September 2012, Volume 34, No. 3
Update Articles

Evidence-based guideline on prevention and management of low back pain in working population in primary care

Lisa Cheng 鄭佩君, Kinson KS Lau 劉健生, WK Lam 林永堃, Dominic MW Lau 劉敏維, MY Ng 吳美儀, PL Lau 劉佩玲, WM Wong 王惠敏, CH Ho 何志軒

HK Pract 2012;34:106-115


Low back pain (LBP) is common in working age-group. Their impact on working life can interfere with activities at work, productivity, sickness absence, long term incapacity and medical retirement. The aim of the project is to systematically develop an evidence-based guideline for the management of LBP in working population in primary care. The Working Group consisted of primary care doctors with expertise in evidence-based medicine, guideline development, health promotion and occupational health. The methodology involved systematic search in database, literature review and critical appraisal. The recommendation statements developed were based on the level of evidence. Consensus were reached through Delphi technique. Peer review was conducted.

Implementation plan was proposed for improving adherence.


腰背痛(LBP)在工作年齡段的人群中很常見。它可影響工作生活,干擾工作活動、生產力,並可導致病假缺勤、長期失能和因病退休。本專案的目的是為在基層醫療管理工作人群的腰背痛而系統地制定循證指南。工作組由在循證醫學、指南制定、健康促進和職業衛生方面富有經驗的基層醫生組成。採用的方法包括系統搜索資料庫、檢索文獻和批判性評估。根據證據的級別提出了建議意見。通過 Delphi 法取得共識,並進行了同行評議。提出了實施計劃以便提高遵守度。


Low back pain (LBP) is a common reason for seeking health care, and is one of the commonest health reasons given for work loss.1,2 Among working adults, 60-80% have experienced LBP at some time, and it is often persistent or recurrent. Physical demands of work (manual materials handling, lifting, bending, twisting, and whole body vibration) can be associated with increased back symptoms, aggravation of symptoms and ‘injuries’.3,4 Care-seeking and disability due to LBP depend more on the complex individual and work-related psychosocial factors than on clinical features or physical demands of work.3,4 Effective management strategies based on sound evidence are necessary to tackle this common problem. Nevertheless, local evidence based occupational guidelines and studies are lacking. It is important to explore and develop this aspect in primary care.5. This paper describes the development of an evidence-based primary care guideline on the management of low back pain among the working population.


The lifetime prevalence of LBP has been estimated at 59% to 90%,7 with an annual incidence of approximately 5%.8 Among the Dutch general population, the annual prevalence was found to be about 50%.9 This Dutch study also showed that in patients with LBP, 28% were restricted in their daily activities, 42% underwent medical treatment, 23% took time off work, 8% received disability pension, and 6% changed jobs or had adaptations in the workplace.9

In Hong Kong, an estimated 57.1% and 42.1% of the population suffered from low back pain at least once in their life time and at least once within the past year respectively.10 In a cross-sectional telephone survey involving 10072 subjects, 6760 episodes of work-related illnesses were reported,10 with 14.6% suffering from LBP.26 LBP was the second most prevalent illness caused by work and the commonest illness made worse by work.10 Sick leave was taken in 10% of the episodes of work related illnesses.10 Among the 3 million working people in Hong Kong, around 900,000 days of sick leave were granted and HK$513 million were paid for doctor consultation because of work related illnesses annually.10


Low back pain is defined as pain at the posterior trunk between the ribcage and the gluteal folds. It includes low extremity pain that results from low back disorder (sciatica/radiating low back pain), whether there is trunk pain or not. Sciatica is radiating, lower extremity pain and may not be associated with back pain.6 Acute LBP is defined as pain that lasts less than six weeks (or four in some studies), sub-acute LBP lasts for six (or four) to twelve weeks, and chronic LBP lasts for longer than twelve weeks. Acute non-specific LBP is defined as back pain that has not lasted more than 6 weeks and does not radiate down the leg or to below the knee, and without features suggestive of potentially serious conditions.6

Management of low backpain – development of an evidence-based guideline


A guideline was developed by the Guideline Development Working Group on evidence-based management of low back pain in working population in primary care. This group was formed in 2010, comprising primary care doctors with expertise in evidence -based medicine , health promotion, clinical audit and guideline development; as well as occupational health and safety officers. 

