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Back pain - low (without radiculopathy)


Overview of management Check for the presence or absence of red flags for serious conditions such as cauda equina syndrome, spinal fracture, cancer, or infection. Assess for psychosocial risk factors for long-term pain and disability. Provide information and self-care advice to foster a positive attitude and realistic expectations. Provide analgesia to manage the pain and to help the person keep active.
For first-line analgesia, offer paracetamol (preferred) or a nonsteroidal anti-inflammatory drug (NSAID) or coxib. For additional analgesia, consider paracetamol combined with an NSAID, or adding a weak opioid such as codeine, dihydrocodeine, or tramadol. If additional analgesics are ineffective, consider offering a trial of a tricyclic antidepressant such as amitriptyline. Rarely, a strong opioid such as morphine is required for uncontrolled pain. If the use of a strong opioid becomes chronic, or the required dose is escalating, refer to, or seek advice from, a pain specialist.

Offer one of the following physical treatments, taking individual preference and availability into account.
A structured exercise programme. A course of manual therapy that includes spinal manipulation. A course of acupuncture.

If the chosen treatment does not result in satisfactory improvement, consider offering one of the other physical treatments. If there is a poor response to treatment, consider referral for a combined physical and psychological pain management programme. If severe pain persists, consider referral to a specialist spinal surgical service for an opinion on spinal fusion. Use clinical judgement to decide if and when to follow up.
When following up, review the diagnosis and assess the person's response to treatment; manage accordingly.

If severe or disabling pain persists for more than a year, consider referral to a pain specialist. How should I assess someone with chronic low back pain for risk of long-term pain/disability? Assess for:
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Misunderstanding of the cause of back pain. The belief that pain and activity are harmful. Sickness behaviours, such as extended rest. Overprotective family. Social withdrawal, lack of support. Emotional problems such as low or negative mood, depression, anxiety, or feeling under stress. Problems with claims for compensation or applications for social benefits. Inappropriate expectations of treatment, such as low expectations of active participation in treatment.

In addition, for employees, assess for:


Prolonged time off work. Problems or dissatisfaction at work. Lack of support from the employer or co-workers. Pessimistic expectations on ability to return to work.

Basis for recommendation These recommendations are based on guidelines from the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Primary Care, 2009]. The guideline development group 'agreed that there is some evidence that screening for those with a poor prognosis should be considered in order to inform treatment decisions and that consideration should be given to referring this group for more intensive treatments'.
One randomized controlled trial (RCT) provides evidence that screening people with chronic musculoskeletal pain could identify those with good, medium, or poor prognosis for return to work, and that the prognosis could be used to decide who should be offered low, moderate, or high intensity treatment [Haldorsen et al, 2002].

The guideline development group agreed that 'there is insufficient evidence to make recommendations for the use of any specific screening instrument'.
Evidence from two recent studies validates questionnaires for assessing prognosis in people with acute or chronic low back pain [Hill et al, 2008; Hill et al, 2009]. The health benefits of using these screening tools in the UK population is currently being tested in a large RCT and economic analysis [Hay et al, 2008]. A systematic review found that systematic reviews of prognostic factors for low back pain varied substantially in design and conduct [Hayden et al, 2009]. Several prognostic factors were consistently reported: older age, poor general health, increased psychological or psychosocial stress, poor relations with colleagues, physically heavy work, worse baseline functional disability, sciatica, and the presence of compensation. Because of methodological shortcomings in primary studies and in the systematic reviews literature, uncertainty remains about the reliability of conclusions regarding prognostic factors for low back pain.
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Because no particular screening instrument is recommended, CKS compiled a list of risk factors from a number of evidence-based guidelines [NZGG, 2004; van Tulder et al, 2004; Waddell, 2004; Health Education Board for Scotland and Health and Safety Executive, 2008; WeMeReC, 2008]. The list of risk factors is similar to the core set of factors proposed by a consensus group for research into the transition from acute to chronic low back pain [Pincus et al, 2008], and to the items in validated questionnaires [Hill et al, 2008; Hill et al, 2009]. What information and advice about self care should I provide someone with chronic low back pain? Provide information and advice to foster a positive attitude and realistic expectations. Avoid the use of language that people might find threatening. For example, say 'the normal ageing process of the spine' rather than 'wear and tear', 'crumbling discs', or 'damage to disc or joint'. Provide information and advice on: Understanding the problem
Non-specific low back pain has a real physical cause. Although psychological issues do affect how well people cope with the pain, they are not the cause of the pain. Non-specific low back pain is a mechanical problem it is caused by disturbance of function, not by serious structural damage. Back pain is an everyday bodily symptom it is not a disease in itself. However, back pain can rarely signal the presence of a serious underlying disease. Although back pain settles in most people, it does tend to recur at irregular intervals, and in some people it can become chronic.

Understanding the treatment


The main aim of treatment for chronic low back pain is to restore the ability to function as normally as possible with everyday activities at home and at work. Recovery is helped by getting moving again and getting back to work as soon as possible.

Self care
A positive attitude is important in coping with the problem. Medication can be taken to effectively relieve the pain and restore the ability to function normally. Staying physically active is likely to be beneficial. Normal activities should be resumed as soon as possible. Because many normal postures and movements will stimulate some pain, resuming normal activities should be paced by conducting them at a reduced level or slower rate. The aim is to do a little more each day. Keeping as active as possible and exercising regularly is important. Participating in a structured exercise programme should be considered (if available). Care should be taken when lifting and twisting. A cold pack or local heat can relieve back pain. A small firm cushion between the knees when sleeping on the side, or several firm pillows propping the knees up when lying on the back, may ease symptoms.
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Return to work as soon as possible


There is no need to wait for complete freedom from pain before returning to work. Work adjustments can make an early return to work possible. Returning to work helps to relieve pain by getting back to a normal pattern of activity and providing a distraction from the pain.

