satisfaction Driving > 2 hours
Reduced endurance
of the spinal muscles Clinical impression
Obesity of disc herniation
Alcohol abuse Highly repetitive work
Exaggerated illness
Low social class pension ongoing Many heavy lifts

Risk factors for the

development of chronic
low-back pain
1) Greatest risk for males aged 40-50. Great risk for females over age 60.
2) Proven as regards chronic back-pain but should be considered a possible risk factor as regards acute back pain.
3) Alcohol, marital or economic difficulties.

During the years many different diagnostic classification
systems of low-back pain have been devised in order to arrive at a
likely diagnosis. Emphasis has either been placed upon the anatomic
localisation, causes or symptoms. None of these attempts at classi-
fying patients has been comprehensive enough to cover the wide spec-
trum of low-back pain.
It has become accepted in professional circles that it is im-
possible to make a specific diagnosis in approximately 70-80% of
cases regardless of how thorough the examination procedures have
been. Due to a lack of solid biological causes the terms “non-specific
back pain” or “simple back pain” have become widely used.
Non-specific low-back pain is divided into the following
classifications, which are based upon patient symptom description.
These divisions have been shown to be of value regarding the health
professionals’ need of further examinations and treatment strategy

◆ Acute low-back pain

◆ Chronic low-back pain
◆ Acute low-back pain with radiating symptoms to the lower extremity
◆ Chronic low-back pain with radiating symptoms to the lower extremity

Certain diagnoses can however be based upon a pathoanatomical

basis. This of course depends upon a clear correlation between ana-
tomical findings and patient symptoms. This is possible in approxi-
mately 30% of low-back pain patients.

Degenerative low-back conditions. This term covers a variety of con-

ditions including spondylosis, disc degeneration/herniation, spondy-
loarthrosis, and is generally considered to imply degeneration taking
place somewhere in the spine. Spinal degeneration is a natural phe-
nomenon, which can commence at different periods of an indivi-
dual’s life. Severe degeneration of the spine can result in either con-
stant or periodic pain. Our present knowledge regarding the biologi-

cal mechanisms of spinal degeneration and their relation to spinal
symptoms is very sparse.



Degenerative Conditions: Other:

Spondylosis/disc degeneration Scheuermann’s Disease
at several levels
Spondyloarthrosis Discitis
Disc herniation Infectious spondylitis
Spinal stenosis Osteoporosis
Spinal tumors

Spondylosis/disc degeneration (osteoarthritis of the bones or discs)

can be identified with the following x-ray findings: Reduced discal
height, sclerosis of vertebral bodies or calcification of the discs. X-ray
findings usually correlate poorly with symptoms. Even severe dege-
nerative findings do not necessarily result in symptoms.

Spondyloarthrosis (degeneration of the true joints of the spine) refer to

degenerative changes of the facet joints between the vertebra. Due to
the anatomy of the region there is a poor correlation between
joint degeneration and pain localisation. It has been shown experimen-
tally, for example, that facet joint irritation can result in gluteal pain.
Spondyloarthosis usually develops as a result of reduced disc height.

Disc herniation is commonly associated with low-back pain in the

general population. Symptoms result from the nucleus of the disc
pressing on the spinal nerves and/or resulting in a chemical irritation
of the nerves due to tears in the discal fibbers. These nerves are a part
of the sciatic nerve. Symptoms can vary according to the level of the
disc herniation, however radiating pain to the leg and weakness of the
foot are frequently observed. Disc herniations can also be found in
individuals that have no symptoms at all. In spite of the oftentimes
dramatic course of events in the acute phase of a disc herniation, the
long-term prognosis is most often favourable. Only one out of four
patients require surgery.

Spinal stenosis refers to a condition with reduced space in the spinal

canal due to degenerative changes. In conditions, which result in

symptoms due to pressure on the nerves, the most usual symptoms
are pain and decreased strength in the legs. Symptoms usually
develop after a period of time.

Scheuermann’s disease occurs in the growth zones of the vertebra.

This results in an alteration of the shape of the bodies of the vertebra
from the classic block-like form to a wedge form. This process takes
place during puberty and is more commonly found in males. This
disease is most commonly seen in the thoracic spine (chest) although
it can also be found in the low-back. Symptoms resulting from a
thoracic Scheuermann are rare whereas symptoms from the low-back
are more frequently (but not always) observed.

Arcolysis is a defect in the part of the bone that connects the facet
joint to the vertebral body. This is a common finding in 5% of the
adult Danish population and can be found in 35% of the Eskimo
population. This condition does not necessarily result in pain. If how-
ever, a spondylolisthesis results in a vertebra slipping forwardly on
the vertebra below symptoms may develop. This condition can also
be found as a result of degeneration of the disc or facet joints.

Scoliosis is a condition with unusual curves of the spine in the side

plane which can be a result of unequal leg lengths (non-structural) in
as much as 20-30% of the population. However, scoliosis may also
be a result of changes in the vertebra, muscles and connective tissues.
In younger people scoliosis is due to a developmental defect while in
older individuals it is oftentimes seen in association with degenerative
changes in the spine.

Discitis is an inflammatory condition (sometimes bacterial) in the

discs of the spine. It most frequently results after surgery (1-2%).

Infectious spondylitis is a bacterial inflammation localised to one or

more vertebrae. The bacteria usually spreads through the blood. This
disease is usually found in individuals with weakened immune
systems, among the elderly, in individuals with systemic disease (dia-
betes), or in drug abusers. Initial symptoms include fever and back
pain. It is characterised by extreme tenderness to pressure of the
adjoining vertebrae.

Sacroiliitis/Ankylosing spondylorarthritis is an inflammatory pro-

cess in the joints of the pelvis and the sacrum as well as in the joints
of the spine. This process can be found in conjunction with other
arthrotides or independently.

Osteoporosis refers to a lack of calcium in the bones resulting in

changes in structure which may result in fractures after seemingly
minor trauma. Osteoporosis is most frequently seen in elderly fema-
les due to decreased estrogen production after menopause. This re-
sults in a negative balance in the process of during which bone tissue
is renewed and torn down.

Spinal tumors include both benign and cancerous tumors. Primary

spinal tumors are quite rare and most are a result of metastasising
cancer from either the lungs, breasts, or bladder. Most patients are
from 50-60 years of age but tumors can be found in all age groups.
Symptoms include pain, which is oftentimes worst at night, weakness
and sensibility changes in the legs. The course can be either slow or
quick depending on the localisation of the tumor.

Diagnostic procedures
For most patients suffering from low-back pain a thorough interview
and clinical examination will suffice. These procedures will reduce
the likelihood of there being an underlying pathology, which is
causing the low-back pain in either acute or chronic low-back pain.
The interview includes a thorough round of questions regarding how
and when the pain developed as well as the course of the symptoms.
Information regarding previous episodes of low-back pain is also
relevant to discuss. A comprehensive review of potential risk factors
regarding the development of chronic low-back pain is also of
extreme importance.
The interview is followed by the clinical examination. The pri-
mary purpose of the clinical examination is to attempt to make a spe-
cific diagnosis as well as to make sure that there is no serious illness
present, which may require further examination. A thorough exami-
nation is also necessary in order to determine the most appropriate
treatment strategy for the patient and to avoid unnecessary repetitive
examinative procedures.
In the opinion of the HTA group, the initial examination is the
singularly most important activity as regards the management of the
low-back patient. If properly carried out one can evaluate the magni-
tude of the patients problem, determine if additional examinations
are necessary and initiate treatment. It may also be possible to weigh
the risk of chronic symptom development and to initiate preventive
The clinical examination should include a relevant number of
the diagnostic tests, which are described below. A particular problem
is the differing attitudes regarding the validity and interpretation of
certain clinical tests both intra- and interprofessionally. This often-
times results in patients receiving contradictory information.

1. Postural anomalies (curved spines)
2. Spinal motion
3. 3. Gait analysis
4. Pain tests (tenderness of the spine)
5. Lasegue’s test (straight leg raising)
6. Neurological tests (sensibility, reflexes, strength)
7. Rectal examination
8. Para-clinical tests (x-ray, blood)


Traditionally, a x-ray of the spine is one of the first examinations un-
dertaken in low-back pain patients. However, this examination for
the most part does not provide any meaningful information for the
majority of patients, as x-ray findings generally correlate poorly to
symptomathology. Additionally, x-ray findings rarely provide useful
information regarding the course of the problem such as the risk of
developing chronic symptoms.

▲ Only in circumstances where the health professional suspects the pre-

sence of infection or other inflammatory conditions, fractures or cancer
will x-rays provide information of importance regarding further examina-
tive procedures and treatment.

It is the opinion of the HTA group that x-rays should only be gene-
rally entertained if the low-back pain has been present for at least
four weeks. Ordering x-rays earlier in the course of events is not
ethically or economically acceptable. Only in circumstances where
the health professional is led to believe that other diseases may be pre-
sent can the above conclusions be circumvented.
One should attempt to secure previously taken x-rays (1-2
years old) at the initial consultation and to make sure that patients
have their x-rays with them if referred to other health professionals
in order to prevent unnecessary x-ray exposures and delays. The rea-
son that x-ray examinations are oftentimes repeated is that they can-
not be retrieved quickly enough or due to poor quality. The HTA
group strongly recommends that guidelines for “proper x-ray proce-
dures” for low-back patients be prepared. This can be done through
co-operation between radiologists, surgeons, chiropractors, rheuma-
tologists and so forth. It is also necessary to evaluate the best method

of storing x-rays so that health professionals can retrieve them as
quickly as possible so that treatment strategies are not delayed.
More advanced imaging such as CT and MRI -scans (with or
without contrast fluids) are rarely indicated in acute low-back pain
for the same reasons as mentioned above. Scanning procedures
should only be entertained if patients are experiencing functionally
disabling symptoms such as severe back or leg pain for more than
month and/or if surgical is likely.
The x-ray procedure involving the injection of contrast fluids
in the spinal canal (myelography) is still commonly used in hospitals
even though the information provided is similar to that of other pro-
cedures. Myelography is not used as frequently as in previous times
due to the risk of pain development, severe headache (days to weeks)
and the slight risk of infection. The HTA groups suggest, in accor-
dance with international trends, that less invasive procedures such as
CT or MRI scans be used as the standard procedure in the investiga-
tion of disc herniations as opposed to myelography. In cases where
there is a suspicion of spinal stenosis (narrowing of the spinal canal)
myelography may be the procedure of choice.
The costs of these different procedures varies from place to
place, with x-rays ranging from 375-1000 DKK myelography 2500
DKK, Ct-scans 4000 DKK and MRI-scans 7000 DKK.
These figures do not include costs associated with treatment
and eventual side effects.
Considerable amounts can be saved by avoiding unnecessary
examinations or repeated examinations and if these procedures are
(as far as is possible) initiated only if surgery is being entertained.

In the vast majority of cases of low-back pain it is not necessary per-
form a blood examination. Indications for blood tests include suspi-
cion of infection, other inflammatory processes or malignancies. The
type of blood tests required will depend upon information gathered
from the interview and clinical examination. The following blood
tests will be sufficient for initial diagnostic considerations: Hemoglo-
bin (blood percent), white blood cell count, serum creatinine (kidney
function), serum calcium (bones), basic phosphates (bones), and
blood sedentary rates (general sickness indicator). Additionally, it
may be relevant to examine the urine for blood and white blood cell
counts if there is any suspicion of urinary disease. If the above men-
tioned tests are all negative it is highly unlikely that low-back symp-

toms are a result of any inflammatory process or other metastatic
The HTA-group recommend that reference programs includ-
ing guidelines as to what blood tests should be done and in which cir-
cumstances. Superfluous examinations are not only expensive but
they also are associated with promoting illness behaviour and indu-
cing unnecessary fear on the part of patients.
Prices for the individual blood tests cannot be given because
the cost of equipment is far greater than costs associated with car-
rying out individual tests. Therefore, the cost of singular tests is de-
pendent upon the total number of tests that are done. Total costs will
only be reduced minimally if the number of examinations are fewer
and conversely will only increase markedly of the number of tests or-
dered increases dramatically resulting in the purchase of additionally
equipment and the hiring of additional personnel.

