Guidelines for the management of Low Back Pain - NICE 2009

 

Early management of persistent non-specific low back pain is important.

This paper highlights the care and treatment that people who have persistent non-specific low back pain can expect from the NHS in England and Wales, to help them manage their pain. It explains guidance (advice) from NICE (the National Institute for Health and Clinical Excellence). It is written for people with non-specific low back pain, but it may also be useful for their families or carers or for anyone with an interest in the condition.
 
‘Non-specific’ low back pain is caused by problems with structures in the back, such as the joints, discs, muscles, tendons and ligaments. This type of back pain is not caused by cancer, infection, a fracture or an inflammatory disorder – these conditions are responsible for only a very few cases of persistent low back pain.
The NICE guideline defines ‘persistent’ low back pain as pain that has lasted for longer than 6 weeks but less than a year.

It can be difficult to completely cure non-specific low back pain, and treatments are usually aimed at helping people manage their condition.
This information is to help you understand the care and treatment options that should be available in the NHS. It does not describe low back pain or the tests or treatments for it in detail. A member of your healthcare team should discuss these with you. There are examples of questions you could ask..
 
The advice in the NICE guideline covers:
Adults (aged 18 or older) who have had non-specific low back pain, with or without pain in the upper leg (above the knee), for between 6 weeks and 12 months.

It does not look at:
Back pain that is caused by any of the following:
– Problems with the bones of the spine (vertebrae), such as a fracture
– Specific diseases or conditions that affect the spine, such as cancer, infections or inflammatory disorders (these specific conditions are all rare).
– Conditions that affect the nervous system, including cauda equina syndrome (compression of the spinal cord, which can cause problems such as loss of bowel or bladder control).
- Pain caused by the irritation or compression of nerves and that mainly affects the legs.
-Low back pain in people under 18 years of age.
- ‘Acute’ low back pain – that is, back pain that has been present for less than 6 weeks.
.- Low back pain that has lasted longer than a year.
 
Your care
Your treatment and care should take into account your personal needs and preferences, and you have the right to be fully informed and to make decisions in partnership with your healthcare team. To help with this, your healthcare team should give you information you can understand and that is relevant to your circumstances. All healthcare professionals should treat you with respect, sensitivity and understanding, and explain low back pain and the treatments for it simply and clearly.
The information you get from your healthcare team should include details of the possible benefits and risks of particular treatments. You can ask any questions you want to, and can always change your mind as your treatment progresses, or your condition or circumstances change. Your own preference for a particular treatment is important and your healthcare team should support your choice of treatment wherever possible.

Your treatment and care, and the information you are given about it, should take account of any religious, ethnic or cultural needs you may have. It should also take into account any additional factors, such as physical or learning disabilities, sight or hearing problems, or difficulties with reading or speaking English. Your healthcare team should be able to arrange an interpreter or an advocate (someone who supports you in putting across your views) if needed.

If you agree, your family and carers should have the chance to be involved in decisions about your care. Family members and carers also have the right to the information and support they need in their roles as carers.

If people are unable to understand a particular issue or are not able to make decisions for themselves, healthcare professionals should follow the advice that the Department of Health has produced about this. You can find this by going to the Department of Health website (www.dh.gov.uk/consent). Your healthcare professional should also follow the code of practice for the Mental Capacity Act. For more information about this, visit www.publicguardian.gov.uk

What is non-specific low back pain?
Low back pain is soreness or stiffness in the back, between the bottom of the rib cage and the top of the legs. Most people’s low back pain is described as 'non-specific', meaning that it is caused by problems with structures in the back, rather than by rare conditions such as cancer, infection, a fracture or an inflammatory disorder.
Non-specific low back pain is very common – in the UK, around 8 out of every 10 people are affected by it at some time in their lives. Fortunately, most people find that their back pain goes away in a few days or weeks. However, in a small number of people the pain lasts a long time and/or is severe. This can be distressing and have wide-ranging effects. Pain may affect your mood, daily activities, sleep and ability to work.

