It must be really difficult to be a reductionist, biomedically-oriented doctor who believes fervently in the need to ‘abolish pain’ in order for people to recover from low back pain. It must be even more difficult when the ‘source of the nociception’ fails to be identified even after numerous placebo-controlled ‘diagnostic’ nerve blocks have been carried out.
For those people who follow guideline-based approaches to managing health problems, the latest NICE guideline probably won’t be much of a surprise. The National Institute for Health and Clinical Excellence (NICE) guideline for low back pain has been published, and along with the recently published American Pain Society guidelines for low back pain management, fails to mention ‘diagnosis’ – instead it focuses on ‘ways improve the early treatment and management of persistent or recurrent low back pain, which is defined as non-specific low back pain that has lasted for more than six weeks but for less than a year.’
Cutting to the chase, these guidelines continue the approach recommended for acute low back pain – good analgesia, maintaining activity, reassurance – oh and not too many diagnostic procedures, because the results simply don’t seem to pan out. What I mean by this is the numbers needed to treat to reach a ‘good’ outcome don’t add up.
The new guideline by NICE suggests ‘… a key focus should be helping people with persistent non-specific low back pain to self-manage their condition, which starts with providing them with advice and information. They should also be offered a structured exercise programme tailored to the individual patient; manual therapy, including spinal manipulation and massage; or a course of acupuncture needling, depending on the patient’s preference.’ My emphasis on ‘self manage’. What does that mean? For most people, it simply means gradually increasing activity levels, using well-established and non-invasive medications and perhaps acupuncture (although I’m personally not strongly supportive of this, given the quality of the acupuncture studies) and for those who don’t respond so well: Patients who continue to have high levels of disability or notable psychological distress despite receiving at least one of the recommended initial treatment options should be considered for referral to a combined physical and psychological treatment programme, with about 100 hours over a maximum of eight weeks, the guideline advises. This should include a cognitive behavioural approach and exercise.’
The medications suggested are ‘regular paracetamol as the first option, moving to non-steroidal anti-inflammatory drugs or weak opioids or both if required. Tricyclic antidepressants should be considered if other drugs give insufficient pain relief, and strong opioids for short term use in people with severe pain.’ Nothing new here.
‘Referral for an opinion on spinal fusion should be considered only in people who have severe non-specific low back pain despite completing the recommended treatment. “Too many people have been referred to see a surgeon in the past, because GPs have had few other places to send patients with persistent low back pain,” suggested Professor Underwood. He added that only a small group of patients will benefit from surgery. Now the point about people being referred to see a surgeon because GP’s have had few other places to send patients is what I think New Zealand’s health care system should reflect on. While we have had great physiotherapy access, the model typically used has been passive ‘treatment’ without a clear focus on self management. And access to management that considers the ‘whole person’ ie a biopsychosocial model, is pretty slim.
I certainly don’t suggest that all people need to see a psychologist, but I do know that pain is a stressor, and that people find it difficult to manage things like their mood, their sleep and their relationships when they’re under strain. So clinicians who can address these things – let alone the beliefs about hurt vs harm that really contribute to high disability – need to be encouraged. I personally favour occupational therapists, physiotherapists, nurses and social workers to provide this practical approach to self management, rather than recruiting psychologists – most of whom in New Zealand have had little exposure to pain management.
Rather than looking to who should provide this input, I think this guideline is yet another one that emphasises self management rather than a simple ‘abolish the pain’ approach. Not only is low back pain commonplace, but many people will experience a re-occurrence (think to yourself: how many genuinely NEW, or acute cases of low back pain have you seen? Most people have had at least one previous episode before seeking treatment.). If it’s a fairly common disorder that recurs frequently, isn’t it time that medical treatment moved from the ‘abolish the pain’ stance and into modern management models where the person learns to self manage?
Low back pain: Early Management of Persistent Non-specific Low Back Pain (NICE clinical guideline 88) is available at www.nice.org.uk.
Mayor, S. (2009). NICE recommends early intensive management of persistent low back pain BMJ, 338 (may27 1) DOI: 10.1136/bmj.b2115