Most people with back pain have tried several things, been offered several more, and have no idea which of them have evidence behind them.
There is a national guideline that answers this, and almost nobody outside the profession has read it.
NICE published its guidance on low back pain and sciatica in over 16s, and it is unusually direct. It names what should be offered, and it names a considerable number of things that should not be.
Here is the summary, in plain terms.
What Comes First
Exercise.
The guideline recommends a group exercise programme within the NHS for people with back pain or sciatica, and that programme may involve biomechanical, aerobic or mind body approaches, or a combination of them.
What that means practically: exercise is the core treatment, and the specific type matters less than most people assume. Strength work, general aerobic activity, Pilates, yoga and combinations have all been examined, and the guideline does not elevate one above the others.
Which has a liberating implication. The best exercise for your back is substantially the one you will actually keep doing.
Alongside exercise, the guideline emphasises self management, including information about the nature of back pain and sciatica and encouragement to continue with normal activities.
What Is Offered Alongside Exercise
Manual therapy, meaning spinal manipulation, mobilisation or soft tissue techniques, is recommended only as part of a treatment package including exercise, with or without psychological therapy.
Read that qualification carefully. Manual therapy on its own is not what the guideline supports. Manual therapy combined with exercise is.
Psychological therapy is similarly recommended as part of a package including exercise, particularly for persistent back pain.
And risk stratification is recommended, using a validated tool to identify who is likely to do well with simple advice and who needs more intensive support. Around three quarters of people with non specific back pain fall into the lower risk categories.
The Medication Position
This surprises people more than anything else in the guideline.
Do not offer paracetamol alone for managing low back pain.
Consider oral anti inflammatories, at the lowest effective dose for the shortest possible period, taking into account risks including gastrointestinal, cardiovascular and kidney effects, and with gastroprotection where appropriate.
Weak opioids may be considered for acute back pain only if an anti inflammatory is contraindicated, not tolerated, or has been ineffective.
Do not routinely offer opioids for acute low back pain.
Do not offer opioids for chronic low back pain or chronic sciatica.
Do not offer gabapentinoids or antiepileptics for low back pain.
And do not offer antidepressants, including SSRIs, SNRIs or tricyclics, for managing low back pain.
Please do not change anything you are taking on the basis of this article. Some of these medications require gradual reduction rather than stopping, and if you have been on something long term, that is a conversation with your GP.
What it is reasonable to do is raise the question. If you have been taking paracetamol daily for years with limited effect, or you are on long term opioids for back pain, those are legitimate things to review.
The Treatments the Guideline Says Not to Offer
This is the list most people have never seen, and several items on it are still widely available.
Belts or corsets.
Foot orthotics.
Rocker sole shoes.
Traction.
Ultrasound.
TENS.
Percutaneous electrical nerve stimulation.
Interferential therapy.
And acupuncture, for low back pain specifically.
Plus, on the invasive side, spinal injections for low back pain, and disc replacement.
A note on that acupuncture entry, because it is frequently misquoted. NICE advises against it for low back pain and sciatica specifically. Separate NICE guidance does recommend considering a course of acupuncture for chronic primary pain, and for the prophylaxis of chronic tension type headache and migraine. Different conditions, different recommendations, and the distinction matters.
And on injections, the guideline distinguishes between spinal injections for low back pain, which it advises against, and epidural injection for acute and severe sciatica, which it says may be considered. Again, the specifics matter.
The Imaging Position
Do not routinely offer imaging in a non specialist setting for people with low back pain with or without sciatica.
And explain to people that if they are referred for a specialist opinion, they may not need imaging.
Why: findings such as disc degeneration and bulges are extremely common in people with no symptoms at all, and their prevalence rises steadily with age. An early scan in an uncomplicated case frequently produces alarming language, more fear, less movement, and no change in treatment.
Imaging is genuinely valuable when there are features suggesting a serious cause, when there is progressive neurological change, or when surgery is being considered. Those are specific indications rather than a default.
How to Use This
If you are being offered something on the do not offer list, that is a reasonable thing to ask about. Not confrontationally, but as a genuine question: what is the evidence for this in my case?
If exercise has not been part of your treatment, that is the gap worth closing, since it is the thing the guideline places first.
If you have had manual therapy alone, without an exercise component, the guideline suggests the combination rather than the technique on its own.
And if your medication has not been reviewed in years, that is worth raising with your GP.
What the Guideline Cannot Tell You
Honesty requires this section.
Guidelines describe populations, not individuals. They are built from averages across trials, and they cannot account for everything about your particular presentation.
Some people respond to things the guideline does not recommend, and a clinician may reasonably deviate from guidance with a clear rationale and informed consent.
And guidance changes. This represents the current position rather than a permanent truth.
The useful stance is not to treat the guideline as a rulebook, but to know what it says so that you can have an informed conversation rather than simply accepting whatever is offered.
Symptoms That Need Urgent Attention
Some back pain is not mechanical, and these are the features that matter.
Go to A&E immediately for numbness in the groin, genitals or inner thighs, new difficulty controlling your bladder or bowels or starting to pass urine, or weakness in both legs.
Contact your GP promptly for progressive weakness in a leg or foot, a foot that drops or catches when you walk, back pain with fever, unexplained weight loss or night sweats, severe unrelenting night pain that does not change with position, back pain following significant trauma, any history of cancer with new back pain, a first significant episode over the age of 50, or sudden localised back pain after a minor fall if you have osteoporosis or take long term steroids.
Let Us Give You the Treatment That Comes First
Exercise, delivered properly and progressed sensibly, is what the national guidance places at the front of the queue. It is also the thing most people have never actually received in a structured form.
Ravenscroft Health offers a free discovery visit at no cost and no obligation. You will get a thorough assessment, a clear explanation of what is driving your symptoms, and a plan built around what the evidence actually supports, with access to GP input, imaging and onward referral where your presentation genuinely warrants it.
