Lower Back Pain Treatment | NICE Guidelines

NICE GuidelinesThe National Institute for Clinical Excellence (NICE) in the UK have released some interesting guidelines on the management of low back pain.

We are all different and our back problems are the result of our own unique bodies and lifestyles. Lower back pain treatment for one person may not be suitable for someone else. A big problem is the lack of high quality research about many of the lower back pain treatment options available. Few treatments have good solid research proving that they really work. This is further confused by the fact that acute back pain gets better by itself - 75% of people are back to work within 4 weeks.(1)

About the NICE guidelines for the treatment of back pain

NICE is a national body that examines the evidence for effectiveness and value for money for many common medical problems.

Up until now there has been little agreement about the best treatment of back pain. If you go and see different health care providers you will often get different information and care.  If you have experienced this I'm sure you would agree that this is confusing and unhelpful. To clear up confusion and help everyone get the best care the expert panel working for NICE looked at the research evidence for the treatment of back pain and agreed on a set of guidelines.  The results make very interesting reading and have caused quite a bit of a stir in the UK.

NOTE - These guidelines are only for those of you with non-specific lower back pain, they don’t cover sciatica or any other condition. 

ANOTHER NOTE - The other important thing to know is that they only cover sub-acute lower back pain. This means lower back pain that you have had for more than 6 weeks but less than one year.

Treatment Recomendations from the guidelines

Try and self manage the problem

If you have back pain you should be encouraged to manage it yourself and try and continue with normal life.

Keep active and stay as normal as possible

Physiotherapists and doctors should reassure you and advise you to keep active and carry on as normally as possible. 

Education about back pain

You should find as much information as you can about non-specific back pain so you understand what it is. My web site here has a lot of useful information that may help you with this.

Get some simple pain relief so you can stay active

The guidelines suggest that if pain relief is needed, paracetamol is a good option, followed by non-steroidal anti-inflammatory drugs (NSAIDs) or weak opioid drugs (e.g. codeine). These are UK drug names but I'm sure the equivalents are available in other countries.

They also suggest that you could try one of these treatments for back pain in addition to the advice above

A supervised lower back exercise programme

This should be tailored to you as an individual and can be either in a group or a one-to-one supervised lower back pain exercise programme.

Spinal manipulation or mobilisation

This is a controversial treatment for lower back pain as the evidence for either is pretty weak.  This has caused a lot of heated debate as there are many people who do not think spinal manipulation is that effective. Nonetheless the guidelines suggest trying up to 9 sessions for up to 12 weeks.

Massage for pain relief

I'm not surprised about this one. I have a section on back massage therapy and the evidence shows that it can be helpful.

Acupuncture

The recommendations suggest a course of acupuncture a maximum of 10 sessions over a 12-week period.

What if none of this works?

The guidelines suggest that you combine physical and psychological treatment (100 hours over a maximum of eight weeks is suggested) if you have had at least one of the treatments above and it has not been effective, or if you have significant disability or psychological distress.

What should you avoid when treating lower back pain?

Injections are not recommended

To start with injections into the back are not advised, this will upset many people who think they are helpful, but the research we have really does not support the usefulness of them.

Electrical Treatments don’t work either

Laser therapy, Interferential therapy, Therapeutic ultrasound, TENS, all get the thumbs down too.  The only one on this list I was surprised about was TENS, but I suppose on reflection I would probably mainly use that with people who have had pain for longer than a year.

Lumbar supports and traction

Nope, these longstanding treatments are also rejected.  This hasn’t surprised me as the research about the lack of effectiveness of these treatments has been there for a long time. We have known for example that traction is unhelpful for years. What surprises me is that people keep getting offered these treatments.

 Should you consider lower back surgery for this problem?

The guidelines are clear that lower back surgery (spinal fusion) is really a last option and should only be considered if you have completed all the treatments for back pain mentioned above. If your back pain is still so severe that you would consider surgery with all its associated risks then you need to discuss your problem with a surgeon.

Is it a good idea to have an X-ray or MRI scan?

The guidelines say no. They say that X-ray of the lumbar spine should not be offered and that lumbar spine MRI should only be arranged if the person with back pain is a very likely candidate for lumbar spine surgery such as a spinal fusion.

The only other reason for undergoing an MRI scan is if the doctor suspects you have a serious back problem such as cancer, infection, inflammatory disease e.g. ankylosing spondylitis, cauda equina or fractures.

The research supporting this advice has been around for a while now, many studies have shown there is little benefit in having these tests for the majority of people with back pain.  You can see more references for this in this page on lower back pain investigations.

Despite this guidance millions of unnecessary scans and x-rays are undertaken every year. This is partly due to patient pressure – many people feel an MRI is needed so that they can know 'exactly what is going on inside'. The scans can indeed be reassuring but more often then not they show up regular changes that have been shown to exist in people regardless if they have back pain or not. Sometimes these normal findings can be an additional source of worry. My advice would be to have frank discussions with your doctor about the usefulness of these types of tests if you have had back pain for less than a year, if nothing serious is suspected and you are not a candidate for surgery.

 

What else do we know about low back pain treatment?

It's not at all hopeless - there are certainly things that can help. These are things that we are confident about and that are backed up by some good quality research.

  • Sustained poor postures (either sitting, standing or lifting) can make the problem worse.

  • Exercise and education are helpful tools in managing lower back pproblems.

  • We know that fear of movement and other unhelpful beliefs (yellow flags) make it more likely that the problem will last longer and be more disruptive.

  • We also know that some treatments help with relieving discomfort- there are a large selection on offer - I have summarised them at in the treatment section.

 

References

NICE Low back pain.<http://guidance.nice.org.uk/CG88>

02-Mar-2015

 

 

 

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