Low back pain and sciatica: summary of NICE guidance
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.i6748 (Published 06 January 2017) Cite this as: BMJ 2017;356:i6748
Infographic available
Click here for a visual overview of assessment and management for those with low back pain and/or sciatica.
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As always David Colquhoun brings us a breath of fresh air. It really is extraordinary that, in the 21st century, we should still be discussing the merits of acupuncture.
It was banned in China in 1929, and resuscitated in 1949 when Chairman Mao sought a pragmatic solution to a political problem. A revival of ancient Chinese medicine allowed him to offer a form of health care to the vast rural population of a country where most of doctors trained in 20th century medicine worked in the cities.
Nixon’s visit to Beijing in 1972 opened up China to the West and acupuncture, with its manikins, Qi channels, golden needles, and evocation of the mysterious Orient, seemed custom-tailored for seekers after alternative healing. The fervour which helped it conquer the West was generated predictably in California.
One evening in 1976 I visited my friend Ralph Schafferzick at St Michael’s Hospital in San Francisco. His last patient had been a woman from Chinatown whose symptoms weren't serious but irksome and hadn’t responded to a variety of treatments. As a last resort, he ‘d suggested they might try acupuncture.
His patient waxed mightily indignant. ‘Acupuncture is very good for Americans visiting China,’ she said. ‘No good for a Chinese woman living in San Francisco’.
Competing interests: No competing interests
It is wonderful to see all the acupuncturists in these rapid response who say that acupuncture works. They would become unemployed if they didn't say that, and there cane be no greater incentive to promote acupuncture.
The fact of the matter is that there are no very effective treatments for non-specific low back pain. Drugs don't work and neither does acupuncture. The revised guidance comes as close as one can expect from an official body to admitting the ghastly truth: nothing works well, And the guidance admits that - nothing is recommended apart from general advice to keep moving as much as you can. (even that isn't really shown to work, but it sounds sensible)
It is quite astonishing that, in the 21st century, we should still be discussing acupuncture -something that was revived by Mao Zedong for political reasons, and is now just big business. It has been shown repeatedly that any effects it may have are too small to have any clinical significance. Yet people like Mel Hopper Koppelman go on promoting their business regardless. All I can do is to advise these people to acquaint themselves with ideas of regression to the mean, and the idea of false positive rates in statistical testing. It is failure to understand these ideas that allows quaint medical myths like acupuncture to survive.
References
The acupuncture myth. http://www.dcscience.net/2013/05/30/acupuncture-is-a-theatrical-placebo-...
Regression to the mean. http://www.dcscience.net/2015/12/11/placebo-effects-are-weak-regression-...
False positive rates. http://rsos.royalsocietypublishing.org/content/1/3/140216
Competing interests: No competing interests
As an expatriate I was very intrigued to read the advice given to people with back ache by the nice people back home. I would suggest that in the real world the patient needs a very different sort of advice.
When I was a student in Liverpool we were told that it is a good idea to ask what makes a symptom worse since this may give a clue to what the pathophysiology is, and maybe even give a clue to what should be avoided. The advice given by NICE makes no reference to the fact that back ache can be brought on or made worse by lifting heavy articles and so should be avoided at all cost. My experience has been that if a patient is unaware of this simple correlation and continues to lift heavy articles his chances of improvement are minimal. Pain medication may be very helpful in enabling the patient to sleep at nights but it should be remembered that it may make things worse since the pain relief may encourage a premature return to lifting. The situation is often made worse by a complicating condition called BITE (Because I’m Too Embarrassed ).They are unwilling to ask for help and continue to suffer as a result. My advice is for them to carry a light weight cane since this will result in help being offered spontaneously by passers by without the need to have to request help.
