Guidelines disagree.
Here is why.
If you read enough about back pain you will find authorities contradicting each other. Your GP starts with paracetamol while the World Health Organization advises against it. Every guideline recommends exercise therapy, while the body that decides what Dutch basic insurance covers concluded that its added value has not been demonstrated.
That is confusing, and it is tempting to pick the source that suits you. This page does the opposite: it shows where the disagreements are and what causes them, so you can see what is actually being weighed when someone advises you.
Three reasons guidelines differ
They weigh benefit against harm differently
A treatment with a tiny effect and no risk can be worth offering. The same tiny effect with a real risk is not. Paracetamol and NSAIDs are the clearest example: comparable modest effects, very different safety profiles, and guidelines that therefore land in different places.
They ask a different question
"Does this work?" and "is this worth paying for out of collective money?" are not the same question. A treatment can be sensible and still fall outside the basic package, if the evidence that it beats doing nothing is not strong enough.
They choose a different comparison
Compared with nothing at all, many treatments look good. Compared with a convincing placebo, most of that advantage disappears. A review of 301 placebo-controlled trials found that only about one in ten non-surgical treatments for back pain beats a placebo, and always by a small margin.
Where they disagree
Five topics on this site where the Dutch position and the international guidelines do not line up.
| Topic | In the Netherlands | Internationally |
|---|---|---|
| Paracetamol | NHG: step one | WHO and NICE: do not recommend |
| Physiotherapy for non-specific back pain | Zorginstituut: not in the basic package | WHO, NICE and KNGF: recommended |
| Acupuncture | Dutch GP literature: mainly placebo | WHO: conditionally recommended, NICE: do not offer |
| Psychological therapy | Common via the GP; the heavier programmes restricted since 2026 | ACP: recommended, NICE: removed from the back pain guideline in 2026 |
| Facet and SI joint denervation | Not covered since 2016 | NICE: only after a positive test block |
Paracetamol
Everyone reads the same trial. It found no effect beyond placebo. WHO and NICE conclude: do not offer it. The Dutch GP standard reasons that no painkiller works particularly well here, so step one of its pain stepladder is the drug that does the least harm.
Physiotherapy for non-specific back pain
The guidelines ask "does supervised exercise help?" and answer yes. The Zorginstituut asks a narrower question: "does the supervision add anything on top of no physiotherapy?" and answers that this has not been sufficiently demonstrated. Different question, different answer.
Acupuncture
The disagreement is about what you compare with. Against no treatment acupuncture looks reasonable; against sham acupuncture the difference is small. Whether that residue counts as an effect is a judgement call, not a fact.
Psychological therapy
Two bodies changed their position in 2026, for the same reason. In July NICE removed its recommendations from the back pain guideline because part of the evidence behind them had been retracted, and chose not to weigh the literature again. In April the Zorginstituut took combined physical and psychological rehabilitation programmes out of the basic package, after two of the studies the reimbursement rested on were retracted. Neither says the treatment fails: NICE still recommends CBT in its chronic pain guideline, and independent research still finds effects a year or two later, though small ones.
Facet and SI joint denervation
A Dutch trial (MINT) found no clinically relevant benefit on top of exercise. The Zorginstituut drew the conclusion for the whole country; NICE kept a narrow door open for a selected group.
What we do with this
We do not pick one guideline and repeat it. Where authorities disagree, we say so and explain what is being weighed, because that is the information you need in order to make a decision with your own doctor. Where the evidence is thin, we say that too, even when a firmer answer would read better.
Sources
- Thuisarts.nl. Ik heb lage rugpijn (NHG)
- NHG-Standaard Aspecifieke lagerugpijn (2017, laatst gewijzigd 2024)
- NHG-Standaard Pijn (2018), tabel 1: het medicamenteuze stappenplan
- Zorginstituut Nederland. Standpunt fysio- en oefentherapie bij lage rugklachten (2024)
- WHO Guideline on management of chronic primary low back pain (2023)
- NICE Guideline NG59: Low back pain and sciatica
- Cashin AG, et al. Analgesic effects of non-surgical and non-interventional treatments for low back pain. BMJ Evid Based Med (2025)
- Jenkins HJ, et al. Long-term effectiveness of non-surgical interventions for chronic low back pain. Lancet Rheumatol (2025)
- Juch JNS, et al. Effect of radiofrequency denervation on pain intensity. JAMA (2017)
Next step