Introduction
Low back pain
This guideline covers the early treatment and management of persistent or recurrent low back pain, defined as non-specific low back pain that has lasted for more than 6 weeks, but for less than 12 months. It does not address the management of severe disabling low back pain that has lasted over 12 months.
Non-specific low back pain is tension, soreness and/or stiffness in the lower back region for which it is not possible to identify a specific cause of the pain. Several structures in the back, including the joints, discs and connective tissues, may contribute to symptoms.
The lower back is commonly defined as the area between the bottom of the rib cage and the buttock creases. Some people with non-specific low back pain may also feel pain in their upper legs, but the low back pain usually predominates.
A clinician who suspects that there is a specific cause for their patient’s low back pain (see box 1) should arrange the relevant investigations. However, the diagnosis of specific causes of low back pain is beyond the remit of this guideline.
Box 1 Specific causes of low back pain (not covered in this guideline)
| MalignancyInfectionFractureAnkylosing spondylitis and other inflammatory disorders |
The management of the following conditions is not covered by this guideline:
- radicular pain resulting from nerve root compression
- cauda equina syndrome (this should be treated as a surgical emergency requiring immediate referral).
Low back pain is a common disorder, affecting around one-third of the UK adult population each year. Around 20% of people with low back pain (that is, 1 in 15 of the population) will consult their GP about it.
There is a generally accepted approach to the management of back pain of less than 6 weeks’ duration. What has been less clear is how low back pain should be managed in people whose pain and disability has lasted more than 6 weeks. Appropriate management has the potential to reduce the number of people with disabling long-term back pain, and so reduce the personal, social and economic impact of low back pain.
A key focus is helping people with persistent non-specific low back pain to self-manage their condition. Providing advice and information is an important part of this. The aim of the recommended treatments and management strategies is to reduce the pain and its impact on the person’s day-to-day life, even if the pain cannot be cured completely.
The guideline will assume that prescribers will use a drug’s summary of product characteristics to inform their decisions for individual patients. This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use (see section 1.8).
Patient-centred care
Low back pain
This guideline offers best practice advice on the care of people with non-specific low back pain.
Treatment and care should take into account patients’ needs and preferences. People with non-specific low back pain should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If patients do not have the capacity to make decisions, healthcare professionals should follow the Department of Health’s advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
Good communication between healthcare professionals and patients is essential. It should be supported by evidence-based written information tailored to the patient’s needs. Treatment and care, and the information patients are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.
If the patient agrees, families and carers should have the opportunity to be involved in decisions about treatment and care.
Families and carers should also be given the information and support they need.
Key priorities for implementation
Information, education and patient preferences
- Provide people with advice and information to promote self-management of their low back pain.
- Offer one of the following treatment options, taking into account patient preference: an exercise programme (see section 1.3.3), a course of manual therapy (see section 1.4.1) or a course of acupuncture (see section 1.6.1). Consider offering another of these options if the chosen treatment does not result in satisfactory improvement.
Physical activity and exercise
- Consider offering a structured exercise programme tailored to the person:
- This should comprise up to a maximum of eight sessions over a period of up to 12 weeks.
- Offer a group supervised exercise programme, in a group of up to 10 people.
- A one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.
- Consider offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks.
Invasive procedures
- Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of up to 12 weeks.
- Do not offer injections of therapeutic substances into the back for
non-specific low back pain.
Combined physical and psychological treatment programme
- Consider referral for a combined physical and psychological treatment programme, comprising around 100 hours over a maximum of 8 weeks, for people who:
- have received at least one less intensive treatment (see section 1.2.5) and
- have high disability and/or significant psychological distress.
Assessment and imaging
- Do not offer X-ray of the lumbar spine for the management of non-specific low back pain.
- Only offer an MRI scan for non-specific low back pain within the context of a referral for an opinion on spinal fusion (see section 1.9).
