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Controversy over NICE back pain guidelines

By Nigel Praities

NICE has controversially promoted spinal manipulation to a first-line treatment for low back pain despite doubts over the evidence and concerns it could be unsafe.

Draft guidance issued jointly with the RCGP advises GPs consider a number of non-pharmacological treatments for back pain alongside drug treatment, including manual therapies such as spinal manipulation, acupuncture or exercise programmes.

It replaces previous RCGP guidelines recommending GPs should only consider manipulation in patients who needed added help after initial drug treatment.

But the recommendation has proved contentious, with a systematic review last year by complementary medicine expert Professor Edzard Ernst finding spinal manipulation was associated with serious side-effects including stroke or even death.

Professor Ernst, professor of complementary medicine at Peninsula Medical School in Exeter, insisted other physical treatment options should have been recommended above spinal manipulation. ‘The evidence for spinal manipulation isn't strong. I would prefer exercise classes because they are far less risky and involve far less cost.'

Dr Louise Warburton, a musculoskeletal GPSI who works in Shropshire, said the guidance was confusing in conflating manual therapy and spinal manipulation, which would only work in a small majority of patients.

‘Manual therapy just means physiotherapy or chiropractic therapy. Spinal manipulation would be reserved for a small proportion of patients who had mal-alignments or hypo-mobility of one or more spinal segments. It wouldn't work for everyone,' she said.

But other experts have vigorously defended the guidance. Dr Nefyn Williams, a clinical senior lecturer in general practice and a GP in Llanfairfechan, Wales, said he was delighted spinal manipulation was included.

‘Hallelujah. Spinal manipulation only has a small to moderate effect compared with standard care, but has important psychological benefits,' he said.

Dr Williams said there were not many comparative trials for non-pharmacological therapies and this explained the range of non-pharmacological options recommended by NICE.

As Pulse revealed in August, the guideline development group considered new evidence on the benefits for the Alexander technique, but while regarding the trial as ‘well conducted with a low risk of bias' it did not include the treatment in the final recommendations.

Drug treatment recommended by NICE includes paracetamol as the first option for back pain, followed by NSAIDs or tricyclic depressants. The guidelines also go further than previous RCGP guidance, by specifically recommending opiods for patients with severe pain.

A consultation on the draft guidance is open until the 26 November.

Back pain guidance

- Advise all patients to maintain a physically active lifestyle
- Paracetamol is the first medication option, consider NSAIDs for short-term use if ineffective. If using NSAIDs or COX-2 inhibitors then also co-prescribe a PPI
- Also consider tricyclics depressants or opiods for severe pain
- Consider on-pharmacological therapies, such as a course of manual therapy, including spinal manipulation, acupuncture, structured exercise programmes or supervised group exercise programmes

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