These brief clinical guidelines and their supporting base of research evidence is
intended to assist in the management of acute back pain. It presents a synthesis
of up-to-date international evidence and makes recommendations on case management.
Recommendations and evidence relate primarily to the first six weeks of an
episode, when management decisions may be required in a changing clinical picture.
These guidelines have been constructed by a multi-professional group and
No Sign of any serious damage or disease.
subjected to extensive professional review.
Full recovery in days or weeks - but may vary.
They are intended to be used as a guide by the whole range of health
professionals who advise people with acute low back pain, particularly simple
backache, in the NHS and in private practice.
Recurrence possible -but does not mean re-injury.
Activity is helpful, too much rest is not.
♦ Consideration of "Red Flag" symptoms.
♦ Recommendation to return to normal activities.
Local ownership is important. Guidelines should be placed in local
No cause for alarm. No sign of disease.
context but not at the expense of changing the principle
Conservative treatment should suffice - but may take a ♦
Multiple methods of implementation are more likely to be effective thatn
single methods. These can include peer groups, audit feedback,
♦ Full recovery expected - but recurrence possible.
Psychosocial 'Yellow Flags'
When conducting assessment, it may be useful to consider
psychosocial 'yellow flags' (beliefs or behaviours on the part of the
patient which may predict poor outcomes).
Possible Serious Spinal Pathology
The following factors are important and consistently predict poor
♦ a belief that back pain is harmful or potentially severely disabling
♦ Some tests are needed to make the diagnosis.
♦ fear-avoidance behaviour and reduced activity levels
tendency to low mood and withdrawal from social interaction
expectation of passive treatment(s) rather than a belief that active
♦ The specialist will advise on the best treatment.
Further information and copies of the full evidence base for these guidelines are available from: Contributing Organisations
Rest or activity avoidance until appointment to see
14 Princes Gate, Hyde Park, London SW7 1PU
Professor Gordon Waddell, NHS Executive, Clinical Standards
The above messages can be enhanced by an educational booklet given
Advisory Group, U.S. Agency for Health Care Policy and Research,
Waddell G, McIntosh A, Hutchinson A, Feder G, Lewis M, (1999) Low Back Pain
at consultation. The back book is an evidence based booklet developed
Swedish SBU, NZ National Health Committee
Evidence Review London: Royal College of General Practitioners
for use with these guidelines, and is published by HMSO.
This document may be downloaded and photocopied freelyDiagnostic triage is the differential diagnosis between:
♦ Assessment
Diagnostic triage forms basis for referral, investigation
♦ simple backache (non-specific low back pain)
♦ Carry out diagnostic triage (see left).
♦ X-rays are not routinely indicated in simple backache.
Royal College of Radiologists Guidelines
possible serious spinal pathology (tumour, infection,
Psychosocial factors play an important role in low back
pain and disability and influence the patients response to
inflammatory disorders, cauda equina syndrome, etc.)
Simple backache: specialist referral not required
♦ Drug Therapy
Paracetamol effectively reduces low back pain.
♦ Prescribe analgesics at regular intervals not p.r.n.
NSAIDs effectively reduce pain. Ibuprofen and
Start with paracetamol. If inadequate substitute NSAIDs
diclofenac have lower risks of GI complications.
(e.g. ibuprofen or diclofenac) and then paracetamol-weak
Paracetamol-weak opioid compounds may be effective
Nerve root pain: specialist referral not generally required
opioid compound (e.g. codydramol or coproxamol). Finally,
when NSAIDs or paracetamol alone are inadequate.
consider adding a short course of muscle relaxant (e.g.
Muscle relaxants effectively reduce low back pain.
within first four weeks, provided resolving
♦ Numbness & paraesthesia in same distribution
♦ Bed Rest
Bed rest for 2-7 days is worse than placebo or ordinary
♦ Do not recommend or use bed rest as a treatment
activity and is not as effective as alternative treatments
♦ Some patients may be confined to bed for a few days as a
for relief of pain, rate of recovery, return to daily
consequence of their pain but this should not be considered
Red flags for Possible serious spinal pathology: prompt referral (less than four weeks)
♦ Advice on staying active
Advice to continue ordinary activity can give equivalent
Advise patients to stay as active as possible and to continue
or faster symptomatic recovery from the acute attack and
lead to less chronic disability and less time off work.
♦ Advise patients to increase their physical activities
♦ If a patient is working, then advice to stay at work or return
to work as soon as possible is probably beneficial.
♦ Manipulation Cauda equina syndrome:immediate referral
Manipulation can provide short-term improvement in
Consider manipulative treatment for patients who need
pain and activity levels and higher patient satisfaction.
additional help with pain relief or who are failing to return
The optimum timing for this intervention is unclear.
The risks of manipulation are very low in skilled hands.
The evidence is weighted as follows:- Back exercises
It is doubtful that specific back exercises produce clinically
*** Generally consistent finding in a majority of acceptable studies.
♦ Referral for reactivation / rehabilitation should be
significant improvement in acute low back pain.
** Either based on a single acceptable study or a weak or inconsistent finding in
considered for patients who have not returned to ordinary
There is some evidence that exercise programmes and physical
reconditioning can improve pain and functional levels in
* Limited scientific evidence which does not meet all the criteria of 'acceptable'
patients with chronic low back pain. There are theoretical
arguments for starting this at around 6 weeks
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These brief clinical guidelines and their supporting base of research evidence is
intended to assist in the management of acute back pain. It presents a synthesis
of up-to-date international evidence and makes recommendations on case management.
Recommendations and evidence relate primarily to the first six weeks of an
episode, when management decisions may be required in a changing clinical picture.
These guidelines have been constructed by a multi-professional group and
No Sign of any serious damage or disease.
subjected to extensive professional review.
Full recovery in days or weeks - but may vary.
They are intended to be used as a guide by the whole range of health
professionals who advise people with acute low back pain, particularly simple
backache, in the NHS and in private practice.
Recurrence possible -but does not mean re-injury.
Activity is helpful, too much rest is not.
♦ Consideration of "Red Flag" symptoms.
♦ Recommendation to return to normal activities.
Local ownership is important. Guidelines should be placed in local
No cause for alarm. No sign of disease.
context but not at the expense of changing the principle
Conservative treatment should suffice - but may take a ♦
Multiple methods of implementation are more likely to be effective thatn
single methods. These can include peer groups, audit feedback,
♦ Full recovery expected - but recurrence possible.
Psychosocial 'Yellow Flags'