Professor Martin Underwood outlines the NICE guideline on non-specific low back pain and explains the rationale behind the recommended treatment options

Nearly everyone will be affected by non-specific low back pain at some time in their lives. For most, this is a short-lived episode not requiring any professional advice. However, many people do seek professional advice for low back pain. In addition to GPs, there are increasing numbers of direct-access physiotherapy services provided by primary care trusts, and a large number of private physical therapists (e.g. chiropractors, osteopaths, physiotherapists) are the first point of contact for people with low back pain. A typical GP may see one or two patients with back pain in every surgery, but for many physical therapists, treatment of this condition is a major part of their working life.

Prevalence and cost of low back pain

There are insufficient data on how many people have back pain lasting between 6 weeks and 1 year because studies do not distinguish between those with pain persisting for more or less than 1 year. Estimates on the prevalence of low back pain vary considerably. It may affect up to a third of the population on any single day and two-thirds over a year.1 Each year approximately 1 in 15 of the adult population (or around 2.6 million people) consult their GP because of low back pain.2,3 In 1998, the cost of treating back pain was £1632 million; one-third of this figure (£565 million) was borne by patients and insurers. It is estimated that in the same year, the cost of lost production was at least £3.4 million in the UK.4


The NICE guideline Low back pain: early management of persistent non-specific low back pain defines this condition as 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 joints, discs, and connective tissues, may contribute to symptoms. The lower back is commonly described as the area bounded by 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 pain in the low back usually predominates.5,6 Most patients with acute low back pain (<6 weeks) who seek help receive the generally accepted advice of maintaining physical activity and the appropriate use of painkillers, and in most cases they improve rapidly. Unfortunately, few people with disabling low back pain that has been present for over 1 year are able to return to normal activities.


The NICE guideline on the early management of persistent low back pain focuses on patients who have had low back pain for between 6 weeks and 1 year of onset.5,6 This stage is crucial because it is the period during which more active interventions may prevent onset of chronic disability. Improved treatment for these patients has the potential to reduce the number of people with disabling long-term back pain, thereby reducing the personal, social, and economic impact of this condition.5,6

The guideline is not intended to inform the management of patients with:5,6

  • chronic (longer than 12 months) disabling non-specific low back pain
  • radicular pain (sciatica)
  • suspected cauda equina syndrome (this should be treated as a surgical emergency requiring immediate referral).


Before using the NICE guideline, the clinician needs to be satisfied that there is not a specific cause for the patient’s pain. The guideline does not make recommendations on how to diagnose specific causes of low back pain.5,6 The diagnosis should be kept under review, particularly if the patient is not improving (see Box 1).

Use of imaging
There is only a very small role for imaging in the management of non-specific low back pain. If a specific cause is suspected, appropriate investigations may include a magnetic resonance imaging (MRI) scan of the lumbar spine (see Box 1). An MRI may also be appropriate in the context of a referral for a surgical opinion. However, apart from such situations, computed tomography scans, MRI scans, and X-rays have no role in the management of persistent non-specific low back pain. Although there is some increase in patient satisfaction following X-rays, they do not improve clinical outcome and they create unnecessary exposure to radiation.

The NICE guideline contains a care pathway that includes the principles of management for patients with low back pain (see Figure 1).7

Box 1: Specific causes of low back pain
  • Malignancy
  • Infection
  • Fracture
  • Ankylosing spondylitis and other inflammatory disorders
Consider ordering a magnetic resonance imaging scan if one of these diagnoses is suspected
Figure 1: Care pathway for early management of persistent non-specific low back pain7
figure 1
National Institute for Health and Care Excellence (NICE) (2009) CG88. Low back pain: early management of persistent non-specific low back pain. London: NICE. Available from Reproduced with permission.

Principles of management

All patients with low back pain should be supported in the self-management of their condition. Specifically, they should be:5,6

  • offered information on the nature of non-specific low back pain
  • advised to exercise, to be physically active, and to continue their normal activities as far as possible
  • offered an educational component consistent with the NICE guideline as part of other interventions (stand-alone formal education programmes should not be provided).

Healthcare professionals should offer pain-killing drugs and a choice of different therapies to patients (Box 2). When considering recommended treatments, the patient’s expectations and preferences should be taken into account, but this should not be used to predict a better outcome.

Pharmacological options
Healthcare professionals should note that several drugs that are effective for relief of low back pain do not have a product licence for such use. Before using such drugs, informed consent from the patient should be recorded.

