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Low back pain and sciatica

About

What is covered

This interactive flowchart covers assessing and managing low back pain and sciatica in people aged 16 and over.

Updates

Updates to this interactive flowchart

26 July 2017 Low back pain and sciatica in over 16s (NICE quality standard 155) added.
10 April 2017 Minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac pain (interventional procedures guidance 578) added to other surgical procedures.
21 February 2017 Lateral interbody fusion in the lumbar spine for low back pain (NICE interventional procedures guidance 574) added to spinal fusion.
13 December 2016 Epiduroscopic lumbar discectomy through the sacral hiatus for sciatica (NICE interventional procedures guidance 570) added to other surgical procedures.
29 November 2016 Updated, restructured and renamed (previously called low back pain (early management)) on publication of NICE guideline on low back pain and sciatica.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on low back pain and sciatica in an interactive flowchart

What is covered

This interactive flowchart covers assessing and managing low back pain and sciatica in people aged 16 and over.

Updates

Updates to this interactive flowchart

26 July 2017 Low back pain and sciatica in over 16s (NICE quality standard 155) added.
10 April 2017 Minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac pain (interventional procedures guidance 578) added to other surgical procedures.
21 February 2017 Lateral interbody fusion in the lumbar spine for low back pain (NICE interventional procedures guidance 574) added to spinal fusion.
13 December 2016 Epiduroscopic lumbar discectomy through the sacral hiatus for sciatica (NICE interventional procedures guidance 570) added to other surgical procedures.
29 November 2016 Updated, restructured and renamed (previously called low back pain (early management)) on publication of NICE guideline on low back pain and sciatica.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac pain (2017) NICE interventional procedures guidance 578
Lateral interbody fusion in the lumbar spine for low back pain (2017) NICE interventional procedures guidance 574
Epiduroscopic lumbar discectomy through the sacral hiatus for sciatica (2016) NICE interventional procedures guidance 570
Insertion of an annular disc implant at lumbar discectomy (2014) NICE interventional procedures guidance 506
Peripheral nerve-field stimulation for chronic low back pain (2013) NICE interventional procedures guidance 451
Transaxial interbody lumbosacral fusion (2011) NICE interventional procedures guidance 387
Non-rigid stabilisation techniques for the treatment of low back pain (2010) NICE interventional procedures guidance 366
Percutaneous intradiscal laser ablation in the lumbar spine (2010) NICE interventional procedures guidance 357
Prosthetic intervertebral disc replacement in the lumbar spine (2009) NICE interventional procedures guidance 306
Automated percutaneous mechanical lumbar discectomy (2005) NICE interventional procedures guidance 141
Low back pain and sciatica in over 16s (2017) NICE quality standard QS155
SimpliCT laser-guided needle placement in interventional radiology (2017) NICE medtech innovation briefing 98

Quality standards

Low back pain and sciatica in over 16s

These quality statements are taken from the low back pain and sciatica in over 16s quality standard. The quality standard defines clinical best practice for managing low back pain and sciatica in over 16s and should be read in full.

Quality statements

Risk stratification

This quality statement is taken from the low back pain and sciatica in over 16s. The quality standard defines clinical best practice for managing low back pain and sciatica in over 16s and should be read in full.

Quality statement

Primary care services have an approach to risk stratification for young people and adults presenting with a new episode of low back pain with or without sciatica.

Rationale

Risk stratification can be used to identify a person’s risk of poor functional outcome or long-term problems from low back pain with or without sciatica. Risk stratification tools can help to determine the complexity and intensity of support that a person may need.

Quality measures

Structure
Evidence of a locally defined approach to risk stratification and of systems in place to make staff aware of the approach.
Data source: Local data collection, for example, service specifications and written communications to staff.

