Q&A on Nice guidance for back pain

Many newspapers have reported that the NHS is now to offer acupuncture for back pain._ The Daily Telegraph_ said that people whose back pain has continued for more than six weeks but less than a year may be offered the option of 12 weeks of complementary therapy on the NHS, consisting of either exercise classes; manipulation sessions by a chiropractor, osteopath or physiotherapist; or acupuncture sessions. However, it warns that few people will have the choice of which of the three treatments they receive, due to a shortage of services.

This coverage is based on new NICE guidance for the early management of non-specific low back pain. Non-specific low back pain is tension, soreness and/or stiffness in the lower back region for which it isn’t possible to identify a specific cause.

Although many of the newspapers have focused on acupuncture, the guidelines cover all aspects for managing this condition. The key advice is that patients are encouraged to manage their back pain themselves, remain physically active and carry on with normal activities as much as possible. Acupuncture is one of several recommended treatments for back pain that has lasted for more than six weeks. Other recommended treatments include exercise programmes and manual therapy such as spinal manipulation.

What are the news reports based on?

The new guidance is on the early management of non-specific low back pain. The term non-specific means it does not have a known, definite cause such as slipped disc causing nerve root compression (for example, sciatica), inflammatory medical conditions (such as ankylosing spondylitis), infection, fracture, malignancy (cancer) or another condition that affects the spine.

This sort of back pain is often muscular and features aches, pain, stiffness and a limited ability to move the lower back. Occasionally, there is also pain in the upper legs, although this is not a predominant feature of non-specific back pain.

The guidance is from the National Institute for Clinical Excellence (NICE). This independent organisation uses the best available evidence to make national guidance and recommendations for medical professionals and healthcare providers on the best clinical practice, use of health technologies and public health issues.

What do the guidelines recommend?

Despite the focus of the news reports on complementary therapies, the guidelines cover all aspects for the management of non-specific back pain.

A key focus of the guidance is that patients are encouraged to manage their back pain themselves. NICE says that effective management is essential for relieving the disability and economic burden that back pain can have and also preventing it from becoming chronic, which can lead to considerable social and personal effects and loss of work. As such, it’s important to enable people to manage the condition themselves so they can continue with normal everyday life.

Healthcare professionals can do this by advising patients to remain physically active and to carry on with normal activities as much as possible. They are also advised to educate patients on the nature of non-specific low back pain.

If pain relief is required, paracetamol is considered the best option, followed by non-steroidal anti-inflammatory drugs (NSAIDs) or weak opioid drugs (for example, codeine).

When considering further treatment, healthcare professionals are advised to take into account patients' preferences. If the chosen treatment fails to improve the patient’s symptoms, another treatment should then be considered. The recommended treatments are:

*Physical activity
*Physical activity and exercise should involve a structured exercise programme tailored to the person. It should consist of up to a maximum of eight sessions over a 12-week period, and may be either a supervised group exercise programme (up to 10 people) or a one-to-one supervised exercise programme.

*Manual therapy
*Manual therapy, including spinal manipulation, mobilisation and massage, should be given by a trained practitioner over a maximum of nine sessions in a 12-week period.

*Acupuncture
*A course of acupuncture needling should involve a maximum of 10 sessions over a 12-week period (injections of therapeutic substances into the back are not advised).

What about more intensive treatments?

Patients should only be referred for combined physical and psychological treatment (100 hours of therapy over a maximum of eight weeks is recommended) when they have had at least one of the less intensive treatments and it has not been effective, or if they have significant disability or psychological distress.

Surgery (spinal fusion) should only be considered if a patient has completed an optimal course of care, including a combined physical and psychological treatment programme, and if their back pain is still so severe that they would consider surgery.

Are there treatments that should not be used?

In addition to advising that therapeutic substances should not be injected into the back, NICE recommends that several other non-medical therapies should not be carried out. These therapies include transcutaneous electrical nerve stimulation (TENS), lumbar supports, traction, laser, therapeutic ultrasound or interferential therapy.