Competing interests: No competing interests
11/02/2017
With respect to Gabriel Symonds’s comments:
We agree that low back pain and sciatica are symptoms rather diagnoses, and are cognisant of the fact that the terms cover a variety of heterogeneous conditions.[1] There are a variety of terms and diagnoses used in the literature that were used in the development of the systematic reviews in the guideline.[3] However, for simplicity, the Guideline Development Group (GDG) used the term ‘low back pain’ to mean “low back pain that is not associated with serious or potentially serious causes, and that is in the scope of the guideline.”[3] We discussed the GDG’s approach to history and examination in our response to Andrew Frank, below. The guideline advises clinicians to be mindful of serious underlying pathology, particular if the person has new or changed symptoms[3] and Appendix P recapped advice on the timing of referral to specialist services.[1]
The GDG recognised the heterogeneous nature of low back pain and considered how to make best use of resources shown to be clinically and cost-effective. Risk stratification consists of two steps: assessing risk and stratifying management. The GDG reviewed whether risk assessment tools could predict those people who might have delayed recovery or a poor outcome from an episode of back pain.[1] The GDG then went on to assess whether matching treatments (stratified management) improved the outcome.[1] The GDG found clinical and cost-effectiveness evidence to support this approach, not just in identifying those at risk of poor outcome and starting appropriate treatments without delay, but also in informing appropriate management for all patients in the scope of the guideline.[1] However, there was insufficient evidence to recommend one tool in particular, or to specify which treatments should be followed for each risk group. An example of a tool that could be used (STarT Back) was provided to aid implementation of this recommendation, as this tool had the best evidence from those reviewed.[3]
Health professionals are recommended to provide advice and information to support a person to self-manage their low back pain at all steps of the pathway. This is because, even for people receiving therapy, the time in contact with a health professional is a very small part of the person’s life. Rapid improvements in pain and disability are often seen following an episode of low back pain[1,3], hence the recommendation to consider simpler and less intensive support for these patients.[3] However, the GDG recognised that risk stratification alone could not account for the clinical context, and so the recommendation stated that this should be used “to inform shared decision-making about stratified management.”[3] The GDG were concerned that commissioners and clinicians, by misinterpreting ‘low risk’ as being synonymous with ‘no treatment’ might deny these patients appropriate and effective care.[1] It may not be possible to predict the likely time course for recovery, particularly in the absence of psychosocial obstacles to recovery[1], so the GDG recommended that risk stratification should only be considered at point of first contact with a healthcare professional for each new episode.[3] This allows for a clinical decision about further treatment options to be made should the person return (e.g. if they are not recovering quickly) rather than reapplying risk stratification.
The GDG reviewed a clinical prediction tool to identify patients likely to benefit from manipulation.[4] However, prognostic accuracy data was only reported for participants in the intervention group, and so could not inform a recommendation about risk stratification.[1] The GDG discussed the inability of some risk tools to subgroup the full spectrum of low back pain patients leaving a large portion of the population unclassified.[1]
The GDG gave examples of management options that could be considered for people at low and high risk of poor functional outcome.[3] The lists are not exhaustive. Clinicians may wish to discuss combined physical and psychological programmes, pharmacological and invasive interventions where clinically appropriate. The GDG acknowledged that avoidance of overtreatment in patients where it was not required was a benefit of the STarT Back risk stratification tool.[1]
The BMJ infographic[5] is a visual summary from the perspective of a patient presenting in primary care, and covers 19 of the 41 recommendations in the NICE guideline.[3] Validation for its use as a clinical decision aid would require a primary research study looking at clinical outcomes, with and without the use of the infographic. Whilst we agree that this is interesting and might improve implementation of the guideline, the GDG did not prioritise this as a research recommendation.[1]
References
1. National Guideline Centre, Royal College of Physicians. Low back pain and sciatica in over 16s: assessment and management—full guideline. National Institute for Health and Care Excellence, 2016. www.nice.org.uk/guidance/ng59/evidence
2. National Institute for Health and Care Excellence. Health and Social Care Directorate Quality Standards Process Guideline. National Institute for Health and Care Excellence, 2014. https://www.nice.org.uk/media/default/Standards-and-indicators/Quality-s...
3. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NICE Guideline NG59). 2016. www.nice.org.uk/guidance/ng59
4. Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Annals of Internal Medicine. 2004; 141(12):920-928. http://dx.doi.org/10.7326/0003-4819-141-12-200412210-00008
5. Bernstein IA, Malik Q, Carville S, Ward S. Low back pain and sciatica: summary of NICE guidance; Visual summary. BMJ 2017:i6748. http://www.bmj.com/content/bmj/suppl/2017/01/06/bmj.i6748.DC1/beri151216...
Competing interests: We declare the following interests based on NICE's policy on conflicts of interests (www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/code-of-practice-for-declaring-and-managing-conflicts-of-interest.pdf). The authors’ full statements are available online (www.nice.org.uk/guidance/NG59/documents/committee-member-list). IB is employed by London North West Healthcare NHS Trust, is a partner at Gordon House Surgery, and is employed by NHS Ealing CCG as clinical commissioning lead for MSk services, London; he received funding, travel, and subsistence allowances for committee work, lecturing, and organising educational workshops from NHS Ealing CCG, the Association for Medical Osteopathy, the Arthritis and Musculoskeletal Alliance, the NHS Alliance, the British Institute of Musculoskeletal Medicine, the British Society for Rheumatology, CloserStill Media Healthcare, Royal College of General Practitioners, Imperial College London, and NICE. SC is employed by the Royal College of Physicians, London. SW is employed by Brighton and Sussex University Hospitals NHS Trust, Brighton. He was a director of Back@Work until January 2016; a company that provides a community pain management service for the residents of mid-Sussex. He received accommodation, travel, and subsistence allowances for committee work and lecturing from the American Society of Interventional Pain Physicians and NICE. He has lectured or provided expert opinion (non-remunerated) at meetings at the Faculty of Pain Medicine, St Thomas’ Hospital, the Congress of the European Pain Federation, and the Spinal Intervention Society.
With respect to Mark Bovey and Mel Hopper Koppelman’s comments about acupuncture:
The GDG, in their response to stakeholders during consultation on the guideline, dispute the suggestion that the recommendation to ‘do not offer acupuncture for managing low back pain with or without sciatica’ was divorced from the evidence that was reviewed.[1] The systematic review demonstrated inconsistent benefits of acupuncture which, when present, were usually observed in the short term only.[2] The GDG noted that although comparison of acupuncture with usual care demonstrated improvements in pain, function and quality of life in the short term, comparison with sham acupuncture showed no consistent clinically important effect.[2] The effect of acupuncture on analgesic use and other health care resource use was mixed.[2] A sensitivity analysis using imputed individual patient data (IPD) was performed where this data was available, to account for differences in baseline characteristics between intervention and control groups.[2] This sensitivity analysis resulted in both sham and true acupuncture effects for pain severity being closer to usual care effects.[2]
The GDG concluded that, despite a large number of trials reporting pain as an outcome and the inclusion of trials with large numbers of patients for these and other outcomes, there was still not compelling and consistent evidence of a treatment-specific effect for acupuncture.[2] The study by Thomas et al, which was included in the economic review, provided evidence of a clinically important difference in health-related quality of life (EQ-5D), but did not show a benefit for pain, function or distress.[3] The GDG therefore questioned the mechanism by which quality of life would be improved, leading to the conclusion that the effects of acupuncture were probably the result of contextual effects.[2] Furthermore they agreed that the high cost did not justify the benefits that were only seen in the short term.[2] The GDG stated that there was a mature evidence base for acupuncture and that further research was unlikely to change their recommendation.[2]
The intervention reviews within the guideline looked to determine both effectiveness and efficacy of treatments and used ‘effectiveness’ as a broad term to cover both. At the outset of the development of the guideline, the GDG discussed the necessity of a body of evidence to show specific intervention effects, which they defined as being over and above any contextual or placebo effects.[2] Throughout the guideline, the GDG was required to make decisions based on the best available evidence by first establishing the clinical effectiveness before assessing whether the net clinical benefit justified any differences in costs between the alternative interventions (i.e. cost-effectiveness).[2] Cost-effectiveness reviews in the guideline were modelled on real-world scenarios from an NHS perspective and could be informed by pragmatic clinical trials where these were available.[2] In the acupuncture review, the GDG concluded that there was insufficient evidence of an overall treatment-specific effect to support a recommendation for acupuncture and so consideration of cost-effectiveness was not considered relevant.[2]
