Management of acute simple low back pain of more than 6 weeks duration

If acute simple low back pain is not responding to treatment then reapply diagnostic triage.

Consider investigations e.g. ESR, calcium, alkaline phosphatase. In general, xrays are not very useful for screening.

NICE suggest that:

• do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica
• X-ray of the lumbar spine is not routinely indicated for the management of non-specific low back pain
  • offer plain film X‑ray of the sacroiliac joints for people with suspected axial spondyloarthritis, unless the person is likely to have an immature skeleton
• MRI (magnetic resonance imaging) is indicated when a diagnosis of spinal malignancy, infection, fracture, cauda equina syndrome or ankylosing spondylitis or another inflammatory disorder is suspected
  

If screening and diagnostic triage confirms simple mechanical back pain then possible therapeutic options include:

• physical activity and exercise
  • consider a group 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
• manual therapy
  • 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 that includes exercise

These management options are detailed in the linked item.

If patient with simple mechanical back pain has not returned to work after 3 months then consider referral to secondary care e.g. rheumatology, orthopaedics, pain management.

Reference:

• 1. ARC - Reports on Rheumatic Diseases 1999;17:1-4.
• 2. Drug and Therapeutics Bulletin 1998; 36 (12): 93-4.
• 3. NICE (July 2026).Low back pain - Early management of persistent non-specific low back pain