◆ In 70-80% of cases it is only possible to arrive at the diagnosis “non-

specific” low-back pain, even after a thorough examination
◆ A diagnosis based on a secure pathoanatomical foundation can only be
made in 20-30% of cases
◆ A diagnosis can only rarely predict the course of the disease
◆ A relevant and comprehensive interview and clinical examination should
always be undertaken during the first consultation with a health profes-
◆ Diagnoses can only in rare situations be arrived upon on the basis of
imaging techniques or blood tests alone
◆ X-ray examinations of the spine should only be undertaken if there is
a suspicion of an inflammatory condition, a fracture, a malignancy, or if
pain continues for more than 4 weeks

How Do We Address the Low-Back
Problem From An Organisational
A considerable increase in the utilisation of both authorised health
care professionals as well as alternative practitioners in the past years
is in all likelihood due to a variety of factors including: Our present
lack of diagnostic capabilities, the unwillingness of individuals to
“accept” pain, and the widespread practice of undocumented treat-
ments. Due to a lack of co-ordination in the authorised health care
system many “services” are repeated. For example, a patient may be
consulting a chiropractor and a physiotherapist at the same time
without any communication between these professionals taking
place. X-rays may be taken at the chiropractic clinic and ordered
from the regional hospital at the same time. This lack of co-ordina-
tion results in inappropriate patient strategies, unnecessary costs, and
the promotion of illness behaviour.


At present, the health care system is composed of primary and
secondary sectors. Figure 4 present the structure of the system as well
as the placement of the different health care professions. In the
Figure, formal referral routes are presented with arrows and informal
referral routes are presented with dotted lines. Patients can be exa-
mined and treated by general practitioners and chiropractors with
support from the National Health Care insurance. Patients receive
financial support from the national health care insurance when being
examined and treated by physiotherapists and specialists, only when
referred by a general practitioner
Treatment at hospitals is also dependent upon a referral from
a general practitioner, a specialist or a physician on call. Two-thirds
of individuals suffering from low-back pain consult their general
practitioners initially and one-third contact a chiropractor (Table 8,
page 24). The selected health professional is responsible for the man-
ner in which the patient is taken care of initially.

The HTA-group is in agreement regarding the following recommen-
dations regarding the organisation of the manner in which low-back
pain should be handled.

◆ Irrespective of whom the patient consults, examination and treatment

strategies should be the same.
◆ Treatment should be carried out in the primary health care sector and
preferably in the region where the patient lives. It is important to avoid
unnecessary waiting times, the promotion of illness behaviour, and
unnecessary costs due to factors such as distance.
◆ Referrals to specialists should not be undertaken prior to comprehensive
assessment and treatment in the primary health care sector.
◆ Referral to a specialist or a hospital department should take place quickly
if there are signs of serious disease or if patients do not improve in spite
of a 4-week trial of recommended treatment in the primary health care
◆ We recommend that as a rule patients not seek care at hospital emer-
gency wards due to acute low-back pain because most acute wards are not
geared to handle this type of problem.
◆ Generally, patients should not be hospitalised due to low-back pain.
Hospitalisation increases the likelihood of promoting illness behaviour
due to patients’ lack of control over the situation. Inactivity is promoted
and costs are high.
◆ In circumstances of serious illness and extremely severe pain, hospitalisa-
tion is of course recommended.
◆ During treatment close co-operation between relevant health care
professionals for example exchanging journals (with patient permission),
x-rays, treatment results and so forth.
◆ Individual patient information is always a central aspect of assessment
and treatment.

In the opinion of the HTA-group, both the formal and informal re-
ferral channels presented in Figure 4 should be upheld. The organi-
sational planning of low-back pain treatment and assessment should
be carried out in accordance with the scope of practice of authorised
health care professionals. This is the only way to minimise the dupli-
cation of services. We have concluded that a more thorough evalua-
tion of the future roles of the differing health professional is not a part
of the HTA-commision.

Present health care sector

Primary health care system

General practitioner Chiropractor
Relaxation therapist
Physiotherapist Specialist Psychologist

Secondary health care sector

Hospital department/outpatient Emergency ward

There are two ports of entry to the public health care system
regarding the treatment of low-back pain; the general practitioner
and the chiropractor. As previously mentioned, two-thirds of patients
contact their general practitioner initially and one-third contacts a
The scope of practice of the general practitioner when dealing
with low-back pain is to make the initial diagnosis and initiate treat-
ment and preventive measures. The general practitioner already has
information regarding previous disease, hospitalisations and so forth
and therefore plays a central role in the public health care system. The
general practitioner is also the referral source to physiotherapists,
specialists and hospital departments as well as being the individual
that does any necessary follow-up work.
The scope of practice of chiropractors includes the diagnosis,
treatment and prevention of biomechanical lesions in patients with
Due to the fact that chiropractors and general practitioners re-
present the most commonly utilised health professions as regards ports
of entry into the public health care system for the treatment of low-
back pain, underscores the importance of increasing communication
regarding mutual patients with low-back pain. These two health pro-
fessions should formalise their communication channels so that rele-
vant patient information can be readily retrieved by each group.
Thorough and individualised patient information regarding
the diagnosis, prognosis, and treatment strategy should always be a
central aspect of all patient consultations for low-back pain.

As previously mentioned acute low-back pain is defined as
pain of less than 3 months duration. Roughly 50% of patients will be
free of symptoms within 3 weeks and 90% within 3 months. Ten per
cent of patients will experience chronic or recurring symptoms. Most
episodes of low-back pain resolve by themselves and only rarely do
chronically disabling symptoms develop. Unnecessary and perhaps
risky treatments can by themselves contribute to maintaining or even
worsening symptoms and promoting illness behaviour.
In order to prevent unnecessary contact to the health care sec-
tor, it is necessary that people are informed about the positive prog-
nosis of most episodes of low-back pain. An important aspect of the
future national strategy regarding the improvement of low-back pain
treatment will be public information campaigns. In the future it will
be important to inform the population about when it is appropriate
to consult the health care system and when it is not necessary. People
need to be informed about the positive prognosis most commonly as-
sociated with low-back pain whether treated or not. The information
must not dramatise the issue but must also include clear guidelines as
to when one should consult a health professional. The HTA-group
recommends that public information include the following:


Many people develop low-back pain.
Important facts to know!
Low-back pain is only rarely a result of a serious illness.
Many people with low-back pain do not need to consult a health
In many cases the low-back pain will resolve within a few days.
It is a good idea to consult a general practitioner or a chiropractor if:
◆ The pain is severe
◆ If the pain prevents you from carrying out your daily activities
for several days
◆ If the pain does not resolve within a few days
If your are experiencing the following symptoms contact your doctor
◆ Low-back pain accompanied with an inability to control bladder
function and a lack of sensation in the groin area.
◆ Low-back pain accompanied by decreased strength in one or
both legs

In the opinion of the HTA-group, patients that consult general prac-
titioners and chiropractors should be examined, observed and treated
according to the guidelines presented below

The suggested course of managing acute low-back pain divided into 2 week modules

First consultation:
Interview and clinical examination and determination if
additional diagnostic measures and treatment are necessary

Evaluation at
Conclude case hospital (1)

2 weeks of treatment
According to needs: Observation or treatment

Status after 2 weeks

Determine wheather to continue treatment,
order additional tests, or refer

If unchanged or
If satisfactory, worsened,
conclude case re-evaluate

Additional 2 weeks of treatment

Status after 4 weeks

If satisfactory omprovement:
Conclude or plan continued care or rehabilitation.
If unchanged or worsened:
Evaluate the need for further examination or refferal

1) If suspicion arises regarding fracture, malignancy, infection, or inflamma-

tory disease (especially arthritic disease): X-ray, blood ( haemoglobin,
sedimentation rate, phosphates, white blood cell count, serum creatinine)
and urine tests for the presence of blood. If there is suspicion of lost blad-
der function or progressive weakness in the lower limbs acute referral to

It is important that the process including examination and treatment
includes goal setting as regards treatment results and that both the
health professional and the patient are conscious of these goals. Treat-
ment results should be evaluated with documented assessment in-
struments. In Denmark the Copenhagen Back Research Association
has developed an widely used evaluation journal and the Danish
DiscBase employs a similar instrument. Examination and treatment
results should be reported to the patient’s general practitioner (con-
ditional upon patient’s agreement) in a readily understandable
fashion, if the patient has been referred. If the patient wishes, this in-
formation should be sent to other health professionals. Suggestions
regarding the future organisation of low-back pain assessment and
treatment should be acted upon.


Chronic low-back pain is defined as pain lasting for more than 3
months. Chronic pain will oftentimes lead to sick-leave and many se-
ries of treatments. Patients suffering from chronic pain (depending
upon the severity of the problem) are a socially threatened group. A
quick and effective examination and treatment strategy must be im-
plemented in order to avoid worsening. Most counties in Denmark
do not have facilities, which can manage these cases.
The most appropriate examination and treatment program for
chronic patients cannot be structured in the same rigid manner as the
case is for acute low-back pain.
An individual strategy must be planned for each patient. X-
rays and blood work will frequently be necessary. Generally, a good
rule to follow is that the magnitude of the examination and treatment
procedures should reflect the magnitude of the problem. In certain
circumstances advice regarding the work place and activation regar-
ding increased physical activity will suffice. In other cases the course
should be addressed in a multi-disciplinary fashion. The latter may
require several months of treatment/observation.

◆ 90% of low-back pain patients will recover spontaneously

◆ Patients should be examined and treated in the primary sector
◆ Treatment strategies should be planned in order to avoid unnecessary
examinations,and if more than one health professional is involved,a high
level of communication must be established
◆ Continued evaluation of the course and individual information is impor-

Summary and suggested areas of focus
Long waiting times for examination and treatment increase the risk
of developing chronic symptoms. Waiting times of more than a week
to consult a health professional or 2-3 weeks to consult a specialist is
unwarranted. Waiting times for surgery (if indications are clear)
should not exceed 2-3 weeks.
The likelihood of returning to work (with an intact work
capability) decreases considerably if disabilities last for more than 1-
3 months. The need of a long-term and costly rehabilitative period
also increases as does the likelihood of developing associated pro-
blems such as stress, anxiety, and depression. Long waiting times also
affect the prognosis of low-back pain negatively because it becomes
increasingly difficult to successfully treat individuals whose status is
affected by these psychosocial factors.
A good opportunity to reduce the number of patients suffering
from chronic disabling low-back pain including the indirect costs due
to loss of ability to work depends upon reducing waiting times for
relevant examinations and treatment.


The HTA-group is of the opinion that co-operation between the dif-
ferent health professionals that deal with low-back pain is unsatisfac-
tory. This has been demonstrated in DIKE’s report from 1995 entit-
led “The Health Care System’s Handling of Back Pain”. According to
our interpretation of the data presented in this report, a continuous
theme in the answers given was the poor communication between dif-
ferent professionals. This is due not only to differing ways of addres-
sing the problem but also to a lack of formalised communication
between health professionals. Possible solutions to this problem have
been discussed in our group. One possibility is the establishment of
“wandering patient files” which go with the patient. This is already
in use with obstetrics patients, a system, which results in all relevant
professionals of being aware of previously undertaken diagnostic
measures and treatment. Common post-graduate courses for physi-
cians, chiropractors and physiotherapists should be expanded in

order to promote a more uniform attitude towards low-back pain
patients and furthermore that commonly utilised terms/classifications
have more common ground than at present. These courses should
also involve other relevant health care groups such as psychologists
and relaxation therapists. The quality of post-graduate education in
both the primary and secondary health care sectors could be enhan-
ced by establishing more professorships and associate professorships.
Special courses for other participants on the low-back issue,
such as social and occupational workers should be upgraded. We
should strive after a situation where decisions made by these indivi-
duals are in as close agreement as possible with the latest scientific
knowledge in the area.
Practice co-ordination must be evaluated and expanded so that
it not only involves private practice and the hospital sector but also
between health professionals and the social and communal sectors.
We suggest that a committee with representatives from all re-
levant health care professionals be established in order to address the
issue of improving inter-professional co-operation and post-graduate


Chronic low-back pain must be understood to be in an existential
“situation” due to the fact that patients may have to learn to live with
a certain degree of pain and disability. Even if the most appropriate
diagnostic and treatment methods are used, it is not always possible
to cure all patient symptoms. In situations such as these, work and
leisure activities must be adjusted in order to maintain as high a level
of “quality of life” as possible, in spite of symptoms.
It is important that patients become activated as early as pos-
sible in their treatment programs. This is most readily achieved with
a thorough information phase. Patients must be made aware of their
own responsibilities and must also be activated to participate in an
active rehabilitation program. This is the best way to maintain their
social position. It may be necessary to repeat information regarding
all aspects of the strategy several times in order for patients to develop
a good insight into the situation. Several health professionals with dif-
ferent backgrounds can be involved in the information phase. Infor-
mation provided should be individualised and based upon the indivi-
dual patient’s situation and needs. The information phase requires
1-2 hours on the part of the health professional depending upon the
magnitude of the problem.

