What non-pharmacological interventions are effective for managing chronic low back pain in a primary care setting?

For managing chronic low back pain in a primary care setting, several non-pharmacological interventions are considered effective:

• Self-management: Provide tailored advice and information to help individuals self-manage their low back pain, including details on the nature of the pain and encouragement to continue with normal activities ¹. Self-management can be used throughout the treatment pathway and complements other therapies ¹,⁵.
• Exercise: Offer a supervised group exercise programme to people aged 16 years and over with chronic primary pain, taking into account their specific needs, preferences, and abilities ². For low back pain with or without sciatica, a group exercise programme (biomechanical, aerobic, mind–body, or a combination) within the NHS can be considered ¹. Individuals should be encouraged to remain physically active for longer-term general health benefits ².
• Manual Therapy: Manual therapy (such as spinal manipulation, mobilisation, or soft tissue techniques like massage) can be considered, but only as part of a treatment package that includes exercise, with or without psychological therapy ¹.
• Psychological Therapies: Psychological therapies using a cognitive behavioural approach can be considered for managing low back pain with or without sciatica, but only as part of a treatment package that includes exercise, with or without manual therapy ¹. For chronic primary pain, acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT) can be considered, delivered by appropriately trained healthcare professionals ².
• Combined Physical and Psychological Programmes: A combined physical and psychological programme, incorporating a cognitive behavioural approach (preferably in a group context), is recommended for people with persistent low back pain or sciatica who have significant psychosocial obstacles to recovery (e.g., avoiding activities due to inappropriate beliefs) or when previous treatments have not been effective ¹,³,⁴. Improvement in functional outcomes for chronic low back pain often depends more on managing psychosocial risk factors than symptomatic treatments ³,⁴.
• Risk Stratification: Consider using risk stratification tools, such as the STarT Back risk assessment tool, at the first point of contact for new episodes of low back pain to inform shared decision-making ¹. This helps determine whether simpler support (e.g., reassurance, advice to keep active) or more intensive support (e.g., exercise programmes with or without manual therapy or psychological approaches) is appropriate ¹.
• Return to Work: Promote and facilitate return to work or normal activities of daily living for individuals with low back pain ¹.

Interventions generally not recommended for managing low back pain include belts or corsets, foot orthotics, rocker sole shoes, traction, acupuncture, ultrasound, percutaneous electrical nerve stimulation (PENS), transcutaneous electrical nerve stimulation (TENS), interferential therapy, and biofeedback ¹,².