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NICE: Exercise not acupuncture for lower back pain

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Exercise should be the first line option for tackling lower back pain, while acupuncture is no longer recommended, according to the National Institute for Health and Care Excellence.

NICE is currently updating its 2009 guidance on the early management of low back pain and has today published draft recommendations for consultation.

“There is a lack of convincing evidence of effectiveness for some widely used treatments”

Mark Baker

The draft recommends all forms of exercise – including stretching, strengthening, aerobic or yoga – as the first step in managing low back pain.

Massage and manipulation by a physiotherapist should only be used alongside exercise, because there is insufficient evidence to show benefit when used alone, said NICE.

In addition, the draft guideline also recommends encouraging people to continue with normal activities, as far as possible.

However, the draft guideline no longer recommends acupuncture for treating low back pain because evidence shows it is not better than sham treatment.

Mark Baker

Mark Baker

Mark Baker

Professor Mark Baker, NICE’s clinical practice director, said: “Regrettably there is a lack of convincing evidence of effectiveness for some widely used treatments.

“For example acupuncture is no longer recommended for managing low back pain with or without sciatica,” he said. “This is because there is not enough evidence to show that it is more effective than sham treatment.”

Paracetamol on its own is no longer the first option for managing low back pain. Instead, the draft recommends that non-steroidal anti-inflammatory drugs should be tried first.

Weak opioids, such as codeine, are now only recommended for acute back pain when NSAIDs have not worked or are not suitable, added NICE.

“The draft guidance promotes combinations of treatments such as exercise with manual therapy”

Ian Bernstein

Meanwhile, combined physical and psychological treatments – talking therapies – are recommended for patients who have seen no improvement in pain after other treatments or have significant psychological and social barriers to recovery.

The updated guideline has been expanded to include sciatica, typically caused by irritation or compression of the nerves that run from the lower back, through the legs to the feet.

It also covers low back pain or sciatica irrespective of how long patients have had it, as opposed to the previous version that only covered between six weeks and 12 months.

Professor Baker said: “The draft guideline continues to recommend a stepped care approach and means people whose pain or function are not improving despite initial treatment should have access to a choice of further therapies.”

He added: “Our aim with this draft guideline is to give clarity and set out the most clinical and cost effective ways to treat low back pain and sciatica based on the best available evidence.

“We now want to hear from all those who provide care for people with these conditions in the NHS, as well as from people with the conditions and their carers, to ensure all relevant views are considered for the final guideline,” he said.

The final version of the updated NICE guideline is due to be published in September 2016.

National Institute for Health and Care Excellence

NICE: Exercise not acupuncture for lower back pain

Ian Bernstein

Dr Ian Bernstein, a member of the group developing the NICE guideline, said: “The diagnosis of back pain includes a variety of patterns of symptoms. This means that one approach to treatment doesn’t fit all.

“Therefore, the draft guidance promotes combinations of treatments such as exercise with manual therapy or combining physical and psychological treatments,” he said. “The draft guideline also promotes flexibility about the content and duration of treatments.”

In the UK it is estimated that low back pain is responsible for 37% of all chronic pain in men and 44% in women.

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Readers' comments (2)

  • I used acupuncture to relieve lower back pain that I had had for years doing manual labour jobs. After a few months of treatment, the pain had gone. That was 5 years ago and my back is still ok. No one asked me about the treatment as it was private and not a referral from my GP. Assuming this is the same for a lot of people, how can any study give an accurate measure of whether it worked or not? And then to compare this ancient Chinese practice to a sham treatment...

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  • Acupuncture relieved my lower back pain/sciatica particularly when muscle spasm was part of the problem. Before this I'd endured the standard Physio exercises which only made the muscles spasm and pain worse. The exercises from the Physio only exaccerbated the pain, whereas yoga has been my long term saviour. More recently Hendrickson massage and reiki relieved terrible back pain within a week. It is a shame that these complementary therapies are not invested in and researched by the 'powers that be' but instead we are led down the same familiar paths that lead to months/ years of suffering.

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