What the quality statement means for different audiences

Service providers (primary care services) have an approach to risk stratification that they communicate to staff who undertake consultations for young people and adults presenting with a new episode of low back pain with or without sciatica. This can help support decisions about whether risk stratification is used with individual patients and, if so, which risk stratification tool is selected.
Healthcare professionals (such as GPs and nurses) are aware of their service’s approach to risk stratification for use at the first consultation with young people and adults presenting with low back pain with or without sciatica. This can determine whether risk stratification is used and, if so, which risk stratification tool is selected.
Commissioners (such as clinical commissioning groups and NHS England) ensure that the services they commission have an approach to risk stratification for people presenting with a new episode of low back pain with or without sciatica and systems in place to make staff aware of their local approach.
Young people and adults presenting with a new episode of low back pain with or without sciatica are assessed in a way that is consistent with a local approach to risk stratification. Their treatment and support is then chosen in line with the results of the assessment.

Source guidance

Low back pain and sciatica in over 16s (2016) NICE guideline NG59, recommendation 1.1.2.

Definition of terms used in this quality statement

Risk stratification
Stratification aims to improve the outcome by selecting treatments that may be more likely to work in certain groups of people. There are several methods of stratification which are all similar in outcome. The STarT Back risk assessment tool is an example of a validated tool for stratification by risk of ongoing functional impairment.
[Adapted from NICE’s guideline on low back pain and sciatica in over 16s, recommendation 1.1.2 with expert opinion]

Referrals for imaging

This quality statement is taken from the low back pain and sciatica in over 16s. The quality standard defines clinical best practice for managing low back pain and sciatica in over 16s and should be read in full.

Quality statement

Young people and adults with low back pain with or without sciatica do not have imaging requested by a non-specialist service unless serious underlying pathology is suspected.

Rationale

Imaging does not often change the initial management and outcomes of someone with back pain. This is because the reported imaging findings are usually common and not necessarily related to the person’s symptoms. Many of the imaging findings (for example, disc and joint degeneration) are frequently found in asymptomatic people. Requests for imaging by non-specialist clinicians, where there is no suspicion of serious underlying pathology, can cause unnecessary distress and lead to further referrals for findings that are not clinically relevant.

Quality measures

Structure
a) Evidence of local arrangements for young people and adults with low back pain with or without sciatica to be referred for specialist opinion.
Data source: Local data collection, for example, service protocols.
b) Evidence of local protocols outlining serious underlying pathology in relation to presentations of low back pain with or without sciatica.
Data source: Local data collection, for example, service protocols.
Process
Proportion of young people and adults with low back pain with or without sciatica who have imaging requested by a non-specialist service when no serious underlying pathology is suspected.
Numerator – the number in the denominator who have imaging requested by a non-specialist service.
Denominator – the number of young people and adults with low back pain with or without sciatica for whom there is no suspicion of serious underlying pathology.
Data source: Local data collection, for example, patient notes.

What the quality statement means for different audiences

Service providers (non-specialist services) ensure that staff are aware of and use local referral pathways to specialist services and do not request imaging for young people and adults with low back pain with or without sciatica unless serious underlying pathology is suspected.
Healthcare professionals (such as GPs and nurses) do not request imaging within a non-specialist service for young people and adults with low back pain with or without sciatica unless serious underlying pathology is suspected. Healthcare professionals should explain to young people and adults who are referred for a specialist opinion that they may not need imaging.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission specialist services with clinicians who have the expertise to make a decision about whether young people and adults with low back pain with or without sciatica should have imaging and that these services accept referrals from non-specialist services.
Young people and adults with low back pain with or without sciatica do not have imaging requested by a non-specialist service (such as a GP practice) unless serious underlying disease is suspected.

Source guidance

Low back pain and sciatica in over 16s (2016) NICE guideline NG59, recommendations 1.1.1 and 1.1.4.

Definitions of terms used in this quality statement

Non-specialist service
Services such as a GP practice in primary care.
[Expert opinion]
Serious underlying pathology
Example of serious underlying pathology include but are not limited to: cancer, infection, trauma or inflammatory disease such as spondyloarthritis. If serious underlying pathology is suspected, refer to relevant NICE guidance on:
[Adapted from NICE’s guideline on low back pain and sciatica in over 16s, recommendation 1.1.1]

Self-management

This quality statement is taken from the low back pain and sciatica in over 16s. The quality standard defines clinical best practice for managing low back pain and sciatica in over 16s and should be read in full.

