Intended for healthcare professionals

Practice Guidelines

Early management of persistent non-specific low back pain: summary of NICE guidance

BMJ 2009; 338 doi: (Published 04 June 2009) Cite this as: BMJ 2009;338:b1805
  1. Pauline Savigny, health services research fellow1,
  2. Paul Watson, professor of pain management and rehabilitation2,
  3. Martin Underwood, professor of primary care research3
  4. on behalf of the Guideline Development Group
  1. 1National Collaborating Centre for Primary Care, Royal College of General Practitioners, London SW7 1PU
  2. 2Department of Health Science, Academic Unit, University of Leicester, Leicester LE5 4PW
  3. 3Warwick Medical School, University of Warwick, Coventry CV4 7AL
  1. Correspondence to: M Underwood m.underwood{at}

    Why read this summary?

    Most episodes of acute low back pain resolve spontaneously.1 However, among those in whom low back pain and disability have persisted for over a year, few return to normal activities. Thus the focus for preventing the onset of long term disability caused by non-specific low back pain is on the early management of persistent low back pain (pain present for more than six weeks and less than one year). No consensus exists on how to help health professionals and their patients choose the best treatments for this condition.

    This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the early management of non-specific low back pain.1 The diagnosis of specific causes of low back pain (malignancy, infection, fracture, ankylosing spondylitis, and other inflammatory disorders) is not part of this guideline.


    NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. The box lists treatments that should not be offered for non-specific low back pain.

    Treatments not recommended for non-specific low back pain

    Do not offer
    • Radiography of the lumbar spine [Based on two high quality randomised controlled trials and economic evaluations]

    • Selective serotonin reuptake inhibitors for treating pain [Based on a high quality systematic review and the experience and opinion of the Guideline Development Group (GDG)]

    • Injections of therapeutic substances into the back [Based on three well conducted studies—two systematic reviews and one randomised controlled trial (RCT)]

    • Laser therapy [Based on one high quality systematic review including low quality RCTs]

    • Interferential therapy (electrical treatment using two alternating medium frequency currents) [Based on the experience and opinion of the …

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