Existing governmental supported programs such as “adult
education” and “spare-time education” should also be utilised for
this purpose.
It is the opinion of the HTA-group that a strengthened indivi-
dualised information effort both in the primary and secondary health
care sectors is an important area, which should be focused upon.
Individualised patient information is so important an area that we
believe that it should be perceived as an independent “service” and
paid for accordingly.

Information to the general public is an area, which needs to receive
more attention in the future. The population needs to be made aware
of our strengths as well as our limitations as regards examination and
treatment. They must be made aware that an episode of low-back
pain is not dangerous and that successful treatment results depend
upon their participation. If chronic pain develops our diagnostic pos-
sibilities become limited, as does the likelihood of curing the patient.
This type of information must be made available to the population at
large. Far too often one witnesses long-term treatment that has not
resulted in a complete cure. Patients become disappointed because of
unrealistic hopes and inadequate information. Public information
campaigns should be planned and carried out with the help of health
professionals as well as experts in communication. Additionally, they
should be repeated several times in order to enhance their effect.


X-rays are very often taken too early in the course of events. X-rays
are also repeated within too short a time frame due to poor commu-
nication between the general practitioner, the chiropractor and the
hospital. This duplication of service is unacceptable also as regards
unnecessary radiation.
Formalised communication channels need to be established in
order to secure that x-rays and their descriptions are always at the
relevant place at the correct time. General agreement needs to be
attained regarding the practical aspects of taking x-rays as well.
The only way to avoid unnecessary exposures and to increase
the quality of x-rays is to develop guidelines for the taking of x-rays
and to develop formalised lines of communication between heath
professionals. Guidelines should be developed by the relevant profes-
sional societies as soon as possible.

Many patients are hospitalised due to low-back pain (Table 4, page
??). It has never been proven that patients benefit from hospitalisa-
tion. Hospitalisation is only indicated under certain conditions.
As previously stated, a precise diagnosis cannot always be
made. Hospitalisation can result in differing and confusing informa-
tion being given to the patient due to his/her coming in contact with
so many different people. Additionally, patients are prone to place the
entire responsibility for their conditions on the hospital staff, which
may lead to increased passiveness and illness behaviour.
The great majority of acute and chronic patients can be exa-
mined without the patient being hospitalised. Preconditions for suc-
cessful outpatient examinations are; that centres have multi-discipli-
nary teams, that only a few people are involved with a patient and
that time is taken to give the patient comprehensive and individua-
lised information.
Multi-disciplinary teams with the resources to carry out high
quality outpatient examinations and treatment should be established
in several areas throughout the country. Treatment of severely pained
patients as well as chronically disabled patients can be carried out at
these centres in order to reduce the number of patients that become


The development of a systematic registration of treatment results
through clinical databases has only recently begun. An example of this
effort is the Danish Disc Base, which is a nation-wide registration of
the clinical results obtained from disc herniation operations. This
effort will be completed within 1-2 years and the information gathe-
red from it will contribute to improving the future treatment of disc
herniations. Other examples of central registration of treatment
results include the database developed by the Copenhagen Back Rese-
arch Association (COBRA). It is extremely important that projects
such as these continue both in the primary and secondary health sec-
tors and that adequate funding is made available. These databases
should utilise validated outcome measurements that are comparable.
This is the only way in which we can develop a picture of the overall
treatment effort/results.
The registration of patient data in clinical databases should
become standard procedure for every health professional. The results
obtained from these databases will form the bases of reference pro-

grams. These reference programs will insure professional development
based upon factual evidence.
We should insure that the development of these clinical data-
bases is undertaken with the participation of all relevant health pro-
fessional associations and that funds are provided for this work. Inter-
disciplinary work groups should also be established.

Many issues relating to the diagnosis and treatment of low-back pain
have not been resolved. There is great need to carry out a large num-
ber of controlled trials in order to enhance our knowledge.
Formalised post-graduate education and courses should be
emphasised in order to insure that patients are treated in accordance
with the newest knowledge in the area. Courses, which emphasise the
latest knowledge regarding the diagnosis and treatment of low-back
pain patients, should be carried out by all health professional associ-
ations. Increased inter-disciplinary course activity should also be
promoted actively.
We must insure that specialists in rheumatology continue to
participate in the professional arena of low-back pain. The education
of these specialists should not be limited to “rare” cases as has been
the case in the last decade. Specialist education should be planned so
that “ordinary” low-back patients are seen regularly as well.


Our knowledge regarding the documentation of how specific and
clear diagnoses are arrived upon as well as which treatments are most
effective for specific conditions and when these treatments should be
administered is lacking. We also lack information about how patients
are treated presently in the public health sector as well as whether the
results obtained are superior to the natural course of events. How
many x-rays are taken? How many injections are given? Do these
treatments help? The lack knowledge in this area has limited our
HTA-group from arriving at clear recommendations involving eco-
nomic issues. In the future it will be necessary to have concrete infor-
mation about all of the abovementioned issues in clinical databases.
This information need not take the form of randomised clini-
cal trials. The code words in these activities include: systematic regi-
stration, prospective observational studies, clinical databases, refe-
rence programs and economic planning. The HTA-groups suggests
that, in addition to establishing data bases and increasing scientific

work, the mapping out of observational data which describe what
happens to the average person when patients experience a bout of
low-back pain be undertaken. Is there a difference in the treatment
given within the same health profession? Are there geographical
differences? Does treatment help? Is the likelihood of developing
chronic symptoms reduced? Why does treatment seemingly help for
some people but not for others?
What are the costs involved in each treatment? The answers to
these questions and others will make it possible to determine the most
appropriate treatment courses and this information will form the
framework for future reference programs.


A will to confront these issues needs to be demonstrated at the
highest levels. The re-distribution of resources should not end up
resulting in simple money saving acts such as reducing the number of
available hospital beds for low-back patients. The re-distribution of
resources should instead channel resources to the areas outlined in
this manuscript. This is necessary in order to effectuate a practical
The project will be made complex by the fact that so many dif-
ferent health professions are involved. This will entail considerable
changes in the different health disciplines as well as increased co-
ordination between the different groups.
Future public health fee schedules should reward the “infor-
mation” phase of any treatment as an independent service. This is the
most effective way to secure the needed emphasis of this important
aspect of treatment.
In the opinion of the HTA-group present fee schedules reward
“treatment”. Increased research will document which treatment acti-
vities are useful and which ones are not. Future professional fee sche-
dules can be determined according to scientific merit and can therefore
serve as a regulatory method to enhance the quality of care provided

◆ Reduce waiting times for relevant examination

◆ Increase the level of information for both the individual patient and for
the population at large
◆ Develop effective channels of communication between health professionals
◆ Establish more multi-disciplinary treatment centres
◆ Develop databases which systematically register examination and treat-
ment procedures
◆ Strengthen research and education
Low-Back Pain
Volume 2

The various Danish health professions
that treat patients with “low-back pain”
There are in Denmark several different health providers, both autho-
rised and unauthorised, which traditionally examine and treat pati-
ents with low-back pain.

The general practitioner (specialist in general medicine) in the primary

health sector
In the Danish health care system the general practitioner has always
played a central role in the treatment of an individual’s illness. The
general practitioner has all relevant information regarding previous
illnesses as well as reports from hospital treatments. Due to the central
role that the general practitioner plays in the health care system he/she
is in a position to prevent “double” examinations and treatment regi-
mens. Information regarding examinations and treatment results
should be forwarded to the general practitioner if the patient so wis-
hes. The general practitioner can, in addition to examining a low-back
patient provide information/advice and initiate treatment such as pain
relieving medication or exercise therapy. Preventive treatment and
social service can also be initiated. Many physicians use or have know-
ledge of manual treatment. The general practitioner can also refer
patients for additional examinations or treatment to a physiotherapist,
a specialist, or a hospital department. Furthermore, the general prac-
titioner can recommend the patient to seek a chiropractor.

The chiropractor in the primary health care sector

The scope of practice of a chiropractor includes the diagnosis, treat-
ment and prevention of biomechanical functional lesions for patients
suffering from low-back pain. Chiropractors received their public
authorisation in 1992 and can examine and treat low-back patients
independently. Due to their educational background chiropractors
have special skills in performing manual therapy including spinal
manipulative therapy. Patients receive reimbursement from the health
care system when receiving chiropractic care whether or not a physi-
cian has referred them. In addition to manual treatment the most im-

portant treatment elements utilised by chiropractors include infor-
mation/advice, exercise instruction and intensive training. Soft tissue
treatment is also used but is not a mainstay of treatment. If the
chiropractor finds consideration for it, the patient is recommended to
see the general practitioner.

The physiotherapist in the primary health care sector

Physiotherapists are authorised by the health authorities and upon re-
ferral from a physician can treat low-back pain patients in conjunction
with the general practitioner or hospital physician. In addition they
carry out follow-up status reports of patients and evaluate whether
further treatment should be carried out. Patients receive reimburse-
ment from the health care system. Physiotherapists inform patients
about the illness and prognosis and can advise/inform patients regar-
ding preventive measures. The physiotherapist carries out functional
examinations, designs training programs and instructs in exercise the-
rapy. Physiotherapists oftentimes carry out manual treatment particu-
larly mobilisation and supplemental soft tissue treatment. Some phy-
siotherapists use spinal manipulation.

The specialist in the primary health care sector

Different medical specialists in the primary health care sector evalu-
ate patients with low-back pain. The medical specialities, which pri-
marily undertake examinations and evaluations of low-back patients,
are rheumatologists and orthopaedic surgeons. Patients who have not
experienced relief of symptoms after treatment at a general practi-
tioner, physiotherapist, or chiropractor or certain patients suffering
from acute or chronic low-back pain should be referred to specialists
for further evaluation such as CT-scans – refer to Low-Back Pain
Volume 1. Specialists also provide individual information/advice, pre-
scribe exercise, and effectuate manual treatments. Advice on preven-
tive measures is also undertaken.

Psychological evaluation and advice undertaken by authorised pro-
fessionals can be relevant in certain cases. It is not customary that
patients consulting psychologists because of low-back pain receive
reimbursement from the health authorities.

Unauthorised health care provider in the primary health care sector

Traditionally, other health care providers treat patients with low-

back pain in the primary health care sector. The relaxation therapist
can carry out individual treatment regimens in private practice or in
group sessions. Group sessions can be carried out under the “law of
public information” at evening school sessions. Treatment at relaxa-
tion therapists involves manual treatment of the musculature, mobi-
lisation and training. The individual treatment is based upon an ana-
lysis of the body at rest and in movement as well as the patient’s
psychological and social situation. Information and instruction are
integral parts of the treatment regimen.
Other forms of training/gymnastics (for example Mensendeck)
are provided by unauthorised individuals, as is alternative treatment
such as acupuncture, zone therapy and dietary advice.

Other players in the primary health sector care

Social workers employed by the local municipality and the Workman
Compensation Board are important players regarding the low-back
pain issue in the primary health sector. They co-operate with health
care professionals particularly in assisting with patients’ maintaining
their connection to the job market in periods of long-term sick leave.
Other important areas include participation in the determination of
the degree of work disabilities, accident and work-related compensa-
tion and/or disability pensions. Case management should be carried
out in close co-operation with health professionals and only after
medical evaluations and reports have been retrieved. The Work En-
vironment Institute participates in the preventive and advisory work
areas at individual work places, and insurance companies play an
important role when accidents have taken place.