The GDG agreed that if placebo or sham-controlled evidence was available, this should inform decision-making to control for contextual effects.[2] However, if there was a lack of placebo or sham-controlled evidence, evidence versus usual care would then be given priority when decision-making.[2] This process was followed consistently throughout the guideline, and meant that each review used the best available controls to inform decision-making.[2] Clearly, some reviews did not find studies with credible placebo or sham controls, such as surgical interventions and exercise. However, levelling down the basis of decision-making in each review to the lowest control in the guideline would have led to evidence being ignored. The evidence base for acupuncture was large and evidence for sham acupuncture controls were available.[2] The appropriateness of sham comparators included in all reviews were verified with the GDG, and in the case of acupuncture, with a topic expert.[1]
The GDG recognised that there was controversy over whether it was possible to effectively deliver an inert sham acupuncture.[1] The GDG took the view that the studies included a variety of sham controls with a varied capacity to elicit physiological effects but that, consistently, acupuncture did not deliver clinically important effects above those shams.[1] This was the case for both penetrating and non-penetrating shams.[1] The GDG therefore came to the view that all the sham comparisons were credible controls.[1]
With respect to exercise, there was evidence of clinically important effects for the pre-determined critical outcomes of pain, function and health-related quality of life in both the short and longer term.[2] The GDG agreed that there were known benefits to general health and wellbeing from exercise and that exercise was an active treatment that people could undertake themselves in the longer term.[2] The GDG noted that the variability in comparators and study designs meant that there was insufficient evidence to prioritise one form of exercise over another.[2] In the absence of a feasible sham control, the GDG agreed that there was sufficient evidence to support a recommendation to consider exercise for people with low back pain with or without sciatica.[2]
Systematic reviews for single treatment options and combinations of treatments were undertaken. The GDG did not find evidence that would support the use of acupuncture in combination with other treatments, or evidence to support its use in particular subgroups.[2]
The algorithm in the guideline[2] and the BMJ infographic[4] indicate the range of treatments that can be considered. The GDG recommended considering using risk stratification to guide a discussion about treatment options,[5] but beyond that, the choice, sequencing and concurrent use of options was left to clinical discretion.[2] The visual placement of the options in the BMJ infographic was intended to guide primary care physicians to consider non-drug treatments as well as reaching for the prescription pad.[4] However, if a decision to use a pharmacological agent had been made, the guideline gave the flexibility to consider a weak opioid for acute low back pain only, and only if an NSAID is contraindicated, not tolerated or ineffective.[5]
The GDG followed the NICE 2007 conflicts of interest policy during the selection of members and the development of the guideline. The methods in the NICE guidelines manual[6] were applied in a consistent manner to the development of the systematic reviews and formation of all the recommendations in the guideline, including acupuncture.[2] The GDG compared interventions robustly and systematically, and did not recommend interventions, such as acupuncture, where the evidence to demonstrate effectiveness was highly inconsistent.[2]
References
1. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management—Consultation comments and responses 1 & 2 (NICE Guideline NG59). 2016. https://www.nice.org.uk/guidance/indevelopment/ng59/documents
2. National Guideline Centre, Royal College of Physicians. Low back pain and sciatica in over 16s: assessment and management—full guideline. National Institute for Health and Care Excellence, 2016. www.nice.org.uk/guidance/ng59/evidence
3. Thomas KJ, MacPherson H, Ratcliffe J, Thorpe L, Brazier J, Campbell Mea. Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. Health Technology Assessment. 2005; 9(32). http://dx.doi.org/10.3310/hta9320
4. Bernstein IA, Malik Q, Carville S, Ward S. Low back pain and sciatica: summary of NICE guidance; Visual summary. BMJ 2017:i6748. http://www.bmj.com/content/bmj/suppl/2017/01/06/bmj.i6748.DC1/beri151216...
5. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NICE Guideline NG59). 2016. www.nice.org.uk/guidance/ng59
6. National Institute for Health and Care Excellence. Developing NICE guidelines: the manual. London. National Institute for Health and Care Excellence, 2014. http://www.nice.org.uk/article/PMG20/chapter/1%20Introduction%20and%20ov...
Competing interests: We declare the following interests based on NICE's policy on conflicts of interests (www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/code-of-practice-for-declaring-and-managing-conflicts-of-interest.pdf). The authors’ full statements are available online (www.nice.org.uk/guidance/NG59/documents/committee-member-list). IB is employed by London North West Healthcare NHS Trust, is a partner at Gordon House Surgery, and is employed by NHS Ealing CCG as clinical commissioning lead for MSk services, London; he received funding, travel, and subsistence allowances for committee work, lecturing, and organising educational workshops from NHS Ealing CCG, the Association for Medical Osteopathy, the Arthritis and Musculoskeletal Alliance, the NHS Alliance, the British Institute of Musculoskeletal Medicine, the British Society for Rheumatology, CloserStill Media Healthcare, Royal College of General Practitioners, Imperial College London, and NICE. SC is employed by the Royal College of Physicians, London. SW is employed by Brighton and Sussex University Hospitals NHS Trust, Brighton. He was a director of Back@Work until January 2016; a company that provides a community pain management service for the residents of mid-Sussex. He received accommodation, travel, and subsistence allowances for committee work and lecturing from the American Society of Interventional Pain Physicians and NICE. He has lectured or provided expert opinion (non-remunerated) at meetings at the Faculty of Pain Medicine, St Thomas’ Hospital, the Congress of the European Pain Federation, and the Spinal Intervention Society.
With respect to Nick Mann’s comments:
This rapid response demonstrates the difficulty in generalising from personal experience and case series without the support of systematic reviews. All three of the trials discussed by Mann were reviewed by the GDG.
In the population with low back pain without sciatica, no clinically important difference between manipulation/mobilisation and sham was demonstrated for pain and function, in both the short and long term.[1] The trial by Licciardone[2] was of mixed modality manual therapy, and was reported as medians, so could not be meta-analysed with the other trials and was considered separately.[1] The GDG stated that mixed modality manual therapy compared with sham treatment in people without sciatica demonstrated a clinically important benefit in the responder criteria (pain reduction) at less or equal to 4 months.[1]
With regards to the UK BEAM trial [3], the description of the treatments in the manipulation arm given in the paper raises uncertainty about the treatment-specific effect of the intervention: "Following initial assessment, manipulators chose from the agreed manual and non-manual treatment options. They agreed to do high velocity thrusts on most patients at least once." The GDG also reviewed a post-hoc responder analysis relating to the UK Beam Study, cognisant of the potential risk of bias.[4] The GDG systematically reviewed eighteen trials that considered manual therapy as an adjunct with exercise.[1] The GDG concluded that soft-tissue techniques (e.g. massage) and manipulation or mobilisation were effective, but only when provided as part of a treatment package alongside exercise, where benefits were observed and seen to be maintained in the longer term.[1]
With regards to the trial of Alexander technique[5], the GDG agreed there was some evidence suggesting clinical and cost effectiveness for Alexander technique[1], but that this was based only on a single trial. The GDG discussed that recommending the intervention would lead to a significant change in practice in the NHS, and more evidence was required before making such a recommendation.[1] The GDG did not feel it necessary to prioritise this for further research as a further large randomised trial of Alexander technique was already underway.[1]
With regards MRI scanning from non-specialist settings of care, NICE makes recommendations for the NHS as a whole, to make best use of limited resources and improve the quality of healthcare.[1] There are, of course, a few GPs who have training in orthopaedics, rheumatology or musculoskeletal medicine, and are working in these specialist roles solely in primary care. However, it could be argued that such arrangements, even if quality assured and with minimal cost-consequence, do not provide equity of access for the whole of a CCG’s population.
