The new NICE guidelines for the management of low back pain have been published. This article is going to look at what the guidelines say and part 2 will look at how the guideline applies to osteopaths.
The guidelines are now much simpler referring to just low back pain with or without sciatica and occasionally chronic or persistent low back pain.
Low back pain and sciatica in over 16s
First of all rule out any underlying conditions, refer if concerned.
Risk stratification is recommended to identify those likely to improve quickly, and those needing more complex or intensive support. How would you do this? Use a tool like the STarT Back Risk Assessment – it’s a really simple 9 question assessment tool developed by Keele University. Find out more here: https://www.keele.ac.uk/sbst/startbacktool/
Simple support à advice and guidance on self-management, keeping active and reassurance
Complex/intensive support à exercise and/or manual therapy and/or psychological approach
What should you do?
Self-management – information on the nature of low back pain and sciatica, encourage normal activities
Exercise – Group exercise according to preferences and capabilities – biomechanical, aerobic, mind-body
Manual Therapy – spinal manipulation, mobilisation or soft tissue techniques but only as part of a treatment package
Psychologial therapies – using CBT approach but only as package including exercise +/- manual therapy
Combined physical and psychological programmes – CBT approach in group taking into account person’s specific needs and capabilities for persistent low back pain or sciatica
- With psychosocial obstacles to recovery or previous treatments have not been effective
Return to work programmes – promote and facilitate return to activities
Oral NSAIDs +/- gastroprotective treatment – lowest dose for shortest time
Weak opioids (with or without paracetamol) if NSAID not tolerated, contraindicated or ineffective
What else might you consider?
Epidural – acute and severe sciatica not neurogenic claudication
N.B. BMI, smoking status or psychological distress must not influence decision to refer for surgical opinion.
What shouldn’t you do?
X imaging – not routinely, only use if it will change management
X lumbar belts
X foot orthoses
X rocker soles
X Manual therapy – no traction
X paracetamol alone
X routine opioids
X opioids for chronic low back pain
X Selective serotonin reuptake inhibitors
X tricyclic antidepressants
X spinal injections
X spinal fusion
X disc replacement
So, there is a clear list of what we should or should not be offering patients with low back pain. The next article will consider how the guidelines apply to osteopathic practice and some very important issues the guidelines highlight.