Hospital ambulatory/departments
In certain situations, a general practitioner or a specialist will refer
patients to a hospital department where several different medical spe-
cialities may be involved in the evaluation of a patient. This may
include rheumatologists, neurosurgeons, orthopaedic surgeons, neu-
rologists, or radiologists. Referrals to hospital departments are most
commonly due to a request for imaging studies such as CT or MRI-
scans. Other reasons for referral may be for special treatment forms
such as rehabilitation or spinal surgery. Hospitalisation in order to
provide relief from daily activities can be necessary in special cases
such as when patients cannot take care of themselves at home.

The treatment of low-back pain patients should to the degree that it
is possible be carried out in the primary health care sector and prefe-
rably in the area where the patient lives. This will limit unnecessary
illness behaviour and resource waste. Health professionals in the
primary health care sector should co-operate in a close fashion for
example, by exchanging journal information, x-rays and treatment
Treatment regimens should be the same regardless of whether
a patient consults a general practitioner or a chiropractor. The infor-
mation given to patients should also be the same regardless of who
evaluates, informs and advises the patient.
In order to insure the fulfilment of these goals and treatment
quality it is necessary to develop inter-disciplinary “low-back pain”
reference programs and quality control systems in the form of nation-
wide databases. These quality control instruments must become a
part of daily procedures in the primary health care sector.
Patients should only be referred to the secondary health care
sector in certain situations. The examination and treatment strategy
design in the secondary health care sector is multi-disciplinary and
should be carried out in an ambulatory fashion as far as possible. Spe-
cial diagnostic examinations such as CT or MRI-scans should be
carried out in close co-operation between the primary and secondary
health care sectors in accordance with an overall priority plan.
Results of x-rays and scanning reports should be provided in a man-
ner such that relevant information follows the patients throughout
the treatment sector. More detailed information is provided in Low-
back Pain, Volume 1.
A smooth and well functioning treatment system is dependent
upon all health professionals being aware of the educational back-
ground and professional capabilities of all other authorised health
professionals. Inter-disciplinary and inter-sector courses and profes-
sional development should be strengthened. These courses should
also include representatives of the social services. There is also a great
need of an increased research in both the primary and secondary
health care sectors in order to among other things to record the
content and results of the treatment regimens that are carried out on
low-back patients in the present as well as the future.

The LPB-group’s analytical method
Our analyses are based upon a systematic review of material, which
was made up of systematically chosen elements which when combi-
ned represent the HTA evaluation of the singularly analysed techno-
logy. The blueprint includes the following:

The area of utilisation
What is the indication for its usage?
Is there agreement regarding the indication?
How many patients are involved?
What are the relevant alternatives?
Alternatives or supplements?
What documentation is there for its effectiveness?
Is it more effective than other technologies?
Is it as effective in our population?
Risk evaluation
Are there side effects?
Are the potential side-effects reasonable compared to the potential clinical

Psychological status
Does the technology result in comfort, discomfort or anxiety?
Social effects
Are daily activities effected?
Is the ability to work effected?
Ethical aspects
Is the patient willing to accept the technology?
Is it acceptable for society?

Should the technology be located at a few centres?
Is decentralisation possible?
Is the work distribution between hospitals and the primary health care
sector altered?
Are new special functions required?
Are visitation criteria altered?
Are work routines altered?
Will the work distribution of different health professionals change?
Will it require additional educational for health care personnel?
Are there opportunities for employment?
Will the external environment be effected negatively?
Is there a risk of a negative effect on the work environment?

Direct costs
What are the direct costs associated with the program, including: side
effects, operations, nursing help at home, transportation, or medicine?
Indirect costs
What are the indirect costs associated with the program such as sick leave
and loss of productivity?
Direct savings
What are the direct savings associated with the clinical effect of the
Indirect savings
What indirect savings will result from the implementation of the program?

We have assessed the division between the state, county, municipality,

patient and others regarding all of the above mentioned savings/
The blueprint was used by the panel as a “reminder sheet”. In
several situations we did not use all of the individual elements of the
blueprint because it would have been irrelevant.
In a few circumstances it was impossible to evaluate the
technology in all aspects because we could not find the necessary

information. It was impossible, for example, to determine how often
every technology is used in Denmark because there is no systematic
registration of this type of data.
Generally, the blueprint was a great help to the panel and it
contributed to the systematic evaluation of the technologies.

In order to assure that our evaluation process was systematic we
developed a scale for the purpose of ranking each item.

1. Firstly, the quality of the scientific foundation for the usage of each
technology was evaluated (with guidance from the international HTA-
2. Then we estimated the expected costs for the individual technology.
3. Finally, the group arrived at a recommendation of either suggesting
or not suggesting the usage of the individual technology.


◆ The recommendations, which follow, are based upon scientific documen-
tation and are ranked on a four-point scale. The reader should be aware
that a recommendation regarding a singular technology could either be
positive or negative as regards its usage. Scientific studies can sometimes
support the usage of a particular technology and in other situations
recommend that they are not used.

The commentary’s weight, Strength A
Strong research based documentation, such that there are many relevant
high quality studies, which support the value of a particular technology.
The commentary’s weight, Strength B
Moderate research based documentation such that there is at least one
relevant high quality study or several medium quality studies, which
support the usefulness of a particular technology.
The commentary’s weight, Strength C
Limited research based documentation such that there is at least one
relevant medium quality study, which support the usefulness of a parti-
cular technology.
The commentary’s weight, Strength D
There is no research-based documentation,which supports the usefulness
of a particular technology

The next process involved direct cost calculations regarding each individual

Simple treatment or exercise, which can be carried out by the patient them-
selves. This type of treatment can as a rule be carried out at home or at work
and does not involve expensive equipment or professional help.

An ambulatory treatment which is carried out at a hospital or at a health
professional in private practice. This type of treatment is not very costly

A treatment that requires hospitalisation. This type of treatment is expensive.

The LBP-group concludes each treatment evaluation with one of the
following recommendations: “Recommended” / “recommended for
certain conditions” / “not recommended”. The numbers given are
2,1,or 0 spines

We wish to emphasise that even if a technology has received 2 spines

we do not mean that it should be used in all circumstances. No treat-
ments are relevant in all situations. That is why we have supplemen-
ted each recommendation with additional commentary. An example
of this commentary would, for example, be that a particular treat-
ment should only be used with certain diagnoses, for a limited period
of time, or in combination with other treatments.

The scale, which represents our recommendations, will appear as

RECOMMENDED (Symbolised with 2 spines)


NOT RECOMMENDED (Symbolised with 0 spines)

As previously stated, the LBP-group will, in addition to providing the

evaluations of “recommended” or “recommended for certain condi-
tions,” provide explanatory commentary, so that additional clarifica-
tion will be presented.
Mostly the reason for a method being “not recommended” is
that there is insufficient documentation for a positive effect in relation
to the resources used for the method. In other cases the treatment can
not be recommended, because there is good evidence for the method
being of no effect. Only in few cases have the LBP-group evaluated
treatments as “not recommended” on the basis of documented evi-
dence for direct harmful effects. In these few cases it will clearly be
noted in the text, that these methods of treatment should not be used.

Ninety percent of patients will recover spontaneously within 12
weeks after experiencing a first-time episode of low-back pain. Fifty
percent will recover within three weeks. The typical course of acute
low-back pain results in a spontaneous recovery for 60-80% of
patients irrespective of treatment. It is precisely this factor, which
necessitate stringent methodological needs in the design of scientific
studies in determining the clinical effect of different treatments.
There are also other methodological difficulties involved in the
design of scientific studies dealing with “low-back pain”.

◆ It is difficult to arrive at a clear diagnostic classification for patients

because the pathoanatomical basis for most diagnoses is questionable.
◆ It is difficult to describe the content of the “tested” treatment because
treatments are often individualised and reflect physical findings.
◆ Studies are designed to evaluate the general effect of a treatment on
a large sample population. In reality the treatment involved may be
effective, indeed very effective for a sub-population of the large patient
sample. This effect may not be “discovered” in the total population
sample. This may be due to the type of research design, or due to the
possibility that the treatment in question is not effective in the remain-
der of the population sample or may in fact be harmful for them.
◆ The ideal “blinding” of the study group vs. health professional can be
difficult to attain.

These factors can individually or in combination with one another

result in it being difficult to carry out a reliable scientific study and
make it difficult to interpret previously carried out studies.


One of the greatest errors in the treatment of low-back pain in this
century has been the unquestioned usage of passive treatments, often-
times initiated when spontaneous recovery has already begun. Passive
treatment runs the inherent risk of promoting passive behaviour

(illness behaviour) and thereby prolonging the course of illness. This
situation may lead to chronicity. Patients bear a degree of responsi-
bility for the overuse of passive care because they have oftentimes
requested or demanded it due to comforting factors. This however,
does not excuse health professionals for their inappropriate choice of
Results of clinical research from the past ten years have clearly
documented that pro-active treatment for both acute and chronic
patients represent the most important factor for the continued effect
of treatment. Patients have to be motivated to participate in active
care if it is to be successful. This is most readily achieved if patients
have been provided with comprehensive information regarding the
diagnosis, prognosis and treatment principles.

Prior to determining the treatment strategy, it is necessary to under-
take an overall evaluation of the patient’s condition. How great is the
problem? How high is the level of pain intensity? Can the patient
manage their work? How has the condition affected the individual’s
ability to manage daily activities? How long has the condition been
present- acute, chronic? The total treatment strategy should be plan-
ned in accordance with the answers to the previous questions. The
total amount of treatment should reflect the magnitude and duration
of the presenting problem.
The ordinary first-time episode of low-back pain will usually
resolve within a few days and besides advice regarding general life-
style and physical fitness, treatment is not usually necessary.
A patient with a chronic condition – perhaps disabling – needs
a more complex treatment strategy often made up of several ele-
ments. It is important to be aware of the multi-factorial nature of
low-back pain. A simple uni-dimensional treatment is rarely suffi-
cient. The goal is therefore to design a treatment strategy that is indi-
vidualised and addresses the differing areas of the problem.

The low-back pain patient has a need of comprehensive information
regarding possible pathological mechanisms as well as the diagnostic
possibilities or the lack thereof. Furthermore, the frequently benign
nature of most episodes of low-back pain should be underscored. The
chosen treatment strategy should also be discussed thoroughly. Prior

to beginning treatment patients should be made aware of goals re-
garding pain relief, improved functional levels, work and so forth.
The duration of treatment as well as eventual risks should also be
Treatment strategies for chronic pain patients necessitate the
active involvement of both the health professional and the patient as
well as co-operation between them. It is important to inform the
patient that there are no miracle cures and that success is dependent
upon sincere participation on the part of the patient. A conversation
with the patient regarding these central principles of illness and treat-
ment cannot be completed in less that 20 minutes. It is often impor-
tant to carry out another information session 2-4 weeks into treat-
ment in order to repeat the most important aspects of the treatment
The following statements include the most important facts
about “low-back pain” – as we know them.

◆ It is not usually dangerous to experience low-back pain and work will only
rarely worsen the condition.
◆ It is almost always best to continue going to work even of there is pain
◆ Long-term sick-leave will not improve the condition – on the contrary,
the risk of never returning to work only increases.


The most commonly used treatments for low-back pain will be
addressed. We begin with the treatments that can be recommended
and follow with those that cannot be recommended. Treatments are
listed in alphabetical order within each category.

Treatments which can generally
be recommended


Manual therapy can be broadly defined as all procedures where the
health professional uses his/her hands in order to influence a joint
complex as well as the surrounding tissues. Treatment is given in
order to relieve pain and improve function.
The procedures include manipulation and mobilisation, but
also related techniques such as manual traction, myofascial release,
and muscle energy techniques. With manipulation a motion segment
of the spine is pushed beyond its normal passive range of movement
by means of a thrust.
This treatment is often combined with other methods such as
soft tissue treatment and medication in the case of acute pain or ex-
ercise in the case of chronic pain.

