Low back pain: early management of persistent non-specific low back pain

National Institute for Health and Clinical Excellence

Specific causes of low back pain (not covered in this guideline)

• Malignancy

• Fracture

• Infection

• Ankylosing spondylitis and other inflammatory disorders

This guideline refers to the management of non-specific low back pain only. Clinical assessment should exclude people with signs and symptoms suggestive of spinal malignancy, infection, fracture, cauda equina syndrome, or ankylosing spondylitis or another inflammatory disorder

Assessment and imaging

• Do not offer X-ray of the lumbar spine

• Only offer magnetic resonance imaging (MRI) for non-specific low back pain in the context of a referral for an opinion on spinal fusion

• Consider MRI if one of these diagnoses is suspected:
• spinal malignancy
• cauda equina syndrome
• infection
• ankylosing spondylitis or another
• fracture inflammatory disorder

Advice and education

• Provide advice and information to promote self-management

• Offer educational advice that:
• includes information on the nature of non-specific low back pain
• encourages normal activities as far as possible

• Advise people to stay physically active and to exercise

• Include an educational component consistent with this guideline as part of other interventions (but don’t offer stand-alone formal education programmes)

• When considering recommended treatments, take into account the person’s expectations and preferences (but bear in mind that this won’t necessarily predict a better outcome)

Drug treatments*

• Paracetamol:
• advise regular paracetamol as the first option
• when regular paracetamol alone is insufficient (and taking account of individual risk of side effects and patient preference), offer non-steroidal anti-inflammatory drugs (NSAIDs) and/or weak opioids

• NSAIDs:
• give due consideration to risk of opioid dependence and side effects, especially in older people and those at increased risk of side effects
• offer treatment with a standard oral NSAID/ cyclooxygenase 2 (COX-2) inhibitor
• co-prescribe a proton pump inhibitor (PPI) for people over 45 (choose the one with the lowest acquisition cost)

• Weak opioids:
• give due consideration to risk of opioid dependence and side effects
• examples of weak opioids are codeine and dihydrocodeine

• Tricyclic antidepressants:
• consider offering if other medications are insufficient; 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

• Strong opioids:
• consider offering for short-term use to people in severe pain
• consider referring people requiring prolonged use for specialist assessment
• give due consideration to risk of opioid dependence and side effects
• examples of strong opioids are buprenorphine, diamorphine, fentanyl, oxycodone and tramadol (high dose)

• For all medications, base decisions on continuation on individual response

Choice of treatments

• Offer one of the following treatment options, taking patient preference into account

• Consider offering:
• structured exercise programme:
• up to 8 sessions over up to 12 weeks
• supervised group exercise programme in a group of up to 10 people, tailored to the person
• one-to-one supervised exercise programme only if a group programme is not suitable
• may include aerobic activity, movement instruction, muscle strengthening, postural control and stretching
• manual therapy^†:
• course of manual therapy, including spinal manipulation
• up to 9 sessions over up to 12 weeks
• acupuncture:
• course of acupuncture needling
• up to 10 sessions over up to 12 weeks

• If the chosen treatment doesn’t result in satisfactory improvement, consider offering another of these options

• Do not offer:
• selective serotonin reuptake inhibitors for treating pain
• injections of therapeutic substances into the back
• laser therapy
• interferential therapy
• therapeutic ultrasound
• transcutaneous electrical nerve stimulation
• lumbar supports
• traction

• Do not refer for:
• radiofrequency facet joint denervation
• intradiscal electrothermal therapy
• percutaneous intradiscal radiofrequency thermocoagulation