References
1. National Guideline Centre, Royal College of Physicians. Low back pain and sciatica in over 16s: assessment and management—full guideline. National Institute for Health and Care Excellence, 2016. www.nice.org.uk/guidance/ng59/evidence
2. Licciardone JC, Kearns CM, Minotti DE. Outcomes of osteopathic manual treatment for chronic low back pain according to baseline pain severity: results from the OSTEOPATHIC Trial. Manual Therapy. 2013; 18(6):533-540. http://dx.doi.org/10.1016/j.math.2013.05.006
3. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: Effectiveness of physical treatments for back pain in primary care. BMJ. 2004; 329(7479):1377-1381. http://dx.doi.org/10.1136/bmj.38282.669225.AE
4. Froud R, Eldridge S, Lall R, Underwood M. Estimating the number needed to treat from continuous outcomes in randomised controlled trials: methodological challenges and worked example using data from the UK Back Pain Exercise and Manipulation (BEAM) trial. BMC Medical Research Methodology. 2009; 9:35. http://dx.doi.org/10.1186/1471-2288-9-35
5. Little P, Lewith G, Webley F, Evans M, Beattie A, Middleton K et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ. 2008; 337:a884. http://dx.doi.org/10.1136/bmj.a884
Competing interests: We declare the following interests based on NICE's policy on conflicts of interests (www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/code-of-practice-for-declaring-and-managing-conflicts-of-interest.pdf). The authors’ full statements are available online (www.nice.org.uk/guidance/NG59/documents/committee-member-list). IB is employed by London North West Healthcare NHS Trust, is a partner at Gordon House Surgery, and is employed by NHS Ealing CCG as clinical commissioning lead for MSk services, London; he received funding, travel, and subsistence allowances for committee work, lecturing, and organising educational workshops from NHS Ealing CCG, the Association for Medical Osteopathy, the Arthritis and Musculoskeletal Alliance, the NHS Alliance, the British Institute of Musculoskeletal Medicine, the British Society for Rheumatology, CloserStill Media Healthcare, Royal College of General Practitioners, Imperial College London, and NICE. SC is employed by the Royal College of Physicians, London. SW is employed by Brighton and Sussex University Hospitals NHS Trust, Brighton. He was a director of Back@Work until January 2016; a company that provides a community pain management service for the residents of mid-Sussex. He received accommodation, travel, and subsistence allowances for committee work and lecturing from the American Society of Interventional Pain Physicians and NICE. He has lectured or provided expert opinion (non-remunerated) at meetings at the Faculty of Pain Medicine, St Thomas’ Hospital, the Congress of the European Pain Federation, and the Spinal Intervention Society.
We thank the rapid responders for the feedback on our summary.[1] The infographic[2] was designed from the perspective of a patient presenting in primary care, and the article focussed on 19 of the 41 recommendations in the guideline[3], as encapsulated in the ‘What you need to know’ box.
With respect to Andrew Frank’s comments:
We agree that that management needs to be personalised. The NICE guideline states: "…the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian…"[3]. Our summary states that clinicians should consider using risk stratification “to inform shared decision-making about stratified management.”
