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Back pain is a very common problem in the UK - with eight out of ten people suffering from it at some point during their lives.
It can affect anyone, at any age, and is usually caused by a sprain or a strain of the muscles, ligaments, joints or discs in the back. Most of us know that this can be very painful, and inconvenient, but it is not serious.
Back pain is classified as acute or chronic, depending on how long the pain has been present. Acute pain is shorter lived and more common. We call back pain chronic once it has been has been present for more than 3 months. Managing back pain well prevents people developing chronic back pain.
Most people experience back pain on one or both sides of their backs but may also feel it around their hips and buttocks and occasionally into one or both thighs. But with simple advice, most people will see a great improvement in their back pain within two weeks.
Chronic back pain can last much longer and usually requires treatment such as medication or physiotherapy. In most cases though, your back will heal itself. It is important that you keep active and continue as normal.
Differentiate between Red Flags (See Red Flags section), nonspecific low back pain (NSLBP) and nerve root pain (sciatica)
History taking is most important in differentiating NSLBP from nerve root pain or stenotic leg pain and serious pathology.
If low severity symptoms, reassure patients that prognosis is good within 6/52 period See guidance on managing low risk patients
If medium or high severity of symptoms;
If patient re-presents to GP with persisting symptoms reassess red flags. See management section.
Consider the following differential diagnoses:
NB: Common findings such as osteoarthritis or lumbar spondylosis are extremely common in asymptomatic people and may not be the source of pain.
The presence of 2 or more Red Flags significantly raises the likelihood of serious spinal pathology. Please refer to the STarT back
Send to ED if suspicion of
Spinal infection (history immunosupression, intravenous drug user (IVDU), fever, blood test sepsis, recent bacterial infection)
Refer URGENTLY to Spinal TEAM at RD&E via DRSS
Mark referrals clearly as URGENT and why.
Current NICE /UKSSB guidelines state MRI only for use in specialist clinic if it will change outcome. Patients should be told they may not need imaging if being referred to specialist clinic. There is a high level of incidental findings on scans e.g. disc degeneration therefore appropriate clinical interpretation is needed when feeding back MRI results is essential.
Refer for x-ray only in cases of suspected fracture:
If fracture is confirmed;
Bloods appropriate for suspicion of infection or cancer.
Self-care and self-management underpins all activities within this guideline, please encourage patients to engage with this approach throughout
Positive attitude to outcome – try to keep patient at work and maintain activity levels. Assess and address issues of distress or depression.
Encourage early activity – activity is not harmful and may help to reduce pain in many patients.
Avoid prolonged bed rest – at most one or two days in simple back pain.
Education and rehabilitation – emphasise self-management and reinforce positive attitudes to outcome.
Give patient supportive information on self-management (see Patient Information below).
At each re-attendance:
The agreed spinal pathway is:
Refer To Physiotherapy:
Refer To RD&E Spinal Team:
Refer via e-Referral Service
Recommended resources for patients and carers. NHS Devon CCG does not take responsibility for the content of third party information resources.
Low back pain, back pain management and understanding pain - Good videos to show to patients (see links below)
Arthritis Research UK - exercises and useful advice (see link below)
McCullough BJ, Johnson GR, Brook MI, Jarvik JG. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology 2012; 262: 941-946.
Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378: 1560-1571
This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.
Publication date: February 2019