Basis for recommendation These recommendations are consistent with the National Institute for Health and Clinical Excellence (NICE) guidelines on persistent low back pain, which provide recommendations on the principles of self care [National Collaborating Centre for Primary Care, 2009]. The specific recommendations on what advice to provide were synthesized from national and international evidence-based guidelines, and apply to both acute and chronic low back pain [NZGG, 2004; van Tulder et al, 2004; Waddell, 2004; Chou et al, 2007; Health Education Board for Scotland and Health and Safety Executive, 2008; Poitras and Brosseau, 2008; WeMeReC, 2008]. NICE recommends:
Providing people with advice and information to promote self-management of their low back pain. Offering educational advice that: Includes information on the nature of non-specific low back pain. Encourages the person to be physically active and continue with normal activities as far as possible. An educational component consistent with this guideline is included as part of other interventions but standalone formal education programmes should not be offered.

NICE based their recommendations on evidence on educational booklets, evidence on group structured education programmes, and the opinion of experts who were in the guideline development group or who reviewed the draft guidelines.
No good evidence of benefit was found for the use of booklets. However, the guideline development group agreed that educational materials may have a role, and that emphasis should be placed on giving information that promotes self management and maintaining, or returning to, normal activities. The content and delivery of education varied greatly between the studies so that it was not possible to make a recommendation regarding the content of the educational component. NICE concluded that there was insufficient evidence of benefit to offer standalone formal education programmes.

The recommendation to stay active is based on moderately high quality evidence from randomized controlled trials that people with acute low back pain who are advised to stay active have a little less pain and recover a small amount more than people who are advised to rest in bed. The recommendation to consider a trial of local heat or cold is made because this is a common practice and there are no concerns about cost or safety; although there is only weak evidence of benefit from applying superficial heat and no evidence to support applying superficial cold. What drug treatments are recommended to treat chronic low back pain?
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Provide analgesia to manage the pain and to help the person keep active. For first-line analgesia offer paracetamol. If paracetamol is insufficient, offer a standard nonsteroidal anti-inflammatory drug (NSAID), or a coxib.
When prescribing an NSAID or coxib: Consider the risk of adverse effects, especially in older people, those at increased risk of gastrointestinal adverse effects, or those with asthma, chronic kidney disease or heart conditions. See the section on People at increased risk in the CKS topic on NSAIDs - prescribing issues. Prescribe a proton pump inhibitor (PPI) for people at increased risk of gastrointestinal (GI) bleeding, for example those older than 45 years of age. Review NSAID/coxib treatment if the person develops dyspepsia. For information on management, see the section on Management with no alarm features, taking NSAID in the CKS topic on Dyspepsia - unidentified cause. In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are recommended as first-line options.

For additional analgesia, consider the following options:


Paracetamol combined with an NSAID/coxib. Adding a weak opioid such as codeine, dihydrocodeine, or tramadol. Give due consideration to the risk of opioid dependence and adverse effects. When prescribing an opioid, consider the need for a laxative to counteract its constipating effects, as straining to defecate can aggravate back pain.

For chronic pain not responding to first-line analgesics and additional analgesics:
Consider offering a trial of a tricyclic antidepressant such as amitriptyline, nortriptyline, or imipramine. Start at a low dosage, particularly in the elderly or frail, and increase up to the maximum antidepressant dosage until either pain is adequately relieved or adverse effects are unacceptable. For further information on contraindications, cautions, and managing adverse effects, see the CKS topic on Neuropathic pain - drug treatment. A strong opioid this is rarely necessary. If a strong opioid (such as standard-release morphine) is to be used: Prescribe it for a short period, and step down to a weak opioid when appropriate. Co-prescribe a laxative and anti-emetic. If the use of a strong opioid is becoming chronic, or if doses are escalating, refer to, or seek advice from, a pain clinic or other specialist service. For morphine doses, and suggested laxatives and anti-emetics, see Prescriptions.