There are a series of factors, which contraindicate manual treatment
in certain conditions. Conditions in which the symptoms are a result
of cancer, inflammation, infection, or when the patient is suffering
from serious and/or progressive nerve root irritation are examples
of this. In situations where the low-back pain is determined to be of
functional origin but where structural weakness of the bones or joints
as seen for example with severe degeneration, osteoporosis or joint
displacement, treatment should be appropriately modified.

- It is not possible to predict which individuals will benefit from
manual treatment (B).
- In addition to pain treatment indication is supported by the clinical
observation of functional disturbances of the motion segments of
the low-back or the joints of the pelvis (D).

- Manual treatment has been investigated in a multitude of clinical
studies and there is evidence that acute low-back pain episodes can
be shortened with manual treatment (B).
- There is evidence that manual treatment has a short-term effect on
chronic low-back pain, but the literature is inconclusive about long-
term benefits. At present there is no evidence of the utility of conti-
nued manual treatment (B).
- There is limited evidence of a positive treatment effect with patients
suffering from nerve root irritation (C).

Risk evaluation
Manual treatment is generally a very safe treatment when relevant
contraindications are addressed. Approximately 25% of patients ex-
perience short-lived tenderness in the treated area. Serious complica-
tions are considered to be rare. The development of cauda equina
syndrome (nerve root pressure with bladder function impairment)
has been described.


Treatment is primarily administrated in the primary health care sector and is


Manual treatment can be recommended for patients suffering from acute low-
back symptoms and functional limitations of more than 2-3 days duration.

Manual treatment can be recommended as an initial treatment for acute exa-
cerbations of recurrent or chronic low-back pain and functional limitation .

Manual treatment can be considered as an element of a broader strategy for
chronic low-back trouble.


Manual treatment can be considered as an element of a conservative
treatment regime in patients suffering from nerve root irritation taking into
account the previously mentioned contraindications.


The term “back school” implies providing information about the
anatomy and function of the spine as well as advice on activities re-
garding prevention and self-treatment. Teaching is carried out in
group sessions. It is common to include instruction and practical gu-
idance for exercise during back school sessions. The total duration of
the back school is approximately 4-6 hours. Oftentimes the theoreti-
cal instruction is an integrated element of a comprehensive course of
back rehabilitation, which also includes exercise programs. The inte-
grated rehabilitation program is usually of 15-30 hours duration,
spread over weeks to months. Back school programs are usually led
by physiotherapists, ergotherapists and relaxation therapists.
The traditional back school has been evaluated in several rand-
omised trials. The philosophy was guided by “be careful” messages,
such as; sit correctly, lift correctly, avoid forward bending, and so
forth. In a modern back school the emphasis is to avoid fear, and the
philosophy is to “ignore the pain as much as possible”. This change
in attitude has resulted in improved preventive results

- There are several scientific studies, which have not demonstrated
any short or long-term effects from the “traditional back school”
with low-back pain patients (B).
- A “modern back school” where teaching has focused upon “igno-

ring the pain as much as possible” has demonstrated a preventive
effect with patients suffering from low-back pain (B).
- Back school should include physical activity and promote attitudes
which work against the development of chronic disabilities rather
than “be careful messages” (B).
- Several scientific studies assessing prevention at the workplace have
shown a reduction in sick leave due to low-back pain (B).
- Patients with a well-defined need of rehabilitation such as post-ope-
rative disc herniation patients demonstrate a reduced likelihood of
developing chronic symptoms after participating in back school/
rehabilitation programs (C).
- As regards lifting technique: Objects should be lifted while “ben-
ding at the knees” as opposed to bending the spine forwards if the
weight is more than 10-12 kilograms. Relatively few lifts of light
objects during the course of a days work will in all likelihood not
increase the risk of injuring the spine and therefore do not require
special precautions. However, repeated lifting during the day – light
or heavy objects – necessitates specific ergonomic instruction (D).
- As regards the ergonomics of sitting: Uncomfortable furniture
should obviously be exchanged in order to achieve a more comfor-
table sitting posture. It is important that individuals have the
opportunity to “test” different types of furniture prior to purchase
because factors reflecting sitting comfort and table height may be
individual (C).
- Other areas of ergonomics not relating to sitting and lifting, such as
the psychological environment of the workplace, have not been
thoroughly investigated in a scientific manner and recommenda-
tions must therefore be guarded (D).


Ambulatory treatment.

Purchase of teaching aides/ergonomic materials.
(From low costs to hign costs depending upon the type of course).


Both the modern back school and group training can be recommended for
patients with low-back trouble if there is a clear need of rehabilitation,or when
preventive efforts are being considered at work places where work tasks can
be challenging for the low-back.


Individual ergonomic instruction – such as advice regarding sitting comfort
and lifting conditions can be considered especially if repetitive lifting can be


Pain relieving medication is sold “over the counter” (without pre-
scription) (for example paracetamol) or with a prescription if a
higher dosage is required such as NSAID (non-steroid anti-inflam-
matory medication = pain relieving arthritic tablets).
Stronger pain relieving medication such as morphine deriva-
tives can also be utilised.

- Several studies have documented the effect of paracetamol, NSAID
and stronger analgesics for the relief of acute low-back pain (B). It
has not been determined whether paracetamol or NSAID is more
effective (C).
- There are no studies, which document an enhanced clinical effect of
morphine derivatives compared to either paracetamol or NSAID (C).
- There are no studies, which document any long-term effect of pain
relieving medication for chronic low-back pain (C).
- There are no studies which document that utilising several medica-
tions at the same time results in additional benefit (C), however, the
risk of side-effects generally increases with the utilisation of several
drugs (B).

- Several studies have shown that a singular medication may result in
a varying effect upon differing individuals (B).
- There is a risk of both physical and psychological dependence when
using morphine derivatives after as short a time as a few weeks (B).




Evaluate if there is in fact a need of pain relieving medication. If there is use
a stepladder approach. Increase the dosage after 1-2 days if there is a lack of
effect from the initial medication .

First step
◆ Paracetamol up to full dosage
If there is a lack of effect, go to the next level:
◆ NSAID up to full dosage
If there is a lack of effect, go to the next level:
◆ A combination of paracetamol and NSAID
If there is a lack of effect, go to the next level:
◆ Tramadol or codeine in conjunction or as a monotherapy (evaluate indivi-
dually). There may be CAVE obstipation from codeine

Individual considerations must be taken into account when using

paracetamol and NSAID. Patients rarely experience benefit of pain
relieving medication for more than a month or so (1-3 months).
Stronger medication (morphine derivative) should only be pre-
scribed for relatively short periods of time (max. 1-2 weeks). These
medications should only be used in periods of severe acute pain, after
surgery, or if the abovementioned principles have been ineffective.
If patients have sleeping difficulties, sleeping pills in addition to
pain relieving medication can be used for a short period of time.
Muscle relaxants such as Diazepam have no place in the treat-
ment of low-back pain. The possible clinical benefit is overshadowed

by the risk of physical and psychological dependency even after short
periods of usage.


Technology as a form of treatment

The background for this exercise program is that movements in the
low-back can either increase or decrease patient symptoms. The the-
rapist can guide patients as they repeat certain movements until they
find the movement which either reduces symptoms or centralizes
them (distal pain moves centrally toward the vertebral column). Pro-
grams are designed according to the “preferred” movements and
patients are instructed to carry out their individual programs up to
several times per day.
There are several studies, which have investigated the McKen-
zie method, but most of them are methodologically weak.
There is little risk of side effects for patients, and an advantage
of these exercises is that patients assume responsibility for carrying
out their treatment and are therefore activated.

There are a few studies, which show a positive clinical effect with
patients suffering from acute low-back pain (with or without radia-
ting symptoms) (C).
A few studies indicate a positive clinical effect with patients
suffering from chronic low-back pain (with or without radiating
symptoms) (C).


Home treatment.

Ambulatory treatment.



McKenzie exercises can be considered as a treatment method for both acute
and chronic low-back pain.

The McKenzie Technology as a diagnostic method

When patients repeat a specific movement the preferred type of
movement can be determined. This is therefore a useful diagnostic
instrument for low-back patients in which the pain source is one or
more discs in the low-back.

- Several studies indicate that the method has value as both a dia-
gnostic tool and a prognostic indicator (+/- discogenic pain) (B).


Home treatment.


This technique can be recommended as a diagnostic method for both acute
and chronic pain syndromes.


The therapy consists of a series of specific movements with the goal
of increasing muscle strength, improving joint movement and body

co-ordination by carrying out a systematic training program. The
expectation is that the exercise therapy/fitness will improve move-
ment restrictions, improve functional levels and reduce pain. Exercise
therapy/fitness can be particularly effective in increasing tolerance for
physical activity and illness behaviour in chronic low-back pain

Documentation for the usage of the technology with acute low-back

pain patients
- There is no evidence that specific exercises introduced in the acute
phase of low-back pain will shorten the duration of the episode.
Patients that are encouraged to remain as active as possible during
the acute phase seem to do better that those patients performing a
series of specific exercises. There are only a few studies in the lite-
rature which deal with this issue (C).
- It is important that patients maintain or improve their physical con-
dition through training after the acute pain has resolved (B).

Documentation for the usage of the technology with sub-acute low-

back pain patients (from 6 weeks to 3 months)
- There are studies, which indicate that back exercises of certain in-
tensity – according to therapeutic instruction- should begin after
6 weeks of continued low-back pain and reduced mobility (B).

Documentation for the usage of the technology with chronic low-

back pain patients
- Several studies document that a high dosage exercise (twice a week
for a period of 2-3 months) is an effective treatment for chronic
low-back pain (B).
- Patients with chronic low-back pain who have psychological pro-
blems and are at risk for losing their contact to the work force can
in certain situations have additional benefit from a combination of
training/ergonomic instruction/psychological intervention (D).


Home exercises.

Ambulatory treatment.


The treatment can be recommended for patients suffering from low-back pain
for 6 weeks or more.


Can be considered as a preventive effort for patients who have experienced
several episodes of low-back pain.

Treatment methods that can be
recommended in certain conditions

The term injections is meant to include the injection of liquid or acu-
puncture needling -dry needling- in soft tissues for example in “trig-
ger points” = special pain centers (muscles), ligaments, fascia, bursae,
in joints, near nerve tissue for example in a joint cavity, or an epidu-
ral injection in the spinal canal.
Injection treatment can be carried out in order to provide
relief or as a diagnostic measure. Relief of pain may provide evidence
that the site of injection was in fact the source of pain.

Treatment can involve/use any of the following:

a. Dry needling/acupuncture
b. Hypertonic salt water
c. Anaesthesia (local anaesthetic)
d. Steroids
f. Phenol
g. Combinations of b,c,or d.

The most common combination is an anaesthetic + steroid usually in

a combined volume of 5-10 ml.
Usually a single injection is performed but there may be a need
of 1-2 repetitions during the course of a month. The total number of
injections should not exceed 3. The time interval between injections
is dependent upon the liquid injected as well as the volume. Acupunc-
ture can be performed by unauthorised health workers provided that
it is done under medical supervision.

Occasionally (less than 1 out of 10,000) a serious complication can
take place in the form of a local infection around the area of the
injection. The risk of infection depends upon the content of the
Repeated injections with steroids involve a risk of serious
systematic side effects.
Injection with phenol is not recommended due to the fact that
permanent damage to the skin and connective tissue in the area of
injection may take place.
Repeated injections increase the risk of passivity and illness
behaviour on the part of the patient and we therefore recommend
extreme caution. Due to this we advise that injection treatment be
combined with patient activating strategies.


- There is limited and non-conclusive research based documentation
regarding the diagnostic or clinical value of injections for acute low-
back pain (C).
- There is limited research based documentation for either the dia-
gnostic value or short-term clinical effect with chronic low-back
pain and no documentation of long-term effects (C).





Facet joint injections cannot be recommended as a treatment but they may
be considered as a diagnostic procedure in certain situations.


