Low back pain has an enormous impact on individuals and health systems. The large majority of individuals with low back pain have non-specific low back pain (also recently called primary low back pain by WHO), where the cause cannot be attributed to a specific pathology. Developing and implementing evidence-based guidelines to manage non-specific low back pain in primary care is essential to reducing the burden on individuals and health systems. Since 2001, periodic overviews of clinical practice guidelines for the management of patients with non-specific low back pain in primary care have been conducted. Since the last overview in 2018, new clinical practice guidelines for the management of low back pain have been published. This Review summarises management recommendations across international low back pain clinical practice guidelines for primary care and explores the changes in recommendations over time in guidelines published between 1994 and 2026.

Abstract Background Patients with degenerative lumbar spinal stenosis (LSS) commonly use analgesics despite not being recommended by clinical guidelines. However, detailed knowledge of utilisation patterns is limited. This study aimed to describe prescribed analgesic use before, during, and after enrolment in a standardised chiropractic care programme, and to examine associations between patient characteristics and continued analgesic use after the programme. Methods This cohort study included patients with LSS enrolled in the chiropractic care programme between 1 April 2017 and 31 December 2022, identified via the Danish National Health Service Register. The programme provides guideline-based non-pharmacological care, structured follow-up, and coordination with the patient's general practitioner. Data on dispensed analgesics were retrieved from the Danish National Prescription Registry. Quarterly prevalence of analgesic use (≥ 1 dispensed prescriptions) and defined daily doses per 1000 individuals were calculated for the year before enrolment, 3 months during, and the year after the programme. The distribution of use was assessed using Lorenz curves and Gini coefficients. Associations between patient characteristics and continued analgesic use (≥ 1 dispensed prescriptions in ≥ 2 of 4 consecutive quarters) after the programme among existing users were examined using robust Poisson regression. Results Of the 7294 included patients, 45% used analgesics in the year before enrolment. Use of paracetamol, non-steroidal anti-inflammatory drugs (NSAID), opioids, and gabapentinoids increased in the year before enrolment, peaked during the programme, and generally declined after. Ten percent of analgesic users accounted for approximately 43%, 49%, 68%, and 57% of the total use of paracetamol, NSAIDs, opioids, and gabapentinoids, respectively. Female sex, having one comorbidity, and pre-existing use of paracetamol, opioid, or gabapentinoid were associated with a 5–16% higher risk of continued use, whereas long-cycle higher education was associated with a 13% lower risk. Conclusions Analgesic use increased before enrolment, peaked during the programme, and then declined after. A small proportion of analgesic users accounted for a large share of the total use. Sociodemographic and health-related factors, and pre-existing analgesic use were associated with continued use. These findings highlight the complexity of analgesic use in this population and emphasise the need for deprescribing strategies that take this complexity into account.

BACKGROUND:Gabapentinoids (gabapentin and pregabalin) are increasingly prescribed for spinal pain despite limited evidence of benefit and recognised risks. Understanding which characteristics influence prescribing and how prescription use has evolved may inform safer and more evidence-based practice. OBJECTIVES:To compare determinants of gabapentinoid use and changes over time between two separate cohorts of patients referred to the Spine Centre of Southern Denmark. METHODS:Our study comprised two cohorts: the first, from 2013 to 2014 (n = 16,732), and the second, from 2021 to 2022 (n = 13,939). Redeemed gabapentinoid prescriptions were assessed within a 12-month window (6 months before and after the spine centre index date) and linked with diagnostic, socioeconomic and patient-reported information. Patients were categorised as continued users, initiators, discontinuers or non-users using a ≥ 30 defined daily dose classification threshold to distinguish sporadic from more sustained dispensing. Multinomial logistic regression, incorporating demographic, socioeconomic and clinical covariates, identified characteristics associated with use. RESULTS:Gabapentinoid use more than doubled from Cohort 1 to Cohort 2, with continued users increasing from 2.4% to 6.6% and initiators increasing from 3.5% to 6.1%. Radiculopathy, higher disability and concurrent opioid or weak analgesic use showed the strongest positive associations with use across both cohorts. CONCLUSIONS:Gabapentinoid use for patients with spinal pain attending secondary care in Denmark increased substantially across the decade, despite only modest differences in patient characteristics. Gabapentinoid use remained concentrated among patients with radiculopathy and concurrent analgesic use, underscoring continued reliance on pharmacological management. SIGNIFICANCE STATEMENT:This study identifies a marked rise in gabapentinoid prescribing for spinal pain in secondary care and shows that the increase was only partly explained by differences in patient characteristics. The findings highlight continued use in patient groups where clinical benefit remains unproven, reinforcing the need for safer, more evidence-based prescribing strategies.