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Basis for recommendation These recommendations follow guidelines of the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Primary Care, 2009]. Adjusting analgesia to the individual's requirements CKS found no evidence on using a stepwise procedure to adjust analgesia to the person's requirements, and no evidence on whether providing optimal analgesia improves the long-term prognosis in terms of being able to cope without analgesia and return to full usual activities of daily life. Following a stepwise procedure to provide sufficient analgesia while minimizing the risk of adverse effects is standard practice in the management of pain in other conditions [WHO, 2003]. Paracetamol preferred for first-line analgesia Because there is insufficient direct evidence from randomized controlled trials (RCTs) to assess the efficacy of paracetamol in people with low back pain, the recommendation is based on indirect evidence from the efficacy and safety of paracetamol used as an analgesic in other conditions. NSAIDs alternative first-line analgesia There is good evidence that NSAIDs are more effective than placebo for short-term symptomatic relief in people with chronic low back pain without sciatica. However, the effect is small. Limited evidence from one small trial found NSAIDs to be more effective than paracetamol. There is moderate evidence to indicate that standard NSAIDs and coxibs are equally effective for chronic low back pain. Coxibs are currently not licensed to treat people with non-specific low back pain, but NICE recognized that practitioners might offer these to people who are at risk of gastrointestinal effects, and referred to the NICE guideline on Osteoarthritis for evidence on minimizing the risk of adverse effects, including the use of PPIs for gastroprotection [National Collaborating Centre for Chronic Conditions, 2008]. The risk of serious adverse effects is higher with NSAIDs than with paracetamol. The evidence on assessing and managing the adverse effects of NSAIDs is reviewed in the CKS topics on Dyspepsia - unidentified cause and NSAIDs - prescribing issues. A proton pump inhibitor (PPI) is recommended for people at increased risk of adverse gastrointestinal effects from NSAIDs.
This recommendation is adapted from the NICE guidelines on osteoarthritis [National Collaborating Centre for Chronic Conditions, 2008]. Because the NICE guidelines on Osteoarthritis were developed to apply to people from the age of 45 years, the low back pain guideline development group clarified the wording of this recommendation to include the age threshold of 45 years for routinely co-prescribing a PPI with standard NSAIDs and coxibs. The evidence on the use of PPIs to prevent the gastrointestinal adverse effects of NSAIDs is also discussed in the CKS topic on Dyspepsia - unidentified cause. Choice of NSAID in people at risk of cardiovascular adverse effects: diclofenac 150 mg daily has a
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similar level of thrombotic risk to etoricoxib and possibly other coxibs. The available data do not suggest an increase in thrombotic risk with naproxen or with lower doses of ibuprofen (up to 1200 mg daily) [CHM, 2006; MHRA, 2007; MHRA, 2009]. For further information, see the section on Supporting evidence in the CKS topic on NSAIDs - prescribing issues .

Opioids for additional analgesia There is evidence from RCTs that opioids (tramadol was the only weak opioid studied) can relieve pain effectively in people with chronic low back pain. There is some evidence that stopping oxymorphone or oxycodone treatment for low back pain is followed by withdrawal symptoms for about 3 days. There is no evidence on long-term effects after stopping treatment. There is no good evidence to prefer any one regimen of opioid treatment over any another. Where there was no good evidence to directly support the recommendations, they were made by consensus of the NICE guideline development group. Tricyclic antidepressants A Cochrane systematic review of 10 RCTs found evidence that tricyclic antidepressants and selective serotonin reuptake inhibitors were no more effective than placebo in terms of pain relief or preventing depression in people with non-specific low back pain [Urquhart et al, 2008]. The authors cautioned that the evidence was not strong enough to recommend against using antidepressants for persistent pain or depression. NICE reviewed these studies and came to similar conclusions. The guideline development group, took into account the limitations of the evidence and recommended the use of tricyclic antidepressants because their cost is low (about the same as that of paracetamol), and the associated risk is low. European and US guidelines [Airaksinen et al, 2006; Chou and Huffman, 2007] recommend the use of tricyclic antidepressants for relieving chronic low back pain, a decision based on findings from four older systematic reviews [Fishbain, 2000; Salerno et al, 2002; Staiger et al, 2003; Schnitzer et al, 2004]. CKS recommends amitriptyline because it is the most widely studied tricyclic antidepressant, and is commonly used for neuropathic pain in the UK. Imipramine and nortriptyline are less sedating alternatives to amitriptyline, but imipramine has more marked anticholinergic adverse effects than other tricyclic antidepressants [BNF 57, 2009]. Treatments not recommended in primary care for chronic low back pain CKS found insufficient evidence to recommend the following therapies for the relief of chronic low back pain in primary care:
Topical NSAIDs Despite the widespread availability of these products, CKS found insufficient evidence to support their use for chronic low back pain. Antiepileptic drugs such as gabapentin and pregabalin CKS recommends that these drugs should not be prescribed without specialist advice, because there is no evidence supporting their use in chronic low back pain without radiculopathy [Chou
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and Huffman, 2007]. Herbal remedies Herbal remedies (such as Harpagophytum procumbens , Salix alba, and Capsicum frutescens ) are not recommended because, although some products have been reported to reduce low back pain more than placebo, a Cochrane systematic review concluded that there was no available evidence for their efficacy and safety for long-term use [Gagnier et al, 2006]. Glucosamine CKS found no clinical trials on glucosamine for back pain.

What physical treatments are recommended to treat chronic low back pain? For people with chronic low back pain, offer one of the following (taking into account individual preference, availability, and the competencies of the person and the therapist):
A structured exercise programme. The programme should have up to eight sessions given over a period of up to 12 weeks. Suitable exercise includes aerobic activity, movement instruction, muscle strengthening, postural control, and stretching. A supervised group of up to 10 people, with exercise that is individually tailored, is preferred. If a group programme is not suitable or is not available, consider a one-to-one supervised exercise programme. A course of manual therapy that includes spinal manipulation. The manual therapy should have up to nine sessions given over a period of up to 12 weeks. Spinal manipulation can be performed by chiropractors and osteopaths, as well as by doctors and physiotherapists who have undergone specialist postgraduate training in spinal manipulation. A course of acupuncture. The course should have up to 10 sessions given over a period of up to 12 weeks.

If the chosen treatment does not result in satisfactory improvement, consider offering one of the other physical treatments. Additional information Manual therapy Manual therapy includes [National Collaborating Centre for Primary Care, 2009]:
Spinal manipulation (a low-amplitude, high-velocity movement at the limit of joint range that takes the joint beyond the passive range of movement). Spinal mobilization (joint movement within the normal range of motion). Massage (manual manipulation or mobilization of soft tissue).

