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NICE guidelines for the management of non-specific low back pain

Issue 27 Synovium (Summer 2009)

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The publication of NICE guidelines for the early management of persistent low back pain1 made the national press recently. Unfortunately, as is often the case with material that makes a good story, the reporting was not always without some inaccuracy: 'Back patients to get acupuncture on the NHS'. However, we must not grumble. Some helpful and important messages were conveyed to newspaper readers. Synovium does not have sufficient space to list let alone discuss all the recommendations. Here we present some editor's highlights.


  1. Offer information about the nature of low back pain and advice to enable self-management of the problem.
  2. Advise patients to take exercise and remain active.
  3. Take into account the patient's expectations and preferences when formulating a management plan.
  4. Consider offering: (a) a structured programme of exercise, OR (b) a course of manual therapy of up to 9 sessions, OR (c) a course of acupuncture of up to 10 sessions. If there is no improvement consider offering one of the other options.
  5. Consider referral for combined physical and psychological treatment of up to 100 hours, including a cognitive behavioural approach and exercise, in patients who have not benefited from a less intensive approach and/or who have high levels of disability and distress.
  6. Consider referral for an opinion regarding spinal fusion in patients who have not benefited from all of the above.
  7. Treat psychological distress appropriately before surgical referral.


  1. Do not order x-rays.
  2. Do not order MRI scans unless fracture, infection, malignancy, inflammatory disease or cauda equina syndrome is suspected.
  3. Do not offer electrotherapies, including interferential, laser, therapeutic ultrasound or transcutaneous nerve stimulation.
  4. Do not offer injection treatments.
  5. Do not offer traction or lumbar supports.

There is much more to read including advice about the prudent use of analgesics and anti-inflammatory drugs and some other interventions that are not considered appropriate.

Implementing these guidelines will require a significant increase in resources to provide the acupuncture, exercise programmes, manipulative therapiy and cognitive behavioural therapy. Clearly these will not appear overnight, especially at a time when health service funding is under pressure from a harsh economic climate – so newspaper claims may be wide of the mark. However, resources will be saved by reduction in the use of imaging and the cessation of ineffective, expensive and invasive treatments, and it is to be hoped that these savings will be directed towards the provision of the treatments that are now recommended.

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