NICE clinical guidelines
Issued: May 2009

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

This is an extract from the guidance. The complete guidance is available at


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)




Ankylosing 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).