Mobilization and massage are performed by a wide variety of practitioners.


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Referral or delegation to practitioners of complementary therapies For GPs who plan to refer people for acupuncture or spinal manipulation, the guidelines developed by the General Practice Committee (GPC) of the British Medical Association (BMA) are relevant [General Practitioners Committee, 2006]. The recommendations include:
'GPs can safely refer patients to complementary therapists who are registered as doctors or nurses with the GMC or Nursing and Midwifery Council (NMC) respectively, because the therapists would be fully accountable to the GMC or NMC for their actions and the patient could seek legal redress against them in the event of an accident. This principle also applies where practising doctors or nurses offer complementary treatment as a supplement to their normal services.' 'There is also no problem with GPs referring patients to practitioners in osteopathy and chiropractic who are registered with the relevant statutory regulatory bodies, as a similar means of redress is available to the patient. Before doing so, they have an obligation to check that the therapist is registered with the appropriate body. These are currently the only complementary therapists subject to statutory regulation, although several others operate under voluntary registering bodies and may be subject to statutory regulation in the future.' 'In either case, the GP must first be satisfied that the patient will benefit from the type of treatment involved. This presupposes that the GP has some knowledge of the basic principles of the therapy, and some belief in its efficacy.' 'GPs can delegate treatment to complementary therapists who are not registered with a statutory regulatory body. In doing so, they remain responsible for the treatment given and would bear some liability should the patient come to any harm. Whether GPs are prepared to delegate treatment in these circumstances would therefore depend principally upon their knowledge of, and belief in the efficacy of, the therapy and their personal knowledge of the competence of the individual therapist.'

Basis for recommendation These recommendations follow guidelines of the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Primary Care, 2009]. Structured exercise programme A structured exercise programme is recommended as an option for people with chronic low back pain because:
There is evidence from randomized controlled trials (RCTs) that structured exercise programmes are effective compared with usual care, although the size of the effect is small. There is evidence from one well conducted RCT and economic analysis that a structured exercise programme is cost effective compared with usual best primary care (but less cost effective than spinal manipulation alone see below) [UK BEAM Trial Team, 2004b]. There is evidence from one well conducted RCT and economic analysis that exercise is more cost effective than lessons in the Alexander technique [Hollinghurst et al, 2008]. The NICE guideline development group considered that a structured exercise programme should be an option for people who prefer exercise to spinal manipulation, or who do not have access to spinal manipulation, or who are not suitable for spinal manipulation.

Group exercise programmes are recommend over one-to-one programmes because:


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There is no evidence that one-to-one exercise programmes are better than group exercise programmes. Individually-supervised exercise programmes are more costly than group programmes. A systematic review using Bayesian multivariate analysis found that the most effective exercise programmes are designed for the individual and offered in a supervised group setting [Hayden et al, 2005].

The number of exercise sessions recommended is based on the number of sessions used in the UK BEAM and ATEAM trials [UK BEAM Trial Team, 2004a; Little et al, 2008], both of which have cost-effectiveness analyses [UK BEAM Trial Team, 2004b; Hollinghurst et al, 2008]. The number of people recommended for group exercise programmes is based on the exercise programmes used in the UK BEAM trial [UK BEAM Trial Team, 2004a]. The recommended components of structured exercise programmes are based on the exercise programmes used in the ATEAM trial [Little et al, 2008]. A course of manual therapy that includes spinal manipulation A course of spinal manipulation is recommended as an option for people with chronic low back pain because:
There is evidence from one large, open, well conducted RCT and economic analysis that spinal manipulation is effective, and more cost effective than an exercise programme or best usual care [UK BEAM Trial Team, 2004b]. The number needed-to-treat (NNT) with spinal manipulation for one person to improve or benefit was estimated to be around 5 at 3 months and around 9 at 12 months. The most cost-effective option is spinal manipulation combined with an exercise programme. There is no evidence that spinal manipulation improves psychological outcomes. There is evidence from one open, well conducted RCT and economic analysis that spinal manipulation is more cost effective than either exercise or usual best primary care, and that spinal manipulation combined with an exercise programme is the most cost-effective option [UK BEAM Trial Team, 2004b]. There is evidence that serious complications following manipulation of the lumbar spine are likely to be rare.

The NICE guideline development group did not recommend that spinal manipulation always be provided together with an exercise programme because there will be people who do not wish to, or are unable to, take part in an exercise programme. There is some evidence that different types of spinal manipulation are similarly effective, and no evidence that any type of expertise in spinal manipulation is more effective than any other. The recommended number of sessions and duration of a course of spinal manipulation was based on the spinal manipulation courses provided in the trials reviewed by NICE. A course of acupuncture A course of acupuncture is recommended as an option for people with chronic low back pain because:
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A systematic review and open RCTs provide evidence that acupuncture is effective at improving disability scores in people with chronic low back pain. One NHS-based open RCT and economic study found that acupuncture is cost effective compared with usual care [Ratcliffe et al, 2006].

The recommended number of sessions and duration of a course of acupuncture was based on the acupuncture courses provided in the trials reviewed by NICE. Controversies over the recommendations in the NICE guidelines A number of recommendations in the NICE guidelines on chronic low back pain were criticized in the media, on blogs, and in the correspondence columns of the BMJ, for example [BMJ Rapid Responses, 2009]. Critics of the recommendations on acupuncture and spinal manipulation raised two main issues:
The specific effects of acupuncture and spinal manipulation are likely to be clinically unimportant. However, the NICE guidelines say that it is the package of care (including specific and non-specific effects) that is of interest. The evidence supporting the recommendations comes from open (unblinded) randomized controlled trials, and the outcome measures were subjective such as pain and disability. Therefore, the results could be confounded by bias effects in the test and comparison groups and by negative placebo (nocebo) effects in the comparison group. The NICE guidelines did not discuss these issues, and assumed that bias effects and negative placebo effects were negligible.