Systematic search was performed in Medline, the Cochrane Library, various websites including the US National Guidelines Clearinghouse, NICE websites, SIGN websites, New Zealand Guideline Group websites, occupational Safety and Health websites of Hong Kong, USA, UK, other EU members, Australia, New Zealand, Singapore, Labour Department of HK, other Asian Countries, UK, USA, Australia and New Zealand. Reviews on international guidelines on occupational health practice for back pain were conducted and critically appraised: UK,12-13 Australia,14-16 USA,17-18 Canada,19 New Zealand20 and Europe21,22 and were adopted according to local applicability and level of evidence.

Search terms used included low back pain, LBP, low back symptom, non-specific low back pain, prolapsed disc, PID, back injury, back sprain, back ache , backache , treatment low back pain, therapy low back pain, occupational low back pain, occupational musculoskeletal disease, occupational musculoskeletal disorder, occupational injury, injury on duty, injury job related, etc. Limits were applied to reviews, systematic reviews, randomized controlled trials (RCTs), meta-analysis and guidelines from 1990-2010.

Guideline working group members assessed the titles and abstracts of the literature searched, using a checklist with a prior defined selection criteria. Relevant studies were retrieved and the full articles were critically appraised by guideline working group members for inclusion. Methodological quality was assessed by Oxford methods for critical appraisal of RCTs and meta-analysis; whereas guidelines were assessed by the Appraisal of Guidelines Research and Evaluation tool.

Regular meeting s were held to review the literatures, identify evidence and develop recommendation statements through structured communication in a panel of working group members. The level of evidence was identified and strength of recommendation defined according to the Scottish Intercollegiate Guidelines Network. Consensus was reached through discussion and by the Delphi technique. Peer review was conducted after the draft was completed. External review was also conducted by professionals with expertise in occupational medicine. Implementation plan was also developed to promote practice improvement and compliance to the guideline.


The followings are the results of the guideline development. They are under the heading of prevention, assessment, management of back pain and management of prolonged back pain. (Table 1). The algorithms of the management of the LBP are shown in Figure 1. The results of the Cochrane systematic reviews on the effectiveness of different treatment modalities are summarized in Appendix 1.


Evidence identified

Traditional biomedical education and lumbar supports do not reduce future LBP and work loss.22,23 (Evidence level 2)

Lumbar belts or supports do not reduce work-related LBP and work loss22,23 (Evidence level 2). Low job satisfaction and unsatisfactory psychosocial aspects of work are risk factors for reported LBP, health care use and work loss, but the size of that association is modest.4 (Evidence level 2)

Joint employer-worker initiatives to monitor and improve safety can reduce the number of reported back ‘injuries’ and sickness absence. It involves organizational culture and high stakeholder commitment to identify and control occupational risk factors and improve safety, surveillance measures and safety culture.23 (Evidence level 2)

There is preliminary evidence that educational interventions which specifically address beliefs and attitudes may reduce future work loss due to LBP.24 (Evidence level 4)

According to Cochrane systematic reviews, there is limited evidence that manual material handling advice and training could prevent back pain, back pain-related disability or reduce sick leave when compared to no intervention.25 (Evidence level 2)


Advise employers that high job satisfaction and good industrial relations are the most important organizational characteristics associated with low disability and sickness absence rates attributed to LBP. (Grade B recommendation)

Do not recommend lumbar belts and supports or traditional biomedical education as methods of preventing LBP. (Grade B recommendation)

Advise on current good working practices such as manual handling technique. (GPP) 

Encourage employers to consider joint employer-worker initiatives: (Grade D recommendation)

– identify and control occupational risk factors.

– improve safety and develop a ‘safety culture’.

– recognise the importance of providing satisfying work in a climate of good industrial relations.

