NICE Drops Psychological Therapy From Its Low Back Pain Guideline
TL;DR
- On 29 July 2026, NICE withdrew recommendation 1.2.13 on psychological therapy for low back pain with or without sciatica.
- NICE also withdrew recommendation 1.2.14 on combined physical and psychological programmes.
- NICE amended recommendation 1.1.3 by removing references to risk stratification as a route to combined physical and psychological treatment.
- NICE amended recommendation 1.2.7. Manual therapy should now be considered only within a treatment package that includes exercise.
- NICE left its guidance on imaging, self-management, group exercise, sciatica medicines, invasive treatments, and return-to-work support unchanged.
What NICE actually withdrew from NG59
NICE fully withdrew two treatment recommendations when it updated NG59 on 29 July 2026. Recommendation 1.2.13 had advised clinicians to consider a cognitive behavioural approach to psychological therapy as part of a package that included exercise. Recommendation 1.2.14 had supported combined physical and psychological programmes for people with persistent low back pain or sciatica when psychosocial barriers were substantial or previous treatments had failed.
NICE based both withdrawals on its surveillance decision. Surveillance reviews assess whether new evidence or changes in clinical practice require NICE to update, replace, or remove existing recommendations. The updated NG59 guidance page records the withdrawals but does not replace the deleted recommendations with another specified psychological intervention.
Two other recommendations remain in place with narrower wording. Recommendation 1.1.3 still advises risk stratification at first contact when it may inform shared decision-making, but NICE removed the reference to directing higher-risk patients towards treatment that used a psychological approach. Physiotherapists can still use stratification to judge the likely level of support a patient needs, although NG59 no longer names a combined physical and psychological pathway as the destination.
Recommendation 1.2.7 still permits manual therapy, including manipulation, mobilisation, or soft tissue techniques, only within a treatment package that includes exercise. NICE deleted the words that had allowed psychological therapy to form part of that package. The restriction against offering manual therapy as a standalone treatment remains unchanged.
The distinction matters because recommendations 1.2.13 and 1.2.14 disappeared completely, while recommendations 1.1.3 and 1.2.7 continue after targeted edits. NICE did not withdraw the wider guideline. Its advice on imaging, self-management, group exercise, return-to-work support, medicines for sciatica, and invasive treatments remains in force unless separately amended.
Before and after: the affected recommendations
The July 2026 update removed two recommendations and edited two others. The pre-update wording below is condensed for readability.
Why this breaks a decade of STarT Back-driven practice
Recommendation 1.1.3 gave risk stratification a direct treatment consequence at first contact. A physiotherapist could use a tool such as STarT Back to estimate a patient’s risk of persistent disability, then match lower-risk patients to simpler support and higher-risk patients to more intensive care. For higher-risk presentations, NG59 explicitly included a psychological approach within that care pathway.
That wording shaped training, local pathways, and service design after 2016. Physiotherapists learned to assess factors such as fear of movement, distress, avoidance, and low confidence because the resulting risk category could support referral into a combined physical and psychological programme. STarT Back therefore served as more than a prognostic questionnaire in routine practice. The tool often helped determine which type of treatment package a patient received.
The July 2026 update removes NICE’s explicit link between a higher-risk score and escalation toward psychological therapy. Physiotherapists can still use risk-stratification tools to inform prognosis, communication, review frequency, or the intensity of physical management. However, NG59 no longer supports a standard pathway in which the risk tier itself points toward a combined physical and psychological intervention.
STarT Back has not been withdrawn as an assessment tool, and the update does not invalidate every care plan built around it. The practical change concerns how you act on the score. A high-risk classification can identify complexity, but it no longer supplies guideline authority for a psychology referral under NG59. Local services may still offer psychological support under other guidance, commissioned pathways, or individual clinical assessment.
Physiotherapy education and pathway documents may now need revision where they present combined care as the expected NG59 response to a high-risk score. Screening can remain useful, but clinicians must separate risk prediction from a treatment recommendation that NICE has withdrawn.
What changes at first contact and what doesn't
At first contact, physiotherapists should no longer use NG59 risk stratification to direct a patient towards psychological therapy or a combined physical and psychological programme. Clinicians can still assess prognosis and psychosocial barriers, but the updated recommendation 1.1.3 no longer specifies more intensive support for people at higher risk of poor outcomes. Risk tools may inform clinical reasoning, but they no longer activate a NICE-endorsed combined pathway.
The withdrawal does not prohibit pain psychology referrals. A physiotherapist may still consider one when an individual assessment, another guideline, or a locally commissioned pathway supports it. Clinicians should document the reason for referral rather than presenting psychological therapy as a standard NG59 recommendation.