For a detailed discussion, see the Supporting evidence section on Acupuncture and spinal manipulation. How should I manage someone with chronic low back pain which persists despite treatment? Recheck for red flags for serious conditions, for indicators of risk of long-term pain and disability, and for signs and symptoms of other conditions that can cause back pain. If distress or disability remains problematic after a course of physical treatment, consider referral for:
Another type of physical treatment (exercise, manual therapy including spinal manipulation, acupuncture). A combined physical and psychological pain management programme which includes a cognitive behavioural approach and exercise around 100 hours over a period of up to 8 weeks.

If severe pain persists despite having completed an optimal package of care and appropriate treatment of any psychological distress, consider referral to a specialist spinal surgical service for an opinion on spinal fusion as recommended by the National Institute for Health and Clinical Excellence. Before referring, discuss the risks of spinal fusion and ensure that the person would consider this surgery. If pain continues to be distressing or disabling, consider referral to a specialist pain service. Additional information Psychological treatments for low back pain
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Guidelines on pain management programmes developed by the British Pain Society recommend offering people a pain management programme when they have persistent pain causing distress, disability, and a negative impact on their quality of life [British Pain Society, 2007]. The pain management programme should address the psychological components of pain by providing:
Education on pain physiology, pain psychology, healthy function and self management of pain problems. Guided practice for participants on setting goals and working towards them, identifying and changing unhelpful beliefs and ways of thinking, relaxation, and changing habits which contribute to disability; participants practise these skills in their home and other environments to become expert in their application and integration. Evaluation of outcomes such as distress, emotional impact of pain, beliefs and thinking biases, range and level of activity, pain experience, healthcare use, and, where relevant, participation in paid employment. Group format so participants can maximize learning from other participants and normalize their pain experience in terms of fears, catastrophic thinking, and self-efficacy.

Risks of spinal fusion The main risk of spinal fusion surgery is continued pain and disability about 20% of operations. Uncommon complications of spinal fusion include:
Failure of the vertebrae to fuse (pseudoarthrosis). Failure of bone grafts or devices such as screws, rods, cages, which may require further surgery. Injury to nerves or major blood vessels.

There are also the risks associated with having a general anaesthetic and surgery. Basis for recommendation These recommendations follow the guidelines of the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Primary Care, 2009]. Considering referral for another type of physical treatment For the reasons for recommending a course of exercise, manual therapy (including spinal manipulation), or acupuncture, see Physical treatments. Considering referral for a combined physical and psychological pain management programme Considering referral for a combined physical and psychological pain management programme is recommended because:
There is some evidence that psychosocial/psychological screening can identify which people may gain the greatest benefit from either general or specific treatments. The NICE guideline development group recommended that those people considered to have a poor prognosis should be referred for more intensive treatments, and those considered to have
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a good prognosis should not be referred for more intensive treatment. There is insufficient evidence to recommend any specific screening instrument. There is limited evidence to support the use of psychological interventions as monotherapy for non-specific low back pain. One randomized controlled trial (RCT) compared a cognitive behavioural treatment with information/pamphlet and found no statistically significant difference in improvement of pain at 12 months' follow up [Linton and Andersson, 2000]. One RCT compared a psychologist-led self-care intervention with usual care, and found that disability was statistically significantly reduced at 3 months, pain was statistically significantly reduced at 6 months' follow up, and there was no effect on mental health [Moore et al, 2000]. No evidence was found for longer treatments of psychological interventions delivered in the absence of concurrent or combined physical therapy. The NICE guideline development group decided by consensus to recommend a combined treatment package where there is stronger evidence of benefit, rather than a standalone psychological intervention.

NICE recommended that a combined physical and psychological pain management programme should have at least 100 hours of exposure to the intervention spread over a period of up to 3 months. This recommendation is based on evidence that the most effective programmes involve participants for more than 100 hours [Guzman et al, 2001]. NICE was unable to recommend in detail which format for a combined physical and psychological pain management programme would be preferred, because there is insufficient evidence to differentiate between the many formats that have been studied. However, NICE did recommend, based on the opinion of expert reviewers, that such programmes should include exercise and cognitive behavioural therapy with goal setting/problem solving. An economic analysis conducted by NICE found that the most cost-effective strategy would be to start with a light programme, moving on to a more intensive programme for those identified as having a poor prognosis and who have not benefited from less intensive interventions. Considering referral for an opinion on spinal fusion Because economic analysis found that the chance is less than 2% that spinal fusion for chronic low back pain is cost effective at 2 years, the guideline development group agreed that spinal fusion should be reserved for the small number of selected individuals who fail to respond to a combined physical and psychological intervention. Considering referral to a pain specialist NICE identified a number of treatments which should not be offered to people with non-specific low back pain persisting for at least 6 weeks but less than a year.
NICE made no recommendations on the management of people who have acute low back pain, or persistent low back pain due to specific causes, or persistent low back pain present for more than a year. CKS has not reviewed the relevant evidence on these treatments, because decisions to use or not use them will be made in secondary care.

