Table 2.

Management of chronic low back pain (without serious pathology)

Chronic low back pain (without serious pathology)
Triage using a clinical assessment (history-taking, physical examination, and neurological tests (to recognize radicular features)
Patients should be screened for ‘red flags’ to exclude serious pathologies, and diagnostic tests (such as imaging) only carried out if suspected
Patients should be screened for psychosocial risk factors (‘yellow flags’ such as low self-efficacy, catastrophizing, fear of movement) to predict poorer outcomes
Use a risk stratification tool (such as STarT)
Non-pharmacological and non-invasive management treatment is recommended that includes education and self-management, and the recommencement of normal activities and exercise, with the addition of psychological programs in those whose symptoms persist (multidisciplinary treatments)
Primary conservative physical treatment exercises include walking, Pilates, tai chi, yoga, progressive relaxation (and massage, and manual therapy in some guidelines)
No evidence available to show that one type of exercise is superior to another Choice may ultimately depend on patients’ preferences and on the experience of the treating therapist A diversity of types of exercises should be used
Physical therapy exercise approach remains a first-line treatment, and should routinely be used Referral could be for an individual or group exercise program Passive physical therapies (massage, spinal mobilization, acupuncture, and spinal manipulation with radiculopathy) are not usually endorsed, or are optional in some guidelines
Passive methods (rest, medications) are associated with worsening disability, and are not recommended
Pharmacological therapies if used include nonsteroidal anti-inflammatory drugs (NSAIDs) and antidepressants at the lowest effective dose and for the least possible time
Injections, denervation procedures, and the use of surgery are generally not endorsed
No improvement after 4 weeks, or pathology or radiculopathy suspected, then specialist consultation