The NICE guideline is about managing non-specific low back pain that has lasted for between 6 weeks and a year (defined in the guideline as 'persistent' low back pain). This can include back pain that gets better for a while, but then comes back again. The guideline describes treatments that you may be offered to improve your back pain, so that it has less effect on your day-to-day life
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The various types of treatment described in this paper may be provided by a range of healthcare professionals who specialise in different treatments. These could include Doctors, Physiotherapists, Osteopaths, Chiropractors, Psychologists and Acupuncturists. All of these practitioners will be professionally trained and experienced in providing the particular treatment.
 
Advice and assessment
When you consult your doctor, he or she will first make sure that your low back pain isn’t caused by cancer, a fracture, an infection or an inflammatory disorder (these are rare causes of low back pain).
Your doctor will talk with you about your low back pain, and will offer you advice on what you can do to reduce the effects of the pain. You should be offered information in the form of leaflets or other materials.

Your doctor should discuss with you the various treatments that can be helpful in managing low back pain. Deciding what treatment to try should take account of your own preferences and expectations. However, you might want to bear in mind that people sometimes find that they respond well to treatments that they thought would not be helpful.

Physical activity and exercise
If you have low back pain, you should be advised to be physically active, including carrying on with your normal activities as much as possible, and to exercise.
You should be offered the opportunity to go to a group exercise class.

Assessment
You should not be offered an X-ray of your spine if you have non-specific low back pain. There isn’t any evidence that X-rays are useful in improving care for people with non-specific back pain, and it is advisable to avoid unnecessary X-rays.
You also should not be offered a type of scan called MRI (magnetic resonance imaging) unless:
• Your doctor thinks that there might be a specific cause of your back pain, such as a fracture, cancer or infection or
• You are being referred for possible spinal fusion.
Questions you might like to ask your doctor
• What can I do to improve my low back pain?
• How can I reduce the effects of my low back pain on my daily life?
• Why isn’t it a good idea to stay in bed and rest?
• Why is it important to continue with my normal activities as far as possible?
• Should I carry on working?
• Can you give me any leaflets or other information that I can take away?
• Are there any support organisations in my local area?

Painkillers
Your doctor can advise you on which painkillers may help to ease your low back pain.
The NICE guideline recommends paracetamol as the first painkiller that you should try.
If regular paracetamol isn’t providing enough pain relief, your doctor may offer you:
• a type of drug called an NSAID (‘non-steroidal anti-inflammatory drug’), which reduces inflammation or:-
• a weak opioid, which is a stronger painkiller than paracetamol.
Your doctor should talk with you about which is the best option for you. This will depend on the possible side effects of the drugs, whether you have had any problems with them in the past, and your own preference. It is possible that you may be offered both types of painkillers.

Your doctor will also discuss with you how long you should continue taking painkillers. This will depend on whether the painkiller has helped you and whether you have experienced any side effects.
Non steroidal anyi-inflammatory drugs (NSAIDs)
Your doctor should advise you about whether you are at increased risk of side effects from these.
NSAIDs can sometimes irritate the stomach and gut, and may cause bleeding. This is more common in older people. So, if you are over 45, you should usually be offered a type of drug called a proton pump inhibitor if you are taking an NSAID, to help avoid this problem.
Opioids - If your low back pain is very bad, your doctor may offer you a strong opioid as a painkiller. Strong opioids can usually only be taken for a short time because they can be habit-forming. If there is a possibility that you may need to use strong opioids for longer, your doctor may refer you to a specialist.

Tricyclic antidepressants for treating pain- Drugs called tricyclic antidepressants are sometimes offered to people with low back pain because they work as painkillers. This is separate from their action in treating depression.
You may be offered a tricyclic antidepressant if other painkillers aren’t giving enough pain relief. The dose should be low to begin with, and may be increased if necessary to improve pain relief.
You should not be offered a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI) for treating low back pain.