The Guideline Development Group (GDG) found no evidence to support the comment "…suggesting that X-Rays can confirm the spine’s suitability for exercise therapy..." Most of the evidence in favour of imaging reviewed by the GDG was obtained from a single RCT performed in a secondary setting of care, and was contrary to the evidence from several large cohort studies.[4] The GDG considered imaging was unlikely to be cost effective in a primary care setting, whilst it could be cost effective in those cases where imaging in specialist settings of care could lead to a change in management.[4]
We agree that ‘remaining in work’ and ‘return to work’ are important outcomes. Our summary mentioned the time lost from work, and the proportion of people who never return to work following an episode of LBP. A systematic review of return to work programmes was included in the full guideline, and stated that there was a "lack of evidence for a specific intervention or programme that could be recommended to enable people to return to work.”[4] The GDG discussed the “broader evidence highlighting [the] benefits of enabling people to return to work or their usual activities…” and agreed a consensus statement that an outcome of the management recommendations in the guideline was to enable people to return to work or their usual activities.[4]
With regards the definition of sciatica, this is defined in the NICE guideline as "leg pain secondary to lumbosacral nerve root pathology”.[3] The guideline explains that “sciatica is a term that patients and clinicians understand, and is widely used in the literature to describe neuropathic leg pain secondary to compressive spinal pathology.”[3] We agree that referred pain in the leg is an important differential and that the approach to management will be different if there is nerve root pathology or dural irritation. Throughout the guideline the GDG considered interventions and outcomes for people with sciatica separately from those with referred pain where the investigators were able to make that differentiation, and this is reflected in the acute sciatica pathway in the BMJ infographic accompanying this article.[2] However, in many studies, the investigators could not rigorously make that differentiation, and the GDG included these studies in the 'low back pain with or without sciatica' population in the pre-specified population groupings for each systematic review.[4] Although diagnostic accuracy reviews have been published, the GDG did not find any evidence for clinical examination tests that would both reliably diagnose sciatica AND lead to specific treatments that would improve patient outcomes (test and treat studies). [4] Therefore, the issue of referred pain versus neuropathic or nerve root pain remains a clinical management issue that was not resolved by the reviews undertaken by the GDG, and hence no recommendations were made in this regard.[4]
References
1. Bernstein IA, Malik Q, Carville S, Ward S. Low back pain and sciatica: summary of NICE guidance. BMJ 2017:i6748. http://dx.doi.org/10.1136/bmj.i6748
2. Bernstein IA, Malik Q, Carville S, Ward S. Low back pain and sciatica: summary of NICE guidance; Visual summary. BMJ 2017:i6748. http://www.bmj.com/content/bmj/suppl/2017/01/06/bmj.i6748.DC1/beri151216...
3. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NICE Guideline NG59). 2016. www.nice.org.uk/guidance/ng59
4. National Guideline Centre, Royal College of Physicians. Low back pain and sciatica in over 16s: assessment and management—full guideline. National Institute for Health and Care Excellence, 2016. www.nice.org.uk/guidance/ng59/evidence
Competing interests: We declare the following interests based on NICE's policy on conflicts of interests (www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/code-of-practice-for-declaring-and-managing-conflicts-of-interest.pdf). The authors’ full statements are available online (www.nice.org.uk/guidance/NG59/documents/committee-member-list). IB is employed by London North West Healthcare NHS Trust, is a partner at Gordon House Surgery, and is employed by NHS Ealing CCG as clinical commissioning lead for MSk services, London; he received funding, travel, and subsistence allowances for committee work, lecturing, and organising educational workshops from NHS Ealing CCG, the Association for Medical Osteopathy, the Arthritis and Musculoskeletal Alliance, the NHS Alliance, the British Institute of Musculoskeletal Medicine, the British Society for Rheumatology, CloserStill Media Healthcare, Royal College of General Practitioners, Imperial College London, and NICE. SC is employed by the Royal College of Physicians, London. SW is employed by Brighton and Sussex University Hospitals NHS Trust, Brighton. He was a director of Back@Work until January 2016; a company that provides a community pain management service for the residents of mid-Sussex. He received accommodation, travel, and subsistence allowances for committee work and lecturing from the American Society of Interventional Pain Physicians and NICE. He has lectured or provided expert opinion (non-remunerated) at meetings at the Faculty of Pain Medicine, St Thomas’ Hospital, the Congress of the European Pain Federation, and the Spinal Intervention Society.
It is disheartening, though hardly unexpected, that the NICE guidance on low back pain and sciatica, similarly to the recent advice on assessment of shoulder pain (1), is singularly unenlightening.
After being told to keep in mind obvious, though relatively rare, serious disorders (cancer, infection, trauma, inflammatory disease) we are adjured to ‘make a positive diagnosis of low back pain and sciatica’. Low back pain and sciatica are symptoms, not diagnoses.