Regular paracetamol is the first medication option. If this provides insufficient pain relief then either non-steroidal anti-inflammatory drugs (NSAIDs) and/or weak opioids can be substituted for, or added to, regular paracetamol. A decision to prescribe either an NSAID/cyclooxygenase-2 (COX-2) inhibitor or a weak opioid should take into account patient preferences and the individual’s risk of side-effects. If NSAIDs or COX-2 inhibitors are prescribed, due consideration needs to be given to the risk of side-effects, particularly in older people and others at increased risk. Patients who are aged over 45 years and those who are at high risk of an upper gastrointestinal haemorrhage should be co-prescribed a proton pump inhibitor with NSAIDs/COX-2 inhibitors.5,6

Tricyclic antidepressants, but not selective serotonin reuptake inhibitors (SSRIs), are effective in reducing low back pain. They can be used if paracetamol, NSAIDs/COX-2 inhibitors, and weak opioids do not provide sufficient pain relief. Typically, when treatment with tricyclics is initiated, a low dose is used (e.g. 10 mg or 25 mg of amitriptyline). However, trials demonstrating the efficacy of tricyclic antidepressants in treating low back pain involved doses equivalent to that in an antidepressant role (e.g. 75–150 mg of amitriptyline).8 For this reason, the NICE guideline recommends starting at a low dose and increasing up to the maximum antidepressant dose until there is therapeutic improvement or unacceptable side-effects prevent a further increase.5,6

Strong opioids can be used for short-term pain relief in patients with severe low back pain, although there is a risk of side-effects and, in particular, dependence. People requiring prolonged courses of strong opioids should be referred for specialist assessment.5,6

Any decisions to continue medication should be based on the individual’s response to treatment.5,6

Therapies for low back pain
Exercise programmes, courses of manual therapy including manipulation, and acupuncture have all been shown to be both effective and cost-effective for low back pain. The cost per quality-adjusted life year (QALY) for all of these treatments is modest:6

  • acupuncture = £4241
  • manual therapy = £4800
  • group exercise = £8700.

Thus, although the average clinical effect of these treatments is small to moderate, they all represent excellent value for the NHS. It is possible that patients will respond differently to different treatments and, for this reason, a choice of these therapeutic options should be available to patients (see Box 2).

Intensive treatment programmes
If a patient continues to have high disability or significant psychological distress after both initial advice and receiving one or more courses of recommended therapies, an intensive course of combined physical and psychological treatments, including both a cognitive behavioural approach and exercise, should be offered. Typically, these should consist of around 100 hours of contact time over 8 weeks.5,6 Few people have been able to access these programmes, and then only if they have long-standing disabling back pain. Ensuring that this type of treatment is made more widely available to patients with severe back pain at a much earlier time during the course of the disorder is an important innovation.

Surgical referral
The only surgical treatment with evidence of effectiveness is spinal fusion. This may be an option for selected patients who continue to have severe pain after intensive conservative treatment and who would consider surgery. Only this group of patients should be referred for a surgical opinion from a specialist spinal surgical service offering spinal fusion.5,6

Box 2: Therapies for persistent non-specific low back pain5,6

Offer a choice of the following therapies, taking patient preference into account:

Structured exercise programme

  • Up to eight 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
  • These may include:
    • aerobic activity
    • movement instruction
    • muscle strengthening
    • postural control
    • stretching

Manual therapy

  • Course of manual therapy, including spinal manipulation
  • Up to nine sessions over up to 12 weeks


  • Course of acupuncture needling
  • Up to 10 sessions over up to 12 weeks

If the chosen treatment does not result in satisfactory improvement, consider offering another of these treatment options

What treatments are not recommended

A wide range of treatments has been suggested for low back pain, but only a few have been recommended in the NICE guideline. All of the positive recommendations regarding treatment are evidence based and there is a lack of evidence of sufficient quality to support the use of other therapies. For some of these interventions there are theoretical reasons to anticipate that they might be effective, but in the absence of data demonstrating effectiveness, they have not been recommended. Treatments that are not recommended for low back pain include:5,6

  • injections of therapeutic substances into the back
  • interferential therapy
  • intradiscal electrothermal therapy
  • laser therapy
  • lumbar supports
  • percutaneous intradiscal radiofrequency thermocoagulation
  • radiofrequency facet joint denervation
  • spinal traction
  • SSRIs for treating pain
  • therapeutic ultrasound
  • transcutaneous electrical nerve stimulation.

Research is needed to demonstrate conclusively whether or not the above interventions are effective. Specific recommendations have been made for further research into educational programmes, facet joint injections, psychological treatments, radiofrequency lesioning, and transcutaneous electrical nerve stimulation.5,6

Service provision

In many ways the NICE guideline represents a sea change in the approach to managing persistent non-specific low back pain. A substantial reorganisation of therapy services will be needed to provide the recommended treatments. This may involve additional training for existing NHS staff to deliver the recommended therapy packages (exercise, manual therapy, and acupuncture) or it may involve purchasing services from providers from a range of professional backgrounds. Significant reorganisation of services and investment in staff training will be needed to allow provision of the intensive rehabilitation programmes for all of those who may benefit.


The NICE guideline provides, for the first time, a clear care pathway for patients with persistent low back pain. Good access to a range of treatments, of proven benefit, has the potential to reduce the number of people who progress from early persistent back pain to chronic disabling back pain. Implementing this guideline should reduce the personal and social costs of back pain disability.