Questions you might like to ask about medication:-
• What painkillers can you give me to help with my low back pain?
• If a particular painkiller isn’t helping much, can I try another one?
• How long should I take the medication for?
• What are the possible side effects of the different painkillers? What should I do if I experience these side effects?
• Why are you giving me an antidepressant for my back pain?
• Will taking a painkiller put me at further risk of damaging my back, by reducing or masking the pain so that I might overdo physical activity or exercise?
 
Treatments for low back pain
There are a number of possible treatments that may help you to manage your low back pain.
Choice of treatments:-
Your doctor should offer you a choice of one of the following treatment options:
• An exercise class that is appropriate for your particular needs.
• A course of manual therapy, which will include manipulation of the spine.
• A course of acupuncture.
Your doctor may offer you another of these options if the chosen treatment doesn’t result in much improvement in your back pain.

Exercise class
If you choose an exercise class, this should involve up to 8 sessions over a period of up to 12 weeks. It will usually be a group class of up to 10 people that is supervised by an appropriately qualified exercise instructor. You might be offered a one-to-one exercise class if a group class is not suitable for you.
The classes may include exercises to strengthen your muscles and improve your posture, as well as aerobic and stretching exercises.
 
Manual therapy
If you choose a course of manual therapy, this should include up to 9 sessions over a period of up to 12 weeks.
There are a number of different types of manual therapy, including manipulation, mobilisation and massage. Mobilisation and massage are performed by a wide variety of healthcare practitioners. Manipulation can be performed by Chiropractors and Osteopaths, as well as by specially trained Doctors and Physiotherapists.

Acupuncture
If you choose a course of Acupuncture, this should include up to 10 sessions over a period of up to 12 weeks.
Acupuncture is a technique used by a wide variety of healthcare practitioners, including specially trained Doctors, Nurses and Physiotherapists, as well as Osteopaths, Chiropractors and specialist Acupuncturists. It involves inserting fine, solid needles at different points in the body. This can help to reduce low back pain.
 
Combined therapy

You may be offered intensive treatment that includes both exercise and psychological treatment if:
• You have tried one or more of the treatments listed above.
• Your low back pain is causing you a lot of distress and/or seriously affecting your ability to work and carry out your daily activities.
This combined programme will involve around 100 hours of therapy over a period of up to 8 weeks.

Questions you might like to ask about treatments:-
• Why have you decided to offer me this particular type of treatment?
• What are the pros and cons of having this treatment?
• What will manual therapy involve?
• What will acupuncture involve?
• What will the combined physical and psychological treatment involve, and why does it take so much time?
• How can a psychologist help with back pain?
• Who will I see for the treatment, and where will I go?
• How will the treatment help me? What sort of improvements might I expect?
• How long will it take to have an effect?
• What are the possible risks associated with these treatments?
Treatments you should not be offered
You should not be offered any of the following treatments (which are not described in this booklet) on the NHS, because there is little evidence that they help in managing non-specific low back pain:
• Laser therapy.
• Interferential therapy.
• Therapeutic ultrasound.
• TENS (transcutaneous electrical nerve simulation).
• Lumbar supports.
• Traction.
• Injections into your back.
 
Surgery for low back pain
Surgery is only rarely suitable for people with non-specific low back pain. There is currently little evidence that any procedures, except for an operation called spinal fusion, are effective in reducing pain.

Spinal fusion
Spinal fusion is appropriate only for a very small number of people with low back pain. However, your doctor may refer you to a specialist for an opinion on whether you might benefit from spinal fusion if:
• You have already had combined therapy that includes both exercise and psychological treatment and:-
• Your low back pain is persistent and severe and
• You would consider surgery.
If your low back pain is causing you a lot of distress, you should be offered treatment for your distress before you are referred for an opinion on whether spinal fusion is suitable for you.
You may be offered an MRI scan if you are referred for a specialist opinion on whether you might be helped by spinal fusion surgery. This will help to identify whether you are likely to benefit from the operation.

Questions you might like to ask about spinal fusion surgery
• Might spinal fusion surgery be suitable for me?
• What does it involve?
• What are the risks and benefits?
• Is there a chance that it won’t work? What will happen if this is the case?
• How long will I have to stay in hospital?
• When will I be able to go back to work?

