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Practice comment

NICE guidance on low back pain should be revised urgently  

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NICE guidance on low back pain should be reviewed to avoid confusion, say Kate Feenan and Paula Banbury

Earlier this year NICE (2009) published guidelines for the early management of persistent non-specific low back pain. They were intended to provide clarity and consistency about diagnosing and treating this common and often mis-treated condition.

Low back pain has a huge socioeconomic impact in the UK in terms of individual suffering, employee absence and the financial burden on health services. Improving its treatment must therefore be a priority and remains a concern to the NHS.

Since the NICE guidance was published, healthcare professionals involved in treating people with long term low back pain have criticised the recommendations. As nurse practitioners working in an interdisciplinary team treating persistent musculoskeletal pain, we support these challenges to the guidelines.

Our attention is particularly drawn to comments made by the British Pain Society in response to the guidance. One key observation is that the guidelines do not apply to all types of low back pain. A further point is that NICE recommends considering referral for an opinion on spinal surgery earlier than would normally be the case as an intervention for people who do not respond to other treatments.

In addition, the Nottingham Back and Pain Team supports the society’s objection that a practising pain physician was not involved in developing these guidelines.

Pain management specialists provide a range of treatments which aim to enhance quality of life. To achieve this, it is widely recognised by experts in the field that a biopsychosocial model in a cognitive behavioural framework is one of the most effective means of treating this patient group.

“It is frustrating for pain management experts that their views have not been wholly considered.”

While we acknowledge that considering referral for a combined physical and psychological treatment programme is recommended, this is only for a specific patient group. In our experience most patients would benefit from this before using passive treatment such as manual therapies and acupuncture, which we believe do not have robust clinical evidence for treating low back pain with long term benefits.

Although the guidelines do acknowledge the significance of exercise and the need to remain active, there is no specific reference in the clinical recommendations to the benefits of remaining in employment. Work is a key issue for people with low back pain and every effort should be made to enable them to stay in work by liaising with employers to support rehabilitation in the workplace. This also serves to reduce the burden on the UK economy.

There is also an issue about the timescale used in the NICE guidelines. The care pathway applies specifically to people who have had low back pain for more than six weeks but less than 12 months. In our experience of working in long term pain management, the majority of people assessed have endured pain for over a year, but these guidelines will apparently not apply to this group. This will cause dissatisfaction and frustration for both patients and the clinicians treating them.

The consensus among practitioners working in the field of long term low back pain is that a review of these guidelines should be a priority. It is frustrating for pain management experts that their views have not been wholly considered and that further confusion about treating people with low back pain has been added to this already complex and often challenging clinical area.

KATE FEENAN and PAULA BANBURY are advanced practitioner nurses, Nottingham Back and Pain Team, Nottingham University Hospitals Trust

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Readers' comments (2)

  • Its a big thank you to Kate Keenan & Paula Banbury for stating what we all know to be true and provoking the debate.
    Myself and a distinguished consultant spine surgeon are in the process of formulating a Domiciliary Spine Care Service using sustained Lumbar Flexion on the domestic bed during sleep, as a diagnostic and Nursing aid in the prevention of chronic low back pain, long over due in the light of the cognitive deficit now associated with chronic pain, this new 'Nursing' pathway will be made available to GP's during the first six weeks of onset and prior to any referral to hospital or Physiotherapy if indeed it will be needed. PCT's are needed to come on board.

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  • Martin Gray

    As a sufferer of low back pain for many years ( I am listed as disabled because of it) I am always astounded at the idea that pain relief is more important than possible surgical intervention now that there are far more prothesies vaialble that have proven to be effective. In my own eyes pain relief does nothing to stop the mechanical wear and tear on the spine, leading to worsening symptoms as the years progress. Would it not be more beneficial, and cheaper in the long term, to take a more proactive approach rather than just a reactive one led by the symptoms of pain? Am I supposed to wait until I can hardly walk before I'm offered surgery, by which time my age and health may very well preclude me from undergoing a general anaesthetic?

    In some cases surgery may not be an option, depending on the actual causative mechanisms that have resulted in LBP. However, for those young enough and currently fit enough, should the choice of surgery be ruled out because ' it's not the done thing'?

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