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The recommendation by NICE that people with persistent non-specific low back pain be referred to a spinal surgeon before referral to a pain specialist is controversial [BMJ Rapid Responses, 2009b]. The controversy centres around the interpretation of the evidence, with the British Pain Society and the Royal College of Anaesthetists arguing that the evidence in support of some treatments recommended (acupuncture and spinal manipulation therapy) is not more reliable than the evidence supporting some treatments that were not recommended [The British Pain Society, 2009; Royal College of Anaesthetists, 2010].

How should I follow up someone with chronic low back pain? Use clinical judgement to decide if and when to follow up the person.
Most people are appropriately invited to return only if they find it necessary. Follow up may be appropriate for people with risk factors for long-term disability.

When following up:


Review the diagnosis look again for red flags for serious conditions, as well as indicators for risk of long-term pain and disability, and signs and symptoms of other conditions that can cause back pain. Assess how the person's pain and disability have responded to treatment, and manage accordingly.

Basis for recommendation These recommendations are in line with guidelines of the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Primary Care, 2009]. In the absence of directly relevant clinical trials, these recommendations are pragmatic and based on expert opinion [Waddell, 2004; Health Education Board for Scotland and Health and Safety Executive, 2008]. What treatments are not recommended by NICE for chronic low back pain? The National Institute for Health and Clinical Excellence (NICE) recommends that people with nonspecific chronic low back pain that persists for less than a year should not be treated with, or referred for: Alexander technique.
Although lessons in the Alexander technique are likely to be effective, this is not recommended for provision by the NHS, because exercise is likely to be more cost-effective. However, people may wish to arrange lessons in the Alexander technique for themselves.

Massage.
Although massage may be effective, this is not recommended for provision by the NHS, because other physical interventions are likely to be more cost-effective. However, people may wish to arrange massage for themselves.

Percutaneous electrical nerve stimulation (PENS). Transcutaneous electrical nerve stimulation (TENS).
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Selective serotonin reuptake inhibitors (SSRIs). Injections of therapeutic substances into the back. Laser therapy. Interferential therapy. Therapeutic ultrasound. Lumbar supports. Traction. Radiofrequency facet joint denervation. Intradiscal electrothermal therapy (IDET). Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT). Neuroreflexive therapy. Basis for recommendation These recommendations are from guidelines of the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Primary Care, 2009]. These guidelines apply to people who have had non-specific low back pain persisting for at least 6 weeks and not more than a year. Massage There is weak evidence from one well conducted systematic review that massage provides short-term pain relief [Furlan et al, 2008]. There is evidence from one well conducted RCT that massage provides short-term reduction in pain and disability [Little et al, 2008]. However, massage is not recommended for provision by the NHS because there is good evidence from a large, well conducted RCT that massage is less effective than exercise (or the Alexander technique), and that massage is not cost effective [Hollinghurst et al, 2008]. Alexander technique Alexander technique is not recommended for provision by the NHS because there is evidence from one well conducted RCT and economic analysis that exercise is more cost effective than lessons in the Alexander technique [Hollinghurst et al, 2008]. However, there is evidence that lessons in the Alexander technique is effective [Little et al, 2008]. Neuroreflexotherapy Neuroreflexotherapy is not recommended because there is only weak evidence from one well conducted systematic review that it may be effective, and it is not available in the UK [Urrtia et al, 2004]. Percutaneous electrical nerve stimulation (PENS) PENS is not recommended because one RCT provides weak evidence that it is not effective
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[Hsieh and Lee, 2002]. Transcutaneous electrical nerve stimulation (TENS) Although TENS is widely used and observational studies have found that it is well tolerated and considered effective, it was not recommended by NICE because there is no evidence from large, high quality randomized controlled trials (RCTs) on the use of TENS for chronic low back pain. Two small RCTs found that TENS was no more effective than sham TENS for chronic low back pain; one small RCT with methodological weaknesses found that TENS provided more pain relief than sham TENS. Other interventions not recommended Reviewing the evidence on the other interventions which are not recommended by NICE is outside the scope of this topic, because the treatment decisions based on the evidence are made in secondary care. The decision by NICE to not recommend these treatments is controversial [BMJ Rapid Responses, 2009b]. The controversy centres around the interpretation of the evidence, with the British Pain Society and the Royal College of Anaesthetists arguing that the evidence in support of some treatments recommended (acupuncture and spinal manipulation therapy) is not more reliable than the evidence supporting some treatments that were not recommended [The British Pain Society, 2009; Royal College of Anaesthetists, 2010]. Prescriptions For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org). Paracetamol Age from 16 years onwards Paracetamol tablets: 500mg to 1g up to four times a day Paracetamol 500mg tablets Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours. Supply 100 tablets. Age: from 16 years onwards NHS cost: 1.44 Licensed use: yes Patient information: Your paracetamol will work best if you take it regularly four times a day. Standard oral nonsteroidal anti-inflammatory drugs (NSAIDs) Age from 16 years onwards