Referral for surgery
- Consider referral for an opinion on spinal fusion for people who:
- have completed an optimal package of care, including a combined physical and psychological treatment programme (see section 1.7) and
- still have severe non-specific low back pain for which they would consider surgery.
[1] The manual therapies reviewed were spinal manipulation, spinal mobilisation and massage (see section 1.4 for further details). Collectively these are all manual therapy. Mobilisation and massage are performed by a wide variety of practitioners. Manipulation can be performed by chiropractors and osteopaths, as well as by doctors and physiotherapists who have undergone specialist postgraduate training in manipulation.
1 Guidance
- 1.1 Assessment and imaging
- 1.2 Information, education and patient preferences
- 1.3 Physical activity and exercise
- 1.4 Manual therapy
- 1.5 Other non-pharmacological therapies
- 1.6 Invasive procedures
- 1.7 Combined physical and psychological treatment programme
- 1.8 Pharmacological therapies
- 1.9 Referral for surgery
The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.
1.1 Assessment and imaging
1.1.1 Keep diagnosis under review.
1.1.2 Do not offer X-ray of the lumbar spine for the management of non-specific low back pain.
1.1.3 Consider MRI (magnetic resonance imaging) when a diagnosis of spinal malignancy, infection, fracture, cauda equina syndrome or ankylosing spondylitis or another inflammatory disorder is suspected.
1.1.4 Only offer an MRI scan for non-specific low back pain within the context of a referral for an opinion on spinal fusion (see section 1.9).
1.2 Information, education and patient preferences
1.2.1 Provide people with advice and information to promote self-management of their low back pain.
1.2.2 Offer educational advice that:
- includes information on the nature of non-specific low back pain
- encourages the person to be physically active and continue with normal activities as far as possible.
1.2.3 Include an educational component consistent with this guideline as part of other interventions, but do not offer stand-alone formal education programmes.
1.2.4 Take into account the person’s expectations and preferences when considering recommended treatments, but do not use their expectations and preferences to predict their response to treatments.
1.2.5 Offer one of the following treatment options, taking into account patient preference: an exercise programme (see section 1.3.3), a course of manual therapy (see section 1.4.1) or a course of acupuncture (see section 1.6.1). Consider offering another of these options if the chosen treatment does not result in satisfactory improvement.
1.3 Physical activity and exercise
1.3.1 Advise people with low back pain that staying physically active is likely to be beneficial.
1.3.2 Advise people with low back pain to exercise.
1.3.3 Consider offering a structured exercise programme tailored to the person:
- This should comprise up to a maximum of eight sessions over a period of up to 12 weeks.
- Offer a group supervised exercise programme, in a group of up to 10 people.
- A one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.
1.3.4 Exercise programmes may include the following elements:
- aerobic activity
- movement instruction
- muscle strengthening
- postural control
- stretching.
1.4 Manual therapy
The manual therapies reviewed were spinal manipulation (a low-amplitude, high-velocity movement at the limit of joint range that takes the joint beyond the passive range of movement), spinal mobilisation (joint movement within the normal range of motion) and massage (manual manipulation or mobilisation of soft tissues). Collectively these are all manual therapy. Mobilisation and massage are performed by a wide variety of practitioners. Manipulation can be performed by chiropractors and osteopaths, as well as by doctors and physiotherapists who have undergone specialist postgraduate training in manipulation.
1.4.1 Consider offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks.
1.5 Other non-pharmacological therapies
Electrotherapy modalities
1.5.1 Do not offer laser therapy.
1.5.2 Do not offer interferential therapy.
1.5.3 Do not offer therapeutic ultrasound.
Transcutaneous nerve stimulation
1.5.4 Do not offer transcutaneous electrical nerve simulation (TENS).
Lumbar supports
1.5.5 Do not offer lumbar supports.
Traction
1.5.6 Do not offer traction.
1.6 Invasive procedures
1.6.1 Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of up to 12 weeks.
