Low back pain

Implementing NICE guidance

2009

NICE clinical guideline 88

 What this presentation covers

Background
Scope
Key priorities for implementation
Pharmacological therapies
Non-pharmacological therapies
Costs and savings
Discussion
Find out more
 Background

Low back pain affects around one-third of the UK adult

population each year

Around 20% of people with low back pain will consult

their GP

Helping people to self-manage their low back pain and

return to their normal activities is a key focus
 Scope

This guideline covers the early treatment and

management of persistent or recurrent low back pain,
defined as non-specific low back pain that has lasted for
more than 6 weeks, but for less than 12 months

It does not cover the management of severe disabling

low back pain that has lasted over 12 months
 What is non-specific low back
pain?
Non-specific low back pain is defined in the
guideline as:
tension, soreness and/or stiffness in the lower
back region for which it isnt possible to identify a
specific cause of the pain
Specific causes of low back pain (not covered by
the guideline) include malignancy, infection,
fracture, and ankylosing spondylitis and other
inflammatory disorders
 Principles of management
Keep diagnosis under review at all times
AND
Promote self-management
AND
Offer drug treatments as appropriate
AND
Offer one of the treatment options listed on the next
slide consider offering another of these if
improvement is not satisfactory
 Information, education and
patient preferences
Provide people with advice and information to promote
self-management

Offer one of the following treatment options, taking

patient preference into account:
an exercise programme
a course of manual therapy
a course of acupuncture
If improvement is not satisfactory, consider offering
another of these
 Structured exercise programme

Consider offering a structured exercise programme:

up to 8 sessions over up to 12 weeks
supervised group exercise programme in a group of
up to 10 people, tailored to the person
one-to-one supervised exercise programme only if a
group programme is not suitable
 Manual therapy

Consider offering course of manual therapy:

including spinal manipulation
up to 9 sessions over up to 12 weeks

Manual therapy: a collective term that includes spinal

manipulation, spinal mobilisation and massage
 Invasive procedures

Consider offering a course of acupuncture needling

comprising up to a maximum of 10 sessions over a
period of up to 12 weeks.

Do not offer injections of therapeutic substances into

the back for non-specific low back pain.
 Combined physical and
psychological treatment
programme
Consider referral for combined physical and
psychological treatment for people who:
have received at least one less intensive treatment
and
have high disability and/or significant psychological
distress.
This treatment comprises around 100 hours over a
maximum of 8 weeks
 Assessment and imaging

Do not offer X-ray of the

lumbar spine

Only offer an MRI scan within

the context of a referral for an
opinion on spinal fusion
 Referral for surgery

Consider referral for an opinion on spinal fusion for

people who:
have completed an
optimal package
of care
and
would consider
surgery for their
low back pain.
 Pharmacological therapies

Advise regular paracetamol as the first option

Offer NSAIDs and/or weak opioids when paracetamol
alone is insufficient
Consider offering tricyclic antidepressants for pain relief
if other medications are insufficient
Consider offering strong opioids for severe pain
For all medications:
consider risks and side effects
base decisions on continuation on
individual response
 Non-pharmacological therapies

Do not offer
Laser therapy
Interferential therapy
Therapeutic ultrasound
TENS
Lumbar supports
Traction
 Costs per 100,000 population

Costs
Recommendations with significant costs ( per year)
Acupuncture 48,208
Manual therapy 31,575
Group combined physical and psychological treatment
programme 20,635

Exercise programme 1,708

Estimated cost of implementation 102,126
 Savings per 100,000 population
Savings
Recommendations with significant cost savings ( per year)

Reduction in injections of therapeutic substances into the

back 66,546
Reduction in MRI scans 23,389
Reduction in X-rays 2,732
Reduction in use of radiofrequency facet joint denervation 5,022
Reduction in other physical therapies 3,501
Estimated saving from implementation 101,190
 Discussion
How do local arrangements for imaging and
assessment compare with the guideline
recommendations?
How does local service provision for the exercise
programme compare with the guideline
recommendations?
What manual therapies are available locally and what
care pathways lead to their use?
How can patients access combined physical and
psychological treatment programmes locally?
 Find out more

Visit www.nice.org.uk/CG88 for:

the guideline
the quick reference guide
Understanding NICE guidance
costing report and template
audit support
factsheet for commissioners
patient information leaflet