Any external product which serves to maintain or improve an individual’s functioning and independence, and thereby promote well-being. In the context of care for people with low back pain, assistive products comprise two main categories: non-rigid and rigid lumbar braces, belts, and supports which limit mobility and reduce physical demand on the lower back; and mobility assistive products which include wheelchairs, mobility scooters, tricycles, crutches, walking sticks and walkers.

Refers to the multiple factors and their interactions that may influence a person’s experience of chronic primary low back pain, including biological, psychological and social factors. Adopting a biopsychosocial approach to assessment and care is more likely to address the factors that influence the experience of pain in a person-centred manner.

The ICD-11 classification system for chronic pain identifies chronic pain as either primary (MG30.0) or secondary owing to an underlying disease or structural lesion or deformity (MG30.3-MG30.6). Chronic primary low back pain (CPLBP) is a subclassification of chronic primary musculoskeletal pain (MG30.02), under the parent classification of chronic primary pain. The International Association for the Study of Pain (IASP) defines CPLBP, previously referred to as “non-specific low back pain”, as pain that persists or recurs for longer than three months, and is associated with emotional distress and/or functional disability, and symptoms that cannot be better accounted for by another diagnosis, such as tissue damage or a disease process (1). Chronic secondary low back pain arises from an identifiable underlying disease process (e.g. cancer, inflammatory disease) or structural lesion/deformity (e.g. a fracture). For the purpose of the guideline, CPLBP was defined as pain that persists or recurs for longer than three months and is associated with symptoms that cannot be better accounted for by another diagnosis, such as a structural lesion or a disease process. No criteria were applied relating to an experience of emotional distress or functional disability.

Refers to adults who live independently in the community, compared with adults who are hospital inpatients or live in residential facilities (e.g. nursing home, assisted living facility).

Any health worker who has acquired health-related qualifications. The term comprises both health professionals and health associate professionals¹.

Health workers are all people primarily engaged in actions with the primary intent of enhancing health¹.

WHO defines herbal medicines as products that contain, as active ingredients, parts of plants, other plant materials or combinations of both (2).

Injectable local anaesthetics include the subcutaneous, myofascial or intramuscular delivery of anaesthetic agents into tissues in the lower back region between the 12th rib and gluteal fold. The injectate is delivered only to extraspinal soft/connective tissue.

The composite of all the physical and mental capacities of an individual (3).

Massage is the manual manipulation of soft body tissues, such as muscle and connective tissue, with the aim of improving health and well-being. Massage includes any soft-tissue manipulation using hands or other mechanical device, inclusive of traditional, complementary and integrative (TCI) medicine massage therapies. It may be applied to any body part, lumbar region only or the whole body.

Multicomponent biopsychosocial care involves delivery of at least two of the three components of care associated with the biopsychosocial model (physical, psychological or social), delivered by a single provider or a multidisciplinary team. These components align with the biopsychosocial model of chronic pain and its applicability to older people. Multicomponent biopsychosocial care adopts a rehabilitation approach that aims to optimize function and reduce disability in individuals with health conditions in interaction with their environment. For the purpose of the guideline, trials of all types of interventions for multicomponent biopsychosocial care were included where they satisfied the criterion of a multicomponent intervention that targets functioning (body structures and functions, activities and participation). The intervention should target at least two domains of the biopsychosocial model: either the biological component targeting physical aspects of functioning such as body structures or functions (e.g. an exercise programme targeting an increase in muscle strength), psychological component (e.g. addressing coping with pain) or social and occupational component (e.g. addressing involvement in meaningful life roles including work).

Needling therapies considered in the guideline included traditional Chinese medicine (TCM) acupuncture and other dry needling modalities (myofascial trigger point needling, neuroreflexotherapy and Western medical acupuncture). These modalities are defined as any intervention where needles are inserted into classical meridian points (TCM acupuncture) or soft-tissue trigger points (other dry needling modalities).

A placebo is a comparator group in a clinical trial, most commonly for testing the benefits and harms of a medicine. Research participants who are randomized to a placebo group receive an inactive treatment (e.g. a pill that has no therapeutic value), while the other group receives the active treatment.

