How should I approach the referral of a patient with low back pain who has not responded to conservative management after six weeks?

Approach to referral for a patient with low back pain not responding to conservative management after six weeks:

• Reassess the patient to exclude any underlying specific causes or new symptoms, and manage accordingly.

• Assess adherence and response to previous self-management strategies and any pharmacological treatments.

• Evaluate for risk factors for prolonged or complicated recovery and address these where possible.

• Consider referral or self-referral to physiotherapy for manual therapy (such as spinal manipulation, mobilisation, or massage) as part of a treatment package including exercise, if not already done.

• Consider referral or self-referral for cognitive behavioural therapy (CBT) as part of a combined physical and psychological treatment approach, especially if psychosocial barriers exist or previous treatments have been ineffective.

• Consider referral to a group exercise programme tailored to the patient’s needs, preferences, and capabilities.

• If chronic low back pain persists and non-invasive treatments are ineffective, consider referral to a specialist back pain service for further management, which may include options such as radiofrequency denervation or spinal cord stimulation, particularly if neuropathic pain is suspected.

• Do not routinely offer imaging unless the result is likely to change management or if red flag symptoms are present.

This approach aligns with NICE guidelines and expert consensus on managing low back pain after failure of initial conservative treatment.