The pain management programme approach to chronic non-malignant pain which specifically addresses low back pain has been dealt with in previously. Therefore, this section will examine other avenues open to managing acute and chronic back problems.
See more: Low Back Pain: Assessment
As early as 1996, the NHS Executive commissioned guidelines from the Royal College of General Practitioners (RCGP) based on systematic reviews of the evidence recommending that simple mechanical back pain should be managed in primary rather than secondary care. Essentially, there should be a cultural change from rest to activity and from a medical to a multidisciplinary model, which would involve using practitioners currently working outside the NHS. The main considerations to this approach are:
The early assessment, triage, drug therapy as well as advice for patients to avoid bed rest and to maintain normal activities.
The identification of those patients with psychosocial ‘yellow flags’ which can lead to pain related disability or chronicity.
To consider manipulation for those patients who are not improving within 6 weeks of onset, by a suitably trained practitioner, which is of low risk in skilled hands and associated with a better outcome to that of the treatments to which it has been compared to.
There is also a growth of evidence for the importance of psychosocial factors as predictors of poor outcomes and progression to chronicity . Behavioural management of which some main components include explanation, reassurance and alleviation of distress seeks to encourage positive attitudes and patient empowerment.
For guidelines recommending clinical assessment, diagnosis and management of Low back pain please consult
NICE guidelines for low back pain: early management of persistent non-specific low back pain
European Guidelines for the Management of Chronic Non-specific low back pain .
Diagnosis and treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society .
Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain 
APS-AAPM Clinical Guidelines for the Evaluation and Management of Low Back Pain
Department of Health 2010. Organising quality and effective spinal services for patients: a report for local health communities by the Spinal
These guidelines are summarised in Table 1. This allows the reader to evaluate each treatment against a number of guidelines and not just the NICE guidelines that have been so heavily criticised by some pain clinicians in the UK. As can be seen there is broad agreement throughout and highlights areas where a need for further research is required.
Simple analgesic therapy is recommended in a number of guidelines. Roelofs et al  performed a systematic review for the treatment of low back pain and concluded that NSAIDS were no more effective for pain relief and global improvement compared with paracetamol for acute low back pain and limited evidence that NSAIDs were more effective than paracetamol in patients with chronic low back pain.
There were several studies that compared NSAIDs with physiotherapy and spinal manipulation in acute low back pain and concluded that there was moderate evidence that NSAIDs were no more effective than either treatment option. Regarding side effects, 33 studies compared different types of NSAIDs and came to no hard and fast conclusion for side effects of one over another due to the heterogeneity of those studied.
The review also concluded that there was no evidence to recommend any other route than oral administration. There is no statistical evidence that there is any difference in pain relief when comparing COX-2 NSAIDs with traditional NSAIDs for acute low back pain or chronic low back pain. The review concludes that NSAIDs are effective in short term global improvement in patients with acute and chronic low back pain without sciatica although the effects are small.
The use of analgesic therapy is assumed to be useful in keeping the patient active which is recommended for simple acute back pain (, , ). However, costs associated with the use of non-steroidal anti-inflammatory drugs are of concern. The risks associated with 2 months of NSAID are that:
1 in 5 patients will have an endoscopic ulcer, 1 in 70 patients will have a symptomatic ulcer, 1 in 150 patients will have a bleeding ulcer, 1 in 1200 patients will die of a bleeding ulcer .
Approximately 12,000 emergency GI admissions are attributable to NSAIDs a year in the UK, of these, there are 2,230 deaths a year (in hospitals) and a further 330 deaths attributable to NSAIDs occur in the community  Hospital admissions resulting from NSAIDs side effects (adapted from Moore and Phillips, 1999) involve 2.4 patients from an individual GP per year, 24 patients from an individual Primary Care Group (PCG) / Local Health Group (LHG) (100,000 patients)
In 1999, in the UK the estimated annual burden of NSAID GI adverse events for an average PCG/LHG (100,000 people on average) was £435,000, the National Health Services spent about £251 million per year for NSAID GI side effects and on average, every patient prescribed an NSAID had an additional hidden cost of £48 a year to pay for the GI adverse events .
This is not to say that patients should not receive adequate analgesia and NSAIDs are extremely useful in providing pain relief in patients with musculoskeletal problems. Not providing appropriate pain relief also has costs in terms of morbidity and mortality and these also need to be considered in terms of risks and benefits in order to make appropriate decisions about patient care
Muscle relaxants are commonly prescribed for acute low back pain but there is conflicting evidence that they are effective compared to placebo and there is insufficient evidence to determine whether they are more or less effective when compared to NSAIDs (, ). Drowsiness, dizziness and dependency are common adverse effects (, ).
Withdrawal symptoms similar to barbiturate or alcohol withdrawal have been reported. During the last decade it has been recognised that skeletal muscle relaxants have the potential for abuse and dependence. Roelofs et al  reviewed three trials that concluded that there was moderate evidence that muscle relaxants in acute low back pain do not provide any additional effects to NSAIDs alone.
Opioid based analgesics are generally classified as either weak or strong. These terms refer to relative efficacy rather than potency. Further, weak opioids exhibit a ceiling to their analgesic effect principally by increased adverse reactions such as somnolence, constipation, nausea, vomiting, pruritis and dizziness far outweigh any benefit that may exist. Clinicians are often reluctant to prescribe opioids for low back pain due to the perceived risk of addiction .
However Savigny et al  recommend that effect of opioids on Quality of Life for chronic low back pain is outweighed by the Quality of Life loss and costs due to side effects. The same guidelines recommend that the long-term use of opioids was considered inappropriate, and should not be preferentially prescribed over NSAIDs following paracetamol.
Antidepressive medication has been used primarily in patients with neuropathic and chronic widespread pain, in particular fibromyalgia. In low back pain they have been prescribed for pain relief, help with sleep and reduce depression. Urquhart et al (2008) in a systematic review could find no clear evidence that anti-depressants were more effective than placebo in the management of chronic low back pain. These do not include patients with a co-morbidity of depression or for neuropathic type chronic low back pain.
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