1. Non-Malignant Chronic Pain Management
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Instructions and acknowledgements
How to use this guide
Trigeminal Neuralgia
Neuropathic pain
Initial Pain Management
Osteoarthritis
Nociceptive Pain
Low Back Pain
early management
Other links
Gabapentin Titration
Pregabalin Titration
Chronic Pain Pathway Secondary Care
Tapentadol in acute pain pro-forma
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2. Instructions
Introduction
These guidelines are intended to assist healthcare professionals manage patients with non-malignant chronic pain in Walsall. They are intended to support the local implementation of the NICE Clinical Guideline on:
Neuropathic pain
Chronic back pain
Osteoarthritis
They were produced by the MSK STaR Group and have been ratified by the Walsall Joint Medicines Management Committee (JMMC) xxxx 2014
Background
This guide is to facilitate the prescribing of appropriate initial treatment. Please refer to the chronic pain pathway for full clinical and referral details. It should be emphasised that medicines play only a minor part in the management of persistent pain and may be of limited benefit for some patients with chronic non-malignant pain. Maintaining fitness, pacing activities and a generally healthy lifestyle are important.
Biopsychosocial approaches to assessing chronic pain and multidisciplinary, multimodal approach to its management is vital.
Non-pharmacological methods of pain relief such as TNS, acupuncture, physical methods in the reduction of muscle spasm are equally important.
These guidelines are based on the best available evidence but their application can always be modified by professional judgement.
Acknowledgments
Many thanks to all health care professionals and patient representatives who have inputted to and commented on these guidelines.
References
NICE Guidance NICE Pathways
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3. How to use this guide
The guide can be used in both directions and therapy should be reviewed for down-titration as well as up-titration. Assess each change to analgesic regimen after 4-6 weeks and review the efficacy of medication in relieving pain, improving function and any side-effects that may impair function.
Consider compliance when prescribing in the elderly particularly in patients who cannot tolerate oral formulations, with mental health problems, those who are socially isolated or with limited assess to care.
Consider low dose PPI (eg. Omeprazole or lansoprazole) for appropriate patients requiring GI protection when NSAIDs are prescribed for prolonger periods (use the lowest effective dose for shortest possible duration – eg 2 weeks).
Give dietary/fluid advice and consider adding a laxative if the patient is on regular co-codamol. Effervescent preparations should be reserved for patients who cannot swallow as these contain high sodium content.
Consider dihydrocodeine (30 mg QDS, max 240 mg/day) in those patients who may be unable to metabolise codeine or morphine – dihydrocodeine does not rely on this process for action, therefore may be a better choice and can be used to determine if the patient responds to weak opioids.
CNS side-effects are common with amitriptyline particularly in the elderly, therefore low doses should be used for initial treatment in this group.
Gradual titration of gabapentin in adults starting at 300 mg at night for 3 days, then 300 mg twice daily for 3 days, then 300 mg 3 times daily for 2 weeks then titrate at 100 mg-300 mg increments according to response is advocated. Reconsider if there is no response by 2400 mg. Slower titration may be required in the elderly, starting at 100 mg and increasing by 100 mg increments.
Caution should be taken when prescribing tramadol as it may increase the risk of convulsions in epilepsy or those susceptible to seizures. It also increases risk of CNS toxicity with SSRIs. Tramadol is contraindicated in those using mono-amine oxidase inhibitors or within two weeks of their withdrawal.
Anti-emetic (e.g. metoclopramide) on a PRN basis may be beneficial during the first 2 weeks of initiation of Butrans® patch as initial nausea can be problematic though eventually wears off.
As per NICE Guidelines – CG173 November 2013: Initial treatment offer a choice of amitriptyline, duloxetine, gabapentin, pregabalin.
Second and third-line treatment: if the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs. If the second and third line drugs tried are also not effective or not tolerated consider switching again.
Strong Opioids Prescribing Advice
Use of strong opioids are only effective in a small group of patients and should be initiated where the need is appropriate. Do not prescribe different opioids concurrently and it is advisable to consider other factors such as age before prescribing a strong opioid. Oxycodone and fentanyl are reserved for patients with cognitive impairment due to Zomorph®. Fentanyl patches will be reserved by patients who have renal impairment or adherence issues.