– monitor back problems and sickness absence due to LBP.

Assessment of LBP workers

Evidence identified

Screening for ‘red flags’ and diagnostic triage is important to exclude serious spinal diseases and nerve root problems.26 (Figure 3) (Evidence level 2)

Individual and work-related psychosocial factors play an important role in persisting symptoms and disability, and influence response to treatment and rehabilitation.

Screening for ‘yellow flags’ can help to identify those workers with LBP who are at risk of developing chronic pain and disability. Workers’ own beliefs that their LBP was caused by their work and their own expectations about inability to return to work are particularly important.1,26,27,30 (Figure 4) (Evidence level 1)

In patients with non-specific LBP, X-ray and MRI findings do not correlate with clinical symptoms or work capacity.28 (Evidence level 2)

Patients who are older (particularly >50 years), have more prolonged and severe symptoms, have radiating leg pain, whose symptoms impact more on activity and work, and who have responded less well to previous therapy are likely to have slower clinical progress, poorer response to treatment and rehabilitation, and more risk of long term disability.27,29 (Evidence level 2)


Take a clinical, disability and occupational history, concentrating on the impact of symptoms on activity and work, and any obstacles to recovery and return to work. (Figure 1) (Grade A recommendation) 

Screen for serious spinal diseases and nerve root problems. (Grade A recommendation)

Consider psychosocial risk factors for chronicity and disability in assessment. (Figure 2) (Grade A recommendation)

Do not recommend X-rays and scans for patient with acute non-specific low back pain. (Grade C recommendation)

Management principles

Evidence identified

Staying active and returning to ordinary activities as early as possible leads to faster recovery and fewer recurrences. (Level 1 evidence)

There is strong evidence that the aforesaid advice can give equivalent or faster symptomatic recovery from the acute symptoms, and leads to shorter periods of work loss, fewer recurrences and less work loss over the following year than ‘traditional’ medical treatment.26,31

Most workers with LBP are able to continue working or to return to work within a few days or weeks: they do not need to wait until they are completely pain free.26 (Level 1 evidence)

Advice to be away from work for as short a time as possible in order to improve the chance of being able to resume work.26 (Level 2 evidence) 

There is strong epidemiological evidence that the longer a worker is off work, the lower their chances of ever returning to work.26 Low back pain is commonly a persistent or recurrent problem and most workers do continue working or return to work while symptoms are still present.26 The above advice can be usefully supplemented by simple educational interventions specifically designed to overcome fear, avoidance beliefs and encourage patients to take responsibility for their own self-care.26,32

There is moderate evidence that the temporary provision of lighter or modified duties facilitates return to work and reduced time off.92 Recommendations should include staying active but avoiding heavy lifting, bending, twisting, and prolonged sitting.20 (Level 3 evidence)

Communication, co-operation and common agreed goals between the worker with LBP, the occupational health team, supervisors, management and primary health care professionals are fundamental for improvement in clinical and occupational health management and outcomes.26,34 (Level 3 evidence)

Workplace organizational and management strategies generally involve organizational culture and high stakeholder commitment to improve safety, provide optimum case management, encourage and support early return to work.3,26 (Level 3 evidence)

There is moderate evidence from systematic review that a combination of optimum clinical management, a rehabilitation programme and organizational adjustments designed for worker returning to work is more effective than single elements alone.33,35,36 (Level 1 evidence)


Address the common misconception among workers and employers of the need to be pain free before returning to work. (Grade A recommendation)

Encourage the worker to resume / continue ordinary activity including their work as normally as possible despite some remaining low back pain. (Grade A recommendation)

Encourage worker to negotiate with work supervisor to consider temporary modification of work duties to facilitate return to work and reduce sick leave due to low back pain. (Grade C recommendation)

Initiate communication and liaise closely with patient’s health professionals and other related stakeholders early in treatment and rehabilitation (Grade C recommendation)