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Ibuprofen tablets: 400mg three times a day Ibuprofen 400mg tablets Take one tablet three times a day. Supply 84 tablets. Age: from 16 years onwards NHS cost: 1.87 OTC cost: 3.30 Licensed use: yes Ibuprofen tablets: 400mg four times a day Ibuprofen 400mg tablets Take one tablet four times a day. Supply 112 tablets. Age: from 16 years onwards NHS cost: 2.49 Licensed use: yes Ibuprofen tablets: 600mg three times a day Ibuprofen 600mg tablets Take one tablet three times a day. Supply 84 tablets. Age: from 16 years onwards NHS cost: 3.63 Licensed use: yes Ibuprofen tablets: 800mg three times a day Ibuprofen 400mg tablets Take two tablets three times a day. Supply 168 tablets. Age: from 16 years onwards NHS cost: 3.74 Licensed use: yes Diclofenac sodium e/c tablets: 25mg three times a day Diclofenac sodium 25mg gastro-resistant tablets Take one tablet three times a day. Supply 84 tablets. Age: from 16 years onwards NHS cost: 1.27 Licensed use: yes Diclofenac sodium e/c tablets: 50mg three times a day Diclofenac sodium 50mg gastro-resistant tablets
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Take one tablet three times a day. Supply 84 tablets. Age: from 16 years onwards NHS cost: 1.43 Licensed use: yes Naproxen tablets: 250mg twice a day Naproxen 250mg tablets Take one tablet twice a day. Supply 56 tablets. Age: from 16 years onwards NHS cost: 2.84 Licensed use: yes Naproxen tablets: 500mg twice a day Naproxen 500mg tablets Take one tablet twice a day. Supply 56 tablets. Age: from 16 years onwards NHS cost: 3.80 Licensed use: yes Coxibs Age from 16 years onwards Etoricoxib tablets: 30mg once a day Etoricoxib 30mg tablets Take one tablet once a day. Supply 28 tablets. Age: from 16 years onwards NHS cost: 13.99 Licensed use: no - off-label indication Black triangle Age from 18 years onwards Celecoxib capsules: 100mg twice a day Celecoxib 100mg capsules Take one capsule twice a day. Supply 60 capsules. Age: from 18 years onwards NHS cost: 21.55
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Licensed use: no - off-label indication Celecoxib capsules: 200mg twice a day Celecoxib 200mg capsules Take one capsule twice a day. Supply 60 capsules. Age: from 18 years onwards NHS cost: 43.10 Licensed use: no - off-label indication Weak opioids: add on to paracetamol/NSAID if required Age from 16 years onwards Codeine 30mg tablets: add on to paracetamol or NSAID if required Codeine 30mg tablets Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours. Supply 56 tablets. Age: from 16 years onwards NHS cost: 3.02 Licensed use: yes Dihydrocodeine 30mg tablets: add on to paracetamol or NSAID if required Dihydrocodeine 30mg tablets Take one tablet every 4 to 6 hours when required for pain relief. Maximum of 6 tablets in 24 hours. Supply 60 tablets. Age: from 16 years onwards NHS cost: 3.74 Licensed use: yes Tramadol 50mg capsules: add on to paracetamol or NSAID if required Tramadol 50mg capsules Take one to two capsules every 4 to 6 hours when required for pain relief. Maximum of 8 capsules in 24 hours. Supply 60 capsules. Age: from 16 years onwards NHS cost: 3.08 Licensed use: yes First-line adjuvant: start a TCA Age from 18 to 60 years
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Amitriptyline: titrate up from 25mg daily until pain settles Amitriptyline 25mg tablets Take one tablet at night. If pain does not settle, increase the dose by one tablet (25mg) at night every 7 days to a maximum of three tablets (75mg) at night. Supply 63 tablets. Age: from 18 years to 60 years NHS cost: 2.34 Licensed use: no - off-label indication Patient information: You do not have to increase the dose any further once the pain has settled, so, for example, if the pain is controlled by taking 2 tablets at night, there is no need to increase the dose any further. Imipramine: titrate up from 25mg daily until pain settles Imipramine 25mg tablets Take one tablet at night. If pain does not settle, increase the dose by one tablet (25mg) at night every 7 days to a maximum of three tablets (75mg) at night. Supply 63 tablets. Age: from 18 years to 60 years NHS cost: 3.85 Licensed use: no - off-label indication Patient information: You do not have to increase the dose any further once the pain has settled, so, for example, if the pain is controlled by taking 2 tablets at night, there is no need to increase the dose any further. Nortriptyline: titrate up from 25mg daily until pain settles Nortriptyline 25mg tablets Take one tablet at night. If pain does not settle, increase the dose by one tablet (25mg) at night every 7 days to a maximum of three tablets (75mg) at night. Supply 63 tablets. Age: from 18 years to 60 years NHS cost: 15.14 Licensed use: no - off-label indication Patient information: You do not have to increase the dose any further once the pain has settled, so, for example, if the pain is controlled by taking 2 tablets at night, there is no need to increase the dose any further. Age from 18 years onwards Amitriptyline: titrate up from 10mg daily until pain settles Amitriptyline 10mg tablets Take one tablet at night. If pain does not settle, increase the dose by one tablet (10mg) at night every 7 days to a maximum of five tablets (50mg) at night.
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Supply 70 tablets. Age: from 18 years onwards NHS cost: 2.58 Licensed use: no - off-label indication Patient information: You do not have to increase the dose any further once the pain has settled, so, for example, if the pain is controlled by taking 2 tablets at night, there is no need to increase the dose any further. Imipramine: titrate up from 10mg daily until pain settles Imipramine 10mg tablets Take one tablet at night. If pain does not settle, increase the dose by one tablet (10mg) at night every 7 days to a maximum of five tablets (50mg) at night. Supply 70 tablets. Age: from 18 years onwards NHS cost: 4.15 Licensed use: no - off-label indication Patient information: You do not have to increase the dose any further once the pain has settled, so, for example, if the pain is controlled by taking 2 tablets at night, there is no need to increase the dose any further. Nortriptyline: titrate up from 10mg daily until pain settles Nortriptyline 10mg tablets Take one tablet at night. If pain does not settle, increase the dose by one tablet (10mg) at night every 7 days to a maximum of five tablets (50mg) at night. Supply 70 tablets. Age: from 18 years onwards NHS cost: 8.45 Licensed use: no - off-label indication Patient information: You do not have to increase the dose any further once the pain has settled, so, for example, if the pain is controlled by taking 2 tablets at night, there is no need to increase the dose any further. Gastrointestinal protection with standard NSAID or coxib Age from 16 years onwards Omeprazole capsules: 20mg once a day Omeprazole 20mg gastro-resistant capsules Take one capsule once a day. Supply 28 capsules. Age: from 16 years onwards NHS cost: 1.71
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Licensed use: yes Lansoprazole capsules: 15mg each morning Lansoprazole 15mg gastro-resistant capsules Take one capsule each morning (on an empty stomach). Supply 28 capsules. Age: from 16 years onwards NHS cost: 1.80 Licensed use: yes Lansoprazole capsules: 30mg each morning Lansoprazole 30mg gastro-resistant capsules Take one capsule each morning (on an empty stomach). Supply 28 capsules. Age: from 16 years onwards NHS cost: 3.09 Licensed use: yes Esomeprazole tablets: 20mg once a day Esomeprazole 20mg tablets Take one tablet once a day. Supply 28 tablets. Age: from 16 years onwards NHS cost: 18.50 Licensed use: yes Pantoprazole e/c tablets: 20mg once a day Pantoprazole 20mg gastro-resistant tablets Take one tablet once a day. Supply 28 tablets. Age: from 16 years onwards NHS cost: 11.83 Licensed use: yes Short-term strong opioid (rarely needed) Age from 16 years onwards Opioid naive: start oral morphine Age: from 16 years onwards Licensed use: no Patient information: In elderly people or frail people, start with morphine 25 mg every 4 hours and as required (up to 2-hourly) for breakthrough pain.
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In young and middle-aged people, start with morphine 510 mg every 4 hours and as required (up to 2-hourly) for breakthrough pain. On weak opioid: start oral morphine Age: from 16 years onwards Licensed use: no Patient information: For people previously on a weak opioid (e.g. codeine), start immediaterelease morphine 10 mg every 4 hours and as required (up to 2-hourly) for breakthrough pain, or modified-release morphine 2030 mg every 12 hours and 10 mg immediate-release morphine as required (up to 2-hourly) for breakthrough pain. Consider starting at a lower dose and titrating carefully if the person is elderly or frail. Laxatives: adjunct to strong opiod therapy Age from 16 years onwards Multi-therapy: Senna tablets + docusate capsules Senna tablets: two tablets at night Senna 7.5mg tablets Take two tablets at night for constipation. Increase the dose to four tablets at night after 2 to 3 days if needed. Supply 30 tablets. Age: from 16 years onwards NHS cost: 1.07 OTC cost: 1.88 Licensed use: yes Docusate sodium capsules: 100mg twice a day Docusate 100mg capsules Take one capsule twice a day for constipation. Increase the dose up to two capsules three times a day if needed. Supply 84 capsules. Age: from 16 years onwards NHS cost: 5.38 Licensed use: no - off-label dose