PURPOSE:Low back pain (LBP) is a complex, multifactorial condition with numerous contributors across biopsychosocial domains. To advance understanding of this complexity, we synthesized diverse expert knowledge on treatment effectiveness and underlying mechanisms using a systems-based, collaborative modeling approach. METHODS:Twenty-nine experts from diverse disciplines created individual fuzzy cognitive maps (FCMs) to represent their understanding of factors affecting pain, disability, and quality of life (QoL), along with treatment mechanisms. These maps were aggregated into a meta-model comprising 142 Components and 1,161 weighted Connections. Centrality was used to quantify the relative contribution of each domain within the meta-model. Simulations with the meta-model based on expert knowledge (1) estimated the relative effectiveness of treatments on pain, disability, and QoL and (2) identified key Mediators and mediating Domains based on their relative contribution to mediating treatment effects. RESULTS:Psychological, biomechanical, and social/contextual Domains were central to expert conceptualizations of LBP. Simulation indicated cognitive behavioral therapy was considered the most effective among all interventions. Most interventions were mediated by Components across multiple Domains, with psychological factors frequently serving as mediators. The structure of the conceptual meta-model reflected both the multifactorial complexity of LBP and the diversity of expert perspectives regarding factors that influence treatment effectiveness. CONCLUSION:The developed meta-model provides a novel, systems-based representation of expert knowledge about LBP, enabling quantitative exploration of treatment effects and underlying mechanisms. This conceptual framework also offers a foundation for advancing research on multi-modal, personalized care.

Objective To compare clinical characteristics of patients seeking primary care for hip osteoarthritis (OA) with and without concurrent low back pain (LBP), to evaluate changes in LBP intensity following participation in a supervised exercise therapy and patient education program targeting hip OA, and to assess whether hip OA responders experience greater LBP improvement. Design This longitudinal analysis included patients from the Good Life with osteoArthritis in Denmark (GLA:D®) program with symptoms primarily related to hip OA. The intervention included supervised education and neuromuscular exercise delivered over 8 weeks. Baseline demographic and clinical characteristics were compared between patients with and without LBP. Changes in LBP intensity (0–10 Numeric Rating Scale) at 3- and 12-month follow-up were analyzed using mixed-effects models. Hip OA pain responder status (≥15-point improvement on the HOOS-12 pain subscale) and its association with change in LBP intensity was assessed via multivariable linear regression analysis. Results Among 5,014 patients with hip OA, 3,079 (61%) reported comorbid LBP. Compared to patients without LBP, those with LBP had higher BMI, worse HOOS-12 pain and function scores, and greater analgesic use. Adjusted analyses showed significant reductions in LBP intensity at 3 months (19% improvement from baseline) and 12 months (21% improvement from baseline). Hip OA responders experienced greater LBP reductions than non-responders at both time points. Conclusions Patients with hip OA and comorbid LBP represent a subgroup with higher hip pain and lower function. Participation in the GLA:D® program was associated with statistically significant LBP improvement, particularly among hip OA responders.

Chronic low back pain (CLBP) is a leading cause of disability and reduced work participation worldwide. Its multifactorial nature—often lacking a clear pathological cause—poses significant challenges for effective treatment. This study reports short-term outcomes from a concentrated, interdisciplinary group-based intervention targeting patients with hard-to-treat CLBP. This study reports outcomes from the CLBP arm of a nonrandomized five-armed transdiagnostic, pre-post intervention trial (2020–2022); no control group or between-group comparisons are included. The intervention comprised SMART (Specific, Measurable, Achievable, Relevant, Time-bound) goal setting, multilevel exercise, patient education, and micro-choice strategies—small, intentional decisions aimed at enhancing functional capacity and reducing symptom-related vigilance—delivered in a concentrated group format. Outcomes were evaluated three months post-intervention and included disability (Oswestry Disability Index, ODI), pain intensity (NRS-11), work ability, medication use, sick leave status, and physical performance tests. Continuous outcomes were analysed using mixed-effects regression models to account for repeated measures, while categorical changes were assessed using symmetry tests for ordinal variables and McNemar’s test for binary variables. The majority in our cohort had low educational levels, were overweight, and welfare recipients, many had multisite pain, used daily pain medication and had a history of back surgery. At follow-up, most outcomes showed statistically significant improvement. Disability decreased by 5.9 points (-18

