Dr Steve Longworth summarises four management principles from the NICE guideline that should be applied to all patients

In a typical day, most GPs will see at least one or two patients with low back pain as it is the third most common symptom that they present with, after headache and fatigue. Most patients with acute back pain experience improvements in pain and disability over time; if they are unable to work at the time of presentation, most return to their job within 1 month. Further smaller improvements can occur up to 3 months later, after which time pain and disability levels remain almost constant. However, low levels of pain and disability persist from 3 months to at least 12 months, and most people will have at least one recurrence within 12 months.1 Although many episodes of acute low back pain will resolve rapidly, the proportion of people who develop chronic disabling back pain may be as much as 30%.2

The NICE guideline on Low back pain: early management of persistent non-specific low back pain is the last guideline to be produced by the National Collaborating Centre for Primary Care prior to its merger with other collaborating centres.3 The document covers the same clinical area as the Low back pain evidence review, the first comprehensive evidence-based guideline from the Royal College of General Practitioners (RCGP), published over a decade ago.4

Remit of the guideline

The NICE guideline covers the early treatment and management of persistent or recurrent low back pain, defined as non-specific low back pain that has lasted for more than 6 weeks, but for less than 12 months.3 ‘Non-specific low back pain’ is defined as tension, soreness, and/or stiffness in the lower back region for which it is not possible to identify a specific cause of the pain.3 Although the full guideline mentions that the lower back is commonly described as the area bounded by the bottom of the rib cage and the buttock creases, this simple but critically important point was not included in the quick reference guide,5 which is probably what most busy GPs will refer to.

The guideline development group has attempted to summarise the recommended care pathway in a colourful but very busy flow diagram, which, while comprehensive, unfortunately covers three A4-sized pages, and may be somewhat intimidating to the non-enthusiast. However, the algorithm is worth spending some time to peruse as it contains sound advice as well as some serious challenges in terms of implementation and a few surprises in the recommendations on non-pharmacological treatments.5

Principles of management

The NICE guideline recommends that treatment and care should take into account the individual needs and preferences of the patient. Good communication between the healthcare professional and the patient is essential. This needs to be supported by evidence-based information, to allow the patient to reach informed decisions about their care.3 Patients should be offered educational advice that:3

  • includes information on the nature of non-specific low back pain
  • encourages him/her to be physically active and continue with normal activities as far as possible.

The guideline does not endorse or recommend any specific source of written information for patients, and so clinicians are left to decide for themselves which written information to give patients. I suggest that primary care trusts should support the implementation of the guideline by purchasing and providing copies of The Back Book6 so that GPs can hand this out to their patients. This publication is cheap (£1.25), readily available, jargon-free, well established (now on its 2nd edition), and was written by a group of renowned national experts with international reputations in back pain research.

I believe that the guideline promotes four management principles that should be applied to all patients.

1) Diagnosis
Clinicians are advised to keep the diagnosis under review at all times. A clinician who suspects that there is a specific cause for their patient’s low back pain (e.g. cancer, infection, ankylosing spondylitis) should arrange the relevant investigations. In the full guideline,7 very brief advice is offered regarding the ‘red flags’ that should prompt such investigations but this topic is not covered at all in the summary, and so I offer my own suggestions (see Box 1).

2) Self management
Healthcare professionals should promote self management and advise people with low back pain to exercise, to be physically active, and to carry on with normal activities as far as possible.3 I offer my patients simple positive messages such as ‘hurt doesn’t mean harm’, ‘pain doesn’t mean damage’, and ‘if you rest, you rust’.

3) Pharmacology
Drug treatments should be offered as appropriate to manage pain and to help people keep active. Pharmacological therapy should start with regular paracetamol and move on to non-steroidal anti-inflammatory drugs, weak opioids, and tricyclic antidepressants, with the possible short-term use of strong opioids.3 I advise my patients to combine treatments to provide an umbrella of pain relief to reduce the frequency, intensity, and duration of painful episodes.

The NICE guideline states that a number of drugs that are commonly prescribed for low back pain do not have UK marketing authorisation. In such circumstances, informed consent should be obtained and documented.3

4) Non-pharmacological options
The guideline recommends offering one of the following treatments, taking patient preference into account:3

  • exercise programme (up to eight sessions over a period of up to 12 weeks)
  • course of manual therapy including spinal manipulation (up to nine sessions over a period of up to 12 weeks)
  • course of acupuncture (up to ten sessions over a period of up to 12 weeks).

If the chosen treatment does not result in satisfactory improvement, the healthcare professional should consider offering another of these options. It is this set of recommendations that I believe will prove to be the most challenging to implement, as either massive investment will be needed in new services, or radical re-deployment of currently available resources (mostly within physiotherapy) will need to take place (with major investment in re-training).

The surprise recommendations are the rejection of the common passive physiotherapy treatments (e.g. laser, ultrasound) and injection therapy, and the prominence given to the use of acupuncture and manipulation. For me, having recently read a fascinating book about complementary medicine,9 the most interesting inclusion in the guideline was that of considering acupuncture. I wonder if this recommendation will survive the future high-quality research that the guideline rightly calls for.

