Most back pain improves within 6 weeks and needs no scan. An MRI early usually finds changes that are present in people with no pain at all, which leads to treatment nobody needed. The appointment exists to exclude the serious causes and get you moving. A consultation is £150.
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Any of these needs to be seen the same day. If you are severely unwell, go to your nearest emergency department or call 999.
Most back pain is non specific, which means no single structure can be identified as the source. That is not a failure of the assessment. It is the accurate description in around 9 out of 10 cases and it carries a good prognosis.New England Journal of Medicine Deyo, 2001
A small proportion is caused by something specific that changes the plan. Nerve compression, inflammatory disease, fracture, infection or cancer. Finding or excluding those is what the first appointment is for.NICE NG59, 2020
Pain that came on with movement, is worse in some positions and better in others, and is easing week by week, behaves like mechanical back pain. Stiffness for more than 30 minutes each morning in someone under 45, improving with exercise, points at inflammatory disease instead.NICE NG59, 2020
Imaging findings are common in people with no pain. In a review of asymptomatic adults, disc degeneration was present on MRI in 37% of 20 year olds and 96% of 80 year olds. Finding degeneration on a scan does not establish that it is causing your pain.American Journal of Neuroradiology Brinjikji, 2015
Send us what you are seeing and we will tell you what it is likely to be.
The appointment is a history and an examination. Where the pain is, what brings it on, what has changed, then movement, power, reflexes and sensation in both legs, and a straight leg raise where a nerve is suspected.NICE NG59, 2020
Scans are for the minority. Imaging is arranged where there are features of a serious cause, where a nerve problem is not settling and surgery or injection is being considered, or where inflammatory disease is suspected.NICE NG59, 2020
Weight loss, night pain, fever or a history of cancer changes the pathway entirely, and those questions are asked at the first appointment rather than after 6 weeks of physiotherapy.NICE NG12, 2015
Staying active
The single most consistent recommendation in the evidence. Bed rest slows recovery. Continuing normal activity, modified rather than stopped, shortens the episode.NICE NG59, 2020
Exercise and a structured programme
The treatment with the best evidence for both current pain and future episodes. Which type matters less than doing one and continuing it.NICE NG59, 2020
Manual therapy alongside exercise
Useful as part of a package including exercise rather than on its own. A course of manipulation with no exercise attached is the version that does not hold.NICE NG59, 2020
Pain relief
Anti inflammatories at the lowest effective dose for the shortest period. Opioids are not recommended for long term back pain and paracetamol alone has little effect.NICE NG59, 2020
Referral for a specialist opinion
For nerve pain that is not settling, for suspected inflammatory disease, and for any red flag. The referral is arranged and the appointment booked rather than described to you.NICE NG127, 2023
Most episodes improve substantially within 6 weeks and the majority of people are back to normal activity well before that. Recurrence within a year is common, which is why the exercise programme continues after the pain has gone rather than stopping with it.NICE NG59, 2020
The inconvenient half. No treatment for non specific back pain produces a large effect. Exercise, manual therapy and medication each produce modest improvements, and anybody promising to fix your back in three sessions is selling something the evidence does not support.New England Journal of Medicine Deyo, 2001
Where wear and tear in a joint is contributing, that is managed rather than cured, and the same principle applies. Movement and strength do more over a year than anything passive.NICE NG226, 2022
Answer four questions before you arrive and you will save half the appointment. When did it start, what were you doing, does it go below the knee, and does anything make it reliably better or worse. Pain below the knee is what separates back pain from a nerve problem.NICE NG59, 2020
Keep moving from day one, in the smallest version you can manage. A 10 minute walk 3 times a day beats resting, and it is what the evidence supports rather than a preference. Take a short walk before you decide you cannot.NICE NG59, 2020
Know the symptoms that mean an emergency department rather than an appointment. Numbness around the back passage or genitals, difficulty passing or controlling urine, or weakness in both legs. Those are the same day, and everything else can wait for a proper assessment.NICE NG59, 2020
Do not buy an MRI in the first 6 weeks of ordinary back pain. Degeneration is present on the scans of people with no pain at all, so an early scan often finds something incidental that then gets treated. This is the most expensive thing on this page and we are telling you not to buy it.American Journal of Neuroradiology Brinjikji, 2015
Do not buy a package of 12 manipulation sessions with no exercise programme attached. Manual therapy has evidence as part of a package that includes exercise and much less on its own.NICE NG59, 2020
Do not accept an opioid prescription for long term back pain. It is not recommended for this, the benefit fades and the dependence does not.NICE NG59, 2020
Step 1
The questions and the examination that separate ordinary back pain from a nerve problem, inflammatory disease, fracture or something else.
Step 2
What to do this week, what to avoid, what pain relief to use and for how long, and a specific exercise programme rather than an instruction to exercise.
Step 3
A scan is arranged where a specialist decision depends on it. Where the pain is settling, the review is the end of it.
Ask before you book if you are not sure this is the right appointment.
Usually not, and not in the first 6 weeks. Disc degeneration shows up on the scans of people with no pain at all, in 37% of 20 year olds and almost everyone by 80. An early scan often finds something incidental, which then gets treated when it was never the cause.
Most episodes improve substantially within 6 weeks and many people are back to normal well before that. Recurrence within a year is common, which is why the exercise programme continues after the pain has gone rather than stopping when it does.
Numbness around the back passage or genitals, difficulty passing or controlling urine, or weakness in both legs. Those need your nearest emergency department or 999 the same day. Fever, night sweats or unexplained weight loss with back pain also need urgent assessment.
No. Bed rest slows recovery and staying active shortens the episode, which is one of the most consistent findings in the evidence. Modify what you do rather than stopping, and a 10 minute walk three times a day is a reasonable starting point.
A 30 minute appointment with a full examination is £150. A same day urgent slot is £220. The 6 week review by telephone is £59. Where inflammatory disease is being considered the Core blood panel is £350.
Manual therapy has evidence as part of a package that includes exercise, and much less on its own. A course of manipulation with no exercise programme attached is the version that does not hold up, whoever is providing it.
Pain that travels below the knee suggests a nerve is involved rather than the back alone, which changes both the examination and the plan. It is still usually managed without surgery, and it is the situation where a scan is more likely to be worth having.
This page is general information about a condition and it is not a diagnosis. Treatment depends on what a doctor finds when they examine you, and no outcome is guaranteed. If you are severely unwell, or if any of the warnings at the top of this page apply to you, go to your nearest emergency department or call 999.
American Journal of Neuroradiology
Systematic literature review of imaging features of spinal degeneration in asymptomatic populationsBrinjikji, 2015
New England Journal of Medicine
Low back painDeyo, 2001
NICE
NICE
Low back pain and sciatica in over 16s, assessment and managementNG59, 2020
NICE
Osteoarthritis in over 16s, diagnosis and managementNG226, 2022
NICE
Suspected neurological conditions, recognition and referralNG127, 2023
Written by the clinical team at The Wellness. Awaiting clinical sign off.
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