Introduction:Spinal disorders are among the biggest contributors to health care utilization (HCU). Objective:To develop and externally validate a prediction model for high all-cause HCU (75th percentile during 1 year after the index date) among patients with spinal disorders visiting multidisciplinary secondary care clinics. Methods:We developed and internally validated the model using the Norwegian Neck and Back Registry, including patients registered between January 1, 2016, and December 31, 2020, linked with national health registries (N = 9092). For external validation, we used data from the Danish SpineData Registry, linked with national registries, for the same period (N = 34,853). We assessed Nagelkerke R 2 , discrimination (area under receiver operating characteristics curve [AUC]), and calibration (calibration-in-the-large [CITL], slope, and calibration plot). Results:The final model included sex, nationality, education, physical activity, smoking, prior HCU, work status, disability, health-related quality of life, medicine use, diagnosis, kinesiophobia, and comorbidity. It demonstrated acceptable discrimination (AUC 0.78, 95% confidence interval [CI], 0.77-0.78), an R 2 of 0.26, and good calibration after internal validation. Upon external validation, the model demonstrated excellent discrimination (AUC 0.81, 95% CI 0.80-0.81) and an R 2 of 0.31. The calibration slope was 1.08 (95% CI 1.06-1.11) and CITL was 0.16 (95% CI 0.12-0.19). Predicted probabilities closely matched observed probabilities across all deciles in internal validation, with slight underestimation of high HCU in the top 3 deciles during external validation. Conclusion:Overall, the model shows promise in predicting high HCU in patients with spinal disorders referred to secondary care but requires further testing and validation in implementation settings before recommendation.

Objectives The primary aim of this scoping review was to synthesise published research priorities for back pain, neck pain and osteoarthritis. The secondary aim was to compare these research priorities to the priority areas identified in the Global Strategy to Improve Musculoskeletal Health.Design Scoping review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews.Data sources Literature searches were performed in MEDLINE, EMBASE and the James Lind Alliance Priority Setting Partnership database from inception to March 2025.Eligibility criteria Peer-reviewed studies reporting the development of a prioritised ranking of research topics related to back pain, neck pain or osteoarthritis were included.Data synthesis Included research priority sets were described. All research priorities for back pain, neck pain and osteoarthritis were presented. Research priorities were categorised according to priority areas identified in the Global Strategy to Improve Musculoskeletal Health.Results 15 studies from 3721 citations and three from the James Lind Alliance were included. Eight priority sets related to back and/or neck pain identified 155 research priorities. 15 priority sets related to osteoarthritis identified 206 research priorities. Most priority sets (69.6%) included patients in the development process, but only 17.4% included policymakers. Just three priority sets included participants from outside Europe, North America or Australia.Most priorities were in the clinical and basic science research priority area (73.1%) followed by the health policy and systems research priority area (14.1%), health economics research priority area (4.7%), public health research priority area (4.4%), epidemiological and population health research priority area (1.9%) and the other priority area (1.7%).Conclusions The majority of published back pain, neck pain and osteoarthritis research priorities fall within clinical and basic science and were developed in high income countries. Given the known high population burden of musculoskeletal conditions, a broader approach to research beyond clinical and basic science is likely required to achieve population-level health benefits. Future initiatives should include all relevant members of the global musculoskeletal health community, including from low- and middle-income countries, to help ensure the development of broad-based research priorities that address all research domains required to improve back and neck pain and osteoarthritis health globally.