Approximately 4 – 12 weeks

Evidence identified

The longer a worker with LBP is off work, the lower his chances of ever returning to work. Once a worker is off work for about 4-12 weeks. He has a 10-40% risk (depending on the setting) of still being off work at one year; after 1-2 years’ absence it is unlikely he will ever return to any form of work in the foreseeable future, irrespective of further treatment.1 (Level 3 evidence)

Various treatments for chronic LBP may produce some clinical improvement, but most clinical interventions are quite ineffective at returning people to work once they have been off work for a protracted period with LBP.37 (Level 2 evidence)

Temporary provision of modified or lighter duties facilitates return to work and reduces time off work.38 (Level 3 evidence)

A combination of optimum clinical management, a rehabilitation programme, and organisational interventions designed to assist the worker with LBP to return to work, is more effective. Changing the focus from purely symptomatic treatment to an ‘active rehabilitation programme’ can produce faster return to work and less chronic disability.34,37,39,40 (Level 1 evidence)


Address the common misconception among workers and employers of the need to be pain-free before return to work. Some pain is to be expected and the early resumption of work activity improves the prognosis. (Grade B recommendation)

Advise on ways in which the job can be adjusted, in order to facilitate return to work. (Grade C recommendation)

Communicate and collaborate with primary health care professionals to shift the emphasis from dependence on symptomatic treatment to rehabilitation and self-management strategies. (Grade B recommendation)

Ensure that workers, employers and primary care health professionals understand that the longer anyone is off work with LBP, the greater is the risk of chronic pain and disability, and the lower the chances of ever returning to work. (GPP)

Encourage the employer to establish a surveillance system to identify those off work for over 4 weeks so that appropriate action can be taken. (GPP)

Discussion and conclusion

LBP is still one of the commonest causes of sickness absence, long-term incapacity and early retirement. Given the right care, support and encouragement, most people with LBP should be able to remain in or return to work. Evidence shows that interventions are effective in reducing sickness absence and the number of people proceeding to long-term incapacity. In addition, effective intervention requires different stakeholders (including workers with LBP, employers and health professionals) to work together towards a common goal or better outcomes. To bridge between research and practice, efficient delivery of effective interventions is crucial. Active educational intervention is one of the ways for effective dissemination.

Interventions to promote implementation with evidence of effectiveness include: reminders, educational outreach, interactive educational activities and by feedback. Clinical audit could be used to monitor and evaluate of dissemination and implementation of the guideline. It is a quality assurance activity to ensure effective interventions implemented are sustainable and to promote standard of management. 


Our special thanks to Dr Ruby Lee, Consultant (Family Medicine), Elderly Health Service, Dr Linda Hui Consultant (Family Medicine), Professional Development and Quality Assurance and Dr Luke Tsang, formerly Consultant (Family Medicine), Service Head, Professional Development and Quality Assurance, Department of Health for support and guidance. Last but not least, I would like to extend my deepest appreciation to the continuous team effort of all dedicated members of the Guideline Development Working Group on evidence-based management of low back pain in working population in primary care without which the review could not be realized.





UA (Key message)

Lisa Cheng, MRCP (UK), MRCPCH, FHKAM (Fam Med), MSc International Primary Health Care (London)
Senior Medical and Health Officer (Ag),
Elderly Health Service.

Kinson KS Lau, MB ChB (Liverpool), FHKCFP, FRACGP, FHKAM (Fam Med)
Medical and Health Officer,
Professional Development and Quality Assurance.,

WK Lam, MBBS (HKU), Post Dip in Comm Geriatrics (HKU), FHKCFP, FRACGP
Senior Medical and Health Officer,
Professional Development and Quality Assurance.

Medical and Health Officer,
Elderly Health Service.

Medical and Health Officer,
Professional Development and Quality Assurance.

Medical and Health Officer,
Professional Development and Quality Assurance.

WM Wong, MBChB (CUHK), DFM (Monash University), FRACGP, FHKCFP
Medical and Health Officer,
Professional Development and Quality Assurance.

Medical and Health Officer,
Elderly Health Service, Department of Health.

