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Practice Guidelines

Early management of persistent non-specific low back pain: summary of NICE guidance

BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b1805 (Published 04 June 2009) Cite this as: BMJ 2009;338:b1805
  1. Pauline Savigny, health services research fellow1,
  2. Paul Watson, professor of pain management and rehabilitation2,
  3. Martin Underwood, professor of primary care research3
  4. on behalf of the Guideline Development Group
  1. 1National Collaborating Centre for Primary Care, Royal College of General Practitioners, London SW7 1PU
  2. 2Department of Health Science, Academic Unit, University of Leicester, Leicester LE5 4PW
  3. 3Warwick Medical School, University of Warwick, Coventry CV4 7AL
  1. Correspondence to: M Underwood m.underwood{at}warwick.ac.uk

    Why read this summary?

    Most episodes of acute low back pain resolve spontaneously.1 However, among those in whom low back pain and disability have persisted for over a year, few return to normal activities. Thus the focus for preventing the onset of long term disability caused by non-specific low back pain is on the early management of persistent low back pain (pain present for more than six weeks and less than one year). No consensus exists on how to help health professionals and their patients choose the best treatments for this condition.

    This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the early management of non-specific low back pain.1 The diagnosis of specific causes of low back pain (malignancy, infection, fracture, ankylosing spondylitis, and other inflammatory disorders) is not part of this guideline.

    Recommendations

    NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. The box lists treatments that should not be offered for non-specific low back pain.

    Treatments not recommended for non-specific low back pain

    Do not offer
    • Radiography of the lumbar spine [Based on two high quality randomised controlled trials and economic evaluations]

    • Selective serotonin reuptake inhibitors for treating pain [Based on a high quality systematic review and the experience and opinion of the Guideline Development Group (GDG)]

    • Injections of therapeutic substances into the back [Based on three well conducted studies—two systematic reviews and one randomised controlled trial (RCT)]

    • Laser therapy [Based on one high quality systematic review including low quality RCTs]

    • Interferential therapy (electrical treatment using two alternating medium frequency currents) [Based on the experience and opinion of the GDG]

    • Therapeutic ultrasonography [Based on the experience and opinion of the GDG]

    • Transcutaneous electrical nerve stimulation (TENS) [Based on one low quality RCT and the experience and opinion of the GDG]

    • Lumbar supports (devices to reduce spinal mobility, such as corsets) [Based on one high quality systematic review including low quality RCTs and on the experience and opinion of the GDG]

    • Spinal traction [Based on one high quality systematic review including low quality RCTs and on the experience and opinion of the GDG]

    Do not refer for
    • Radiofrequency facet joint denervation [Based on three RCTs of moderate or low quality]

    • Intradiscal electrothermal therapy [Based on one systematic review of moderate quality]

    • Percutaneous intradiscal radiofrequency thermocoagulation [Based on one systematic review of moderate quality]

    Information, education, and patients’ preferences

    • Offer educational advice that:

      • -Includes information on the benign nature of non-specific low back pain (tension, soreness and/or stiffness in the lower back region arising from several structures in the back, including joints, discs, and connective tissues)

      • -Encourages the person to be physically active and continue with normal activities as far as possible.

    [Based on the experience and opinion of the Guideline Development Group (GDG)]

    • Take into account the person’s expectation and preferences but do not use their expectations and preferences to predict their response to treatments. [Based on the experience and opinion of the GDG and on generic NICE guidance on patient centred care]

    Therapies for low back pain

    • Offer one of the following treatment options, taking into account the patient’s 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. [Based on the experience and opinion of the GDG]

    Exercise

    • Consider offering a structured exercise programme tailored to the person, comprising up to eight sessions over a period of up to 12 weeks. [Based on two RCTs of high quality]

    • Offer a group (rather than a one to one) supervised exercise programme (in a group of up to 10 people). Consider offering a one to one programme if a group programme is not suitable. [Based on the experience and opinion of the GDG]

    • Exercise programmes may include the following elements:

      • -Aerobic activity

      • -Movement instruction

      • -Muscle strengthening

      • -Postural control

      • -Stretching.

    [Based on several randomised controlled trials of high, medium, and low quality and the experience and opinion of the GDG]

    Manual therapy

    • Consider offering a course of manual therapy, including spinal manipulation, comprising up to nine sessions over a period of up to 12 weeks. [Based on one high quality RCT with economic evaluation and several moderate or low quality RCTs]

    Acupuncture

    • Consider offering a course of up to 10 sessions of acupuncture needling over a period of up to 12 weeks. [Based on several high quality RCTs, one with an economic evaluation]

    Combined physical and psychological treatment programme

    • Consider referral for a combined physical and psychological treatment programme (about 100 hours over a maximum of eight weeks) for people who have received at least one less intensive treatment and also have high disability and/or substantial psychological distress. [Based on low quality RCTs and health economic modelling using a high quality RCT on psychosocial screening]

    • Combined physical and psychological treatment programmes should include a cognitive behavioural approach and exercise and may include goal setting and problem solving. [Based on low quality RCTs]

    Drug treatments

    • Advise regular paracetamol as the first medication option. [Based on the experience and opinion of the GDG]

    • When paracetamol alone provides insufficient pain relief, offer non-steroidal anti-inflammatory drugs (NSAIDs) or weak opioids, or both.[Based on a high quality systematic review and the experience and opinion of the GDG]

    • Take into account the individual risk of side effects and the patient’s preference. [Based on the experience and opinion of the GDG]

    • Give due consideration to the risk of side effects from NSAIDs, especially in older people and others at increased risk of side effects. [Based on the experience and opinion of the GDG]