Healthcare utilization is high for people with spinal disorders. We aimed to investigate differences in recommended versus actual healthcare use among individuals with back neck pain compared to individuals with isolated back or neck pain. Additionally, we aimed to examine variations in healthcare utilization patterns before and after a specialist evaluation based on the location of pain. We linked the Norwegian Neck and Back Registry with health registries, including patients with spinal disorders registered between January 1st, 2016, and December 31st, 2020 (9316 patients (63

Objectives: Implementing motivational self-management support in low back pain care remains challenging due to barriers including health care providers’ limited confidence in addressing behavioral aspects of pain, people with low back pain’s expectations, and time constraints. To promote person-centered low back pain care, this project engaged people with low back pain, health care providers, and researchers in a co-design process to develop a dialogue tool aimed at supporting motivational conversations and facilitating self-management.Methods: Guided by Design Thinking principles, we conducted a co-design process informed by self-determination theory and structured around the 5A’s model for behavior change (Assess, Advise, Agree, Assist, Arrange). The process included fieldwork, workshops, prototype development, and iterative refinements. To inform refinements, acceptability, appropriateness, and feasibility of the dialogue tool were evaluated through surveys (n = 9 health care providers) and in semi-structured interviews with health care providers (n = 6) and people with low back pain (n = 4).Results: The final product was an analog tool comprising 7 dialogue sheets and 5 information postcards aligned with the 5A’s components. Both health care providers and people with low back pain found the prototype tool acceptable and feasible for structuring person-centered conversations about pain and self-management. The most frequently used elements were those to support a person-centered assessment of pain complexity (Assess) and to provide options for managing pain (Assist). Barriers included lack of experience and need of supplementary training in use of the dialogue tool.Conclusions: Using a co-design process, we developed an analog dialogue tool to facilitate a person-centered approach to support self-management of low back pain. Effects of the tool and strategies for implementation are still to be tested.Practice implications: The dialogue tool may support structured, person-centered conversations about pain beliefs, factors affecting pain, and self-management strategies linked to meaningful goals and activities.

BACKGROUND:Access to greenspace (eg, parks) may improve aspects of physical and mental health that are known biopsychosocial contributors to back pain. However, little is known about the association between access to greenspace and back pain. METHODS:This cross-sectional analysis used data from the Study of Osteoporotic Fractures (SOF) and the Osteoporotic Fractures in Men Study (MrOS) to investigate the association of proximity to greenspace with back pain among community-dwelling older adults living in Portland, Oregon, USA. Geospatial software characterized proximity to greenspace (distance from residential address to nearest park) into three categories thought to be relevant for walkability among older adults: <0.125, 0.125-0.5, and >0.5 mile. We estimated the crude prevalence of any back pain (yes/no) during the past year by proximity-to-greenspace categories and their association as gender-specific prevalence ratios (aPRs) using log-binomial regression models adjusted for age, race, education, and neighborhood socioeconomic status. RESULTS:Participants were 1839 SOF women (mean age = 74.6 years, SD = 5.3) and 422 MrOS men (mean age = 73.7 years, SD = 5.8). Living >0.5 mile from a park, compared to living <0.125 mile, was associated with a greater prevalence of back pain among women (crude prevalence: 71.1% vs. 61.6%, aPR = 1.15 [1.02-1.29]) but not men (64.2% vs. 76.4%, aPR = 0.82 [0.66-1.02]). Sensitivity analyses that used more severe back pain phenotypes provided heterogenous results. CONCLUSION:In this cross-sectional study, living near a park was associated with a modestly lower prevalence of back pain for women but not men. Large prospective studies are needed to further evaluate whether living close to parks, or other greenspaces, is associated with back pain in older adults.

Objectives. We aimed to develop a booklet for people with low back pain (LBP) and their healthcare professionals (HCPs), which provides coherent, evidence-based patient education to support helpful pain-related behaviours tailored to individual needs.Methods. People with LBP, HCPs, educators, researchers, and a visual artist were included in a co-design process. Booklet content was developed in an iterative approach comprising three surveys and three in-person workshops. First, HCPs contributed suggestions for educational content in a survey. These were then organised into themes, drafted as text paragraphs and metaphors, and refined through three workshops and two subsequent survey rounds involving all stakeholder groups. Illustrations were sketched during workshops and discussed in surveys.Results. Three overarching themes were agreed on: (1) creating an alliance (HCPs and people with LBP working collaboratively), (2) explaining LBP, and (3) managing LBP. The booklet included these themes by combining suggestions for factual explanations, metaphors, and practical strategies for facilitating a collaborative approach to patient education. In the final survey, the texts for all of 17 outlined messages were endorsed by more than 90% (n = 27) respondents. Of 11 proposed metaphors for explaining LBP, one was excluded due to lack of consensus.Conclusions. We developed a booklet for people with LBP and for HCPs in a co-design process. The content covers topics previously identified as important for LBP education, while the booklet emphasises individualised education delivered through interaction and dialogue rather than generic information transfer. Future research should explore the booklet’s usefulness for supporting people with LBP in managing their condition, and a tailored implementation plan should be developed.Practice implications. The booklet “When Your Back Hurts – A Guide to Back Pain” is available as a source of current information about LBP meant to support an individualised clinical dialogue.