Quality statement

Young people and adults with low back pain with or without sciatica are given advice and information to self-manage their condition.

Rationale

Low back pain and sciatica are common and recurrent conditions that can be long term. It is therefore important that the person learns how to manage their symptoms to reduce their pain and distress and improve their functioning and quality of life. Healthcare professionals can support the person’s ability to self-manage their condition by giving reassuring advice about the benign nature of the condition, the high probability of a rapid improvement in symptoms and the importance of early return to normal life activities. These include returning to work where applicable, physical activity and exercise.

Quality measures

Structure
Evidence of local arrangements to ensure that staff have access to information and the knowledge needed to signpost to other services for young people and adults with low back pain with or without sciatica.
Data source: Local data collection, for example, service protocols.
Process
Proportion of young people and adults with low back pain with or without sciatica who are given advice and information to self-manage their condition.
Numerator – the number in the denominator who are given advice and information to self-manage their condition.
Denominator – the number of young people and adults with low back pain with or without sciatica.
Data source: Local data collection, for example, audit of patient notes.
Outcome
a) Number of repeat GP appointments for young people and adults with low back pain with or without sciatica.
Data source: Local data collection, for example, audit of patient notes.
b) Levels of satisfaction amongst young people and adults with the management of their low back pain with or without sciatica.
Data source: National Pain Audit 2012 and local data collection.

What the quality statement means for different audiences

Service providers (such as GP practices) ensure that staff have the knowledge and information needed to support young people and adults with low back pain with or without sciatica to self-manage their condition. This can include having the expertise to give verbal information, providing leaflets or giving information about access to exercise schemes such as walking support groups.
Healthcare professionals (such as GPs, nurses and physiotherapists) advise and provide information to young people and adults with low back pain with or without sciatica to help them self-manage their condition. This can include verbal information provided by a healthcare professional, leaflets, or information about access to exercise schemes such as walking support groups.
Commissioners (such as clinical commissioning groups and NHS England) ensure that the services they commission employ healthcare professionals with the expertise to give verbal information, provide leaflets or give information about access to exercise schemes such as walking support groups for young people and adults with low back pain with or without sciatica to self-manage their condition.
Young people and adults with low back pain with or without sciatica are given advice and information to manage their condition themselves. The information can cover the importance of continuing with normal activities and, where applicable, returning to work and access to exercise schemes such as walking support groups.

Source guidance

Low back pain and sciatica in over 16s (2016) NICE guideline NG59, recommendation 1.2.1.

Definition of terms used in this quality statement

Advice and information to self-manage their condition
People are provided with advice and information, tailored to their needs and capabilities, to help them self-manage their low back pain with or without sciatica, at all steps of the treatment pathway. It includes:
  • information on the nature of low back pain and sciatica
  • encouragement to continue with normal activities and access to exercise schemes.
[Adapted from NICE’s guideline on low back pain and sciatica in over 16s, recommendation 1.2.1 with expert opinion]

Anticonvulsants, antidepressants and paracetamol for low back pain without sciatica

This quality statement is taken from the low back pain and sciatica in over 16s. The quality standard defines clinical best practice for managing low back pain and sciatica in over 16s and should be read in full.

Quality statement

Young people and adults are not given paracetamol alone, anticonvulsants or antidepressants to treat low back pain without sciatica.

Rationale

The use of medicines without a significant clinical benefit in managing low back pain with or without sciatica can lead to unnecessary side effects for the person, risk of dependency and inappropriate use of resources.