Most first-contact management remains unchanged. Physiotherapists should provide self-management advice, encourage normal activity, and consider group exercise where appropriate. NICE also retains return-to-work promotion. Manual therapy remains an option only within a treatment package that includes exercise, although recommendation 1.2.7 no longer refers to psychological therapy.
The update therefore narrows the recommended treatment options rather than discarding biopsychosocial MSK care. Psychological and social factors can still affect communication, goal setting, adherence, and return-to-work planning. Physitrack’s discussion of the biopsychosocial model provides broader context for applying that framework without treating every psychosocial barrier as an indication for formal psychological therapy.
For exercise-led care, clinicians still need to choose an appropriate programme, explain its purpose, and review the patient’s response. Physitrack’s home exercise programme tools can support exercise delivery and self-management between appointments, while clinical decisions remain with the treating physiotherapist.
Answering the patient who expected a psychology referral
Patients need to hear that NG59 has changed its recommendation, rather than that psychological factors no longer matter. NICE withdrew psychological therapy and combined physical and psychological programmes after its evidence surveillance process. The update changes what the guideline recommends as routine low back pain care.
A physiotherapist could explain the position in these terms. “NICE has reviewed the guidance and no longer recommends referral to psychological therapy or a combined programme as a standard pathway for low back pain or sciatica. We will continue to assess how pain affects your activity, work, sleep, and confidence, and we will plan your care around your current needs.”
The withdrawal does not establish that psychological support can never help an individual patient. NG59 no longer directs physiotherapists towards that pathway, but another guideline, specialist assessment, or locally commissioned service may still support referral. Clinicians should explain any local options and avoid promising access that the updated guideline no longer supports.
Existing referrals deserve an individual review rather than automatic cancellation. The referring clinician should consider why the referral was made, whether another condition or clinical need supports it, and what the local service provides. Exercise, self-management advice, return-to-work support, and manual therapy within an exercise-inclusive package remain available, so patients should leave the conversation with a clear plan for continuing care.
Where exercise and self-management fit now
NICE continues to centre low back pain care on exercise and supported self-management. Physiotherapists should give tailored information, encourage patients to continue normal activities, and consider group exercise programmes suited to each person’s needs and preferences.
Physiotherapists can turn those recommendations into a clear plan with agreed exercises, realistic progression, and regular review. Patient feedback on pain, difficulty, and completion can guide adjustments between appointments. Manual therapy remains an option only within a treatment package that includes exercise.
Home exercise programmes extend supervised care into daily life. Physitrack lets clinicians prescribe exercise through PhysiApp and review completion, sets, repetitions, pain, and difficulty at session level. Those records can support follow-up conversations and help clinicians adjust the programme when a patient struggles or progresses.
Self-management advice should also prepare patients to respond to symptom changes without unnecessary dependence on appointments. Clear instructions can explain which activities to continue, how to progress exercise, and when to contact the clinical service for reassessment.
FAQ for physiotherapists
Does the update apply to existing care plans?
NICE guidance informs current clinical decisions but does not automatically cancel existing plans. Physiotherapists should review affected referrals and combined programmes against the updated NG59 recommendations. Individual clinical needs, shared decisions, and local service policies still apply.
Does NG59 now prohibit pain psychology referrals?
NG59 no longer recommends psychological therapy or combined physical and psychological programmes for low back pain or sciatica. The withdrawal does not prohibit referral when another clinical indication or relevant guideline supports it. Physiotherapists should explain the basis for any referral clearly.
Does the update change the 2020 sciatica medication guidance?
The July 2026 update leaves the 2020 pharmacological recommendations unchanged. Existing restrictions and advice on medicines for sciatica therefore remain in place. Prescribers should continue to follow those sections of NG59.
Should physiotherapists stop using risk stratification tools?
NICE removed the instruction to use risk stratification to select more intensive support. Physiotherapists do not necessarily need to discard tools such as STarT Back, but local pathways should no longer treat their psychological pathway logic as an NG59 requirement. Services should review templates, referral prompts, and first-contact protocols accordingly.
What remains recommended for physiotherapy care?
NICE retains self-management advice, group exercise programmes, and return-to-work promotion. Manual therapy remains an option only within a treatment package that includes exercise. Imaging restrictions and invasive-treatment recommendations also remain unchanged.
Where can physiotherapists find the official update?
NICE publishes the current wording on its NG59 guidance page. The page’s update information and recommendation history record the changes made on 29 July 2026. Clinicians should use that version rather than archived pathway documents or local summaries.
