People with LBP that is resistant or unresponsive to primary care and exercise or manual therapy are considered for referral to a physical and/or psychological treatment programme (multi-disciplinary).
Maher, C., Underwood, M. and Buchbinder, R., 2017. Non-specific low back pain. The Lancet, 389(10070), pp.736-747.
Qaseem A, Wilt TJ, McLean RM, Forciea MA.Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166:514-530. doi:10.7326/M16-2367
Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)
NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE Guideline [NG59] November 2016. Available at: https://www.nice.org.uk/guidance/NG59
Consider psychological therapies using a cognitive behavioural approach for managing low back pain with or without sciatica but only as part of a treatment package including exercise, with or without manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage).
Consider a combined physical and psychological programme, incorporating a cognitive behavioural approach (preferably in a group context that takes into account a person's specific needs and capabilities), for people with persistent low back pain or sciatica when they have significant psychosocial obstacles to recovery (for example, avoiding normal activities based on inappropriate beliefs about their condition) or when previous treatments have not been effective.
NHMRC Australian Acute Musculoskeletal Pain Guidelines Group 2003. Evidence-based Management of Acute Musculoskeletal Pain. Available at: https://www.nhmrc.gov.au/
Cognitive behavioural therapy reduces general disability in the long-term compared to traditional care in mixed (acute/chronic) populations with back pain.
Group cognitive behavioural therapy sessions may reduce sick leave and healthcare utilisation in the long-term compared to general educational information in mixed populations with back pain.
While cognitive behavioural strategies are often included as part of specific interventions for acute low back pain such as exercise and activity restoration, there are no studies on the use of this approach as a single intervention.
No Level I or II Evidence
TOP 2015. Toward Optimised Practice - Evidence-Informed Primary Care Management of Low Back Pain: Clinical Practice Guidelines. 3rd Edition. December 2015. Institute of Health Economics, Alberta, Canada.
Refer patient with disabling back or leg pain, or significant limitation of function including job-related activities, within two to six weeks to a spinal care specialist such as a physical therapist, chiropractor, osteopathic physician, or physician who specializes in musculoskeletal medicine
Refer patient significantly affected by chronic low back pain and no improvement with primary care management to a multidisciplinary chronic pain program.
Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, Johnson K, Kramer C, Mueller B, Peterson S, Setterlund L, Timming R. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 2012.
Clinicians should consider cognitive behavioral therapy in the treatment of subacute low back pain
Low Back Pain: Medical Treatment Guidelines. July 2007. Department of Labor and Employment, State of Colorado, USA.
Psychosocial treatment is a well-established therapeutic and diagnostic intervention with selected use in acute pain problems and more widespread use in sub-acute and chronic pain populations. Psychosocial treatment is recommended as an important component in the total management of a patient with chronic low back pain and should be implemented as soon as the problem is identified.
Psychosocial interventions include psychotherapeutic treatments for mental health conditions, as well as behavioral medicine treatments. These interventions may similarly be beneficial for patients without psychiatric conditions, but who may need to make major life changes in order to cope with pain or adjust to disability. Examples of these treatments include cognitive behavioral therapy (CBT), relaxation training, mindfulness training, and sleep hygiene training.