Correspondence to: Dr Lisa Cheng, Elderly Health Service, Room 3502-4, 35/F,
Hopewell Centre, 183 Queen's Road East, Wanchai, Hong Kong SAR.

  1. Waddell G. The Back Pain Revolution. Edinburgh: Churchill Livingstone, 1998.
  2. Department of Health. The Prevalence of Back Pain in Great Britain in 1998., 1999.
  3. Burton AK. Back injury and work loss: biomechanical and psychosocial
    influences. Spine 1997;22:2575-2580.
  4. NIOSH. Musculoskeletal Disorders and Workplace Factors. A Critical Review of Epidemiologic Evidence for Work-related Musculoskeletal
    Disorders of the Neck, Upper-extremity, and Low Back. Cincinnati, OH: NIOSH, 1997.
  5. ASL Leung. Prevalence of low back pain in the population of Hong Kong: A telephone survey II: Frequency and utilisation of services. Department of Rehabilitation Services, The Hong Kong Polytechnic University. January 1999 HSRC Report # 9.
  6. Adult low back pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2002. University of Michigan Health System.
    Guidelines for Clinical Care. Acute Low Back Pain. Updated 2003 with revision 2004.
  7. Lic. Rik Op De Beeck Dr. Veerle Hermans. European Agency for Safety and Health at Work. Research on work-related low back disorders at work. 2000.
  8. Andersson GBJ. Epidemiological features of chronic low-back pain. The Lancet 1999;354:581-585.
  9. Hoogendoorn WE, van Poppel MNM, Bongers PM, et al. Physical load during work and leisure time as risk factors for back pain, Scand J Work Environ Health 1999;25(5):387-403.
  10. Hong Kong Occupational Safety and Health Council. A telephone survey on self-reported work-related illness and perceived hazards in Occupational Safety and Health in Hong Kong. Department of Community Medicine 1999, The University of Hong Kong.
  11. Yip Y. B. A study of work stress, patient handling activities and the risk of low back pain among nurses in Hong Kong. Journal of Advanced Nursing, December 2001, vol. 36, no. 6, pp. 794-804(11).
  12. Carter JT, Birrell LN. Occupational Health Guidelines for the Management of Low Back Pain at Work: recommendations. Faculty of Occupational Medicine, London 2000, ISBN 1 86016 131 6 (also on
  13. Waddell G, Burton AK. Occupational Health Guidelines for the Management of Low Back Pain at Work: evidence review. Faculty of Occupational Medicine, London 2000, ISBN 1 86016 131 6 (also on [UK].
  14. Steven ID (Ed) Guidelines for the management of back-injured employees. Adelaide: South Australia Workcover Corporation. 1993 [Australia].
  15. Victorian Workcover Authority. Guidelines for the management of employees with compensable low back pain. Melbourne, Victorian
    Workcover Authority. 1993 and revised Edition 1996 [Australia].
  16. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence based-management of acute musculoskeletal pain: A guide for clinician. Australian Academic Press, Bowen Hills, 2004.
  17. Fordyce WE (Ed). Back Pain in the Workplace: Management of Disability in Nonspecific Conditions. Seattle, IASP Press. 1995 [US – International].
  18. Low back disorders. Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. 2nd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM);2007.366.
  19. Spitzer WO, Leblanc FE, Dupuis M. Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task force on Spinal disorders. Spine 1987;12(Suppl.7S):1-59. [Canada].
  20. Accident Compensation Corporation. New Zealand Acute Low Back Pain Guide. Wellington, New Zealand, Oct 2004.
  21. Work-related musculoskeletal disorders: Back to work report. European Agency for Safety and Health at Work 2007.
  22. Working Group on Guidelines for Prevention of Low Back Pain. European guidelines for prevention in low back pain. Nov 2004,at:
  23. Van Poppel MNM, Koes BW, Smid T, et al. A systematic review of controlled clinical trials on the prevention of back pain in industry. Occup Environ Med 1997;54:841-847.
