Volume 12, Issue 4 , Pages 113-114, December 2009
NICE clinical guidelines. Low back pain: The early management of persistent non-specific back pain
Article Outline
- 1. Scope of the guideline
- 2. Process
- 3. The guideline
- 4. Research
- 5. Implementation and the future
- Declaration of interest
- References
- Copyright
In May 2009 the National Institute for Health and Clinical Excellence (NICE) published a guideline to improve the early management of low back pain.1 NICE clinical guidelines recommend the care that is suitable for most patients with an identified condition in the National Health Service (NHS) for England and Wales. The development of the guideline involved assessing the clinical and cost effectiveness of treatments and management strategies for non-specific low back pain of between 6 weeks and 12 months duration. They are based on the best available research evidence and expert consensus.2 The back pain guidelines are good news for patients and practitioners alike. They offer guidance on treatments that have been shown to be effective and a common pathway for care that will allow consistent access to evidence based treatment for patients.
Whilst the guidance is specifically aimed at care in the NHS, they have direct relevance to osteopaths working privately and for the NHS in the UK. Private practitioners will be able to evaluate their practice against the guideline using published audit support tools1 and are likely to have increased opportunities to provide the types of treatment they commonly perform in public sector settings. For osteopaths already working in the NHS, the guideline gives a clear context for osteopathic treatment and an opportunity to have osteopaths' role in back pain management part of a clear pathway of care. NICE guidance is also aimed at helping patients make choices about the best treatment for them. A specific version of the guidance is written to help patients understand NICE guidelines.3 Patients may use this information to help them decide upon preferred treatment options.
1. Scope of the guideline
As part of the process of developing a NICE guideline an initial scope is drafted which is then finalised after open consultation.4 For the back pain guideline the key elements of the scope were that the guideline focussed on adults over 18 with “non-specific” low back pain that had not resolved in 6 weeks of initial onset, consultation or exacerbation, up to a period of 12 months. Whilst “non-specific” back pain may to some osteopaths seem like an unhelpful description, there is little evidence to provide a robust diagnostic classification for back pain involving tension, soreness and or stiffness in the lower back region arising from a range of structures including joints, discs and connective tissues. Specific causes of back pain such as malignancy, infection, fracture, ankylosing spondylitis and other inflammatory disorders were not part of the guideline. Cauda equina syndrome and radiculopathy were also outside the scope of the guideline.
2. Process
Recommendations were developed by the Guideline Development Group (GDG) using systematic reviews of best available evidence. The GDG was made up of nine clinicians from a variety of backgrounds, two patient representatives, and two co-opted members. The GDG was supported by the National Collaborating Centre for Primary Care, The Royal College of General Practitioners and NICE who provided project management, reviewers, health economists and advisors. It was made clear at the outset that members of the GDG were bringing their experience and expertise to the group rather than being there as a representative of a society or specialty. When minimal evidence was available the GDG used their opinions and experience to develop a consensus for the recommendation. Evidence levels for recommendations are available in the full guideline. When reviewing the evidence the primary outcomes that were of interest were pain, disability and psychological distress. Studies were identified by literature searches and the data was extracted and presented to the GDG. The GDG then spent many hours considering the evidence to ensure that each recommendation was based on the best evidence available. In situations where there may have been a conflict of interest, members of the GDG were absent for the decision to include or exclude a particular intervention. For example, the surgeon on the group stepped out for the decision on surgery and the manipulators did not take part in the decision on manual therapy and manipulation.
The resultant recommendations are produced for different types of practitioners in different settings – from primary to secondary care. Therefore the guidance has varying importance for osteopathic practice depending on the context of the individual practitioner and the patient that they are working with.
