The Royal College of General Practitioners (RCGP) is a network of more than 52,000 family doctors working to improve care for patients, encouraging and maintaining the highest standards of general medical practice and acting as the voice of GPs on education, training, research and clinical standards.

GP Guidelines for Treatment of Lower Back Pain

After the Chiropractic trials in 1990 and 1995, showing Chiropractic is safe and effective at treating back pain, the RCGP wrote the GP Guidelines for Management of Low Back Pain and included chiropractic treatment as a preferred treatment, with a switch from the old narrative of weeks of immobility or bed rest to treat back pain. Instead, they prescribed the following advice:

  • Keep active with minimal bed rest!
  • Joint manipulation helps, is low risk and has high patient satisfaction

Summarised below are the main finding of the studies.

Royal College of General Practitioners (RCGP) Guidelines for the Management of Acute Low Back Pain (1996, 1999, 2001)

  1. Strong evidence that manipulation provides better short-term improvement in pain and activity and higher patient satisfaction
  2. Moderate evidence that risks are very low in trained hands
  3. Avoid bed rest: It has been shown NOT to be effective in trials of simple backache or nerve root pain
  4. Strong evidence that bed rest leads to debilitation, disability and difficult rehabilitation
  5. Evidence in favour of activity is strong and unequivocal. Activity is helpful.
  6. Hurting does not mean harm! Stay as active as possible.
  7. Continue normal daily activities and increase physical activity progressively over a few days or weeks.
  8. Stay at work or return to work as soon as possible as it is beneficial.
  9. Strong evidence that back exercises do NOT produce any significant improvement in acute back pain.
  10. Moderate evidence that exercise programmes can improve pain and function in chronic low back pain.
  11. Encourages positive attitudes towards recovery: adequate pain relief and continuation of work.
  12. Reassurance and encouragement to keep active, chiropractic manipulation should be considered.
  13. Back problems become less common after the age of 50-60.

Download Acute low back pain guidelines.pdf for further information.

‘Red Flags’

Clearly there are other medical causes of back pain that GPs and Chiropractors need to be aware of. These may require more immediate medical attention; we can refer to them as ‘Red Flags’. If any suspicion or doubt arises regarding the history of the patient or their response to treatment, referral for further investigation may be required.

RCGP Lower Back Pain Diagnostic Advice for Health Care Practitioners

Back pain is separated into three categories:

  1. Simple backache (non-specific low back pain).
    Most common type of back pain; no specialist referral required.

  2. Nerve root pain
    Specialist referral is not generally required within the initial acute stage, provided the condition is resolving or not deteriorating. Symptoms may include:
    Leg pain down one side that can radiate to the foot or toes
    Numbness, pins and needles or paraesthesia
    Weakness in the toe or ankle muscles
    Clinical reflex and nerve tension neurological tests may be positive.

  3. Possible ‘Red Flag’ serious spinal pathology:
    A prompt referral may be required (less than 4 weeks) if the pain is non-mechanical:
    Possible unwellness, weight loss.
    Widespread neurological symptoms.
    Signs of structural deformity.
    Possible past history of carcinoma, steroids, HIV and more.

Cauda equina syndrome: immediate referral

This is a serious condition. Symptoms may include:

  • Sphincter or gait disturbance
  • Saddle anaesthesia.

This is a rare condition but one that Chiropractors are thoroughly trained to spot.

Please see my article medical causes of back pain for more in-depth information on the above red flags.

Other Guidelines for Lower Back Pain

The National Institute for Health and Care Excellence (NICE) also has its own set of guidelines regarding the treatment of lower back pain.

Comments from Chair of the RCGP, Professor Helen Stokes-Lampard, on the NICE guidelines for lower back pain 2016:

  1. Emphasis on promoting exercise for patients with lower back pain.
  2. Other therapies should be recommended in conjunction with exercise.
  3. Physical, psychological and social factors need to be considered.
  4. In more serious cases, there is a limit to the amount of exercise that should be carried out.
  5. There is no “one-size-fits-all” solution for patients with lower back pain.
  6. Emphasis on a combination of therapies – be these physical, psychological or pharmacological.

Drug Treatments for Lower Back Pain

In terms of drug therapies for lower back pain, there are some options. These recommendations might be controversial, but they take into account the latest research findings.

  1. Paracetamol has little more benefit for patients with lower back pain than a placebo.
  2. NSAIDs (Nonsteroidal Anti-Inflammatory Drugs), as an alternative to paracetamol, can be effective but they can have severe side-effects for patients, especially if they are taken over a long period of time or in those who are more prone to problems like bleeding of the gastrointestinal system.
  3. NSAIDs should only be prescribed at the lowest possible dose for the shortest possible time.