BACKGROUND:Illness perceptions, reflecting cognitive and emotional representation of a condition, may influence how people with low back pain (LBP) seek care. Evidence in this area remains limited. This study examines whether illness perceptions are associated with healthcare visits and diagnostic imaging in people seeking care for LBP. DESIGN AND METHODS:In this prospective cohort study, patients consulting general practice for LBP completed the Brief Illness Perception Questionnaire (BIPQ; 0-80) at baseline. Two outcomes were assessed after three months: repeated healthcare visits (≥2 vs < 2 visits) and diagnostic imaging (X-ray, CT, or MRI; yes/no). Associations were analysed using logistic regression, adjusted for baseline pain intensity, disability, and episode duration. RESULTS:Analysis included 214 adults (mean age, 55 years; 56% women). At three-month follow-up, 31% had ≥2 healthcare visits, and 19% had undergone diagnostic imaging. More threatening illness perceptions were associated with multiple healthcare visits (adjusted OR 1.04 per BIPQ point; 95% CI, 1.00-1.07) and diagnostic imaging (adjusted OR 1.04 per point; 95% CI, 1.00-1.08). The estimated odds corresponded to predicted probabilities increasing from 26% to 36% of healthcare visits and from 14% to 22% for imaging, comparing the highest and lowest BIPQ quartiles. For individual BIPQ items, emotional response (BIPQ8) was associated with visits, whereas recovery expectations (BIPQ2) were associated with diagnostic imaging. CONCLUSION:Illness perceptions were associated with healthcare visits and diagnostic imaging in people with LBP, independent of pain, disability, and episode duration, and addressing these perceptions may support guideline-concordant care.

Patient education is considered a core aspect of health care, aimed at helping individuals understand and manage their conditions. However, no systematic overview across patient education approaches exists that can guide the optimization of educational strategies for musculoskeletal disorders. This scoping review aimed to map 1) recommendations provided about patient education in clinical practice guidelines (CPGs), 2) research on the effectiveness of patient education, and 3) educational content recommended for chronic spinal pain, osteoarthritis, and mixed chronic primary musculoskeletal pain. Following JBI guidance for scoping reviews, we searched MEDLINE, Embase, and PsycINFO from January 2014 to July 2025 for systematic and scoping reviews, Delphi-studies, and consensus studies on patient education. Study selection and data extraction were conducted by pairs of reviewers. Findings were summarized within and across evidence types. Out of 4,243 unique records screened, 178 full-texts were assessed, and 66 papers included. CPGs consistently recommended patient education, and patients emphasized a need for individualization. Educational themes included helping people understand their condition and factors impacting pain, providing reassurance, and guiding management strategies. There was substantial uncertainty about the effectiveness of various types of patient education, and no reviews investigated individualized education. Patient education is central in recommendations of care for musculoskeletal pain disorders, but effectiveness is uncertain, and no specific approach has been shown to be superior. We identified a gap between patient preferences for education individually tailored in a collaborative process and effectiveness studies focusing on pre-defined patient education programs.

