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NICE guidelines – early management of persistent non-specific low back pain

I'm a bit slow on reporting this, but at the end of May the UK's National Institute for Health and Clinical Excellence (NICE) published a guideline on "Early management of persistent non-specific low back pain".   I've blogged before about NICE.  They publish very widely with, for example, 82 guidelines on musculoskeletal disorders generally.  They have also recently launched NHS evidence which aims " ... to provide easy access to a comprehensive evidence base for everyone in health and social care who takes decisions about treatments or the use of resources - including clinicians, public health professionals, commissioners and service managers - thus improving health and patient care. It will build on NICE's significant international reputation for developing high quality evidence-based guidance. It provides access to a range of information types, including primary research literature, practical implementation tools, guidelines and policy documents."

But getting back to the back pain guideline, NICE state "Non-specific low back pain is caused by problems with structures in the back, such as joints, discs, muscles, tendons or ligaments. The guideline covers the management of pain that has lasted for longer than 6 weeks but less than a year."  The full guideline document - with typical NICE thoroughness - is 240 pages long and there are also 7 additional appendices.  The quick reference guide is a slim 10 pages and states "Non-specific low back pain is tension, soreness and/or stiffness in the lower back region for which it isn't possible to identify a specific cause of the pain ... A clinician who suspects that there is a specific cause for their patient's low back pain (malignancy, inflammatory disorders, infection, fracture) should arrange the relevant investigations.  A key focus is helping people with persistent non-specific low back pain to self-manage their condition. Providing advice and information is an important part of this. The aim of the recommended treatments and management strategies is to reduce the pain and its impact on the person's day-to-day life."   The guideline advises sufferers to continue to exercise and perform normal activities (within reason) and suggests doctors should "Offer drug treatments as appropriate to manage pain and to help people keep active."    

The recommendation is to "Offer one of the following treatment options, taking into account patient preference: an exercise programme, a course of manual therapy or a course of acupuncture. Consider offering another of these options if the chosen treatment does not result in satisfactory improvement.
Physical activity and exercise
_ Consider offering a structured exercise programme tailored to the person:
- This should comprise up to a maximum of eight sessions over a period of up to 12 weeks.
- Offer a group supervised exercise programme, in a group of up to 10 people.
- A one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.
Manual therapy
_ Consider offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks.  (The manual therapies reviewed were spinal manipulation, spinal mobilisation and massage. Collectively these are all manual therapy. Mobilisation and massage are performed by a wide variety of practitioners. Manipulation can be performed by chiropractors and osteopaths, as well as by doctors and physiotherapists who have undergone specialist postgraduate training in manipulation.)
Invasive procedures
_ Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of up to 12 weeks.
_ Do not offer injections of therapeutic substances into the back for non-specific low back pain.
Combined physical and psychological treatment programme
_ Consider referral for a combined physical and psychological treatment programme, comprising around 100 hours over a maximum of 8 weeks, for people who:
- have received at least one less intensive treatment and
- have high disability and/or significant psychological distress."  

The quick reference guide provides a good flow chart with a lot of further information.  Fascinating how, just a few years ago, acupuncture and manipulation were considered "alternative nonsense" by many conventional doctors.  Now they are a cornerstone of evidence-based guidance!  

NICE guideline on Early management of persistent non-specific low back pain at http://guidance.nice.org.uk/CG88  Accessed July 9 2009.

NICE low back pain quick reference guide at http://www.nice.org.uk/nicemedia/pdf/CG88QuickRefGuide.pdf  Accessed July 9 2009.

NHS Evidence http://www.evidence.nhs.uk/  Accessed July 9 2009

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