Changes

August 2026 — minor update. Removed the recommendations on psychological therapy for low back pain with or without sciatica, and combined physical and psychological programmes, in line with the update to NICE guideline Low back pain and sciatica in over 16s: assessment and management.

Update

Goals

To support primary healthcare professionals to:

• Make an accurate assessment and diagnosis of non-specific low back pain.
• Offer advice on sources of information, support, and self-management strategies.
• Offer advice on appropriate drug treatment(s) if needed.
• Offer advice on referral to group exercise, physiotherapy, cognitive behavioural therapy (CBT), occupational health, or a specialist low back pain service, if clinically appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

The NICE quality standards relevant for this CKS topic are:

• Statement 1 Primary care services have an approach to risk stratification for young people and adults presenting with a new episode of low back pain with or without sciatica.
• Statement 2 Young people and adults with low back pain with or without sciatica do not have imaging requested by a non-specialist service unless serious underlying pathology is suspected.
• Statement 3 Young people and adults with low back pain with or without sciatica are given advice and information to self-manage their condition.
• Statement 4 Young people and adults are not given paracetamol alone, gabapentinoids, antiepileptics or antidepressants to treat low back pain without sciatica.
• Statement 5 Young people and adults are not given opioids to treat chronic low back pain without sciatica.
• Statement 6 Young people and adults do not have spinal injections for low back pain without sciatica with the exception of radiofrequency denervation for people who meet the criteria.

[NICE, 2017]

What is it?

• Low back pain often refers to pain in the lumbosacral area from the 12th ribs to the iliac crest, and sometimes the buttocks and gluteal folds [Knezevic, 2021].
• 'Non-specific' low back pain has traditionally described pain not attributable to an underlying cause [Will, 2018; Knezevic, 2021]. It may also be referred to as 'mechanical', 'musculoskeletal', or 'simple' low back pain in the literature [NICE, 2020].
  
  • Some commentators state the term 'non-specific' back pain is ambiguous and recommend the term 'nociplastic' pain to describe back pain due to central sensitization, which may co-exist with other types of low back pain such as neuropathic or radicular pain [Knezevic, 2021].
• The National Institute for Health and Care Excellence (NICE) defines [NICE, 2020; NICE, 2021a]:
  • Acute low back pain as lasting less than 3 months.
  • Chronic low back pain as lasting 3 months or more.

How common is it?

Low back pain is common in the general population [Campbell and Colvin, 2013].

• Expert opinion in a review article notes that up to 60% of the adult population will have low back pain at some point in their lifetime [Campbell and Colvin, 2013]:
  • 3–4% of adults below 45 years of age have chronic low back pain.
  • 5–7% of adults over 45 years of age have chronic low back pain.
• An Australian review article states that non-specific low back pain accounts for 90–95% of cases of low back pain presenting to primary care [Bardin, 2017].
• A British prevalence study using two postal surveys with a 10-year interval (1987–8 and 1997–8) found [Palmer et al, 2000]:
  • The one-year prevalence of low back pain increased from 36.4 to 49.1%. The trend was consistent across all ages, in men and women, in different socioeconomic classes, and across geographical regions.
• A UK population-based cross-sectional study of adults aged 25 years and older (n = 15,272) found [Macfarlane et al, 2012]:
  • The 1-month period prevalence of low back pain was 28.5%, peaking at age 41–50 years.
  • Low back pain was reported by one in four people aged over 80 years.
• A global systematic review of 165 studies from 54 countries found [Hoy, 2012]:
  • The estimated point prevalence of low back pain lasting more than one day was 11.9%.
  • The 1-month prevalence of low back pain lasting more than one day was 23.3%.
  • Low back pain was most common in women and people aged 40–80 years.

What are the risk factors?

Low back pain may result from a dynamic interaction between social, psychological, and biological factors [Knezevic, 2021].

• Risk factors for the development of non-specific low back pain include [Maher, 2017] [Chou, 2021]:
  • Obesity.
  • Physical inactivity.
  • Occupational factors (such as heavy lifting, bending, or twisting).
  • Stressful life events or depression.

• Risk factors for the development of chronic pain and disability include [Campbell and Colvin, 2013] [NICE, 2020] [Chou, 2021] [Knezevic, 2021] [NICE, 2021a]:
  • Pain lasting longer than 12 weeks.
  • High baseline pain intensity and disability.
  • Anxiety and/or depression.
  • Stressful life events including previous or current physical or emotional trauma.
  • Previous or current substance misuse.
  • Perceived risk of persistent pain.
  • Maladaptive coping strategies and 'fear avoidance' (avoidance of work, movement, or other activities due to fear of exacerbating pain or damaging the back), or negative beliefs about pain and activity.
  • Pain coping characterised by excessively negative thoughts about pain and the future ('catastrophizing').
  • Past history of other chronic pain syndrome(s).

What is the prognosis?

Non-specific low back pain is a self-limiting condition for the majority of people affected, and usually resolves within a few weeks [Campbell and Colvin, 2013] [Chou, 2021].

• People who have had low back pain often have episodes of recurrence and may develop repeated 'acute on chronic' symptoms [Chou, 2021].
• An Australian cohort study of people presenting to primary care with acute non-specific low back pain of less than 2 weeks' duration (n = 973 consecutive patients) found [Henschke et al, 2008]:
  • About 50% of people who had reduced their work activities had returned to normal work within 14 days, and 83% had returned to normal work by 3 months.
  • 40%, 52%, and 57% of study participants reported being pain-free at 6 weeks, 3 months, and 12 months follow-up respectively.
  • Pain symptoms took a median of 58 days to recover, and functional impairment took a median of 31 days to recover.
  • Only 72% of study participants had made a full recovery by 12 months follow-up.