X-ray of the lumbar spine is also not advised and any other imaging (MRI) should only be considered when the person with non-specific pain is being referred for consideration of surgery or when other pathology is suspected.

What is the evidence that these complementary therapies work?

These complementary treatments have limited evidence of benefit in some areas. However, NICE considered there to be insufficient evidence of no effect to rule against these treatments (that is, they could not say that they had no possible place in care). Each of the therapies had the following evidence:

Exercise
NICE found that there were no randomised controlled trials (RCTs) (which are the best way of investigating the efficacy of a treatment) that compared advice to maintain normal physical activity/general exercise levels with no advice or advice to rest.

There was one well conducted RCT (579 people) that investigated prescription to various types of exercise intervention in those who had been suffering back pain for more than three months. Results showed improvement in pain and disability scores at three months compared with the control group, and the intervention was still found to be effective at one year. Specifically, the ‘Alexander Technique’ of exercise is considered effective, although more costly than GP advice to exercise.

There was also evidence from a systematic review which found that a structured exercise programme is effective for improving function and reducing pain and disability (although these effects were small and the trials included variable exercise intensity).

There was no evidence that one-to-one exercise was better than group exercise.

*Manual therapy
*Several separate RCTs investigated the efficacy of manual therapy, including spinal manipulation. These studies found that such therapy had a modest effect on pain and disability and was at least equivalent to usual care and, therefore, may give symptom improvement when given in conjunction with usual care. The combination of spinal manipulation with exercise was the most cost-effective intervention in the studies.

One well conducted RCT was described as providing “weak” evidence of short-term pain relief from massage. There was no evidence that demonstrated any serious adverse effects of spinal manipulation for non-specific low back pain, although NICE emphasises that manipulation elsewhere in the spine other than the lumbo-pelvic region has not been investigated.

*Acupuncture
*For acupuncture, there were four RCTs and one systematic review. These studies had varied interventions, population groups and follow-up periods. The pooled analysis of these studies in the systematic review (314 people) suggested there was evidence of pain relief at short-term follow-up (up to three months) compared with sham acupuncture or no treatment. However, these effects were not evident at the long-term follow-up, and there was little observed effect on functional outcomes.

The first RCT found acupuncture gave pain-relief at one year compared with no acupuncture, but there was no difference compared with minimal acupuncture. The second RCT found similar results when it was compared with sham acupuncture at six months. The third RCT found pain improvement with acupuncture after two years compared with usual care and the fourth found improvement in pain, function and quality of life compared with no acupuncture.

Overall, evidence suggested an improvement in pain with acupuncture compared with usual care, but there was not much difference when compared with sham acupuncture. After looking at economics, short-term courses of acupuncture were considered to be cost effective, but more evidence on longer-term use is needed.

Are these complementary therapies cost effective?

NICE says that the complementary therapies of manipulation and massage, exercise and acupuncture are cost-effective alternatives to usual care. However, it does say there are cost implications when people do not respond to treatment and require multiple complementary treatments. NICE, therefore, recommends that further research is carried out to test the effectiveness of proceeding with another care option when the first chosen treatment has failed.

How can I get these treatments?

NICE guidance is effective as soon as it is published, and recommendations should be incorporated into current medical practice. People should go to their GP if they are suffering from low back pain. Provided other pathological causes of low back pain have been excluded, the GP may advise short-term pain-relief medications, continued activity (avoidance of bed-rest) and discuss with patients the use of these alternative treatments.

When considering whether a patient should be prescribed an exercise programme, manual therapy or acupuncture, healthcare professionals should take into account the patient’s preferences, previously tried treatments, the duration of their condition, specific features of the pain they experience and any other medical conditions.

Availability of some treatments through local services is likely to be patchy at present. Professor Martin Underwood, chair of the committee that created the guideline said, “In some areas, people will get quite good access to these facilities but in other areas they won't be available. In very few areas… patients will have the choice of these three options at the moment.”