- There is only limited scientific evidence of any clinical effect regar-
ding acute or chronic low-back trouble (C).
- There is no documentation of any clinical effect of injecting the
sacroiliac joints, but there is some documentation for the utility of
this method as a diagnostic tool (C).


The treatment is carried out in an ambulatory manner at hospitals with
imaging guidance.



Facet joint injections cannot be recommended as a treatment but they may
be considered as a diagnostic procedure in certain situations.


- There is limited research based evidence that steroid injections with
or without local anaesthetic have a pain relieving effect for
weeks/months with acute low-back pain patients with radicular
symptoms (C).
- There is no evidence of any clinical effect with acute low-back
patients without radiating symptoms or with chronic low-back
pain patients (D).
There is evidence of a risk of rare but serious complications from
injections (A).






- There is a limited amount of research based evidence for a short-
term pain relieving effect with acute or chronic low-back pain
patients but no evidence of any long-term effect (C).




We do not recommend that acupuncture be used for low-back pain patients
because the possible clinical benefits do not outweigh the costs and eventual


Soft tissue treatment, which increases blood circulation or decreases

- There are a few studies, which demonstrate a short-term pain
relieving effect but no long-term effects (B).


Home treatment.

Ambulatory treatment .



We do not recommend this treatment generally but it can be considered for
pain relief for localised muscle pain or for initial pain relief/relaxation prior to
using other documented treatment methods such as manipulation, exercise
therapy and so forth.


The technology
There are several different operative methods as well as operation
types for differing conditions in the back. In the text that follows ope-
ration types are grouped into three main categories. This report will
not deal with all of the different operative methods involved for
example in treating fractures or different anomalies of the spine such
as scoliosis:

A: Operation or re-operation for a disc herniation.

B: Operation for spinal stenosis (narrowing of the spinal canal).
C: Operation for spinal instability.

There can of course be situations where a combination of the above

mentioned procedures or indeed all of them may be involved. Ope-
rations are rarely performed purely on the basis of low-back pain but
more often due to low-back pain with radiations to the leg or legs.
Dominant leg pain will more frequently result in surgical intervention
than low-back pain alone. There is a lack of prospective controlled
clinical trials for all of the procedures mentioned.
Both neurosurgeons and orthopaedic surgeons perform the
above mentioned operations. Local and regional organisational fac-
tors determine which medical departments perform the different
procedures described. The important developments in spinal surgery
necessitate that both of the medical specialities involved need to
co-ordinate their activities to a greater degree so that patient selection
and chosen operative techniques in all regions are conducted accor-
ding to a common consensus.
The total number of surgeries (A, B, & C) performed in Den-
mark number approximately 4,000 per year.

Disc herniation
The technique used for performing first-time or repeat surgery for
disc herniations is well known and requires low-tech equipment. The
procedure is carried out by means of a partial laminectomy (hemila-
minectomy). A small amount of bone tissue is removed and the ex-
posed nuclear and disc tissue is removed. A repeat surgery is essen-
tially the same procedure but more bone tissue is removed prior to
removing scar tissue.

First-time surgeries are not usually performed before conservative
therapy has been attempted for 4-6 weeks. In addition there has to be
a positive correlation between clinical findings and imaging reports.
Subacute operations may be performed if a patient is experiencing
progressive weakness in the leg during the course of a few days or if
the pain is extremely severe in spite of medication.
Acute operations (within hours or days) are carried out if there
are signs of cauda equina syndrome.

Three thousand operations of this type are performed per year. In the
counties that have departments of neurosurgery operations are pri-
marily carried out at these departments. However, these procedures
are also carried out at orthopaedic departments particularly in coun-
ties in which there are no neurosurgery departments.
In addition to the described operation technique other tech-
niques such as microsurgery (involving a microscope) may be used.
This type of surgery has not demonstrated shorter post-operative
hospitalisation stays. It seems as though microsurgery results in a
greater number of relapses.

- There are many relevant but uncontrolled studies, which demon-
strated a long-term effect on pain after surgery. Only a single ran-
domised study compared the results of operations to conservative
care (C).
- Success rates are in the range of 70-90%. The risk of serious com-
plications is rare (A).




Surgery can be recommended provided that the above mentioned criteria are


Procedures for spinal stenosis involve well-known and low-tech

instrumentation. This procedure involves a more comprehensive
removal of bone tissue and nerve decompression than disc herniation
The diagnosis is made with MR-scans or with functional
myelography eventually supplemented with CT-scans

There must be a clear correlation between long-term functional distur-
bances, objective clinical findings and imaging results before considering
this procedure.

These operations are carried out at either neurosurgery or orthopae-
dic departments. Approximately 300 are performed per year.

- There is scientific documentation as regards pain relief in 60-70%
of patients when the previously mentioned criteria are present (B).
- Symptom relief of more than a few years has not been proven but
benefits can be difficult to demonstrate due to the progressive
nature of degenerative processes (D).





This procedure can be recommended in certain instances if the previously
mentioned criteria are present.


Stabilising back surgeries require more operation equipment, speciali-

sed tools, metal for fixation, and bone transplant material (preferably
from the patient or from a bone bank). This procedure is therefore
both a low and a high-tech procedure. This operation (3-8 hours) is
much more invasive that the previous procedures. Particularly long
lasting operations may require blood transfusions. This type of opera-
tion results in more complications than the previously discussed pro-
cedures and complications may be of a very serious nature.
Twenty to forty per cent of patients require additional surge-
ries because of a lack of healing of the bones.

The surgical candidate must undergo a comprehensive examination
program possibly involving a test period during which he/she wears
a corset. This may help in determining whether a “stiffening” opera-
tion will be helpful. The radiological examination procedures are also
considerable. In addition to plain x-rays one or several of the fol-
lowing examinations may be involved; MR-scan, myelography and
In order to determine whether there is a clear indication for
surgery there has to be a clear correlation between the history, the
symptoms, the objective examination and the imaging results.

Five to six hundred patients undergo this procedure each year. Pain
may be due to instability or painful movement. Patients will often-
times have undergone operations for disc herniations or spinal steno-

This type of operation should be performed in a few centres
only and in close co-operation between neurosurgeons, orthopaedic
surgeons and rheumatologists. The uncomplicated cases can be ope-
rated on in smaller centres in co-operation with major centres.

- There is no clear scientific documentation for pain relief or func-
tional gains. There is empirical evidence that states that 50-70% of
all patients experience benefit if the previously mentioned criteria
are present (D).





This procedure can only be recommended in particularly well chosen cases
in which the patient has clear surgical indications.

Work is going on to define more certain operation indications and
prognostic factors.
Costs can run up to 80-100.000 DKK per operation. This pro-
cedure is still in a developmental stage and more controlled studies
need to be carried out.


The technology
In cases where there is a suspicion of disc herniation bed rest (23-24
hours per day) is carried out in order to unburden the back.

- There is evidence that even a few days of bed rest for patients where
there is no suspicion of disc herniation increases functional loss and
enhances the likelihood of chronic symptom development (B).
- There is empirical evidence that patients who are suspected of suf-
fering from disc herniations will benefit from bed rest of up to one
week’s duration. This benefit can result in long-term pain relief for
some patients (D).


Home treatment.



Bed rest for patients not under suspicion for disc herniation should be dis-
couraged.If patients are suffering from severe pain, bed rest can be considered
as a pain relieving measure for a maximum of 1-2 days.


The technology
- There are several studies dealing with this treatment but results are
unclear. Some studies demonstrate an apparent pain reduction in
patients suffering from chronic symptoms (B).


Home treatment.



We do not recommend this treatment as a commonly used procedure. It can
be considered in certain patients suffering from chronic pain.

Treatments that cannot
be recommended


The technology
Specially sown material corsets or soft material belts.

- A positive clinical effect has never been demonstrated and there is
little scientific data (D).




Cannot be recommended.


The technology:
This treatment is carried out with an apparatus, which stretches the
back as well as the paraspinal structures.

- There are approximately 20 studies of good scientific merit. These
studies do not indicate a clear clinical effect of traction with either
acute or chronic patients with or without sciatica (A).


Ambulatory treatment.



We do not recommend this treatment for low-back pain with or without
sciatica. There is a risk of symptom exacerbation in rare circumstances


The Technology
Soft tissue treatment with ultra sound/laser/short-wave therapy.

Several studies have been carried out. There is no documented clini-
cal effect (A).




These therapies cannot be recommended.

The most important elements in the design of effective preventive
efforts have already been mentioned in this report. This chapter will
therefore summarise the most important areas that should be
focused on.
The scientific evidence regarding proven prophylactic inter-
ventions is not strong. The literature on prevention is sparse. In addi-
tion, social and cultural factors in different societies will greatly effect
the manner in which the individual patient as well as society at large
will perceive concrete prophylactic projects. This makes it difficult to
determine how prophylactic measures in one society will work in

◆ As the case has been for international consensus reports dealing with
the area of prevention/prophylaxis our group has been unable to find suf-
ficient data to undertake an HTA-evaluation of the individual measures.
Due to the same reasoning we will NOT grade the individual interven-
tion’s strength.

Prevention can be divided into two different “areas of effort” which

are defined according to the group, which is the focus of the inter-
Primary prophylaxis is defined as interventions for people who
have no low-back symptoms either at the present time or in the past
and who have no identifiable risk factors. Examples of primary pro-
phylaxis include ergonomic changes at home or at work, advice re-
garding physical activities, information campaigns to the general
public about how to react to an episode of acute low-back pain and
so forth.
Secondary/tertiary prophylaxis refers to interventions for indi-
viduals who have already suffered from low-back pain. The effort is
primarily aimed at preventing a reoccurrence of symptoms (second-
ary prophylaxis), or reducing the effects of poor health or reducing
the social costs of already existing low-back pain so that chronic
disabilities are prevented (tertiary prophylaxis).

Primary prophylaxis is often seen in public information campaigns, in
which the public at large is warned about improper behaviour. These
campaigns have rarely shown their effectiveness. A short-term infor-
mation campaign has no long-term effect on the health attitudes/
behaviour of the general public. Only back school carried out at work
places (page 66) has demonstrated a preventive effect as regards sick-
leave due to low-back pain .
Ergonomic interventions have only demonstrated a marginal
effect in several scientific studies. A reduction in the frequency of
heavy and repetitive lifting and the elimination of inappropriate work
stations (page 66) can have a certain effect on the frequency of future
episodes of low-back pain. When workers feel “comfortable” it is
doubtful that further ergonomic intervention will result in any mea-
ningful gains. It is therefore most important to weigh any possible
intervention with possible benefits.
It is therefore important to regard most “general” ergonomic
initiatives as being geared to improve the job satisfaction rates of wor-
kers rather than an effort to actually reduce sick leave due to low-back
pain. In other words: Ergonomic improvements can have a great effect
on the comfort levels or workers without reducing sick leave.
We recommend that future primary prophylactic initiatives
focus upon the avoidance of clearly inappropriate work situations
such as the elimination of very heavy or repetitive lifting, or sudden
unexpected movements which can stress the back. This may reduce
the number of accidents and other work-related injuries.
Other ergonomic projects such as the changing of all non-ad-
justable writing desks to desks which can be adjusted in height have a
primary goal of improving comfort as opposed to reducing the num-
ber of work related injuries and accidents. The economic priorities
related to differing prophylactic interventions should be based upon
realistic expectations as regards possible meaningful results.
We must be aware of the fact that information campaigns with
slogans such as: “4 hours of physical activity a week”, or “10 minutes
of exercise at every break”, or “an hour a week at a fitness centre” and
so on have not demonstrated any short or long term effect. Experience
tells us that individuals who are not ill are not motivated to participate
in preventive activities. There is also the risk of a counter productive
effect from messages of this sort. It is important that the central mes-
sages of information campaigns are not moralising. Information

should be presented in a neutral fashion such as explanatory informa-
tion about the function of the back, examination techniques and
available treatments. Advice about how future patients should tackle
their first episode of low-back pain would also be helpful. This type of
message does not demand something of the individual in the immedi-
ate future such as doing something that will promote health but rather
increases the publics level of knowledge about the low-back issue.
Informed individuals will possible react more rationally if they
encounter a future episode of low-back pain.