Introduction This paper highlights research relating to the prevention and management of non-specific low back pain (LBP) published between January 2020 and December 2025. Methods To identify studies for inclusion, MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews were searched. Relevant studies were grouped according to topic area. From those results, studies that were perceived to be of great clinical importance and particularly high quality were selected. Results This narrative review synthesised five key themes in contemporary LBP management. Theme 1 (Prevention) demonstrated consistent evidence that exercise-based programs, particularly when combined with education, reduce the risk and impact of recurrent LBP. Theme 2 (Non-pharmacological management) showed that education, exercise, manual therapy, acupuncture and psychologically informed approaches generally produce small to moderate effects on average, with the strongest and most sustained benefits observed for exercise and psychologically informed approaches. In Theme 3 (Pharmacological management), it was found that commonly used medicines provide at best small benefits while carrying meaningful risks, reinforcing their limited and time-restricted role in care. Theme 4 (Invasive and surgical interventions) highlighted that most invasive procedures offer little to no meaningful benefit for LBP and expose patients to substantial harm and cost. Finally, Theme 5 (Special populations) showed that older adults, children, adolescents, and Indigenous and underserved communities remain under-represented in clinical trials and are more likely to receive non-guideline concordant care, emphasising the need for tailored, equity-oriented approaches. Conclusion LBP care is most effective when it is active and person‑centred. Education, exercise and psychologically informed approaches should be prioritised, while medicines and invasive procedures offer little benefit and carry risk; care should be tailored to reduce persistent inequities across populations.

This study aimed to investigate the distribution of all-cause primary healthcare use (general practitioners [GPs], physiotherapists, chiropractors) and identify patient characteristics related to high use in the year following an assessment at a hospital spine clinic among patients with spinal pain. We linked self-reported data from 48,616 adult patients assessed at a Danish hospital spine clinic between 2016 and 2021 with national registry data. We investigated the distribution of consultations with GPs and physiotherapists/chiropractors in the year following the assessment using Lorenz plots. Multivariable logistic regression was used to examine associations between sociodemographic and clinical patient characteristics and high (versus low) healthcare utilization. All analyses were conducted separately for consultations with GPs and physiotherapists/chiropractors. Overall, 25

This review summarises how non-specific low back pain is a common and recurrent symptom among people of all ages, and a leading cause of disability that is projected to increase in the coming decades. It is a clinical diagnosis that is most often made in primary care without imaging. Serious medical causes of low back pain are rare but must be considered. Recent evidence-based guidelines recommend a shift away from pharmacological treatment to supported self-management through patient education and treatments that help people remain physically active and at work. This is poorly implemented in health systems.

Injuries sustained during healthcare consultations are a significant concern, and compensation claims relating to injuries in health systems are increasing. Extensive research has addressed injuries in the secondary sector, whereas knowledge about injuries sustained in primary care remains sparse. This retrospective register-based study aimed to describe compensation claims involving chiropractors in Denmark between 2013 and 2022. All claims related to chiropractors from 2013 to 2022 were accessed in the Danish Patient Compensation Association Register and analyzed using the Healthcare Complaints Analysis Tool. Data on patient characteristics, injuries, processing time, decisions, appeals, and financial compensation were collected. Claims were categorized as relating to clinical, management, or patient-clinician relationship, alongside nine symptom-based injury classifications. Data relating to cervical artery dissection were examined separately and in greater detail, including information on presenting symptoms, International Classification of Primary Care, Second Edition code recorded by the chiropractor, treatment modalities used, time from treatment to onset of symptoms, and type of vascular injury subsequently diagnosed. Descriptive statistics summarized findings. A total of 535 chiropractor-related claims were identified, with 519 included for analysis. The number of claims per 100,000 consultations increased from 1.03 in 2013 to 3.57 in 2022. Most claims (84

Objective This study aims to investigate how authors attribute causality in case reports and case series describing ischaemic stroke following cervical manual therapy. Methods This qualitative, document-based study is nested within a larger epidemiological investigation evaluating the association between cervical manual therapy and ischaemic stroke (PROSPERO ID: CRD42024602659). Eligible case reports and case series will be identified through a systematic review of biomedical databases. A software-assisted qualitative content analysis will be undertaken in MAXQDA, combining deductive coding, guided by counterfactual theory and the concept of hypothesis generation, with inductive coding to capture linguistic patterns. Conclusion This research protocol presents a novel approach to examining how causality is attributed in case reports and case series, addressing the relationship between ischemic stroke following cervical manual therapy for headaches or neck pain. The anticipated findings have implications for improving the clarity and responsibility of scientific communication and informing the interpretive boundaries and appropriate use of descriptive research designs in clinical and policy contexts.