by Mark Elmes, Chartered Physiotherapist & Certified Strength & Conditioning Specialist @ McEntee Performance Physio
The National Institue for Health and Care Excellence (NICE) released an update of their guidelines for low back pain and sciatica in over 16s on the 30th November 2016. The institute was founded in 1999 to prevent variability in the quality and provision of treatment in the National Health Service (NHS) in England. In 2013 the group become a non-departmental body and began the development of guidelines with respect to managing a multitude of conditions across many disciplines. As we are essentially across the pond from the NHS, they are the most appropriate guidelines for us to follow. The group are rigorous in their reviews and assessments of the current evidence base for what we do and we like to stick by them. They are bulletproof! They are also very beneficial for sufferers of low back pain to understand. Therefore, we decided to run through it and break it down for some take home messages for you.
Back pain is a very common, normal and complex phenomenon. It is our job to determine whether your case is one of these instances or something that requires further attention. Please be aware that pain doesn’t mean damage in most cases but we do stress guidance and professional help is a good strategy to follow with the initial onset.
Stratification of Care
This means we will aim to delineate the most pertinent factors contributing to your pain and refer to other health professionals as required with your discretion. Stratified care like this improves outcomes for you and gets you back to normal faster (Foster et al, 2014). We believe in the Multi-Disciplinary Team (doctors, physios, radiology, psychologists, pain management etc) approach ensuring your care is targeted and individualised. It allows us to care for you as a person.
Imaging
Routine imaging is not recommended and potentially a hazardous procedure. Evidence shows that early MRI in back pain leads to prolonged issues and utilisation of medical services that may be unnecessary (Webster et al, 2014). This cascade of cost and service use was much more associated to the timing of the MRI rather than indicators of pain. We also know that “abnormal findings” on an MRI are common and normal processes of aging in people without any back pain at all (Brinjikji et al, 2015). We’re not saying an MRI is not helpful. What we’re saying is that it’s not the be all and end all. You are. Your symptoms, your physical capacity and your feelings are all just as relevant and should be considered. We are more than happy to discuss the use of MRI for you as an individual should you require physiotherapy.
Non-invasive Management
Here’s the bulletproof bit. In our book this is pretty black and white. NICE have looked at this thoroughly and given us clear information on what does work and what doesn’t…
Green Light
· Exercise
· Return-to-work programmes (pain does not necessarily mean further damage)
· advice and education for self-management (we want you out enjoying your life, not suffering on a plinth)
· Psychology (this is an essential component to your care)
Orange Light
· Manual Therapy – we stress this should only be used in conjunction with exercise and will not fix your back alone
Red Light
· Acupuncture is no longer considered effective
· Orthotics or Insoles
· Electrotherapy
· Supports or Braces
Pharmacology
This is not our area of expertise but we do know about it. We stress that some of the medication considered effective is only available on prescription and you should talk to your doctor about the same. Please do not be afraid to discuss the options with your doctor. Healthcare should be about shared decision making.
· Paracetemol alone is not effective
· The lowest dose of Non-Steroidal Anti-Inflammatories to reduce your pain should be your first port of call.
· Thereafter if unsuccessful it is recommended that you are prescribed weak opioids but only in acute (short-term) cases not chronic (long-term).
· Spinal Injections are not recommended as they are considered ineffective.
Invasive Management
Surgery
· Spinal decompression is a last resort for people with sciatica when conservative approaches fail. We will generally be able to tell by your assessment whether or not this may be needed and we’ll know very quick with management whether or not it is improving.
· Spinal fusion should not be offered unless part of a controlled trial
· Disc replacement should not be offered
Closing Remarks
Back pain is a very common, normal and complex phenomenon. It is our job to determine whether your case is one of these instances or something that requires further attention. We hope at the very least the above piece will encourage you to ask your healthcare provider a little more about the treatment they recommend. As we stated above healthcare is a shared decision making process and it is our job as professionals to sift through the fog and give you a clear picture.
References
Brinjikji W, Luetmer PH, Comstock B, et al (2015). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology, Vol: 36, pp. 811-816
Foster NE, Mullis R, Hill JC, et al (2014). Effect of Stratified Care for Low Back Pain in Family Practice (IMPaCT Back): A Prospective Population-Based Sequential Comparison. Annals of Family Medicine, Vol: 12(2), pp. 102-111
NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (NICE), 2016. Low back pain and sciatica in over 16s: assessment and management. London: NICE.
Webster BS, YoonSun Choi MA, Bauer AZ, et al (2014). The Cascade of Medical Services and Associated Longitudinal Costs Due to Nonadherent Magnetic Resonance Imaging for Low Back Pain. Spine, Vol: 39(7), pp. 1433-1440