  24. Symonds TL, Burton AK, Tillotson KM, et al. Absence resulting from low back trouble can be reduced by psychosocial intervention at the work place. Spine 1995; 20: 2738–2745.
  25. Martimo KP, Verbeek JH, Karppinen J, et al. Manual material handling advice and assistive devices for preventing and treating back pain in workers. Cochrane Database of Systematic Reviews 2007, Issue 3.
  26. Royal College of General Practitioners. Clinical Guidelines for the Management of Acute Low Back Pain. London: Royal College of General Practitioners, 1999.
  27. Lancourt J, Kettelhut M. Predicting return to work for lower back pain patients receiving workers compensation. Spine 1992; 17: 629–640.
  28. van Tulder MW, Assendelft JJ, Koes BW, et al. Spinal radiographic findings and nonspecific low back pain: a systematic review of observational studies. Spine 1997; 22: 427–434.
  29. Haldorsen EMH, Indahl A, Ursin H. Patients with low back pain not returning to work: a 12-month follow-up study. Spine 1998; 23: 1202– 1208.
  30. Kendall NAS, Linton SJ, Main CJ. Guide to Assessing Psychological Yellow Flags in Acute Low Back Pain: Risk Factors for Long-term
    Disability and Work Loss.Wellington: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National
    Health Committee, 1997.
  31. Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and advice to stay active for acute low back pain. Br J Gen Pract 1997;47:642.
  32. Burton AK, Waddell G, Tillotson KM, et al. Information and advice to patients with back pain can have a positive effect: a randomized
    controlled trial of a novel educational booklet in primary care. Spine 1999;24:2484-2491.
  33. Krause N, Dasinger LK, Neuhauser F. Modified work and return to work: a review of the literature. J Occup Rehabil 1998;8:113-139.
  34. Loisel P, Abenhaim L, Durand P, et al. A population-based, randomized clinical trial on back pain management. Spine 1997;22:2911-2918.
  35. HeymansMW, van TulderMW, Esmail R, et al. Back schools for nonspecific low-back pain. Cochrane Database of Systematic Reviews 2004, Issue 4.
  36. Karjalainen KA, Malmivaara A, van Tulder MW, et al. Multidisciplinary biopsychosocial rehabilitation for subacute low-back pain among working age adults. Cochrane Database of Systematic Reviews 2003, Issue 2.
  37. van Tulder MW, Goossens M, Waddell G, et al. Conservative treatment of chronic low back pain. In: Nachemson A, Jonsson E, eds. Swedish SBU Report. Evidence Based Treatment for Back Pain. Stockholm/ Philadelphia, PA: Swedish Council on Technology Assessment in Health Care/Lippincott.
  38. Krause N, Dasinger LK, Neuhauser F. Modified work and return to work: a review of the literature. J Occup Rehabil 1998; 8: 113–139.
  39. Tate RB, Yassi A, Cooper J. Predictors of time loss after back injury in nurses. Spine 1999;24:1930-1936.
  40. van Tulder MW, Esmail R, Bombardier C, et al. Back schools for nonspecific low back pain (Cochrane Review). The Cochrane Library, Issue 3. Oxford: Update Software, 1999.
  41. Roelofs PDDM, Deyo RA, Koes BW, et al. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database of Systematic Reviews 2008, Issue 1.
  42. van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for nonspecific low-back pain. Cochrane Database of Systematic Reviews 2003, Issue 4.
  43. Furlan AD, ImamuraM, Dryden T, et al. Massage for low-back pain. Cochrane Database of Systematic Reviews 2008, Issue 4.
  44. Deshpande A, Furlan AD, Mailis-Gagnon A, et al. Opioids for chronic lowback pain. Cochrane Database of Systematic Reviews 2007, Issue 3.
  45. Furlan AD, van TulderMW, CherkinD, et al. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1.
  46. Walker BF, French SD, Grant W, et al. Combined chiropractic interventions for low-back pain. Cochrane Database of Systematic Reviews 2010, Issue 4.
  47. Khadilkar A, Odebiyi DO, Brosseau L, et al. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database of Systematic Reviews 2008, Issue 4.