• Low back pain (LBP) is defined as pain and/or discomfort below the costal margin and above the inferior gluteal folds, with or without leg pain
  • Non-specific LBP is defined as tension, soreness and/or stiffness in the lower back that is not - attributed to a known specific pathology

In clinical practice, there are no sharp distinctions between acute, subacute and persistent LBP; however, for research purposes the following definitions have been described:

  • acute – pain present for less than 6 weeks (although some guidelines define this as pain present for less than 4 weeks, and others as less than 3 months)
  • persistent non–specific pain present for more than 6 weeks (although some guidelines define this as being more than 12 weeks)
  • sub-acute – has been used to describe pain that is of intermediate duration (typically 6-12 weeks), although many guidelines and literature sources do not refer to subacute chronicity (pain related disability) at all. The American Guidelines use the starting point for sub-acute pain as 4 weeks.
  • chronic - defined as constant or intermittent pain (in same pain site) for 6 months or longer (in the older adult, this is reduced to 3 months)
Table 1. Evidence for acute and chronic non-specific / simple mechanical back pain
  Guidelines: see key below
  Recommendations A B C D E F
Self Care Stay active and continue normal daily activities including work a a a a a  
Back Book / handouts a a a a a  
Application of superficial heat a x x x    
Stand alone formal educational programmes         x  
Assessment and diagnosis Focused history and diagnostic triage a a a a    
Red Flags a a a a    
Risk Factors for chronicity (Flags) a a a a a  
Routine radiographic imaging is not recommended (used for structural deformities) a a a a a  
Routine MRI / CT is not recommended (used in patients with severe or progressive neurological deficits/suspected serious conditions) a a a a Only for an opinion on spinal fusion  
Pharmacological interventions Paracetamol a a a a a  
NSAIDs a a a a a  
Muscle relaxants a x a a    
Antidepressants x a x a a  
Antiepileptics x ? x ?    
Systemic corticosteroids x x        
Weak opioids a a   a x  
Strong opioids (used judiciously/short term use) a a   x a  
Non-pharmacological treatments Exercise x a x a a  
Manipulation a a a a a  
Acupuncture x a x x a  
Massage x a x x x  
CBT x a x a a  
Multidisciplinary rehabilitation x a x a a a
TENS x x x x x  
Traction x x x x x  
Back school (short term) x x x a a  
Electromyography x x x      
Laser therapy     x x x  
Lumbar supports x x x x x  
Short wave diathermy ? ? x      
Interferential therapy x x x      
Therapeutic ultrasound     x   x  
Supervised educational programmes       a    
Interventions Epidural/intrathecal steroids x x x x x x
  Intra-articular steroids       x x  
Facet nerve blocks       x x x
Botulinum injections       x x x
Sacroliliac injections of steroids       x x x
Injections of sclerosants / Prolotherapy       x x  
Trigger point injections       x x x
Intradiscal injections       x x x
Neuroreflexotherapy       a x  
RF facet denervation       x x x
Intradiscal radio frequency       x x  
Electrothermal coagulation       x x x
Radio-frequency denervation       x x x
Spinal cord stimulation       x x x
Fusion surgery   Ref spinal surgeon   After 2 years and after evidence based treatment exhausted After a year and after evidence based treatment exhausted a
Artifical disc replacement           ?


A = American Low back pain (2007): Acute: less than 4 weeks

B = American Low back pain (2007): Sub acute - chronic: greater than 4 weeks

C = European Acute Back Pain Guidelines (2006): Acute: less than 6 weeks

D = European Chronic Non Specific Low Back Pain (2004): Chronic: 12 weeks or more

E = NICE Low Back Pain Guidelines: Sub-acute to chronic (2008): greater than 6 weeks and up to a year

F = American Pain Society Guidelines Interventional therapies (2009)


  • Airaksinen O, Brox JI, Cedraschi C. European guidelines for the management of chronic non-specific low back pain. Brussels: European Commission Research Directorate General;2005.
  • Chou R, Qaseem A, Snow V et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. AnnInternMed2007;147:478-91.
  • Clinical Knowledge Summaries (CKS). Back pain low (without radiculopathy). Newcastle upon Tyne:CKS;2009.
  • McIntosh G,Hall H. Lowbackpain(acute).ClinEvid2008;10:1102-32.
  • McIntosh G, Hall H. Lowbackpain(chronic).ClinEvid2008;10:1116-44.
    National Health and Medical Research Council (NHMRC). Evidence based management of acute musculoskeletal pain. Canberra:NHMRC;2003.
  • National Institute of Health and Clinical Excellence (NICE). Low back pain. Clinical guideline 88. London: NICE; 2009.
  • Shiri R, Karppinen J, Leino-Arjas P et al. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol 2010;171:135-54.
  • Van Tulder M, Becker A, Bekkering T et al. European guidelines for the management of acute nonspecific low back pain in primary care. COST Action B13.Brussels:European Commission Research Directorate General;2004.