New NICE Guidelines for Early Management of Non-specific Low Back Pain
Non-specific low back pan which persists for some time is a common presentation for various health care practitioners to deal with, representing a major reason for absence from work due to sickness. Research has moved ahead quickly over the last decade, making a scientific view of assessment and treatment recommendations possible which could lead to predictable benefits for patients with persistent low back pain. The National Institute for Clinical Excellence (NICE) has just released a new set of guidelines in May 2009.
The first thing is to make a clear diagnosis of the low back pain. In non-specific low back pain the source may not be found but various diagnoses have to be ruled out, including tumours, infections, fractures, ankylosing spondylitis or other arthritic diseases. Reassessment of the potential diagnosis should be kept in mind as time progresses, and if a specific diagnosis is suspected at any time then investigations should be requested. Nerve root compression, often referred to as sciatica, can cause radicular pain in the leg and cauda equina syndrome can cause very severe pain and important symptoms. These conditions need surgical consultation.
Clinicians and researchers have classified low back pain into three categories, acute back pain, sub-acute back pain and chronic back pain. If the back pain has lasted for less than six weeks it is said to be acute, if it lasts from six to twelve weeks it is sub-acute and if it continues after the twelve week point it is said to be chronic. This system of back pain classification is only partly useful as its rigid boundaries often do not correspond to the persistence and variability of back pain as people typically experience it.
In the UK adult population around a third are thought to suffer from an episode of low back pain every year. Of this number around a fifth of sufferers will attend their GP to seek help for their back pain. Research has shown that it persists for a long period with 62% of sufferers still having pain at one year after the onset. Patients who are unable to work due to their back pain episode have a 16% probability of still being off work due to back pain after a year. The disability and pain improves rapidly over the first month but with little more after three months.
The cost to society of back pain problems is high but modern figures are not available, with the UK market having a large expenditure on private therapists as well as NHS costs, including private physiotherapists, acupuncturists, chiropractors and osteopaths. When someone develops an exacerbation of their back pain or a new episode it is crucial to exclude non-mechanical causes. Older people are more susceptible to malignancies as is anyone with a history of cancer types with are known to spread to bone. A compromised immune system should raise the suspicion that infection is a possibility. Osteoporotic fractures are more common in those on oral steroids and in older people.
The risks of having low back pain which continues beyond six weeks and towards a year is that it will develop into significant back-related disability, high pain levels and a loss of the ability to work. These factors should be addressed to increase the chances of a good result. High levels of distress of a psychological nature, significant disability and reported high pain levels all indicate an increased risk of a poor outcome. Therapies for back pain are extremely varied and numerous although little solid evidence to back up any claims is available to guide the choice of one or another. NICE has decided to concentrate on the whole package of caring for this condition, applicable to many professional groups, rather than specific treatments.
Typical interventions for the management of low back pain include:
Psychological therapies such as a form of cognitive behavioural therapy, mindfulness and self-management.
Non-invasive physical therapies such as transcutaneous electrical nerve stimulation, traction, spinal corsets, interferential, laser and ultrasound.
Education for patients such as group sessions, written explanatory material and individual instruction from therapists.
Manual techniques such as mobilisations, massage and manipulation.
Psychological management involves self management, mindfulness and different types of cognitive behavioural therapy.