Management of low back pain and sciatica

Back pain is very common and normally improves within a few weeks or months. Pain in the lower back is particularly common, although it can be felt anywhere along the spine – from the neck down to the hips. In most cases the pain isn't caused by anything serious and will usually get better over time.

Compression or pressure on any of the nerve roots in the low back can cause pain, numbness or weakness along the different nerves as they travel down through the leg and into the foot. Because the sciatic nerve is commonly affected, leg pain and related symptoms are often generally referred to as sciatica.

The information below is based on the following NICE guideline:

With each new episode of low back pain with or without sciatica, consider using the 9 point STarT Back risk assessment tool to inform shared decision-making

Based on risk stratification, consider:

  • Simpler and less intensive support for people with low back pain with or without sciatica 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 with low back pain with or without sciatica at higher risk of a poor outcome (for example, exercise programmes with or without manual therapy or using a psychological approach)

Click on the links below for useful patient information:

Northern Devon Healthcare NHS Trust: Coping with back pain

The Chartered Society of Physiotherapy: 10 things you need to know about your back

Non- pharmacological interventions

Self-management

People with low back pain with or without sciatica should be encouraged to continue with normal activities. Provide advice and information (including the nature of low back pain and sciatica) to help them self-manage at all steps of the treatment pathway.

Exercise

Consider an exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica. Take people's specific needs, preferences and capabilities into account when choosing the type of exercise.

Manual therapies

Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy.

Psychological therapy

Consider psychological therapies using a cognitive behavioural approach for managing low back pain with or without sciatica but only as part of a treatment package including exercise, with or without manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage).

Combined physical and psychological programmes

Consider a combined physical and psychological programme, incorporating a cognitive behavioural approach for people with persistent low back pain or sciatica:

  • when they have significant psychosocial obstacles to recovery (for example, avoiding normal activities based on inappropriate beliefs about their condition) or
  • when previous treatments have not been effective.

Pharmacological interventions

Sciatica

For recommendations on pharmacological management of sciatica, see formulary guidance on management of neuropathic pain.

Low back pain
  • Consider oral non-steroidal anti-inflammatory drugs (see section 10.1.1 Non-Steroidal anti-inflammatory drugs (NSAIDs))
    • When prescribing oral NSAIDs, think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
  • Do not routinely offer opioids for managing acute low back pain.
    • Only if an NSAID is contraindicated, not tolerated or has been ineffective, consider weak opioids e.g. codeine (with or without paracetamol) for acute low back pain (see section 4.7.2 Opioid analgesics)
    • In such circumstances, advise intermittent (not regular) use of opioid analgesia
  • Do not offer opioids for managing chronic low back pain
  • Do not offer paracetamol alone for managing low back pain.

 

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