low back pain
NICE guidance
Background
• 33% incidence LBP adult population
• 1 in 5 will consult a GP
• key focus – patient empowerment
Scope
• adults age 18+, non-specific lower back pain
• no radiculitis or radiculopathy
• 6 weeks to 12 months symptoms
• symptoms over 12 months
What is non-specific low back
pain?
• tension, soreness and/or stiffness in the lower
back region for which it isn’t possible to identify a
specific cause of the pain
• excludes: malignancy, infection, fracture, and
ankylosing spondylitis and other inflammatory
disorders
• hx of malignancy – back pain considered
metastases until proven otherwise
• hx of ank spond – fracture until proven otherwise
Principles of management
promote self-management
AND
offer drug treatments as appropriate
AND
consider additional non-pharmacological interventions
(x 2 trials)
avoid long-term withdrawal from normal activity
Information, education and
patient preferences
• advice and information to promote self-management
an exercise programme
a course of manual therapy
a course of acupuncture
• offer up to 2 of these
Structured exercise programme
• up to 8 sessions over up to 12 weeks
• supervised groups (max 10) or 1 on 1
• aerobic activity
• movement instruction
• muscle strengthening
• postural control
• stretching.
• may get worse before gets better - compliance
Manual therapy
• including spinal manipulation
• up to 9 sessions over up to 12 weeks
• spinal manipulation, spinal mobilisation and massage
• manipulation not supported by latest meta-analysis
(Rubinstein, 2011)
Invasive procedures
• acupuncture - maximum of 10 sessions, 12 weeks.
• 3 cochrane reviews for accupuncture & LBP
inconclusive (Lee, 2011)
• electro-accupuncture good results seen anecodtally in
clinic. Cochrane review (2006) ALTENS has odds
ratio of 6.6 for improveing pain
• do not offer steroid injections for non-specific low back
pain
Combined physical and
psychological treatment
programme
• people who:
have received at least one less intensive treatment
and
have high disability and/or significant psychological
distress.
• 100 hours over a maximum of 8 weeks
Assessment and imaging
• no x-ray of the
lumbar spine
• MRI only if considering fusion
or to exclude other pathology
Referral for surgery
• opinion on spinal fusion for people who:
have completed an
optimal package
of care
and
would consider
surgery for their
low back pain.
Referral for surgery
Surgery for radiculopathy with herniated lumbar disc and
symptomatic spinal stenosis is associated with short-term benefits
compared to nonsurgical therapy, though benefits diminish with
long-term follow-up in some trials.
For nonradicular back pain with common degenerative changes,
fusion is no more effective than intensive rehabilitation, but
associated with small to moderate benefits compared to standard
nonsurgical therapy.
Chou, Spine, 2009
Pharmacological therapies
• regular paracetamol as the first option
• NSAIDs and/or weak opioids 2nd line
• tricyclic antidepressants, gabapentin, pregabalin
more useful for radicular pain
• strong opioids for severe pain
Non-pharmacological therapies
Do not offer
•laser therapy
•therapeutic ultrasound
•TENS
•lumbar supports - QUESTION
•traction
Costs per 100,000 population
Costs
Recommendations with significant costs (£ per year)
Acupuncture 48,208
Manual therapy 31,575
Group combined physical and psychological treatment
programme 20,635
Exercise programme 1,708
Estimated cost of implementation 102,126
Savings per 100,000 population
Savings
Recommendations with significant cost savings (£ per year)
Reduction in injections of therapeutic substances into the
back 66,546
Reduction in MRI scans 23,389
Reduction in X-rays 2,732
Reduction in use of radiofrequency facet joint denervation 5,022
Reduction in other physical therapies 3,501
Estimated saving from implementation 101,190
sciatica (if time)
• radiculitis vs. radiculopathy
• acute & chronic
• natural history – 70% improve in 6 weeks
• degenerative stenosis