    • Either an oral NSAID (such as diclofenac, ibuprofen, or naproxen) or a cyclo-oxygenase-2 (COX 2) inhibitor (such as celecoxib) may be offered when an anti-inflammory painkiller is recommended. In either case (oral NSAID or a COX 2 inhibitor), for people aged over 45 coprescribe a proton pump inhibitor, choosing the one with the lowest acquisition cost. [Based on the NICE guidance on osteoarthritis2 ]

    • Base decisions on whether to continue drugs on individuals’ responses. [Based on the experience and opinion of the GDG]

    • For people in severe pain consider offering strong opioids for short term use. [Based on two high quality RCTs and the experience and opinion of the GDG]

    • For people who may need prolonged use of strong opioids, consider referral for specialist assessment. [Based on the experience and opinion of the GDG]

    • Give due consideration to the risk of opioid dependence and side effects for both strong and weak opioids. [Based on the experience and opinion of the GDG]

    • Consider offering tricyclic antidepressants if other drugs provide insufficient pain relief. Start at a low dosage and increase to the maximum dosage until a therapeutic effect is achieved or unacceptable side effects prevent further increase [Based on a high quality systematic review and the experience and opinion of the GDG]

    Surgery

    • Consider referral for an opinion on spinal fusion for people who have completed an optimal package of care (including a combined physical and psychological treatment programme) and who have persistent severe non-specific low back pain for which they would consider surgery. [Based on two systematic reviews of moderate quality, a health economic evaluation, and the experience and opinion of the GDG]

    • Offer anyone with psychological distress appropriate treatment for this before referral for an opinion on spinal fusion. [Based on the experience and opinion of the GDG]

    • Refer the patient to a specialist spinal surgical service if spinal fusion is being considered. [Based on the experience and opinion of the GDG]

    Overcoming barriers

    The services and staff needed for people with back pain to access the recommended treatment programmes are not widely available. This applies to individual therapies and in particular to the intensive combined rehabilitation programme. To achieve this, services will require some reorganisation and the pool of available therapists will need to be expanded. This may involve the retraining of existing NHS therapists, making more use of private therapists to deliver NHS services, or recruiting additional NHS staff from different disciplinary backgrounds who are skilled in delivering acupuncture, exercise programmes, and manual therapy.

    Further information on guidance

    Methods

    The guideline was developed by the National Collaborating Centre for Primary Care, whose members worked alongside a Guideline Development Group that included patient representatives and healthcare professionals with expertise in treating low back pain in primary and secondary care.

    The Guideline Development Group followed standard NICE methodology for the development of this guidance (www.nice.org.uk/aboutnice/howwework/how_we_work.jsp). The group conducted a systematic review of the literature, assessed the quality of the literature, and qualitatively synthesised the included evidence as it related to both clinical and cost effectiveness.

    After an external consultation with stakeholders, the development group assessed stakeholders’ comments and modified the guideline appropriately. An independent Guideline Review Panel assessed the appropriateness of the responses to the stakeholders.

    NICE has produced three difference versions of the guideline: a full version, a quick reference guide, and a version for patients and the public. All versions are available from the NICE website (www.nice.org.uk/88).

    Background

    Estimates of the prevalence of low back pain vary considerably between studies—up to 33% for point prevalence, 65% for one year prevalence, and 84% for lifetime prevalence.3 No convincing evidence exists for age affecting the prevalence of back pain.4 Annually, low back pain probably affects a third of people. About a fifth of those affected (1 in 15 of the population) will see their general practitioner for advice.5 This results in 2.6 million people in the UK seeking advice about back pain from their general practitioner each year.6

    Few epidemiological data are directly relevant to the target population for these guidelines. Published data do not distinguish between low back pain that persists for over a year and low back pain that lasts less than a year.

    This guideline focuses on the management of low back pain that has been present for more than six weeks but less than 12 months. This includes people with recurrent low back pain lasting for more than six weeks. This guideline does not discuss the management of severe disabling low back pain that has lasted longer than 12 months.

    What’s new?

    The guideline emphasises helping people to manage their condition themselves through providing advice and information and encouraging an active lifestyle supported by a choice of interventions (acupuncture, exercise, manual therapy) rather than “structure targeted treatments” (such as injections, ablations, and electrotherapies). The guideline proposes that people with continuing severe problems have access to intensive (>100 hours) multidisciplinary treatment programmes much earlier than is the current practice.

    Questions for future research

    For people with persistent non-specific low back pain:

    • What is the clinical and cost effectiveness of screening protocols to target treatments?

    • How can education be delivered effectively?

    • What is the effectiveness and cost effectiveness of sequential treatments (manual therapy, exercise, and acupuncture) compared with single interventions with respect to pain, functional disability, and psychological distress?

    • What is the effectiveness and cost effectiveness of psychological treatments?

    • What are the most effective and cost effective facet joint injections and radiofrequency lesioning procedures?

    • Is transcutaneous electrical nerve stimulation effective?

    Notes

    Cite this as: BMJ 2009;338:b1805

    Footnotes

    • This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

    • Contributors: All authors helped to write and revise this article, and they all approved the final manuscript. MU is guarantor

    • Funding: The National Collaborating Centre for Primary Care was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.

    • Competing interests: All authors were members of the Guideline Development Group. MU has received funding from the Medical Research Council and the NHS Health Technology Assessment programme for research into low back pain and from the Arthritis Research Campaign for research into chronic musculoskeletal pain. He is lead applicant on a current proposal to the National Institute of Health Research on the treatment of low back pain. He was corresponding author for the UK BEAM trial that helped to inform the GDG’s decisions about manual therapy and exercise. PW has received funding from the Department for Work and Pensions, Pfizer (joint applicant), and the charity BackCare for research into chronic musculoskeletal pain.

    • Provenance and peer review: Commissioned; not externally peer reviewed.

    References