Further information

  • Detailed information underpinning the guideline recommendations can be found in the following guideline: National Collaborating Centre for Primary Care. Low back pain: early management of persistent non-specific low back pain. London: RCGP, 2009. Available at:
  • BackCare website—general advice for patients and a helpline service manned by volunteers with back pain (


I am grateful to the other members of the NICE Guideline Development Group whose hard work has made this guideline possible:

  • Nicola Brown, Health Services Research Fellow, National Collaborating Centre for Primary Care (NCCPC)
  • Mrs Elaine Buchanan, Consultant Physiotherapist, Nuffield Orthopaedic Centre, Oxford
  • Dr Paul Coffey, General Practitioner, Eynsham Medical Group, Witney, Oxon
  • Marian Cotterell, Information Scientist, NCCPC
  • Peter Dixon, Chiropractor Chairman, General Chiropractic Council, London
  • Christine Drummond, patient representative
  • Mrs Margaret Flanagan, Nurse Clinician, Western Avenue Medical Centre, Chester
  • Professor Charles Greenough, Consultant Spinal Surgeon, James Cook University, Middlesbrough
  • Dr Mark Griffiths, Consultant Clinical Psychologist, Halton and St Helens PCT
  • Dr Jacqueline Halliday Bell, Medical Inspector, Health and Safety Executive, Birmingham
  • David Hill, Project Manager, NCCPC
  • Dr Dries Hettinga, patient representative, Head of Research and Policy, BackCare
  • Stefanie Kuntze, Health Economist, NCCPC
  • Chris Rule, Project Manager, NCCPC
  • Gill Ritchie, Guideline Lead, NCCPC
  • Pauline Savigny, Health Services Research Fellow, NCCPC
  • Mr Steven Vogel, Vice Principal (Research and Quality), British School of Osteopathy, London
  • Dr David Walsh, Associate Professor, Kings Mill Hospital, Sutton in Ashfield
  • Professor Paul Watson (Clinical Advisor), Professor of Pain Management and Rehabilitation, Department of Health Sciences, University of Leicester.
NICE implementation tools

NICE has developed the following tools to support implementation of its guideline on Low back pain—early management of persistent non-specific low back pain. They are now available to download from the NICE website:

Costing tools

National cost reports and local cost templates for the guideline have been produced:

  • costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.

Slide set

The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences. This information does not supersede or replace the guidance itself.

Audit support

This tool has been developed to support the implementation of the NICE guideline on low back pain. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. The audit support is based on the key recommendations of the guidance and includes criteria and data collection tools.

Key Points
  • Keep the diagnosis under review
  • Do not offer X-rays for non-specific low back pain
  • Only perform magnetic resonance imaging scans if a specific cause of back pain is suspected (i.e. cancer, infection, fracture, ankylosing spondylitis)
  • Offer a choice of therapies (e.g. acupuncture, manual therapy, or exercise) taking into account patient preference
  • Offer intensive treatment for people not improving after less intensive treatment
  • Consider referral to a specialist spinal surgery service for consideration of spinal fusion for selected patients with severe pain who have not responded to conservative treatment


  1. Walker B. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord 2000; 13 (3): 205–217.
  2. Macfarlane G, Jones G, Hannaford P. Managing low back pain presenting to primary care: where do we go from here? Pain 2006; 122 (3): 219–222.
  3. Arthritis Research Campaign. Arthritis: the big picture. Chesterfield: Arthritis Research Campaign, 2002. Available at:
  4. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000; 84 (1): 95–103.
  5. National Institute for Health and Care Excellence. Low back pain: early management of persistent non-specific low back pain. Clinical Guideline 88. London: NICE, 2009. Available at:
  6. National Collaborating Centre for Primary Care. Low back pain: early management of persistent non-specific low back pain. London: RCGP, 2009. Available at:
  7. National Institute for Health and Care Excellence. Low back pain: early management of persistent non-specific low back pain. Quick Reference Guide. London: NICE, 2009. Available at:
  8. Urquhart D, Hoving J, Assendelft W et al. Antidepressants for non-specific low back pain. Cochrane Database Syst Rev 2008; (1): CD001703.G
  • The NICE guideline covers a specific subset of patients with back pain and excludes many individuals who present with this condition
  • A clinical algorithm as part of a structured care pathway could help ensure appropriate referrals and prevent expenditure on ineffective therapies
  • For PBC consortia, this guideline encourages commissioning of therapies that were not previously commissioned (e.g. acupuncture and manual therapy)
  • These treatments are not covered by the tariff, but represent new costs unless referrals to orthopaedic services or pain clinics can be saved (this should happen)
  • Clinical protocols in line with the NICE guideline will be vital as specifications in any newly commissioned services are needed to ensure they remain cost effective
  • PBC consortia should closely monitor trends in orthopaedic referrals to ensure this occurs and that new services are cost effective
  • Tariff costs: orthopaedic outpatient: £135 (new), £74 (follow up)a