Quality measures

Structure
Evidence of local arrangements to ensure that no GP prescriptions include paracetamol alone, anticonvulsants or antidepressants to treat young people and adults with low back pain without sciatica unless the young person or adult has other indications for those medicines.
Data source: Local data collection, for example, service protocols.
Process
a) Proportion of young people and adults with low back pain without sciatica, who are given anticonvulsants and have no other indications for them.
Numerator – the number in the denominator who are given anticonvulsants.
Denominator – the number of young people and adults with low back pain without sciatica and no other indications for anticonvulsants.
Data source: Local data collection, for example, GP prescribing audits.
b) Proportion of young people and adults with low back pain without sciatica, who are given antidepressants and have no other indications for them.
Numerator – the number in the denominator who are given antidepressants.
Denominator – the number of young people and adults with low back pain without sciatica and no other indications for antidepressants.
Data source: Local data collection, for example, GP prescribing audits.
c) Proportion of young people and adults with low back pain without sciatica, who are given paracetamol alone and have no other indications for it.
Numerator – the number in the denominator who are given paracetamol alone.
Denominator – the number of young people and adults with low back pain without sciatica and no other indications for paracetamol.
Data source: Local data collection, for example, GP prescribing audits.
Outcome
Number of medicines-related adverse events for young people and adults with low back pain without sciatica.
Data source: Local data collection, for example, GP prescribing audits.

What the quality statement means for different audiences

Service providers (such as GP practices) have systems in place to make staff aware that they should not give paracetamol alone, anticonvulsants or antidepressants to treat low back pain without sciatica. Young people and adults should only be given these medicines if they have other indications for them.
Healthcare professionals (such as GPs and nurses) do not treat low back pain without sciatica with paracetamol alone, anticonvulsants or antidepressants. They should only offer these medicines if there are other indications for them.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they have agreed service specifications which state that services do not treat low back pain without sciatica with paracetamol alone, anticonvulsants or antidepressants.
Young people and adults with low back pain without sciatica are not given paracetamol alone, anticonvulsants or antidepressants unless they need them for other conditions. This is because these medicines are not effective in either easing back pain or restoring function such as walking and doing daily tasks.

Source guidance

Low back pain and sciatica in over 16s (2016) NICE guideline NG59, recommendations 1.2.21 and 1.2.24–25.

Opioids for chronic low back pain without sciatica

This quality statement is taken from the low back pain and sciatica in over 16s. The quality standard defines clinical best practice for managing low back pain and sciatica in over 16s and should be read in full.

Quality statement

Young people and adults are not given opioids to treat chronic low back pain without sciatica.

Rationale

The use of opioids does not have a significant clinical benefit in the management of chronic low back pain without sciatica. It can therefore lead to unnecessary side effects for the person, risk of dependency and inappropriate use of resources.

Quality measures

Structure
Evidence of local arrangements to ensure that no GP prescriptions include opioids to treat young people and adults with chronic low back pain without sciatica unless they have other indications for those medicines.
Data source: Local data collection, for example, service protocols.
Process
Proportion of young people and adults who are given opioids to treat chronic low back pain without sciatica and have no other indications for them.
Numerator – the number in the denominator who are given opioids.
Denominator – the number of young people and adults with chronic low back pain without sciatica and no other indications for opioids.
Data source: Local data collection, for example, GP prescribing audits.
Outcome
Number of opioids-related adverse events for young people and adults with chronic low back pain without sciatica.
Data source: Local data collection, for example, GP prescribing audits.

What the quality statement means for different audiences

Service providers (such as GP practices) have systems in place to make staff aware that they should not give opioids to treat chronic low back pain without sciatica. Young people and adults should only be offered opioids when there are other indications for those medicines.
Healthcare professionals (such as GPs and nurses) do not give opioids to young people and adults to treat chronic low back pain without sciatica. They should only offer opioids when there are other indications for those medicines.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they have agreed service specifications which state that services do not treat chronic low back pain without sciatica using opioids.
Young people and adults with low back pain without sciatica are not given opioids to treat their condition unless they need them for other conditions. This is because these medicines are not effective in either easing pain or restoring function such as walking and doing daily tasks.

Source guidance

Low back pain and sciatica in over 16s (2016) NICE guideline NG59, recommendation 1.2.23.

Definition of terms used in this quality statement

Chronic low back pain
Having symptoms for more than 3 months.
[Adapted from NICE’s full guideline on low back pain and sciatica in over 16s]

Spinal injections

This quality statement is taken from the low back pain and sciatica in over 16s. The quality standard defines clinical best practice for managing low back pain and sciatica in over 16s and should be read in full.