What are the complications?

Possible complications of non-specific low back pain include:

• Impact on daily activities and function including household chores, study, leisure, and sleep [Bardin, 2017; Maher, 2017; NICE, 2020; Traeger, 2022].
• Depression and anxiety [Bardin, 2017; Knezevic, 2021; Traeger, 2022]. See the CKS topics on Depression and Generalized anxiety disorder for more information.
• Time off work, reduced productivity, and loss of employment [Chou, 2021].
  • The UK Health and Safety Executive (HSE) publication of annual statistics states that in 2020–21, 39% of all reported work-related musculoskeletal disorders were due to back pain [HSE, 2021].
• Increased risk of falls [Traeger, 2022]. See the CKS topic on Falls - risk assessment for more information.
• Immobility and physical deconditioning, particularly in older people [Traeger, 2022].
• Chronic pain and possible development of associated chronic pain syndromes [Campbell and Colvin, 2013].

How should I assess a person with low back pain?

If a person presents with low back pain, exclude an underlying cause and assess for prognostic indicators to help guide management.

• Ask about: 
  • The onset, type, site, and pattern of pain; any pain radiation; duration of symptoms; aggravating and relieving factors; previous episodes; associated symptoms such as morning stiffness, leg pain or weakness, muscle spasm, numbness or paraesthesia, weight loss.
    • Non-specific lower back pain typically varies with posture and time, and is exacerbated by movement.
  • Any red flag symptoms that may indicate a serious underlying cause, such as cauda equina syndrome, spinal malignancy, vertebral fracture, or spinal infection.
  • Impact on daily functioning including work, study, relationships, and sleep, and impact on psychological wellbeing.
    • Pain severity does not necessarily correlate with functional impairment.
  • Any risk factors for non-specific back pain and a prolonged or complex recovery.
  • Any drug treatments, including over-the-counter medication.
• Examine the person:
  • Assess the person's gait, posture, and spine for deformity; palpate for localized spinal tenderness and decreased range of movement.
  • Assess for any red flag signs that may indicate a serious underlying cause.
    • Consider checking anal sphincter tone and perianal sensation, depending on clinical judgement.
  • Perform a neurological examination and assess for lower limb signs of nerve root compression or other neurological deficits, such as:
    • Numbness, paraesthesia, motor deficits and muscle weakness, or abnormal tendon reflexes; positive straight leg raising test; extensor plantar response. See the CKS topic on Sciatica (lumbar radiculopathy) for more information.
• Assess for an underlying cause(s) of low back pain, and manage appropriately. See the section on Differential diagnosis for more information.
• If no specific underlying cause is suspected, use a risk stratification screening tool, such as the Keele STarT Back tool, to identify people with risk factors for prolonged or complex recovery, to help guide appropriate management.
  • See the University of Keele's (website www.startback.hfac.keele.ac.uk) clinician STarT Back resources which include a patient questionnaire online calculator for use during a consultation, a case study, and other training resources.
• Do not routinely arrange a spinal X-ray or other imaging to diagnose non-specific low back pain in primary care.
  • Spinal X-ray may be indicated if there is suspicion of a specific pathology, such as a compression fracture due to osteoporosis or bone pain due to malignancy. See the CKS topics on Osteoporosis - prevention of fragility fractures, Bone and soft tissue sarcoma - recognition and referral, and Multiple myeloma for more information.

What else might it be?

Alternative conditions that may present with low back pain include:

• Neurological
  • Sciatica. See the CKS topic on Sciatica (lumbar radiculopathy) for more information.
  • Myelopathy or a higher cord lesion. 
  • Peroneal palsy or other neuropathies, such as nerve entrapment at the fibular head. 
  • Deep gluteal syndrome/piriformis syndrome (where the sciatic nerve is compressed or irritated where it is covered by the piriformis muscle). 
  • Spinal stenosis.
• Systemic
  • Sacroiliitis in ankylosing spondylitis and other spondyloarthropathies. See the CKS topic on Ankylosing spondylitis for more information.
  • Vascular claudication.
• Other
  • Abdominal aortic aneurysm.
  • Aseptic necrosis of the femoral head.
  • Facet joint arthropathy.
  • Greater trochanteric pain syndrome. See the CKS topic on Greater trochanteric pain syndrome for more information.
  • Intra-abdominal pathology. See the CKS topics on Cholecystitis - acute, Dyspepsia - proven peptic ulcer, Pancreatitis - acute, Renal or ureteric colic, Pyelonephritis - acute, Prostatitis - acute, and Pelvic inflammatory disease for more information.
  • Osteoarthritis of the spine or hip. See the CKS topic on Osteoarthritis for more information.
  • Osteoporosis. See the CKS topic on Osteoporosis - prevention of fragility fractures for more information.
  • Polymyalgia rheumatica. See the CKS topic on Polymyalgia rheumatica for more information.
  • Rheumatoid arthritis. See the CKS topic on Rheumatoid arthritis for more information.
  • Shingles (herpes zoster). See the CKS topic on Shingles for more information.

Scenario: Management

From age 16 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of low back pain (without radiculopathy).

Search dates

March 2017 - October 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• back pain/, low back pain/, low back pain.tw.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.