NICE clinical guidelines
Issued: May 2009
CG88

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

View the summary and implementation tools

This is an extract from the guidance and may be misleading if read alone. The complete guidance is available at guidance.nice.org.uk/cg88

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.

Manual therapy [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.

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.