Patients should be reminded to avoid alcohol when prescribing dihydrocodeine, amitriptyline, gabapentin, tramadol and the strong Opioids such as Morphine based products.
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4. Initial Pain Management
Regular paracetamol 1 g QDS (or appropriate lower dose)
If ineffective then consider adding an NSAID - assess patient risk factors
Cardiovascular risk
Gastrointestinal risk
Renal risk
GI risk factors
Click here for details of these risks
*Any patient with GI risk factors should receive gastroprotection with omeprazole, lansoprazole, misoprostol or ranitidine at licensed doses for duration of NSAID use
Other cautions for NSAID use: Asthma, hepatic impairment/failure, smokers, heavy alcohol use, previous sensitivity to aspirin/NSAIDs and women attempting to conceive.
Add 1st choice- ibuprofen 400 mg TDS unless contraindicated*
Or if inadequate pain relief or side effects 2nd choice naproxen 500 mg BD unless contraindicated*
Failure to control pain, intolerance or contraindications
Comprehensive assessment: Somatic, visceral or neuropathic
Healthcare professionals should consider the use of TENS as an adjunct for pain relief. (TENS machines are generally loaned to the person by the NHS for a short period, and if effective the person is advised where they can purchase their own.)
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5. Return to Initial Pain Management
Risk factors
Cardiovascular risk
Caution on patients with CVD Risk Factors
Established CVD
Hypertension
Heart Failure
Diabetes
Age>65 especially if male
COX-2 inhibitors and diclofenac cause an increase in thromboembolic events e.g. MI and death even with short term use
This increase in risk is not seen with ibuprofen or naproxen at doses below
Gastrointestinal risk
All NSAIDS are associated with GI toxicity. The lowest GI risk is seen with ibuprofen ≤1200mg/day
This risk is seen as soon as the treatment is started and increases with treatment duration and dose. Concomitant use of low dose aspirin will further increase this risk
Renal risk
All NSAIDSs increase the risk of renal events. Particular concern should be exercised in elderly patients on ACEi or AIIRBs or long term usage
NSAIDs should be avoided if possible in patients with pre-existing renal impairment
GI risk factors
Age ≥65
Previous GI history
Serious co-morbidity
Concomitant antiplatelets, SSRIs, oral steroids, anticoagulants
Long term use of NSAIDs e.g. OA, RA, age >45yrs with low back pain
Active inflammatory bowel disease
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6. Offer carbamazepine as initial treatment for trigeminal neuralgia
Trimernial Neuralgia
Offer carbamazepine as initial treatment for trigeminal neuralgia
If initial treatment with carbamazepine is not effective, is not tolerated or is contraindicated, consider seeking expert advice from a specialist and consider early referral to a specialist pain service
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7. Return to Osteoarthritis management
Nociceptive Pain
Consider trial of opioid therapy
Stop and review diagnosis before switching to co-codamol
Start with co-codamol 8/500 1 or 2 tablets QDS, PRN titrate up to co-codamol 30/ tablets QDS. Dihydrocodeine may be considered in patients who may be unable to metabolise codeine (30 mg QDS max 240 mg). Prescribe drugs regularly to achieve effective analgesia
Stop and review before switching co-codamol to paracetamol
paracetamol plus immediate release tramadol.
Start at 50 mg up to QDS (max.100 mg QDS).
Set maximum dose, treatment period (e.g. 1 month) and acceptable response.
Stop and review diagnosis before switching to strong opioid
Zomorph® 10 mg BD as starting dose.
(morphine sulfate mr)
Swallowing difficulties: remember Zomorph® capsules can be opened.
Where compliance is an issue consider buprenorphine patch (BuTrans®)
Starting from 5 mcg/hr patch every 7 days, titrating up after 2 weeks if need be.
If there is cognitive impairment due to Zomorph®
stop and review diagnosis before switching to either.
Oxycodone modified release
Start with 10 mg BD.
Increase if necessary according to severity.
Fentanyl Patch
 For patients unable to swallow or who are renally impaired.
