Introduction/Objective: During recent years evidence based clinical guidelines for the management of (acute) low back pain have been issued in the USA, the UK and the Netherlands. The objective of this study is to compare the recommendations in the different guidelines concerning the use of spinal manipulation during the first 4-6 weeks of an episode of low back pain. Potential determinants of different recommendations will be considered.

Methods: Descriptive study focusing on the content of the written recommendations in the published guidelines at issue. Description and comparison of the following variables: date of publication, availability of evidence (RCTs) in the literature, use of evidence (RCTs), weighting of the evidence (system and outcome), number and discipline of members of the guideline-committee, aspects of healthcare system.

Results: Both the USA and the UK guidelines recommend (the consideration) of spinal manipulation during the first 4-6 weeks of the symptoms. The Dutch guidelines state that spinal manipulation during the first 6 weeks is not useful. Most apparent differences in the development of the guidelines seem to be the number of RCTs used, the weighting system of the evidence used (and the conclusion regarding the evidence), the number and disciplines of members involved in the committees and healthcare system in the countries at issue (direct access or GP as gatekeeper).

Discussion: Based on the same available evidence different recommendations may derive due to a number of reasons. These may include weighting the evidence (and thus the resulting strength of the evidence), magnitude of effects (including side-effects and costs), membership of the guideline committee and different setting in which the guideline should be implemented. Guidelines should be as explicit as possible in describing the route from the available evidence to the content of the recommendations.