At six weeks, if the pain has failed to settle, the patient should be offered a course of either:

  • acupuncture (10 sessions over 12weeks)
  • continuing with the course of manual therapies, including spinal manipulation (9 sessions over 12 weeks). Manual therapy is a collective term that includes spinal manipulation, spinal mobilisation and massage
  • a course of group based exercise in a class of up to 10 people (8 sessions over a period of up to 12 weeks) with encouragement to return to activity and achieving the aim of restored function. This may include aerobic activity, movement instruction, muscle strengthening, postural control and stretching
  • a one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.

These sessions should also focus on teaching the patient the principles of cognitive behavioural approach and taking into account identified yellow flags.

Do not offer/refer for:

  • SSRIs for treating pain
  • injection of therapeutic substances into the back
  • laser therapy
  • interferential therapy
  • therapeutic ultrasound
  • TENS
  • lumbar supports
  • traction

Do not refer for:

  • radio frequency facet joint denervation
  • IDET(intradiscal electrothermal therapy)
  • PIRFT(percutaneous intradiscal radio frequency thermo-coagulation treatment)

References:
Airaksinen O, Brox JI, Cedraschi C. European guidelines for the management of chronic non-specific low back pain. Brussels:European Commission Research Directorate General;2005.
Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):505-514.
Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007: 147(7):492-504.
Chou R, Qaseem A, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.
Chou R, Huffman LH. Guideline for the evaluation and management of low back pain. Glenview, Il: American Pain Society; 2009.
Chou R. et al. Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain.Spine 34: 1006-1077.
Clinical Knowledge Summaries (CKS). Back pain - low (without radiculopathy). Newcastle upon Tyne:CKS; 2009.
McIntosh G, Hall H.Lowbackpain(acute).ClinEvid2008;10:1102-32.
National Health and Medical Research Council (NHMRC). Evidence based management of acute musculoskeletal pain. Canberra:NHMRC;2003.
National Institute of Health and Clinical Excellence (NICE). Low back pain. Clinical guideline 88. London: NICE; 2009.
National Institute of Health and Clinical Excellence (NICE). Low back pain. Clinical guideline 88. London:NICE; 2009.
Organising quality and effective spinal services for patients: a report for local health communities by Spinal Taskforce. London: Department of Health; 2010.primarycare.COSTActionB13.Brussels:European Commission Research Directorate General;2004.
Van Tulder M, Becker A, Bekkering T et al. European guidelines for the management of acute nonspecific low back pain in primarycare. COSTActionB13.Brussels:European Commission Research Directorate General;2004.