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24 March 2016

Exercise not acupuncture for people with low back pain says NICE in draft guidance

NICE is updating its 2009 guidance on the early management of low back pain and has today published draft recommendations for public consultation.

The draft guideline recommends exercise, in all its forms (for example, stretching, strengthening, aerobic or yoga), as the first step in managing low back pain.

Massage and manipulation by a therapist should only be used alongside exercise because there is not enough evidence to show they are of benefit when used alone.

The draft guideline also recommends encouraging people to continue with normal activities as far as possible.

The draft guideline no longer recommends acupuncture for treating low back pain because evidence shows it is not better than sham treatment i. Paracetamol on its own is no longer the first option for managing low back pain. Instead, the draft guideline recommends that non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin should be tried first. Weak opioids, such as codeine, are now only recommended for acute back pain when NSAIDs haven’t worked or aren’t suitable.

Combined physical and psychological treatments (talking therapies) are recommended for people who have not seen an improvement in their pain on previous treatments or who have significant psychological and social barriers to recovery.

The updated draft guideline has been expanded to include people with sciatica, a painful condition typically caused by irritation or compression of the nerves which run from the lower back, through the legs and down to the feet.

Unlike the previous guideline, which only covered the management of low back pain that had lasted between 6 weeks and 12 months, the updated guideline covers people with low back pain or sciatica irrespective of how long they have had the condition

Professor Mark Baker, clinical practice director for NICE, said: “Millions of people are affected every year by these often debilitating and distressing conditions. For most their symptoms improve in days or weeks. However for some, the pain can be distressing and persist for a long time.

“Regrettably there is a lack of convincing evidence of effectiveness for some widely used treatments. For example acupuncture is no longer recommended for managing low back pain with or without sciatica. This is because there is not enough evidence to show that it is more effective than sham treatment.”

Professor Baker continued: “It is possible to reduce the impact that low back pain and sciatica can have on people’s lives. The draft guideline continues to recommend a stepped care approach and means people whose pain or function are not improving despite initial treatment should have access to a choice of further therapies.

“Our aim with this draft guideline is to give clarity and set out the most clinical and cost effective ways to treat low back pain and sciatica based on the best available evidence. We now want to hear from all those who provide care for people with these conditions in the NHS, as well as from people with the conditions and their carers, to ensure all relevant views are considered for the final guideline.”  

According to musculoskeletal physician and GP Dr Ian Bernstein*, who is on the group developing the guideline: “The diagnosis of back pain includes a variety of patterns of symptoms. This means that one approach to treatment doesn’t fit all. Therefore the draft guidance promotes combinations of treatments such as exercise with manual therapy or combining physical and psychological treatments. The draft guideline also promotes flexibility about the content and duration of treatments, and the choices made should take into account people’s preferences as well as clinical considerations.” 

A recent studyii found that lower back pain caused more disability than any other condition, affecting 1 in 10 people and becoming more common with increasing age. 

In the UK it is estimated that low back pain is responsible for 37% of all chronic pain in men and 44% in womeniii and the total cost of low back pain to the UK economy is reckoned to be over £12 billion per yeariv.

Sciatica is also a relatively common condition, with estimates suggesting that as many as 40% of people will experience it at some point in their lives.


For more information call the NICE press office on 0300 323 0142 or out of hours on 07775 583 813.

*Dr Bernstein explains some of the key points in the draft guideline in a short film which is available on NICE’s YouTube channel.


Notes to Editors

References and explanation of terms

      i.        Sham treatment is an inactive treatment or procedure that is intended to mimic as closely as possible a therapy in a clinical trial.

     ii.        Newton JN, Briggs ADM, Murray CJL, Dicker D, Foreman KJ, Wang H, et al. Changes in health in England, with analysis by English regions and areas of deprivation, 1990–2013: a systematic analysis for the Global                               Burden of Disease Study 2013. The Lancet. 2015;386(10010):2257–74.

    iii.        Health survey for England 2011

   iv.         The economic burden of back pain in the UK.

About the draft guidance

  1. The draft guideline will be available at  from Thursday 24 March 2016.
  2. The final guideline is due to be published in September 2016.
  3. Low back pain is common in working-age adults (particularly between the ages of 40 and 60 years). A UK survey reported that in 1998, 40% of adults had had low back pain lasting longer than 1 day in the previous 12 months.
  4. Treating all types of back pain costs the NHS more than £1000 million per year. In 1998 the direct healthcare costs of all back pain in the UK were estimated at £1623 million – approximately 35% of costs were related to services provided by the private sector. The costs of care for low back pain exceed £500 million per year.
  5. Therapies and interventions are used to help people to manage and improve their back condition and to lessen the intensity, recurrence and/or duration of back pain. They aim to help people to remain more physically and socially active in their daily lives and to reduce absence from work. There are many therapeutic and rehabilitation strategies that can be used for low back pain. These include:
  • patient education and advice to support self-management
  • occupational health and ergonomic advice
  • exercise (for example stretching, strengthening, aerobic or yoga)
  • manual therapies (for example, massage and joint manipulation)
  • psychological treatments (for example, cognitive behavioural pain management)
  • pharmacological treatments (for example, analgesics)

 About sciatica

  1. Sciatica is a relatively common condition with a lifetime incidence ranging from 13 to 40%. The corresponding annual incidence of an episode of sciatica ranges from 1 to 5%.
  2. The incidence of sciatica is related to age. Rarely seen before the age of 20, incidence peaks in the fifth decade and then declines.
  3. People who have sciatica usually have pain in the leg, and may also have low back pain. It is most commonly caused by a herniated intervertebral disc, but there are other causes of impingement of nerve roots in the lower back.
  4. Treatment of sciatica depends on the cause of the nerve impingement as well as the severity of symptoms. In the majority of cases, symptoms caused by a herniated disc resolve with conventional management.
  5. If symptoms persist, injection treatments (for example, epidural or nerve root injections) or surgical treatment (for example, microdiscectomy) can be offered. In cases where progressive neurological deficit is diagnosed, urgent surgical treatment is needed. The potential for faster recovery with invasive interventions for sciatic pain is a consideration as well as the potential for recovery without surgery, cost-effectiveness and increased complication rates of these procedures.
  6. Pharmacological treatments for sciatica are covered in the NICE clinical guideline on Neuropathic pain in adults (CG173)

About NICE

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