Guideline

• 1. firstly you screen to patient to clear red flags
  2. then provide education and advice on self management and then stratify on level of risk of not getting better

  
• Assessment and risk stratification:

  • Think about alternative diagnoses when examining or reviewing people with low back pain, particularly if they develop new or changed symptoms
  • Exclude specific causes of low back pain, for example cancer, infection, trauma or inflammatory disease such as spondyloarthritis
  • Consider using risk stratification (for example, the STarT Back risk assessment tool) at first point of contact to inform shared decision-making

  
• STarT Back risk assessment

  
• STarT Back scoring

  
• Based on risk stratification, consider::

  • >simpler and less intensive support for people likely to improve quickly and have a good outcome (for example, reassurance, advice to keep active and guidance on self-management)
  • more complex and intensive support for people at higher risk of a poor outcome (for example, exercise programmes with or without manual therapy or using a psychological approach)
• Self management: Low back pain ± sciatica:

  • Provide people with advice and information, tailored to their needs and capabilities, to help them selfmanage their low back pain ± sciatica:
  • the benign nature of the condition
  • the good probability of a rapid improvement in symptoms
  • the importance of early return to normal life activities, including return to work where applicable
  • the value of engaging in exercise
• Imaging: Low back pain ± sciatica:

  • Do not routinely offer imaging in a non-specialist setting for people with low back pain ± sciatica
  • Explain to people with low back pain ± sciatica that if they are being referred for specialist opinion, they may not need imaging
  • Consider imaging in specialist settings of care (for example, a musculoskeletal interface clinic or hospital) for people with low back pain ± sciatic only if the result is likely to change management
• Non-invasive treatments: CONSIDER:

  • Exercise in group programme LBP
  • Manual therapy only as part of a treatment package including exercise, with or without psychological therapy
  • Psychological therapies (using a cognitive behavioural CBT approach) only as part of a treatment package including exercise, with or without manual therapy
  • Combined physical and psychological rehab programmes incl. CBT approach where psychosocial obstacles to recovery or previous treatments not effective
  • Promote and facilitate return to work or normal activities of daily living
• Pharmacological treatments:

  • Consider oral NSAIDs for managing low back pain
  • taking into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person’s risk factors, including age
  • NSAIDs
  • Think about appropriate clinical assessment
  • Ongoing monitoring of risk factors
  • Use of gastroprotective treatment
  • Lowest effective dose for the shortest possible period of time
  • Consider weak opioids (with or without paracetamol) for managing acute low back pain only if an NSAID is contraindicated, not tolerated or has been ineffective
• Sciatica pathway Non-invasive treatments, as above - Epidural steroid + local anaesthetic:

  • For acute and severe sciatica of less than 3 months duration, for people who would be considered for surgery
  • Do not use for claudicant leg pain due to central spinal canal stenosis: insufficient evidence of clinical benefit
• Sciatica pathway Non-invasive treatments, as above - Surgical decompression:

  • Consider spinal decompression for people with sciatica when non-surgical treatment has not improved pain or function and their radiological findings are consistent with sciatic symptoms
  • Dont allow a person’s BMI, smoking status or psychological distress to influence the decision to refer them for a surgical opinion for sciatica
• Radiofrequency denervation for Chronic low back pain:

  • Consider referral for assessment for RF denervation for people with chronic low back pain when:
  • non-surgical treatment has not worked for them and
  • main source of pain is thought to come from structures supplied by the medial branch nerve and
  • moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at time of referral
• Do not offer:

  • Manual therapy without exercise - Conflicting evidence, and uncertainty about long term clinical and cost effectiveness of manual therapy alone. Some evidence for use alongside exercise
  • Psychological treatments without exercise - Limited clinical evidence of small effects. Conflicting cost effectiveness evidence of psychological treatments alone. Some evidence for use alongside exercise
• Do not offer:

  • Acupuncture - No important effect over sham, no evidence for subgroups who might benefit, further research unlikely to change recommendation
  • Orthotics, belts, corsets, rocker sole shoes - Very limited clinical evidence of benefit
  • Traction - Very limited clinical evidence of benefit
  • Electrotherapies:
  • PENS: insufficient evidence as recommendation would be a significant change in clinical practice
  • TENS: conflicting evidence
  • Interferential: evidence of no clinical benefit
  • Therapeutic ultrasound: insufficient evidence of clinical benefit
• Do not offer:

  • Paracetamol - No efficacy for acute LBP, no evidence for chronic LBP
  • Opioids* - *except weak opioids ± paracetamol for acute LBP if NSAID not tolerated or ineffective
  • Antidepressants: Amitriptyline, SSRIs, SNRIs (for back pain) - No clinically important differences compared to placebo
• Do not offer:

  • Spinal injections for low back pain (without sciatica)
  • Facet joint injections
  • Medial branch blocks
  • Intradiscal therapy
  • Prolotherapy
  • Trigger point injections
  • Epidural steroid
  • Spinal fusion for low back pain, except as part of RCT
  • Lumbar disc replacement