The National Institute for Health and Care Excellence (NICE) has published new guidelines on early management of low back pain in adults. The authors made their recommendations based on systematic reviews of the best available evidence, as well as consideration of cost effectiveness. The new document replaces the 2009 guidelines and was summarized in a Jan. 5 article in BMJ.1
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The guidelines begin by noting that low back pain causes long-term disability and affects individuals throughout the world. In most cases, general practitioners will diagnose and treat low back pain, and imaging will not be necessary. Even when patients with back pain are referred to a specialist for treatment, imaging will be required rarely. Specialists should only request imaging if they feel that the results are necessary for determining a course of treatment.
That said, the diagnosis of low back pain does require the exclusion of specific causes of low back pain, such as cancer, infection and spondyloarthritis. Risk stratification tools, such as the STarT Back Screening Tool, may be helpful in excluding such specific causes of low back pain and in identifying patients who are more likely to have poor outcomes. Such tools can be used to describe and score each new episode of low back pain with or without sciatica.
After the physician makes the diagnosis of low back pain and evaluates the patient’s likely recovery outcome, the NICE guidance suggests that patients who are likely to improve quickly and who have a good outcome should be given reassurance and advice to keep active. Appropriate activities include stretching, strengthening, aerobics, yoga and/or tai chi. Not only are these exercise programs effective, but they can be continued beyond the episode of low back pain. These patients are also likely to benefit from advice and information on how to help them self-manage their low back pain. Above all, most patients need to hear that they can continue with their normal activities.
The guidance recommends that physicians target more intensive support to those individuals who are less likely to recover quickly. These individuals often demonstrate pain avoidance, have low mood and may be in the process of ongoing litigation. Some of these patients may also have experienced treatment failure in the past or have substantial psychosocial obstacles to recovery and avoid normal activities. These patients, in particular, may benefit from psychological approaches, such as cognitive behavioral therapy. In addition, manual therapy, such as manipulation, mobilization or massage, may help patients who are at higher risk of a poor outcome. In all cases, manual therapy and psychotherapy should be combined with an exercise program. A group exercise program that is biomechanical, aerobic and/or mind-body exercises, such as yoga or tai chi, may be especially beneficial for individuals with a specific episode or flare up of low back pain. The NICE guidance notes there is no evidence to support the use of acupuncture or electrotherapies.
Some patients may require a short course of non-steroidal anti-inflammatory drugs or a weak opioid. Although the guidelines caution against using paracetamol alone for low back pain, they note that sciatica may respond to neuropathic drugs, such as gabapentin and epidural steroids.
Lara C. Pullen, PhD, is a medical writer based in the Chicago area.
- Bernstein IA, Malik Q, Carville S, et al. Low back pain and sciatica: Summary of NICE guidance. BMJ. 2017 Jan 6;356:i6748. doi: 10.1136/bmj.i6748.