One of the most important goals of this type of prophylaxis is to pre-
vent an ordinary acute episode of low-back pain from developing
into a chronic and disabling low-back condition. Many risk factors
can contribute to the development of chronic pain in the 10-15% of
people with acute low-back pain that develop chronic symptoms.
Particular factors such as long-term sick-listing, psychological stress
or depression, and poor job satisfaction play important roles. See
Low-back Pain vol. 1 pages 26-28.
In the future it is important that the average course of treat-
ment addresses these known risk factors in order to decrease the
likelihood of chronic pain development. In order to reduce illness be-
haviour double treatment should be avoided. It is also important to
reduce waiting times for examinations and treatments. Patients risk
developing chronic symptoms while simply waiting for further treat-
ment or examinations. We refer to Low-back Pain vol. 1 page 43.
Lastly, we must make sure that patients are provided with thorough
information about their condition, treatment, prognosis, and preven-
tion so that uncertainties and anxiety levels are reduced.
An important area which should be focused upon is providing
special rehabilitation programs for patients who have experienced
long-term low-back pain or serious disabilities regarding the ability
to manage daily activities, so that functional capacities can become
normalised or at least as good as they can be. Studies show that re-
habilitation programs for patients who have undergone disc surgery
insure that a larger number of patients return to a normal level daily
functioning at their jobs and at home than if a rehabilitation program
is not completed.
Further research is still necessary in order to identify the most
important secondary/tertiary efforts where the effect of the interven-
tion is greatest related to associated costs.

An area, which requires additional focus, is the co-operation between
health professionals, the social sector and the work place.
The opportunity to return to work in a flexible manner such as
short or long-term “protected jobs” is important in order to secure
that individuals suffering from severe acute pain can maintain their
The rehabilitation of injured workers should also be co-or
dinated by the abovementioned sectors.
It is important that all relevant social services are utilised when
needed by individual patients. They include:

- Sick-listing.
- An agreement in which sick leave support is paid from the first day
- Declarations suggesting that workload be lessened.
- Work tests.
- The design of work places and tools.
- Wage support during periods of re-schooling.
- Assessing workers capabilities.
- Flex jobs.
- Protected jobs.
Additionally, we refer to the Service Law of July 1, 1998.

“The sick-listing of patients should as far as possible be done by

general practitioners in order to secure that he/she retains their pri-
mary role in the co-ordination of continued treatment (see page ??).”
Every individual county should take the initiative to develop
and maintain close co-operation between all professionals involved.
In order to secure that all relevant social services are provided to in-
dividual patients, it is necessary to have procedures clearly delineated.
The previously mentioned secondary/tertiary prophylactic
measures may appear to be rather obvious. However, they are not
carried out in reality because the health care sector cannot offer the
necessary rehabilitation and work hardening programs due to a lack
or co-ordination between the different players and due to a lack of

We mentioned several of the difficulties in calculating the total costs
to society of low-back pain in “Low-back Pain, Vol. 1”. There is a
lack of clarity about the total treatments provided in both the primary
and secondary health care sectors. Different methods of calculation
result in different conclusions. Lastly, it is difficult to calculate many
of the individual services. How much does it cost to carry out a x-ray
examination. Should one include the costs of maintaining a x-ray unit
or building costs? What about heating the premises? It is difficult to
separate singular costs out of the total costs of running a department
because many different activities take place in the same area by the
same personnel.
We calculated in “Low-back Pain, Vol.1” that the total yearly
costs related to low-back pain was approximately 10 billion Danish
DKK of which 3 billion DKK were direct costs and the remainder in-
direct costs.


It is easier to calculate treatment costs than total costs to society. In
the Appendix we have attempted to clarify the costs associated with
different treatments for the individual patient that are typically offe-
red in the health care sector. In order to simplify the problem costs are
based upon a typical 4-week examination and treatment course in
which a particular examination and treatment activity is carried out.
We point out whom it is that pays for treatment; the commune, the
state or the patient.
Note that we have chosen typical and common examination
and treatment courses but one can easily imagine many other equally
typical courses.
The reader should be warned against comparing the cost of
one type of service with another and thereupon concluding that funds
can be saved if we always utilise the least expensive service. For
example, 4 weeks of pain relieving medication treatment is much
cheaper than a 4-week course of treatment at a physiotherapist or a
chiropractor. Treatment types are rarely comparable. The content of
treatments differs, as do patient needs.

Calculations should primarily serve to provide us with an over-
view of the costs associated with an individual course of treatment
and which extra costs can be incurred if inappropriate treatment is


The table on page 94 contains a so-called box-economical analysis.
In other words a view of which boxes finance the given examples of
health services for patients with back pain. Treatment at a relaxation
therapist is not subsidised by the public health care system and pay-
ment is therefore made by the patient alone. On the other hand a con-
sultation at a general practitioner or a specialist is fully paid for by the
public health care system. Medication is partially subsidised. Patients
receive compensation (in the table we have used 50%). As regards
support for privately practising physiotherapists and chiropractors
support from the public health care system is 40% and 30% respec-
tively. Hospital treatment is completely paid for by the county.
Pay during sick leave is paid for by the employer, public em-
ployers, and the commune. Private employers pay for the first 2
weeks of sick leave while the remaining sick leave period is paid for
by the commune in which the individual resides. Public employers
pay for the entire sick leave period. Employers who continue to pay
full wages under sick-leave are entitled to receive the support that the
commune would have paid to the employee during the sick-leave
period. The state refunds 75% of the costs incurred by the commune
for sick-leave wages.

Examples of treatment courses and the division of boxes of typical services in DKK
Cost categories County Municipality The state Patient In total
Public health insurance Hospital sector
General practitioner *) 396 0 0 0 0 396
Physiotherapist in private practice **) 576 0 0 0 864 1.440
Chiropractor in private practice **) 221 0 0 0 1.104 1.325
Medical specialist **) 907 0 0 0 0 907
- inexpenive 28 0 0 0 28 56
- expensive 98 0 0 0 98 196
Relaxation therapist 0 0 ****) 0 1.200 1.200
Hospital treatment 0 24.246 0 0 0 24.246
2 weeks of hospitalisation for
a disc herniation operation 0 17.964 0 0 0 17.964
Ambulatory treatment 0 7.141 0 0 0 7.141


Sick-leave benefits *****) 0 0 672 2.016 0 2.688
*) From the Department of Health Insurance, Århus County.
**) The office of the Department of Health Insurance. 1998, Schultz law service – Health laws. Schultz Information.
***) On the precondition that sick-leave benefits are paid entirely by the commune whereupon the state refunds 75% of the costs.
****) Some communes subsidise treatment costs.
*****) Per week.


In order to arrive at the possible economic savings attainable if we
strive to carry out desired treatment courses, the LBP-group has con-
structed 2 typical treatment courses. We have calculated the direct
costs as well as the costs associated with sick-leave benefits.
For an example we have chosen treatment of an acute low-
back disc herniation. In both of the “constructed” cases conservative
treatment has failed and surgery has followed. We preclude that sur-
gery has been successful and that the patient returns to work in good
health. The examples are typical of long-term treatment courses.
Upwards of 10,000 patients per year are treated for acute low-back
disc herniations for shorter or longer periods of time. Conservative
treatment is successful in the majority of patients but surgery is
necessary for 25-30% of patients. Patients are typically sick-listed for
4-12 months in conjunction with treatment for disc herniations. As
described in Low-back Pain, Vol. 1 many acute episodes of low-back

pain (including those without disc herniations) lead to long-term sick-
listing, much treatment and the occasional hospitalisation. We as-
sume that many more than the 10,000 disc herniation patients go
through similar courses of treatment as we described. The exact num-
ber is impossible to present.

The recommended course

Patients receive treatment in the primary health care sector. Only the
necessary health professionals are involved and there is good com-
munication between them and no unnecessary waiting time. A phy-
siotherapist or chiropractor carries out the treatment in association
with the patient’s general practitioner. As there is no effect from the
administered treatment the patient is referred to the spine center of
the hospital. There is no effect of the hospital treatment but treatment
is carried out without wasting time. This is followed by a CT-scan,
surgery and rehabilitation (also without undue waiting time).

The non-recommended course

The patient is examined and treated by several health professionals in
the primary health care sector. There is insufficient communication
between the health professionals and unnecessary waiting times
develop. Due to a lack of improvement the patient is hospitalised on
two different occasions for further examination and treatment. The
first hospitalisation was of 2 weeks duration during which conserva-
tive treatment was attempted without clinical results, and a CT-scan
was ordered. There is considerable waiting time both for the CT-scan
as well as for surgery. At present, waiting times for a CT-scan are ap-
proximately 3 months as are waiting times for surgery. In this exam-
ple, rehabilitation will be necessary for a longer period of time than
in the desired course of treatment due to the fact that the physical
state of the patient is relatively worse after surgery and the many
months of waiting.

The Figure, which follows, illustrates the two different treat-
ment courses plotted against a time axis. The recommended course
ends with a discharge after 20 weeks while the non-recommended
treatment course ends with a discharge after 44 weeks.


The desired course

General Phys. Back Operation
pract. Chiro. center Rehabilitation


0 4 8 12 16 20
Time axis/weeks

The undesirable course


General Phys. Chiro. Waiting Waiting Waiting time Operation

pract. time time Rehabilitation


0 4 8 12 16 20 24 28 32 36 40 44
Time axis/weeks

As we can see from the following calculation the “undesired treat-
ment course” is more than twice as expensive to carry out as the
“desired treatment course”. Patients in the “desired treatment
course” in all likelihood experience a greater degree of patient satis-
faction. There is a greater chance of achieving a complete cure and
maintaining work capabilities for these patients as well. However,
our calculations only relate to economic costs.

Costs associated with the “desired treatment course” (in DKK):

General practitioner 384.-
Physiotherapist/Chiropractor (average) 1.390,-
Back center 7.141,-
Hospitalisation and operation 17.964,-
Rehabilitation (alternative 1) 2.000,-
Inexpensive + expensive medication 1.008,-
Sick-leave benefits *) 53.760,-
In total 83.647,-

Costs associated with the “undesired treatment course” (in DKK):

General practitioner 384,-
Physiotherapist 1.440,-
Chiropractor 1.325,-
Medical specialist 907,-
First hospitalisation 24.246,-
Hospitalisation and operation 17.964,-
Rehabilitation (alternative 1) 2.000.-
Inexpensive + expensive medication 2.772.-
Sick-leave benefits *) 118.272.-
In total 169.310.-
*) In an economic analysis one should also include production loss in conjunction with sick-
leave. Due to the uncertainties associated with loss of productivity we have included the
costs associated with sick-leave benefits instead.

One should also include the costs associated with disability pensions
for patients, who have not been helped by treatment and must leave the
work force. Patients, who receive the middle level of pension, are paid
9,097 DKK per month, which results in a yearly cost of 110,000 DKK.
Should an individual receive a disability pension for the rest of his/her
life this will result in a considerable amount of money.

The implementation of improved and more effective treatment
courses will in addition to saving money in the health care system also
reduce costs related to sick-leave benefits and disability pensions.