If ineffective switch to Tapentadol 50 mg bd and titrate upwards and review after 4 weeks, titrate up to 250 mg daily
Return to Osteoarthritis management
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8. Neuropathic pain Neuropathic pain Diabetic Neuropathy
Amitriptyline (caution in the elderly>75yrs) Start at 10 mg ON and titrate up to max. 50 mg/day
Gabapentin +/- Amitriptyline (dose above)
Titrate up to an effective dose(e.g mg/day)
If not tolerated then titrate down.
Titrate up to 150 mg BD while assessing response max 300 mg BD.
If not tolerated then wean down and discontinue.
Duloxetine +/-
Gabepentin (dose above)
Start with low dose of 30 mg/day.
Gradually titrate up to an effective dose (max. 90 mg/day).
Gabapentin titration and PIL
Pregabalin +/- Amitriptyline (dose above) or when sleep deprivation is a concern use Pregabalin.
Starting with 75 mg BD for 1 week and titrate up to 150 mg BD while assessing response max 300 mg BD.
If not tolerated then wean down and discontinue.
Pregabalin +/- Duloxetine (dose above)
(Resticted for patients who are intolerant of gabapentin or where gabapentin is ineffective) Start at 75 mg bd and
titrate up to mg BD.
If not tolerated then titrate down.
Pregabalin titration and PIL
Add Tramadol 50 mg up to QDS.
(Caution > 70 yrs of age)
Titrate up to max.100 mg QDS if needed
Set treatment period (eg 1 month) and acceptable response.
If Tramadol already titrated to max dose then titrate to maximum dose
Go to nociceptice pain-Zomorph level
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9. Gabapentin Titration for Neuropathic pain
1st and 2nd week
Day
Dose (mg)
Instructions
Dosage interval
One
100
At night
24 hourly
Two
Three
One in the morning and one at night
12 hourly
Four
Five
Three times a day
8 hourly
Six
Seven
For second week
200mg
[2x100mg] caps
Supply 60 x 100mg capsules for the initial 2 weeks
3rd week
Day
Dose (mg)
Instructions
Dosage interval
Every Day
300
Three times a day
8 hourly
4th Week and beyond-Review patient and increase dose according to response in steps of 300mg daily (in 3 divided doses)every 2-3 days up to 3.6 g daily.
Gabapentin patient leaflet
Return to Neuropathic pain
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10. Pregabalin Titration for Neuropathic pain
Day
Dose (mg)
Instructions
Dosage interval
Week 1
25mg
At night
24 hourly
Week 2
50mg
[ 2x25mg capsules]
Week 3
75mg
[ 3x25mg capsules]
One 25mg capsule in the morning and two at night
12 hourly
Week 4
100mg
[ 4x25mg capsules]
One 25mg capsule in the morning and three at night
Supply 70x25mg capsules for the first 4 weeks
[75mg, 150mg and 300mg capsules are currently the same price]
5th Week and beyond-Review patient and increase dose according to response in steps of 25mg daily (in 2-3 divided doses) up to 600mg daily.
Pregabalin patient leaflet
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11. Person with suspected osteoarthritis
Diagnosis
NICE pathway on patient experience in the NHS
Management
Follow-up and review
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12. Back to osteoarthritis
Diagnosis
Diagnose osteoarthritis clinically without investigations if a person:
is 45 or over and
has activity-related joint pain and
has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.
Be aware that atypical features, such as a history of trauma, prolonged morning joint-related stiffness, rapid worsening of symptoms or the presence of a hot swollen joint, may indicate alternative or additional diagnoses.
Important differential diagnoses include gout, other inflammatory arthritides (for example, rheumatoid arthritis), septic arthritis and malignancy (bone pain).
NICE has also produced a pathway on rheumatoid arthritis.
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13. Back to osteoarthritis
Management
Person with a diagnosis of osteoarthritis
Holistic approach to self-management
Core treatments : information exercise and weight loss
Additional treatments as needed, depending on the patient preference, needs and risk factors
Adjuncts to core treatments: pharmacological
Adjuncts to core treatments: non pharmacological
Referral for consideration of joint surgery
Possible surgical options
Follow up and review
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14. Back to osteoarthritis
Follow-up and review
Offer regular reviews to all people with symptomatic osteoarthritis. Agree the timing of the reviews with the person (see also below). Reviews should include:
monitoring the person's symptoms and the ongoing impact of the condition on their everyday activities and quality of life
monitoring the long-term course of the condition
discussing the person's knowledge of the condition, any concerns they have, their personal preferences and their ability to access services
reviewing the effectiveness and tolerability of all treatments
support for self-management.