Psychological interventions considered for the guideline comprised five interventions: operant, respondent, cognitive, cognitive behavioural and mindfulness-based stress reduction therapies. Three interventions (operant, respondent and cognitive therapies) aligned with an earlier Cochrane review of behavioural treatments for LBP (4). Each of these interventions focuses on modifying one of the three response systems which characterize emotional experiences: behaviour, physiological reactivity and cognition, respectively. However, there is an acceptance that psychological interventions are complex and multifaceted and that treatment for chronic pain may not be appropriately bound by this classification (5). These three interventions are therefore often applied in a combined treatment approach, commonly referred to as cognitive behavioural therapy (CBT). Acceptance and commitment therapy, an extension of CBT, was not considered for the guideline. Mindfulness-based stress reduction was also considered as an intervention for the guideline. This intervention aims to reduce pain through improved tolerance/acceptance of body sensations. Further definition of each intervention is provided below:

• Operant therapy aims to replace pain-related behaviours with helpful, healthy behaviours (e.g. exercise, work). Time-contingent exercises (i.e. quotas) and encouraging people to increase their activity levels are its main principles. This type of therapy is aligned with behavioural activation therapy.
• Respondent therapy aims to modify the physiological response system to pain by reducing muscular tension through biofeedback, progressive relaxation and applied relaxation. This type of therapy is aligned with relaxation therapy.
• Cognitive therapy aims to identify and modify cognition regarding pain and disability. It is proposed that beliefs about the meaning of pain and expectations regarding control over pain can be directly modified using cognitive restructuring techniques such as imagery and attention diversion.
• Cognitive behavioural therapy (CBT) is based on a multidimensional model of pain and focuses on reducing pain and distress by modifying physical sensation, catastrophic thinking and unhelpful behaviour(s). Treatment may include education about a multidimensional view of pain, identifying pain-eliciting and pain-aggravating situations, thoughts and behaviours, and using coping strategies and applied relaxation; in sum, integrating components of operant, respondent and cognitive therapies. Goal-setting and activity increases are encouraged as the basis of CBT to reduce feelings of helplessness and help the person gain control over their pain experience.
• Mindfulness-based stress reduction (MBSR) therapy aims to reduce stress by developing mindfulness: a non-judgemental, moment-by-moment acceptance of awareness. The intervention is free of any cultural, religious and ideological factors, but it is associated with the Buddhist origins of mindfulness.

Spinal manipulative therapy is considered any “hands-on” treatment that involves movement of the spinal joints. Mobilization uses low-grade velocity (relative to manipulation) and small or large amplitude passive movement techniques within the person’s spinal joint range of motion and control, while manipulation uses a high-velocity impulse or thrust applied to a synovial joint over a short amplitude.

A sham is a comparator group in a clinical trial. Research participants who are randomized to a sham group receive a treatment/intervention that is designed to mimic as closely as possible the intervention being studied, without receiving the actual intervention. For example, in sham ultrasound, the machine’s capacity to deliver an ultrasonic wave may be disabled.

A summary statistic in meta-analyses when a variety of studies all assess the same outcome but measure it in different ways: results have to be standardized to a uniform scale before being amalgamated. The standardized mean difference (SMD) therefore expresses the size of any intervention effect in a study relative to the observed variability.

“Education and/or advice” aims to improve the understanding of the pain experience for a person with CPLBP and guide their self-management and well-being. Evidence reviewed for the guideline included “structured and standardized education and/or advice”, defined as the provision of structured and standardized information delivered by health workers(s) to a person with CPLBP. This is distinct and separate from education and/or advice provided by a health worker to a person with CPLBP as part of a clinical encounter. Structured and standardized advice may not be tailored or personalized. Among the trials identified to inform the guideline, this intervention was delivered by health practitioners.

Exercise is a subcategory of physical activity that is planned, structured, repetitive and purposeful in the sense that improvement or maintenance of one or more components of physical fitness is its objective. Structured exercise therapies or programmes are prescribed or planned by health workers, often delivered with instruction and supervision and may be standardized or individualized. These therapies are broadly defined as “a series of specific movements with the aim of training or developing physical capacity (e.g. muscle and joint strength and function, range of motion or aerobic capacity) by repetition or as physical training to promote good physical health” with the goal of reducing pain and functional limitations (6). They include adopting postures, movements or activities, or a combination (e.g. strengthening, stretching, aerobic exercise) of varying duration, frequency and intensity. Exercise modalities considered for the guideline included: aerobic exercise; muscle strength training; stretching, flexibility or mobilizing exercises; Yoga; core strengthening; motor control exercise; functional restoration exercise; Pilates; Tai Chi; Qigong; aquatic/hydrotherapy; and mixed exercise therapies (i.e. two or more types of exercise in which one did not clearly predominate). Among the trials identified to inform the guideline, this intervention was delivered by health practitioners.

Therapeutic ultrasound is an electrophysical treatment modality postulated to deliver sonic energy to deep tissue sites through ultrasonic waves, to increase tissue temperature and create non-thermal physiological changes, which are purported to improve symptoms and promote or accelerate tissue healing.

Traction is the application of a distraction force along the long axis of the spine, and is achieved using body weight, external weights or pulleys. It may be mechanical or motorized, manual, self-operated (auto-traction), underwater, gravitational or inverted, delivered intermittently or continuously, and applied for a few seconds to several hours.

TENS is a non-invasive electrical stimulation modality applied to the skin using surface electrodes which generate a low-voltage electrical current to modify the perception of pain.