The next step, we are advised, is to consider ‘risk stratification’. How is that supposed to help the patient? Never mind. For people likely to improve quickly – but how do you decide? – we should ‘consider simpler and less intensive support.’ This amounts to doing nothing, unless you consider ‘reassurance, advice to keep active and self-medication’ as treatment.
For those unfortunate patients ‘at a higher risk of a poor outcome’ – again, how are we to know who these are? – we are guided to offer ‘more complex and intensive support’. And this, believe it or not, is ‘exercise programmes with or without manual therapy or using a psychological approach’.
What about taking the history and performing a clinical examination in order to make a diagnosis? How to do this has been clearly set out (2) (3). Then one might be in a better position to decide which patients are likely to respond, for example, to spinal manipulation.
Even the authors don’t seem to have much confidence in their advice. In the smallest of small print in a corner of the summary diagram we are informed: ‘This infographic is not a validated clinical decision aid.’ Then what use is it?
symonds@tokyobritishclinic.com
(1) BMJ 2016;355:i5783
(2) Cyriax J, Textbook of Orthopaedic Medicine, Vol I. Diagnosis of soft tissue lesions. London: Baillière Tindall,1982.
(3) Ombregt L, A System of Orthopaedic Medicine. Churchill Livingstone, 2013.
Competing interests: No competing interests
As a social enterprise and educational yoga Institute, supported by Arthritis Research UK, dedicated to knowledge transfer, we welcome NICE's recommendation to offer patients the choice of yoga as a first step to managing low back pain. However, it is important to note that not all yoga classes would be suitable. With the vast array of different types of yoga available, it is helpful for healthcare professionals to note that the specific 'Yoga for Healthy Lower Backs' programme was designed by yoga specialists overseen by back pain experts and was used successfully in the University of York randomised control trial. This identification name is specifically is mentioned within the published Annals of Internal Medicine paper (and also in the NICE guidelines long version - H. Tilbrook et al and LH Chuang; 313 participants).
This 12-week mind-body, long-term self-management, back-care yoga course is specific and appropriate for beginners. It has a very gentle approach and is taught by highly-qualified and experienced yoga teachers who have additional British Wheel of Yoga recognised Yoga for Healthy Lower Backs Institute 300-hour training. Qualified and part-qualified teachers appear on a Register at www.yogaforbacks.co.uk and more information can be requested via atrewhela@orangehome.co.uk. The evidence-based programme is taught according to 12 class plans (according to a Teachers' Manual with allowable modifications for individualisation) by teachers trained by the same yoga programme designer, Alison Trewhela. Course attendees are supported to practise safely and appropriately at home through the original research's educational resources (relaxation CD, 5 home practice sheets, pain-relieving poses 'Menu sheet', hand-outs, students' manual).
There are over 350 Yoga for Healthy Lower Backs teachers throughout the UK with good course attendee outcomes. A study shows this 12-week course is performing better than in the original trial. It is currently being taught within the NHS in Cornwall and we have support of GPs and commissioners.
More can be seen via our social enterprise website www.yogaforbacks.co.uk and/or via November 2016 presentation link on the RCGP website (copy and paste - RCGP Website Link to Alison Trewhela’s 2016 Yoga for Healthy Lower Backs Presentation plus Dr. A Huette’s 2016 Yoga GP Quality Improvement Pilot Project Powerpoint
http://www.rcgp.org.uk/learning/wales-and-south-west-england/tamar-facul...)
Competing interests: I was the lead yoga consultant who designed the yoga programme used in Arthritis Research UK randomised control trial (University of York) and run a social enterprise set up to educate and promote the yoga programme, Yoga for Healthy Lower Backs mentioned in the Annals of Internal Medicine published paper (for identification purposes).
Re: Low back pain and sciatica: summary of NICE guidance
Dear Editor
NICE updated its guidance on the pharmacological management sciatica in 2020, including recommendations about gabapentinoids and opioids. Please see the updated guidance on the NICE website: https://www.nice.org.uk/guidance/ng59
Competing interests: No competing interests