Consider an annual review for any person with one or more of the following:
troublesome joint pain
more than one joint with symptoms
more than one comorbidity
taking regular medication for their osteoarthritis.
Apply the principles in the patient experience in adult NHS services pathway with regard to an individualised approach to healthcare services and patient views and preferences.
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15. Management-Holistic approach to self management Back to osteoarthritis
Assess the effect of osteoarthritis on the person's function, quality of life, occupation, mood, relationships and leisure activities. Use figure 1 in the NICE guideline as an aid to prompt questions that should be asked as part of the holistic assessment of a person with osteoarthritis.
Agree a plan with the person (and their family members or carers as appropriate) for managing their osteoarthritis. Apply the principles in the patient experience in adult NHS services pathway in relation to shared decision-making.
Take into account comorbidities that compound the effect of osteoarthritis when formulating the management plan.
Discuss the risks and benefits of treatment options with the person, taking into account comorbidities. Ensure that the information provided can be understood.
Self-management
Agree individualised self-management strategies with the person with osteoarthritis. Ensure that positive behavioural changes, such as exercise, weight loss, use of suitable footwear and pacing, are appropriately targeted.
Ensure that self-management programmes for people with osteoarthritis, either individually or in groups, emphasise the recommended core treatments (see core treatments in this path), especially exercise.
See also adjuncts to core treatments: non-pharmacological in this path for self-management options.
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16. Management-Core treatments: information, exercise and weight loss
Osteoarthritis
Management-Core treatments: information, exercise and weight loss
Offer advice on the following core treatments to all people with clinical osteoarthritis.
Access to appropriate information.
Activity and exercise.
Interventions to achieve weight loss if the person is overweight or obese (see also the obesity pathway).
Patient information
Offer accurate verbal and written information to all people with osteoarthritis to enhance understanding of the condition and its management, and to counter misconceptions, such as that it inevitably progresses and cannot be treated. Ensure that information sharing is an on-going, integral part of the management plan rather than a single event at time of presentation.
Offer advice on appropriate footwear (including shock-absorbing properties) as part of core treatments for people with lower limb osteoarthritis.
NICE has written information for the public explaining the guidance on osteoarthritis.
Exercise
Advise people with osteoarthritis to exercise as a core treatment, irrespective of age, comorbidity, pain severity or disability. Exercise should include:
local muscle strengthening and
general aerobic fitness.
It has not been specified whether exercise should be provided by the NHS or whether the healthcare professional should provide advice and encouragement to the person to obtain and carry out the intervention themselves. Exercise has been found to be beneficial but the clinician needs to make a judgement in each case on how to effectively ensure participation. This will depend upon the person's individual needs, circumstances and self-motivation, and the availability of local facilities.
Weight loss
Offer interventions to achieve weight loss as a core treatment for people who are obese or overweight. (see the obesity pathway for more details).
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17. Osteoarthritis Management-Adjuncts to core treatments: Pharmacological
Oral analgesics also see Initial Pain Management
Healthcare professionals should consider offering paracetamol for pain relief in addition to core treatments (see core treatments in this path); regular dosing may be required. Paracetamol and/or topical NSAIDs should be considered ahead of oral NSAIDs, COX-2 inhibitors or opioids.
If paracetamol or topical NSAIDs are insufficient for pain relief for people with osteoarthritis, then the addition of opioid analgesics should be considered. Risks and benefits should be considered, particularly in older people.
Topical Treatments
Consider topical NSAIDs for pain relief in addition to core treatments (see core treatments in this path) for people with knee or hand osteoarthritis. Consider topical NSAIDs and/or paracetamol ahead of oral NSAIDs, COX-2 inhibitors or opioids.
Topical capsaicin should be considered as an adjunct to core treatments (see core treatments in this path) for knee or hand osteoarthritis.
Do not offer rubefacients for treating osteoarthritis.
NSAIDs and highly selective COX-2 inhibitors also see Initial Pain Management
Although NSAIDs and COX-2 inhibitors may be regarded as a single drug class of 'NSAIDs', these recommendations use the two terms for clarity and because of the differences in side-effect profile.