Box 1: Red flags in back pain8

Age

  • Age of onset <20 years or first episode >55 years

Onset, behaviour, location, and progress of pain

  • Violent trauma (e.g. road traffic accident or fall from a significant height)
  • Non-mechanical pain–constant, progressive, not related to posture/activity
  • Severely disturbed sleep ('spent all night in a chair')
  • Nerve root pain that is bilateral or switches sides
  • Pain not helped at all by simple analgesia
  • Pain worse on lying down (possible spinal tumour)
  • Thoracic pain (often mechanical in young primary care patients, may indicate a condition, such as cancer, in older patients)
  • Prolonged (>1 hour) morning/inactivity stiffness in the low back that responds dramatically to oral non-steroidal anti-inflammatory drugs (ask about personal and family history of iritis, psoriasis, inflammatory bowel disease, and a family history of ankylosing spondylitis)

Past medical history

  • History of cancer–lung, breast, prostate, kidney, and thyroid are the most common primary sources. Back pain may be the first presentation of cancer elsewhere as a result of pain from metastases–examine the possible primary sites
  • Vitamin D deficiency is a common cause of widespread musculoskeletal pain–risk groups include people: with dark skin, with little sun exposure to the skin, on strict vegetarian diets, with malabsorption syndromes

Mnemonic: Remember what I SAID

  • Systemic steroids (increased risk of osteoporotic vertebral collapse)
  • Anticoagulation problems (increased risk of spinal bleed/haematoma)
  • Immunosuppression by disease or drugs (increased risk of infection)
  • Drug abuse (increased risk of infection)

Systemically unwell–mnemonic: Fever WARMS

  • Ask about: Fever, Weight loss, Anorexia, Rigors, Malaise and Sweats

Examination

  • Systemically unwell (weight/temperature/pulse)
  • Structural deformity
  • Persisting severe restriction of lumbar flexion
  • Widespread (polyradicular) neurology and/or upper motor neurone signs
  • Gait disturbance

If there are suspicious clinical features or the pain has not settled in 6 weeks, review and consider arranging investigations

Don't forget that serious visceral disease may present with back pain (e.g. aortic aneurysm, pancreatic cancer, peptic ulcer, renal disease [cancer, stones, infection])

Imaging and surgery

The guideline contains advice about when to order imaging (infrequently) and when to refer for a combined physical and psychological treatment programme or an opinion about spinal fusion surgery.3 I agree with the advice about imaging, but I think that the evidence for benefit from spinal fusion surgery compared to a rigorous rehabilitation programme is unconvincing. Only when all other options have been vigorously and thoroughly explored should a patient be referred to an experienced specialist spine surgeon to discuss the benefits and risks of fusion surgery.

Cause of controversy

The NICE guideline also contains a number of recommendations on therapies that should not be offered, which I suspect is going to upset a good many vested interests. This includes lumbar supports and traction, which will probably come as little surprise to anyone who has read the RCGP guidance published in 1996.4 However, many physiotherapists may be alarmed to see that laser therapy, interferential therapy, and therapeutic ultrasound are not recommended. Transcutaneous electrical nerve stimulation is also not recommended in the guideline; this is undoubtedly going to cause some consternation in my local pain clinic.

The guideline has already had a stormy reception in one quarter, with one of the lead authors being forced to step down as President of the British Pain Society after a campaign from members who were unhappy with the guideline.10 The main sticking point was the recommendation that injections of therapeutic substances into the back for non-specific low back pain should not be offered, as the evidence of effectiveness is lacking.

Conclusion

The NICE guideline on low back pain is an honest attempt at a very difficult task. I suspect that there are few healthcare professionals specialising in treating back pain who will wholeheartedly embrace the guideline in its entirety and that most clinicians will emphasise and ignore various parts of the guidance depending on their own background, biases, and beliefs. It will be fascinating to see how the guidance evolves over the next decade and how effectively it is implemented in practice.

  1. Pengel L, Herbert R, Maher C, Refshauge K. Acute low back pain: systematic review of its prognosis. BMJ 2003; 327 (7410): 323.
  2. Thomas E, Silman A, Croft P et al. Predicting who develops chronic low back pain in primary care: a prospective study. BMJ 1999; 318 (7199): 1662–1667.
  3. National Institute for Health and Care Excellence. Low back pain: early management of persistent non-specific low back pain. Clinical Guideline 88. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG88
  4. Waddell G, McIntosh A, Hutchinson A et al. Low back pain evidence review. London: Royal College of General Practitioners, 1996.
  5. National Institute for Health and Care Excellence. Low back pain: early management of persistent non-specific low back pain. Clinical Guideline 88. Quick reference guide. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG88
  6. Burton K, Cantrell T, Klaber Moffett J et al. The Back Book 2nd ed. London: The Stationery Office, 2002.
  7. National Collaborating Centre for Primary Care. Low back pain: early management of persistent non-specific low back pain. London: Royal College of General Practitioners, 2009. Available at: www.nice.org.uk/guidance/index.jsp?action=folder&o=44335
  8. Cohen S, Argoff C, Carragee E. Management of low back pain. Clinical Review. BMJ 2008; 337: a2718.
  9. Singh S, Ernst E. Trick or treatment: alternative medicine on trial. London: Bantam Press, 2008.
  10. Kmietowicz Z. President of British Pain Society is forced from office after refusing to denounce NICE guidance on low back pain. BMJ 2009; 339: b3049.G