1.6.2 Do not offer injections of therapeutic substances into the back for non-specific low back pain.
1.7 Combined physical and psychological treatment programme
1.7.1 Consider referral for a combined physical and psychological treatment programme, comprising around 100 hours over a maximum of 8 weeks, for people who:
- have received at least one less intensive treatment (see section 1.2.5) and
- have high disability and/or significant psychological distress.
1.7.2 Combined physical and psychological treatment programmes should include a cognitive behavioural approach and exercise.
1.8 Pharmacological therapies
Both weak opioids and strong opioids are discussed in the recommendations in this section. Examples of weak opioids are codeine and dihydrocodeine (these are sometimes combined with paracetamol as co-codamol or co-dydramol, respectively). Examples of strong opioids are buprenorphine, diamorphine, fentanyl and oxycodone. Some opioids, such as tramadol, are difficult to classify because they can act like a weak or strong opioid depending on the dose used and the circumstances.
No opioids, cyclooxygenase 2 (COX-2) inhibitors or tricyclic antidepressants and only some non-steroidal anti-inflammatory drugs (NSAIDs) have a UK marketing authorisation for treating low back pain. If a drug without a marketing authorisation for this indication is prescribed, informed consent should be obtained and documented.
1.8.1 Advise the person to take regular paracetamol as the first medication option.
1.8.2 When paracetamol alone provides insufficient pain relief, offer:
- non-steroidal anti-inflammatory drugs (NSAIDs) and/or
- weak opioidsTake into account the individual risk of side effects and patient preference.
1.8.3 Give due consideration to the risk of side effects from NSAIDs, especially in:
- older people
- other people at increased risk of experiencing side effects.
1.8.4 When offering treatment with an oral NSAID/COX-2 (cyclooxygenase 2) inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor. In either case, for people over 45 these should be co-prescribed with a PPI (proton pump inhibitor), choosing the one with the lowest acquisition cost. [This recommendation is adapted from ‘Osteoarthritis: the care and management of osteoarthritis in adults’ (NICE clinical guideline 59).]
1.8.5 Consider offering tricyclic antidepressants if other medications provide insufficient pain relief. Start at a low dosage and increase up to the maximum antidepressant dosage until therapeutic effect is achieved or unacceptable side effects prevent further increase.
1.8.6 Consider offering strong opioids for short-term use to people in severe pain.
1.8.7 Consider referral for specialist assessment for people who may require prolonged use of strong opioids.
1.8.8 Give due consideration to the risk of opioid dependence and side effects for both strong and weak opioids.
1.8.9 Base decisions on continuation of medications on individual response.
1.8.10 Do not offer selective serotonin reuptake inhibitors (SSRIs) for treating pain.
1.9 Referral for surgery
1.9.1 Consider referral for an opinion on spinal fusion for people who:
- have completed an optimal package of care, including a combined physical and psychological treatment programme (see section 1.7) and
- still have severe non-specific low back pain for which they would consider surgery.
1.9.2 Offer anyone with psychological distress appropriate treatment for this before referral for an opinion on spinal fusion.
1.9.3 Refer the patient to a specialist spinal surgical service if spinal fusion is being considered. Give due consideration to the possible risks for that patient.
1.9.4 Do not refer people for any of the following procedures:
- intradiscal electrothermal therapy (IDET)
- percutaneous intradiscal radiofrequency thermocoagulation (PIRFT)
- radiofrequency facet joint denervation.
2 Notes on the scope of the guidance
NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover. The scope of this guideline is available.
How this guideline was developed
NICE commissioned the National Collaborating Centre for Primary Care to develop this guideline. The Centre established a Guideline Development Group (see appendix A), which reviewed the evidence and developed the recommendations. An independent Guideline Review Panel oversaw the development of the guideline (see appendix B).
There is more information about how NICE clinical guidelines are developed on the NICE website. A booklet, ‘How NICE clinical guidelines are developed: an overview for stakeholders, the public and the NHS’ is available.