Where paracetamol or topical NSAIDs are ineffective for pain relief for people with osteoarthritis, then substitution with an oral NSAID/COX-2 inhibitor should be considered.
Where paracetamol or topical NSAIDs provide insufficient pain relief for people with osteoarthritis, then the addition of an oral NSAID/COX-2 inhibitor to paracetamol should be considered.
Use oral NSAIDs/COX-2 inhibitors at the lowest effective dose for the shortest possible period of time.
When offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor (other than etoricoxib 60 mg). In either case, co-prescribe with a PPI, choosing the one with the lowest acquisition cost.
All oral NSAIDs/COX-2 inhibitors have analgesic effects of a similar magnitude but vary in their potential gastrointestinal, liver and cardio-renal toxicity; therefore, when choosing the agent and dose, take into account individual patient risk factors, including age. When prescribing these drugs, consideration should be given to appropriate assessment and/or ongoing monitoring of these risk factors.
If a person with osteoarthritis needs to take low-dose aspirin, healthcare professionals should consider other analgesics before substituting or adding an NSAID or COX-2inhibitor (with a PPI) if pain relief is ineffective or insufficient.
Intra-articular injections
Intre-articular corticosteroid injections should be considered as an adjunct to core treatments (see core treatments in this path) for the relief of moderate to severe pain in people with osteoarthritis.
Do not offer intra-articular hyaluronan injections for the management of osteoarthritis.
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18. Osteoarthritis
Management-Adjuncts to core treatments: Non-pharmacological
Thermotherapy
The use of local heat or cold should be considered as an adjunct to core treatments (see core treatments in this path).
Electrotherapy
Healthcare professionals should consider the use of TENS as an adjunct to core treatments (see core treatments in this path) for pain relief. (TENS machines are generally loaned to the person by the NHS for a short period, and if effective the person is advised where they can purchase their own.)
Aids and devices
People with osteoarthritis who have biomechanical joint pain or instability should be considered for assessment for bracing/joint supports/insoles as an adjunct to their core treatments (see core treatments in this path).
Assistive devices (for example, walking sticks and tap turners) should be considered as adjuncts to core treatments (see core treatments in this path) for people with osteoarthritis who have specific problems with activities of daily living. If needed, seek expert advice in this context (for example, from occupational therapists or Disability Equipment Assessment Centres).
Manual therapy
Manipulation and stretching should be considered as an adjunct to core treatments (see core treatments in this path), particularly for osteoarthritis of the hip.
Interventions that should not be offered
Nutraceuticals
Do not offer glucosamine or chondroitin products for the management of osteoarthritis.
Acupuncture
Do not offer acupuncture for the management of osteoarthritis.
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19. Referral for consideration of joint surgery
Osteoarthritis
Management-Referral for consideration of joint surgery
Referral for consideration of joint surgery
Clinicians with responsibility for referring a person with osteoarthritis for consideration of joint surgery should ensure that the person has been offered at least the core (non-surgical) treatment options (see core treatments in this path).
Base decisions on referral thresholds on discussions between patient representatives, referring clinicians and surgeons, rather than using scoring tools for prioritisation.
Consider referral for joint surgery for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment.
Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain.
Patient-specific factors (including age, sex, smoking, obesity and comorbidities) should not be barriers to referral for joint surgery.
When discussing the possibility of joint surgery, check that the person has been offered at least the core treatments (see core treatments in this path) for osteoarthritis, and give them information about:
the benefits and risks of surgery and the potential consequences of not having surgery
recovery and rehabilitation after surgery
how having a prosthesis might affect them
how care pathways are organised in their local area.
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20. Management-Possible surgical options Back to osteoarthritis
Invasive treatments for knee osteoarthritis
Do not refer for arthroscopic lavage and debridement as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (as opposed to morning joint stiffness, 'giving way' or X-ray evidence of loose bodies).
The recommendation above is a refinement of the indication in Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis (NICE interventional procedure guidance 230). A review of the clinical and cost-effectiveness evidence for this procedure led to this more specific recommendation on the indication for which arthroscopic lavage and debridement is judged to be clinically and cost effective.
