Guidance on low back pain from the British Pain Society and Map of Medicine aims to make treatment consistent between specialties and help commissioners set standards
The British Pain Society and Map of Medicine have published guidance on the treatment of low back pain. The aim of the guideline is to ensure continuity of care between the many specialties often involved in patients’ care. This article describes the care pathway.
Citation: Lee J (2013) The management of low back pain. Nursing Times; 109: 51, 10-11.
Author: John Lee is consultant in pain medicine, Cayman Islands Hospital, and senior lecturer, University College London
- This article has been double-blind peer reviewed
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Low back pain is one of the most common medical conditions, with almost every adult experiencing it at some point and 11% or more of the population being disabled by it (Chou, 2010). It is well recognised that people who regularly lift, bend and twist are at greater risk of developing back pain and that the condition is frequently associated with low mood and loss of employment due to ongoing ill health.
A variety of specialists are available to help manage low back pain, ranging from hands-on clinicians such as physiotherapists, chiropractors and osteopaths to GPs, rheumatologists, spinal experts and pain specialists. Many of these have different management strategies for patients with low back pain and radicular pain (pain felt in the distribution of a spinal nerve in the lower limb (often termed “sciatica”). Guidance has been published to create a more uniform approach to managing care between these different groups and specialties (Lee et al, 2013; Map of Medicine and British Pain Society, 2012). The guidance, which is available at tinyurl.com/BPS-LBPMap, addresses acute rather than chronic low back pain.
A major aim of the guidance is to empower people with low back pain to take control of their own lives and self-manage their condition as much as possible rather than be the passive recipients of care, which stops once they leave the surgery or clinic.
This is emphasised early in the care pathway to help care providers focus on how patients can make the best use of available information. To do this, information needs to be tailored to the individual; for some, an internet resource is the best solution, whereas others may prefer a leaflet or book.
The initial management of low back pain is supported by general recommendations on prescribing and a tool for assessing efficacy. Prescribing is linked to neuropathic pain guidance where there is a significant neuropathic element, for example radicular pain.
Patients with symptoms of cauda equina compression (lumbosacral nerve root compression with bowel and bladder dysfunction) should be referred immediately to the accident and emergency department.
Red flags for spinal pain include a history of cancer, weight loss, possible fracture, systemic ill health, and age over 55 years; these require swift referral.
Patients experiencing severe pain or pain not relieved by any of the recommended initial treatments should also be referred to a specialist centre early.
As with previous guidelines, it is recommended that treatment is started quickly and that bed rest is avoided, even though people in pain tend to think that this will help.
STarT Back Screening Tool
In primary care settings, patients should be assessed using the STarT Back Screening Tool if their pain has not been improved by initial treatments (Hill et al, 2011). This tool is relatively new and has generated significant clinical and research interest.
It is able to determine severity, impact and risk of permanent disability, allowing the assessor to target treatment for patients in the greatest need rather than provide all with the same treatment. Patients are given timescales for reassessment so that any necessary referrals can be made early and to stop them from entering cycles of therapy that do not change their outcomes. In this way, the pathway encourages the best use of resources.
The STarT Back Screening Tool categorises patients into low, medium and
high risk. Each has a clear pathway of care with increasing intensity. Treatment strategies range from physical therapy, manual therapy, acupuncture, massage and transcutaneous electrical nerve stimulation (TENS) to a more psychosocial approach for those at high risk. It is likely that commissioners of care will be able to use the guideline to ensure service delivery in the community is in line with recommended best practice. Providing community-based psychology services may be a challenge as these tend to be relatively scarce.
After the general management of low back pain pathway, there are two further trees: one for the specialist management of low back pain and another for managing radicular pain. The specialist management tree is made up of the following:
- Lists of different sequenced injections, which should be performed only with radiological imaging;
- Description of how rational polypharmacy may be appropriate in this group of patients, and how opioids may be given for the most severe pain, provided there is a clear management plan if the objectives and manner of their use are not met;
- Recommendations around surgical referrals, including a multidisciplinary approach and minimally invasive interventions that should be considered before major surgery;
- A cognitive behaviourally based pain management programme that is delivered by an interdisciplinary team in a group setting to reduce the distress and disability of long-term pain where pain relief is not the primary goal.
The radicular pain pathway is a novel aspect of guidance; many previous low back pain guidelines, such as those produced by the Royal College of General Practitioners (Waddell et al, 1999), have not made specific recommendations for treatment when there is some form of neural deficit.
In this section, there is a faster referral flow from presentation to urgent imaging and intervention for the most severely affected. It is recommended that practitioners should only request an MRI scan if they have the skills to interpret it, after which an imaging-guided steroid injection can be given. If pain persists to a significant degree after the injection, the patient needs referral to a spine surgeon. There is good evidence that earlier surgical intervention can help this group of patients make a faster functional recovery, which also has economic benefits (van den Hout et al, 2008).
Onward treatment for radicular pain is similar in many ways to the specialist management of low back pain. However, the range of options includes more detail about drugs that target neuropathic pain which can accompany nerve root irritation, with cross reference to the related neuropathic pain pathway (Map of Medicine and BPS, 2013; tinyurl.com/BPS-NeuropathicMap).
Repeat surgery and consideration of spinal cord stimulation is suggested for the most difficult cases. A spinal cord stimulator is a permanently implanted subcutaneous electrical generator that stimulates the spinal cord through percutaneous or surgically placed epidural electrodes, controlled by an external hand-held device. These generators are a similar size to a pacemaker and many of them can now be recharged without the need to replace the device.
The guidance gives specific direction on the types of interventions that should be used when managing people with low back pain and radicular pain, adding to existing published best practice, such as that developed by the National Institute for Health and Clinical Excellence (2009).
It is arguably the most comprehensive guidance to date, and describes both primary and specialist care with enough detail to enable commissioners and others to set measurable standards of care for delivery.
As with all guidelines, new evidence may lead to updates, and the publication of revised NICE guidelines on neuropathic pain may affect this part of the pathway.
The pathway can be found on the Map of Medicine website as well as a British Pain Society microsite: https://www.britishpainsociety.org
- Low back pain, including radicular pain, is a common condition
- Assessment tools are recommended from an early stage to guide treatment and the use of resources
- Treatment should focus on self-management, information, keeping active and avoiding bed rest
- Referrals to specialist centres, where necessary should be made as early as possible
- Community therapies for pain include clinical psychology and social support
Chou R et al (2010) Will this patient develop persistent disabling low back pain? Journal of the American Medical Association; 303: 13, 1295-1302.
Hill JC et al (2011) Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet; 378, 1560-1571.
Lee J et al (2013) Low back and radicular pain: a pathway for care developed by the British Pain Society. British Journal of Anaesthesia; 111: 1, 112-120.
Map of Medicine and the British Pain Society (2013) Neuropathic pain. England View.
Map of Medicine and British Pain Society (2012) Low back and radicular pain. England View.
National Institute for Health and Clinical Excellence (2009) Early management of persistent non-specific low back pain. London: NICE.
Van den Hout WB et al (2008) Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial. British Medical Journal; 336: 7657, 1351-1354.
Waddell G et al (1999) Low Back Pain Evidence Review. London: Royal College of General Practitioners.