Quality statement

Young people and adults do not have spinal injections for low back pain without sciatica with the exception of radiofrequency denervation for people who meet the criteria.

Rationale

Spinal injections for treating low back pain without sciatica are not clinically or cost effective, except for people who meet the criteria for a procedure called ‘radiofrequency denervation’. To determine whether these people will benefit from this procedure, they may be offered a diagnostic block of the nerves that supply the joints between the vertebrae. If they experience significant pain relief they may then be offered radiofrequency denervation in an attempt to achieve longer-term relief.

Quality measures

Structure
Evidence of local arrangements to ensure that spinal injections are not given to young people and adults to treat low back pain without sciatica, with the exception of radiofrequency denervation for people who meet the criteria.
Data source: Local data collection, for example, service protocols.
Process
Proportion of young people and adults who have spinal injections for low back pain without sciatica who meet the criteria for radiofrequency denervation.
Numerator – the number in the denominator who meet the criteria for radiofrequency denervation.
Denominator – the number of young people and adults who have spinal injections for low back pain without sciatica.
Data source: Local data collection, for example, patient notes.

What the quality statement means for different audiences

Service providers (such as hospitals) have systems in place to make staff aware that spinal injections for low back pain without sciatica should not be performed, with the exception of radiofrequency denervation for people who meet the criteria.
Healthcare professionals (such as physicians, surgeons and radiologists) do not give young people and adults spinal injections for low back pain without sciatica, with the exception of radiofrequency denervation for people who meet the criteria.
Commissioners (such as clinical commissioning groups and NHS England) specify in contracts that services that treat young people and adults with low back pain without sciatica do not perform spinal injections, with the exception of radiofrequency denervation for people who meet the criteria.
Young people and adults with low back pain without sciatica do not have spinal injections with the exception of the procedure of ‘radiofrequency denervation’ for people who meet the criteria. To check whether the procedure is suitable for the person, an anaesthetic is injected to temporarily block some of the nerves in the spine. If the pain is significantly reduced, the nerves are permanently sealed off using heat (radiofrequency ablation). This stops them from transmitting pain signals.

Source guidance

Low back pain and sciatica in over 16s (2016) NICE guideline NG59, recommendations 1.3.1, 1.3.2 and 1.3.3.

Definitions of terms used in this quality statement

Spinal injections
These are injected agents which aim to either reduce inflammation in tissues (for example, steroid injections), induce inflammation to stimulate healthy tissue regrowth (for example, prolotherapy) or reduce firing of nerve fibres that may be contributing to pain (for example, local anaesthetic). However, medial branch block injections can be used as a diagnostic tool to establish whether the person is likely to respond to radiofrequency denervation.
[Adapted from NICE’s guideline on low back pain and sciatica in over 16s with expert opinion]
Radiofrequency denervation
The procedure called ‘radiofrequency denervation’ involves sealing off some of the nerves to the joints of the spine to stop the nerves transmitting pain signals. It aims to achieve longer-term pain relief in people with low back pain who experience significant but short-term relief after a diagnostic block by injection of local anaesthetic.
[Adapted from NICE’s guideline on low back pain and sciatica in over 16s with expert opinion]
Criteria
Referral for assessment for radiofrequency denervation for people with chronic low back pain should be considered using the following criteria:
  • non-surgical treatment has not worked for them and
  • the main source of pain is thought to come from structures supplied by the medial branch nerve and
  • they have moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral.
Only perform radiofrequency denervation in people with chronic low back pain after a positive response to a diagnostic medial branch block.
[Adapted from NICE’s guideline on low back pain and sciatica in over 16s, recommendations 1.3.2 and 1.3.3 with expert opinion]

Effective interventions library

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Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

non-steroidal anti-inflammatory drugs
percutaneous electrical nerve stimulation
transcutaneous electrical nerve stimulation
pain in the back between the bottom of the rib cage and the buttock creases. A diagnosis of non-specific low back pain simply means that the back pain is very unlikely to be because of a serious problem such as cancer, infection, fracture, or as part of more widespread inflammation

Paths in this pathway

Pathway created: January 2013 Last updated: July 2017

© NICE 2017

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