Total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip
Prostheses for total hip replacement and resurfacing arthroplasty are recommended as treatment options for people with end-stage arthritis of the hip only if the prostheses have rates (or projected rates) of revision of 5% or less at 10 years.
These recommendations are from total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip (review of technology appraisal guidance 2 and 44). (NICE technology appraisal guidance 304).
NICE has written information for the public explaining the guidance on prostheses for end-stage hip arthritis.
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21. Low Back Pain (early management
Person presenting with non-specific low back pain that has lasted for more than 6 weeks but for less than 12 months
NICE Pathway on patient experience in adult NHS services
Keep diagnosis under review at all times
Assessment and imaging
Advice, information and promoting self-management
Offer:
Drug treatments to manage pain AND
A choice of physical treatments
Drug Treatments
Choice of physical treatments
Treatments that should not be offered
Consider referral for combined physical and psychological treatment programme if improvement is unsatisfactory
Consider referral for an opinion on spinal fusion if improvement is unsatisfactory
Do not refer for other procedures
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22. Low Back Pain (early management)
Person presenting with non-specific low back pain that has lasted for more than 6 weeks but for less than 12 months
Specific causes of low back pain that are not covered in this pathway are malignancy, infection, fracture, and ankylosing spondylitis and other inflammatory disorders. A clinician who suspects that there is a specific cause for their patient's low back pain should arrange the relevant investigations.
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23. Low Back Pain (early management)
Assessment and imaging
Do not offer X-ray of the lumbar spine.
Only offer MRI for non-specific low back pain in the context of a referral for an opinion on spinal fusion (see consider referral for an opinion on spinal fusion if improvement is unsatisfactory in the NICE pathway).
Consider MRI if one of these diagnoses is suspected:
spinal malignancy
infection
fracture
cauda equina syndrome
ankylosing spondylitis or another inflammatory disorder. .
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24. Low Back Pain (early management)
Advice, information and promoting self-management
Provide advice and information to promote self-management.
Offer educational advice that:
includes information on the nature of non-specific low back pain
encourages normal activities as far as possible.
Advise people to stay physically active and to exercise.
Include an educational component consistent with this pathway as part of other interventions (but do not offer stand-alone formal education programmes).
When considering recommended treatments, take into account the person's expectations and preferences (but bear in mind that this will not necessarily predict a better outcome).
NICE has written information for the public explaining its guidance on the early management of persistent non-specific low back pain.
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25. Low Back Pain (early management)
Drug Treatments
Base decisions on continuation on individual response
Follow the Nociceptive Pain Pathway in this Guidance
Tricyclic antidepressants
Consider offering tricyclic antidepressants if other medications are insufficient; start at a low dosage and increase up to the maximum antidepressant dosage until:
therapeutic effect is achieved or
unacceptable side effects prevent further increase.
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26. Low Back Pain (early management)
Choice of physical treatments
Offer one of the following treatment options, taking patient preference into account.
Structured exercise programme:
up to 8 sessions over up to 12 weeks
supervised group exercise programme in a group of up to10 people, tailored to the person
one-to-one supervised exercise programme only if a group programme is not suitable
may include aerobic activity, movement instruction, muscle strengthening, postural control and stretching.
Manual therapy:
course of manual therapy, including spinal manipulation
up to 9 sessions over up to 12 weeks.
Acupuncture:
course of acupuncture needling
up to 10 sessions over up to 12 weeks.
If the chosen treatment does not result in satisfactory improvement, consider offering another of these options.
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27. Low Back Pain (early management)
Treatments that should not be offered
Do not offer:
selective serotonin reuptake inhibitors (SSRIs) for treating pain
injections of therapeutic substances into the back
laser therapy
interferential therapy
therapeutic ultrasound
transcutaneous electrical nerve stimulation (TENS)
lumbar supports
traction.
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28. Low Back Pain (early management)
Consider referral for combined physical and psychological treatment programme if improvement is unsatisfactory
Consider referral for a combined physical and psychological treatment programme, comprising around 100 hours over a maximum of 8 weeks, for people who:
have received at least one less intensive treatment (see choice of physical treatments in this pathway) and
have high disability and/or significant psychological distress.
Combined physical and psychological treatment programmes should include a cognitive behavioural approach and exercise.
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