A member of the NICE guideline development group highlights the important issues for the latest evidence-based guideline for readers of Nursing Times
Key words: Back pain, Primary care, Exercise
Back pain affects around one in three adults in the UK each year, with an estimated 2.5 million people seeking help from their GP or other primary healthcare professional. For many, the pain resolves in days or weeks but, for some, it persists and changes their lives, reducing function and ability to work.
The NICE (2009) guideline for the early management of persistent non-specific low back pain recommends management for people who have experienced pain for more than six weeks but less than one year, where the pain may be linked to structures in the back such as joints, muscles and ligaments.
It sets out a range of effective mainstream and complementary treatments and recommends the care and advice that should be offered to people with low back pain.
Caring for people with back pain is a multidisciplinary effort. As the NHS evolves and nurses and other healthcare professionals are accepting extended roles for which further education is required, this guideline opens many doors for nursing intervention.
The document is evidence based but, where there is a lack of evidence concerning treatments, recommendations are made for research to be undertaken. Since many treatment topics are within the nursing domain, they may offer useful suggestions on research topics for nurses working towards higher degrees.
The recommendations for treatment of patients with low back pain were developed to:
- Improve patient outcomes – especially with regard to pain, disability and psychological distress;
- Promote patient choice and give them advice and information to promote self-management of low back pain;
- Reduce variation in the treatment offered to patients.
Many nurses now work as first point of contact clinicians in primary care, when assessment and diagnostic skills are paramount. Nurses are the patient’s advocate and can be pivotal in patient care, providing them with advice and a friendly ear if they run into problems.
Recommendations from the guideline for healthcare professionals include:
- Advise people with low back pain that staying physically active as much as possible is likely to help, and provide advice and information to help them manage their pain;
- Offer one of the following treatment options, taking into account the patient’s preference, and consider offering another of these options if the first choice does not result in satisfactory improvement:
- - A structured exercise programme;
- - A course of manual therapy including spinal manipulation, spinal mobilisation and massage;
- - A course of acupuncture.
- Offer a combined intensive exercise and psychological treatment programme for people who have already received at least one less intensive treatment but still have disabling pain which causes significant distress or seriously impacts on daily life.
The guideline advises that injections of therapeutic substances into the back for non-specific low back pain are not recommended, and that an X-ray of the lumbar spine for the management of non-specific low back pain should not be offered. An MRI scan should only be offered within the context of a referral for an opinion on spinal fusion.
It should be remembered that pain management is highly significant to patients with low back pain. Medicines management is an important aspect of the treatment of low back pain and the NICE guideline sets out which drug treatments to consider to help ease the pain.
Many nurses are now supplementary and independent prescribers. There is also the opportunity for nurses to explain the potential complications of pain medication to patients – for example, evidence suggests that the common side-effect of opioid-related constipation can cause back pain to deteriorate. Patients can be advised how to prevent side-effects.
There is evidence that patient education enhances recovery in conjunction with other treatments – if patients understand their condition, they can manage it more effectively.
One of the important issues is that back pain, while a life-limiting condition, is not life-threatening and patients should try to live life as normally as possible. This can be difficult if they are in pain and many people still believe that rest will cure back pain. Nurses can help to change this view through explanation and discussion.
The guideline offers many opportunities for nurses, such as personal research and training, coordination of treatment and opportunities to diversify. During their careers, nurses develop their skills of assessing, planning and implementing care; these can be used with great success in treating patients with low back pain.
AUTHOR Margaret Flanagan, MSc, BA, RGN, ONC, is nurse clinician, Western Avenue Medical Centre, Chester
NICE (2009) Low Back Pain: Early Management of Persistent Non-specific Low Back Pain. London: NICE.