NICE clinical guidelines
Issued: May 2009
CG88

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 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.