It is important to underscore that the desired treatment course can
enhance the likelihood of achieving satisfactory treatment results thus
decreasing the likelihood of chronic symptom development in addi-
tion to considerable savings.
The amount of savings is particularly dependent upon our
ability to succeed in the following:

◆ To avoid “expensive” waiting times

◆ To achieve the best possible communication between the involved health
professionals and the relevant social authorities.
◆ To avoid unnecessary and meaningless examinations and treatments

Concluding Comments
The first meeting of our Low-back pain group that produced “Low-
back Pain, Volumes 1 and 2”was held in Copenhagen on the first of
August 1995. Since that time, there have been over 5 million contacts
with patients in the primary and secondary health care sectors due to
low-back pain. Some patients have experienced severely disabling
symptoms while others have experienced a lesser degree of trouble.
Our work group is very aware of the size of the low-back pain
problem and it has been very gratifying to note that we have discer-
ned a willingness to tackle the problem seriously at all decision ma-
king levels of the health care system. The awareness of this issue was
already great during our work on “Low-back Pain, Vol. 1” Since the
publication of our first volume, health professionals and decision ma-
kers in the health care system have participated in intense professio-
nal and organisational discussions based upon our initial recommen-
dations. Many new initiatives have already taken place. For example,
in over 7 counties (as of June 1998) there have been inter-disciplinary
meetings, which have dealt with the possibilities of implementing our
recommendations at the local level.
Professional developments in the international forum regar-
ding the “back problem” are being carried out at a rapid pace. New
knowledge in research reports and evidence based clinical “guide-
lines” are also being published at a pace, which far surpasses pre-
vious rates. It is already time to consider when we should begin plan-
ning the updating of “Low-back Pain Vol. 1 & 2”. In all likelihood
this should be carried out within 3-4 years.
Only if we are at the forefront of international developments
will we be able to offer optimal treatments at the local level. It is
therefore important to conclude with the same message that we pre-
sented in Low-back Pain Volume 1. That a massive effort involving
increased research, post-graduate education, the implementation of
inter-disciplinary reference programs and guidelines and improved
professional co-operation and communication are all essential, if we
are to optimise our efforts in the assessment and treatment of low
back pain

Examples of costs associated with
the treatment of “low-back pain”
Examples of the costs associated with the assessment and treatment
of low-back pain patients in the primary health care sector are shown
in Table 1. The calculations begin with a hypothetical treatment
course lasting for a period of 4 weeks. The fee schedule for consulting
a general practitioner was provided by the National Public Health
Insurance, Århus County, 1997. The fee schedule for physiothera
pists, chiropractors and medical specialists were provided by the
National Public Health Insurance Department of Negotiations and
are given as 1997 figures. The fees for relaxation therapists and
medication costs are based upon evaluations by the expert panel.

General Practitioner
The fee schedule for consulting a general practitioner was provided
by the National Public Health Insurance, Århus County, 1997. During
the period of treatment in our hypothetical model we assumed that a
patient would consult his general practitioner 4 times. The cost of
a consultation is 96 DKK and this covers a consultation during
opening hours from Monday to Friday from 8 a.m. to 4 p.m.

Practising Physiotherapist
The fee schedule for consulting a physiotherapist (1997 figures) has
been provided by the National Public Health Insurance Department
of Negotiations. The costs include treatment as well as individual ex-
ercise therapy. The fees are for a consultation from Monday to Friday
from 8 a.m. to 4 p.m. Consultation costs are derived according to a
module system in which every module is defined as an independent
service and is estimated to take approximately 15 minutes. A module
is compensated by the same amount regardless of its content. A con-
sultation is made up from 1-6 modules per session and the duration
of a consultation will therefore last from 15-90 minutes. During the
period of treatment in our hypothetical 4-week treatment model we
assumed that a patient would consult a physiotherapist a minimum

of 8 times averaging 3 modules per visit. The cost of each module is
60 DKK

Practising Chiropractor
The fee schedule for consulting a chiropractor (1997 figures) has been
provided by the National Public Health Insurance Department of
Negotiations. During the period of treatment in our hypothetical
4-week treatment model we assumed that a patient would consult a
chiropractor 7 times. Consultations are divided into; 1) chiropractic
examination and treatment, 2) chiropractic treatment, 3) supplemen-
tary services and 4) x-ray examination.

Medical Specialist
During the period of treatment in our hypothetical 4-week treatment
model we assumed that a patient would consult a medical specialist
3 times. The given fees are those agreed upon by the National Public
Health Insurance Department of Negotiations and the Association
of Medical Specialists for patients with ordinary public health insu-
rance. The fees include a supplement of 12.8% as well as holiday pay.
Consultation fees include extra services involved in treatment such as
injections and so forth.

Relaxation Therapist
During the period of treatment in our hypothetical 4-week treatment
model we assumed that a patient would consult a relaxation thera-
pist once a week. The fee has been set at 300 DKK per visit.

Medication Costs
We assume that medication treatment will last for a minimum of 4
weeks. Our calculations begin with an inexpensive pain relieving me-
dicine in full dose as well as an expensive arthritic medication. The in-
expensive medication is paracetamol which we assume will be taken in
a daily doses of 4 grams. During the course of treatment approximat-
ely 200 tablets will be taken. Costs according to 1996 prices are 1.85
DKK per day, if pills are purchased in bottles of 100 pills. This results
in a total cost of 56.00 DKK for 30 days. The expensive medicine
chosen was tiaprofensyre where the daily doses has been set at 2 times
300 mg. The price per day will be 6.5 DKK if pills are purchased in bot-
tles of 100 pills (1996 prices). Costs related to the expensive medication
during the 4-week period will therefore amount to 196.00 DKK.

Diagnostic Imaging
Table 1 also includes costs associated with different types of diagno-
stic imaging which would be relevant in conjunction with the treat-
ment of back patients. X-ray examination of the lumbar spine will
usually involve 4 projections. Costs given for imaging examinations
are based upon previously undertaken calculations1 as well as cal-
culations carried out at the Hillerød Hospital (MR-scans).

Costs associated with 4 weeks of treatment for low-back patients in the
primary health care sector
Number Type of service DKK In total
General practitioner:
4 Consultations 96 384
Physiotherapist in private practice:
8 Treatments 180 1.440
Chiropractor in private practice:
1 Chiropractic basic examination and treatment 295 295
6 Chiropractic service 147 882
2 Supplementary services 74 148
In total 7, visits at a chiro. in private practice 1.325
Medical specialist:
1 Initial consultation 434 434
1 Additional services 50 50
1 Second consultation 217 217
1 Additional services 50 50
1 Third consultation 106 106
1 Additional services 50 50
In total, 3 consultations at a medical specialist 907
Relaxation therapist:
4 Treatments 300 1.200
1 - Inexpensive medication 56 56
1 - Expensive medication 196 196
Diagnostic imaging:
1 - X-ray examination of the spine,chiropractor 377
4 - X-ray examination of the spine,hospital 360 1.440
1 - CT-scan 1.000 1.000
1 - MR-scan 1.000 1.000

1) Anni-Ankjær-Jensen. Cost calculations for the department of radiology in the DSI-report 94-04. “Production- and
effectiveness measurements in the hospital sector- cost models used in practice”.

The following examples of costs associated with hospital treatment
are based upon figures from a particular hospital. Calculations use
total average costs because costs involve both direct costs (such as
physician and nurse times, materials, etc.) and indirect costs (utilisa-
tion of administration, heat, cleaning, etc.). All calculations are
excluding interest and depreciation costs.

We have used to different methods for our calculations. The “top-
down” principle involves a division of the total costs by the total acti-
vity in the department in question during the period in question. This
principle is used for calculations related to costs per day for hospita-
lised patients.
The “bottom-up” principle involves adding all of the direct
costs that are related to a given activity/treatment. This principle is
used to calculate costs associated with ambulatory treatment in spine
centers and for cost calculations associated with disc herniation ope-
rations including costs related to anaesthesia. This method only ad-
dresses the costs, which can be directly related to the given activity.
One is left with the indirect costs such as wages during breaks and
waiting time, daily operational expenses, costs related to educational
activities and new major purchases. If it is desired one can add an am-
ount which represents a part of the indirect costs associated with the
department. Due to the fact that the total direct costs of the depart-
ment cannot be exactly determined, 30% is the number usually used.
The hospital’s costs associated with administration, repairs,
water, heat, electricity and so forth represent approximately 32% of
the costs associated with running the departments in which patients
are treated. We have therefore added a cost to all treatments of 32%,
which we have called “overhead”. A more detailed description of this
method of calculation is provided in appendix C.

Conservative treatment while hospitalised for 2 weeks or treatment at a

spine center
Table 2 includes examples of two alternative treatments in the hospi-
tal sector for patients suffering from low-back pain. 1) conservative
care while hospitalised for 2 weeks and 2) ambulatory treatment in a
spine centre. The first alternative includes the cost for using a hospi-

tal bed2 in the department where the patient is hospitalised. In addi-
tion, there are costs associated with resources provided by other
hospital departments. We assume that during the period of hospitali-
sation a plain x-ray as well as a CT scan will be undertaken. The costs
associated with the latter alternative include wages to the personnel
that are involved with the ambulatory care (physician, nurse, phy-
siotherapist, secretary and so forth). In addition to material costs
there are the costs associated with x-ray and CT scans. We assume
that treatment at a spine centre involves 4 ambulatory consultations
(30 minutes each) as well as one telephone contact in conjunction
with each consultation.

Costs associated with 2 weeks of conservative treatment at a hospital and
ambulatory treatment at a spine center
Alternative I (hospitalisation)
Number Cost category DKK In total
14 Days of hospitalisation 1.629 22.806
4 X-rays of the spine 360 1.440
Samlet alternativ I 24.246
alternative II (ambulatory care)
Salaries Min. DKK In total
4 ambulatory treatments of < 30 min.duration
1 physician 120 376 752
1 nurse 120 154 308
1 physiotherapist 120 180 360
1 secretary 120 148 296
Other costs such as materials etc. 100 100
4 telephone conversations of < 20 min.duration
physician time 80 376 501
Number Cost category DKK In total
4 X-rays of the spine 360 1.440
In total, alternative II 3.757
+30% indirect costs associated
with using the department 1.127

2) We refer to appendix B for a more detailed review of the method used to calculate the costs associated with the utili-
sation of a hospital bed.

Operation for disc herniation
Table 3 illustrates a calculation of the costs associated with hospitali-
sation and operation for a disc herniation. The resource utilisation
can be divided into 4 phases: 1) pre-hospitalisation examination, 2)
a consultation with an anesthesiologist, 3) the operation and anest-
hesia, 4) hospitalisation. Appendix A includes a more detailed review
of the calculations associated with each of these 4 areas.

Costs associated with a disc herniation operation
Cost category DKK
Pre-operative examination/CT-scan 1.580
Anesthesia consultation 269
Operation department 2.937
Anesthesia department 1.775
7 days of hospitalisation 11.403
Total direct costs 17.964


Table 4 shows 3 alternative methods of rehabilitation a spine. The
first alternative is treatment at a “back school”, which takes place at
a hospital. The cost was estimated by an expert panel. The second

Costs associated with post-operative rehabilitation
Cost category DKK In total
Alternative l:(treatment at a back school)
Total cost for alternative I: 2.000 2.000
Alternative II:(treatment at a physiotherapy clinic)
24 training sessions – 28 modules: 60 1.680
Alternative III:(treatment at a chiropractic clinic)
12 basic clinical services: 147 1.764
12 training sessions 74 888
2 supplementary services 74 148
Total costs of alternative III: 2.800

alternative takes place at a physiotherapy clinic, during which the
patient receives 28 modules of rehabilitation. The last alternative
takes place at a chiropractic clinic. The patient will receive 12 basic
services, 12 training sessions and 2 supplemental basic services.

These appendices (in danish only) can be retrieved by contacting:

Danish Institute for Health Technology Assessment

National Board of Health
13 Amaliegade
P.O. Box 2020
DK-1012 Copenhagen


In Table 5, the maximum sick-leave benefit that a patient can receive
per week is given. The benefits are based upon the person’s income
and are calculated according to the hourly wage that the wage earner
would receive during sick leave minus the amount that would be paid
to the work-market contribution fund. It is necessary to know the
numbers of hours as well as the hourly wage during sick leave in
order to calculate benefits. Sick-leave benefits are calculated by mul-
tiplying the number of hours by the hourly wage. The hourly wage
includes the basic wage plus eventual additional moneys paid for
working at odd hours as well as other personal supplements. Not
included are holiday benefits, weekend and holiday pay, pension and
social security contributions. The maximum hourly wage cannot ex-
ceed the maximal total sick-leave benefit divided by the number of
weekly hours that have been agreed upon by the Danish Employers
Association and the Labour Unions. In practical terms, one would
receive full pay during sick-leave if one’s hourly wage is less that
72.65 DKK per hour..

Sick-leave benefits for 2 weeks
Number of weeks Sick-leave benefits per week In total
2 2.688 5.376
Source: Social services 1998: Insurance information, Copenhagen