Multi-therapy: Senna tablets + lactulose solution Senna tablets: two tablets at night Senna 7.5mg tablets Take two tablets at night for constipation. Increase the dose to four tablets at night after 2 to 3 days if needed. Supply 30 tablets.
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Age: from 16 years onwards NHS cost: 1.07 OTC cost: 1.88 Licensed use: yes Lactulose solution: 15ml twice a day Lactulose 3.1-3.7g/5ml oral solution Take 15ml twice a day for constipation. Increase the dose by 5ml twice a day every 2 to 3 days if needed. (Aim to produce one or two soft, formed stools every one or two days.) Supply 500 ml. Age: from 16 years onwards NHS cost: 2.96 OTC cost: 5.22 Licensed use: yes

Multi-therapy: Senna tablets + macrogol 3350 (Movicol) sachets Senna tablets: two tablets at night Senna 7.5mg tablets Take two tablets at night for constipation. Increase the dose to four tablets at night after 2 to 3 days if needed. Supply 30 tablets. Age: from 16 years onwards NHS cost: 1.07 OTC cost: 1.88 Licensed use: yes Movicol: one sachet once a day Movicol 13.8g oral powder sachets Take the contents of one sachet (dissolved in half a glass of water) once a day for constipation. Increase the dose by one sachet every 2 to 3 days if needed, up to a maximum of three sachets per day. Supply 30 sachets. Age: from 16 years onwards NHS cost: 6.95 Licensed use: yes

Anti-emetics: adjunct to strong opioid Age from 18 years onwards Haloperidol tablets: 1.5mg at night and when required Haloperidol 1.5mg tablets
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Take one tablet at night AND when required to relieve nausea and vomiting. Supply 14 tablets. Age: from 18 years onwards NHS cost: 0.75 Licensed use: no - off-label indication Patient information: If you need to take more than two additional doses to control your nausea or vomiting, contact your healthcare professional as you may need a higher dose or a different medicine. Age from 20 years onwards Metoclopramide 10mg three times a day Metoclopramide 10mg tablets Take one tablet up to three times a day when required for sickness. Supply 56 tablets. Age: from 20 years onwards NHS cost: 2.00 Licensed use: yes

NHS Institute for Innovation and Im prove m e nt

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