NICE Guidelines For Non-Specific Low Back Pain

By: David Ravech

Persistent low back pain of non-specific origin is commonly assessed and managed by healthcare practitioners, making up a major proportion of all those people off work due to sickness absence. During the last ten years there have been significant increases in valid research work on this subject, allowing for the first time an evidence based set of recommendations for the assessment and management of longer term back pain. In May 2009 the National Institute for Clinical Excellence (NICE) has published updated guidelines.

To conclude that the diagnosis is non-specific low back pain many conditions have to be excluded. These include infections, cancers, broken bones and arthritic diseases such as ankylosing spondylitis, and diagnosis should be reviewed periodically, with appropriate requesting of investigations, if there is any suspicion of a particular diagnosis. Cauda equina syndrome and sciatica (radicular leg pain) are neurological compression syndromes and should be urgently referred for consultation with a spinal surgical specialist.

The classification of low back pain has been traditionally divided into chronic back pain, sub-acute back pain and acute back pain. Chronic back pain refers to pain persisting longer than 12 weeks with sub-acute back pain lasting between 6 and 12 weeks. Under six weeks duration is referred to as acute low back pain. However, due to the variability of symptoms and the long term nature of many back pain syndromes this classification system is too rigid to be useful in the assessment and management of back pain.

Low back pain is estimated to affect around 30 percent of the population of the UK every year, with about a fifth of this number consulting their general practitioner about their back pain. In the past most back pain was thought to settle by six weeks but more recent research has shown that a year after their back pain episode sixty-two percent of sufferers still have pain. In those who are off work with their back pain sixteen percent are still off work at a year. The first month shows a rapid improvement in pain and disability but this is not much improved by three months.

Contemporary figures for the costs of back pain to society are not available but are known to be very high. Patients spend a lot of money on private therapists in the UK, patronising private physiotherapists, acupuncturists, osteopaths and chiropractors. A new episode or a worsening of low back pain makes the exclusion of non-mechanical causes for the back pain vital. Infection is more common in people with immune system problems such as HIV. The incidence of the types of cancers which spread to bone is higher in older age groups. Fractures due to osteoporosis have a higher incidence in older people and anyone on steroids.

The early management of non-specific low back pain which persists for any time from six weeks to a year is to ensure the episode does not turn into long term disability, loss of normal activities and loss of work. Distress, disability and pain are the important factors which must be addressed to improve the outcome, as high levels of pain, high disability and psychological distress are predictive of a poorer outcome. A very large number of treatments exist and are claimed to be helpful but the scientific basis for most treatments is not good. The NICE group decided to look at an overall package of care, potentially deliverable by many professional groups, rather than individual therapies.

The large number of potential interventions for low back pain includes:

Psychological therapies such as a form of cognitive behavioural therapy, mindfulness and self-management.

Exercises which cover individual programmes to group based exercise classes, both on land and in water.

Education for patients such as group sessions, written explanatory material and individual instruction from therapists.

Manual techniques such as mobilisations, massage and manipulation.

Exercise programmes, either in water or on land, either individually or in groups.

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Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Hartlepool. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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