3. The guideline
The full guideline recommendations and quick reference guide are available for down load from the NICE website.1 The guideline is made up of a series of recommendations which have been summarised to make a clinical pathway for patients with non-specific back pain. The categorisation of back pain into non-specific back pain should be kept under constant review at each stage in the pathway. Patients enter the pathway at six week duration of symptoms. All patients should be offered advice to be physically active and to pursue normal activities as far as possible. Self management should be promoted. Medications for pain relief should be offered to allow patients to keep active. An educational leaflet for patients was produced in conjunction with BackCare and this is freely available for distribution from the NICE website.5
Patients should be offered one of three treatments (group exercise programme, manual therapy including manipulation, or acupuncture). Should there not be satisfactory improvement, patients may be offered another of these options. For those who continue to have high levels of disability and or significant psychological distress referral for a combined physical and psychological treatment programme may be considered. This programme should include a cognitive behavioural approach along with physical exercises. For those who have received the combined programme and have had psychological distress appropriately managed, but continue to have high levels of pain, consideration should be given to refer for an opinion on spinal fusion. This should be to a specialist spinal surgical service and take account of the possible risks of surgery. Further details of the duration and extent of the interventions recommended should be taken from the details in the guideline.
The guideline also recommends that some practices should not be used in the management of non-specific low back pain. These include injections of therapeutic substances into the back, referral for intradiscal electrothermal therapy, radiofrequency facet joint denervation, and percutaneous intradiscal radiofrequency thermocoagulation. In addition X-rays should not be used and MRI is only recommended in the context of a referral for an opinion about spinal fusion.
4. Research
The “Holy Grail” of matching treatments to identified subgroups remains a goal of researchers and clinicians alike. The guideline represents a stepped care approach in the absence of clear indicators for subgroups. Several priority areas for future research were identified and these included a suggestion that screening protocols should be evaluated to test their effectiveness in targeting patients with treatments. Other research recommendations included evaluating the effectiveness of injections, psychological treatments, TENS machines, education delivery, and sequential therapy compared with single interventions for manual therapy, exercise programmes and acupuncture.
5. Implementation and the future
The implementation of the guideline offers the opportunity for a clear and equitable pathway of care for people with persistent non-specific back pain based on the best available evidence. Whilst individual trials may suggest modest effects for interventions, taken on a population level the implementation of the guidelines represents a significant step forward for both patients and practitioners. Patients will be offered treatment based on effective interventions and practitioners will have clear guidance about the management of non-specific back pain. Practitioners and commissioners of services are now charged with assessing their local care arrangements and seeking to align them with the NICE guideline. With respect to manual therapy and osteopathy, the question arises as to what services are available locally and in what way patients can access them. Primary care organisations are currently evaluating their services and it may be that osteopaths will be able to offer themselves as practitioners with the right skills to deliver care to patients. Engaging with the health service represents its own challenges, but the opportunity to deliver care to the wider public is now available more strongly than ever before.
Declaration of interest
The author is an osteopath. He was a member of the GDG for the NICE clinical guideline on the early management of persistent non-specific low back pain.
The views expressed are those of the author and not necessarily of the GDG or of NICE.
References
- . Low back pain: early management of persistent non-specific low back pain. (Clinical guideline 88) 2009;www.nice.org.uk/cg88
- . The guidelines manual. (Clinical guideline 88) 2009;http://www.nice.org.uk/aboutnice/howwework/developingniceclinicalguidelines/clinicalguidelinedevelopmentmethods/GuidelinesManual2009.jsp
- . CG88 low back pain: understanding NICE guidance. 2009;http://guidance.nice.org.uk/CG88/PublicInfo/pdf/English
- . Low back pain final scope. 2007;http://www.nice.org.uk/nicemedia/pdf/LowBackPain_FinalScope.pdf
- National Institute for Health and Clinical Excellence / BackCare. Low Back Pain: Patient information 2009. http://www.nice.org.uk/nicemedia/pdf/CG88PatientInformationLeaflet.pdf
PII: S1746-0689(09)00074-1
doi:10.1016/j.ijosm.2009.09.002
© 2009 Published by Elsevier Inc.
Volume 12, Issue 4 , Pages 113-114, December 2009