Other procedures
There are some procedures  that you should not be offered for treating non-specific low back pain on the NHS, because there is little evidence that they help. These are called:
• Intradiscal electrothermal therapy (IDET).
• Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT).
• Radiofrequency facet joint denervation.
 
Explanation of medical terms
Acupuncture
- A type of therapy that involves inserting solid needles into any part of the body to prevent or treat disease, or to maintain health.
Exercise - Exercise programmes for treating low back pain may include aerobic and stretching exercises, movement instruction and exercises to strengthen muscles and improve posture.
Manual therapy - A general term for therapies that involve manipulation, massage and mobilisation of soft tissues and joints. It can be provided by a doctor, Chiropractor, Osteopath or Physiotherapist.
MRI (magnetic resonance imaging) -  A type of scan that uses a strong magnetic field and radio waves to produce detailed pictures of the inside of the body.
‘Non-specific’ low back pain - Soreness or stiffness in the back, between the bottom of the rib cage and the top of the legs. It is caused by problems with structures in the back, such as joints, discs, muscles, tendons and ligaments. It isn’t caused by rare conditions such as cancer, infection, a fracture or an inflammatory disorder.
NSAID (non-steroidal anti-inflammatory drug) - A type of drug that reduces inflammation and pain. Examples include diclofenac, ibuprofen and naproxen.
Opioid - A type of painkiller used for moderate to severe pain. Examples of weak opioids include codeine and dihydrocodeine. Examples of strong opioids include buprenorphine, diamorphine, fentanyl and oxycodone.
‘Persistent’ low back pain - In the NICE guideline, persistent low back pain is defined as having lasted for more than 6 weeks but less than a year.
Proton pump inhibitor - A type of drug that reduces the production of acid in the stomach, and is used to treat indigestion and stomach ulcers. Examples include omeprazole and lansoprazole.
Psychological treatment - A general term for a range of ‘talking’ therapies. There are several different broad approaches, including cognitive behavioural therapy (CBT), which is based on how a person’s thoughts, beliefs, behaviour and physical symptoms all fit together.
Spinal fusion - An operation in which two or more bones in the spine (vertebrae) are fused together using either bone grafts or metal rods.
Tricyclic antidepressant (TCA) - A type of drug that can be used to treat back pain – this use is different from its action in treating depression. Examples include amitriptyline and imipramine.
 
More information
The organisation below can provide more information and support for people with low back pain.
BackCare, 0845 130 2704
www.backcare.org.uk
NHS Choices (www.nhs.uk) may be a good place to find out more. Your local patient advice and liaison service (usually known as 'PALS') may be able to give you more information and support. You should also contact PALS if you are unhappy with the treatment you are offered, but you should talk about your care with a member of your healthcare team first. If your local PALS is not able to help you, they should refer you to your local independent complaints advocacy service. If you live in Wales you should speak to NHS Direct Wales for more information on who to contact.
About NICE
NICE produces guidance (advice) for the NHS about preventing, diagnosing and treating medical conditions. The guidance is written by independent experts including healthcare professionals and people representing patients and carers. They consider the evidence on the condition and treatments, the views of patients and carers and the experiences of doctors, nurses and other healthcare professionals. Staff working in the NHS are expected to follow this guidance.
To find out more about NICE, its work and how it reaches decisions, see www.nice.org.uk/aboutguidance
This booklet and other versions of the guideline aimed at healthcare professionals are available at www.nice.org.uk/CG88
You can order printed copies of this booklet from NICE publications (phone 0845 003 7783 or email publications@nice.org.uk and quote reference N1866). The NICE website has a screen reader service called Browsealoud, which allows you to listen to our guidance. Click on the Browsealoud logo on the NICE website to use this service.
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National Institute for Health and Clinical Excellence
MidCity Place, 71 High Holborn, London, WC1V 6NA; www.nice.org.uk
ISBN 1-84629-966-7
N1866 20k 1P May 09


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