NICE recommends exercise and not acupuncture for low back pain

BMJ 2016; 352 doi: (Published 29 March 2016) Cite this as: BMJ 2016;352:i1765
  1. Jacqui Wise
  1. London

Acupuncture is no longer recommended for the management of non-specific low back pain with or without sciatica because evidence shows that it is no better than sham treatment, says new draft guidance from the National Institute for Health and Care Excellence (NICE).1

The guideline recommends exercise such as stretching, yoga, or aerobic exercise as the first step in managing low back pain, and people should also be encouraged to continue with normal activities as much as possible. It recommends that manipulation, mobilisation, and massage should be used only alongside exercise because of insufficient evidence to show their benefit when used alone.

The draft guideline uses a stepped care approach to managing low back pain. Paracetamol on its own is no longer the first option: instead, oral non-steroidal anti-inflammatory drugs (NSAIDs) should be offered at the lowest effective dose for the shortest possible time. Opioids should not be routinely offered, but weak opioids with or without paracetamol may be offered if an NSAID is either contraindicated, not tolerated, or ineffective.

Combining physical treatment with psychological treatment such as cognitive behavioural therapy is recommended for people who have not seen an improvement in their pain or who have significant psychosocial barriers to recovery, the draft guideline says.

Unlike the previous NICE guideline on managing persistent lower back pain that had lasted six weeks to 12 months, the updated guideline covers people with low back pain and sciatica irrespective of how long they have had the condition. Consultation on the draft guidance closes on 5 May 2016.

Lower back pain reportedly affects one in 10 people in England and becomes more common with age. It is estimated to be responsible for 37% of all chronic pain in men and 44% in women. Treating all types of back pain costs the NHS more than £1bn (€1.27bn; $1.41bn) a year.

Mark Baker, clinical practice director at NICE, said, “Regrettably, there is a lack of convincing evidence of effectiveness for some widely used treatments. For example, acupuncture is no longer recommended for managing low back pain with or without sciatica. This is because there is not enough evidence to show that it is more effective than sham treatment.”

Ian Bernstein, a GP and musculoskeletal physician who helped develop the guideline, commented, “The diagnosis of back pain includes a variety of patterns of symptoms. This means that one approach to treatment doesn’t fit all. Therefore, the draft guidance promotes combinations of treatments such as exercise with manual therapy or combining physical and psychological treatments.

“The draft guideline also promotes flexibility about the content and duration of treatments, and the choices made should take into account people’s preferences as well as clinical considerations.”


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