New NICE Guidelines for Early Management of Non-specific Low Back Pain
Low back pain which persists and does not have a specific origin is a frequent source of consultation for professionals in the healthcare professions, consisting of a high percentage of sickness absence from work. The last ten years have seen a great improvement in the quality and quantity of research work on this subject, finally leading to the ability to give scientific advice about the management of low back pain of a persistent nature. NICE, the National Institute for Clinical Excellence, has just published its latest guidelines in May 2009.
The first thing is to make a clear diagnosis of the low back pain. In non-specific low back pain the source may not be found but various diagnoses have to be ruled out, including tumours, infections, fractures, ankylosing spondylitis or other arthritic diseases. Reassessment of the potential diagnosis should be kept in mind as time progresses, and if a specific diagnosis is suspected at any time then investigations should be requested. Nerve root compression, often referred to as sciatica, can cause radicular pain in the leg and cauda equina syndrome can cause very severe pain and important symptoms. These conditions need surgical consultation.
Clinicians and researchers have classified low back pain into three categories, acute back pain, sub-acute back pain and chronic back pain. If the back pain has lasted for less than six weeks it is said to be acute, if it lasts from six to twelve weeks it is sub-acute and if it continues after the twelve week point it is said to be chronic. This system of back pain classification is only partly useful as its rigid boundaries often do not correspond to the persistence and variability of back pain as people typically experience it.
In the UK adult population around a third are thought to suffer from an episode of low back pain every year. Of this number around a fifth of sufferers will attend their GP to seek help for their back pain. Research has shown that it persists for a long period with 62% of sufferers still having pain at one year after the onset. Patients who are unable to work due to their back pain episode have a 16% probability of still being off work due to back pain after a year. The disability and pain improves rapidly over the first month but with little more after 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.
Typical interventions for the management of low back pain include:
External physical interventions such as transcutaneous electrical nerve stimulation (TENS), laser, ultrasound, interferential, spinal traction and lumbar supports.
Patient education via information either from a professional individually or in a formal group session, including written materials.
Education for patients such as group sessions, written explanatory material and individual instruction from therapists.
Manual therapies such as manipulative techniques, mobilisation and massage.
Psychological interventions to improve self management, either mindfulness or a form of cognitive behavioural therapy.
The first thing is to make a clear diagnosis of the low back pain. In non-specific low back pain the source may not be found but various diagnoses have to be ruled out, including tumours, infections, fractures, ankylosing spondylitis or other arthritic diseases. Reassessment of the potential diagnosis should be kept in mind as time progresses, and if a specific diagnosis is suspected at any time then investigations should be requested. Nerve root compression, often referred to as sciatica, can cause radicular pain in the leg and cauda equina syndrome can cause very severe pain and important symptoms. These conditions need surgical consultation.
Clinicians and researchers have classified low back pain into three categories, acute back pain, sub-acute back pain and chronic back pain. If the back pain has lasted for less than six weeks it is said to be acute, if it lasts from six to twelve weeks it is sub-acute and if it continues after the twelve week point it is said to be chronic. This system of back pain classification is only partly useful as its rigid boundaries often do not correspond to the persistence and variability of back pain as people typically experience it.
In the UK adult population around a third are thought to suffer from an episode of low back pain every year. Of this number around a fifth of sufferers will attend their GP to seek help for their back pain. Research has shown that it persists for a long period with 62% of sufferers still having pain at one year after the onset. Patients who are unable to work due to their back pain episode have a 16% probability of still being off work due to back pain after a year. The disability and pain improves rapidly over the first month but with little more after 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.
Typical interventions for the management of low back pain include:
External physical interventions such as transcutaneous electrical nerve stimulation (TENS), laser, ultrasound, interferential, spinal traction and lumbar supports.
Patient education via information either from a professional individually or in a formal group session, including written materials.
Education for patients such as group sessions, written explanatory material and individual instruction from therapists.
Manual therapies such as manipulative techniques, mobilisation and massage.
Psychological interventions to improve self management, either mindfulness or a form of cognitive behavioural therapy.
About the Author:
Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapist in Blackpool visit his website.