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NICE's back pain guidance is a pain in the...

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So, on the same day I finally get round to reading the NICE draft guidance on back pain, something ironic happens. No, ha ha, I don’t pop a disc. And a good job too, because if I had, and followed NICE’s advice, I’d have been stumped. Paracetamol is a no-no, apparently – though try telling that to the thousands who self-medicate – and if NSAIDs don’t help, it’s co-codamol, but that’s only for three days, of course, (says so on the box), so after that, you’re on your own, mate.

NICE has to realise that in back pain, our management will be a pragmatic compromise

No, the irony is that I read a survey demonstrating that a third of back pain sufferers feel their GP doesn’t take their problem seriously. As in, (I’m guessing here, but I know I’m right), not seriously enough to arrange an immediate X-ray or scan, and/or not seriously enough to be able to wave a magic wand over their symptoms.

So there we are, neatly between the rock of NICE saying there’s sod all you can do and the hard place of the public wanting us to do more. I’m all for EBM, but NICE has to realise that in something as common as back pain, unless we can educate the punters to stay away completely, our management will be a pragmatic compromise – because it’s not about the appliance of science, necessarily, it’s about keeping patients with bad backs off ours while we let nature do its thing. So it’s all very well NICE trying to justify narrowing our options, but the public wants them widened, at least by the time they’ve negotiated an appointment with us. Under these circumstances, withdrawing a standard painkiller from standard care sure won’t have us scoring any better in ‘How seriously does your GP take you?’ surveys.

Funnily enough, being between that rock and hard place really is playing my back up. I need to take something, so pass me that guidance, will you? Actually, don’t bother.

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield


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Readers' comments (6)

  • I thought the NICE back pain guidance was like a breath of fresh air. At last someone had the courage to say that it's an unsolved problem.

    In most cases there is no effective treatment. That should be obvious because if there were an effective treatment, it wouldn't be such a huge problem.

    One certainly has to sympathise with GPs who have to tell patients the bad news (or to disguise it, according to taste)/

    At least acuquacks are no longer an option.

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  • Hahaha 'acuquacks'.

    Acupuncture nuts to descend on this thread in 3....2....1.....

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  • Why not try a Maitlands or Mckenzie trained Chartered Physiotherapist? You'll probably have to pay as great shortage of specialist Chartered physios. Not only GPs but NHS physios often constrained by care pathways and time constraints to undertake adequate assessment, examination and treatment!

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  • Why not try .....
    Ask dr swinyard...small practices care and support

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  • Any nice advice on fibromyalgia

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  • Not true that you can't show patients you take them seriously without giving tablets. While letting nature take its course is exactly right it is useful to remember that it's the brain that decides whether one has pain. The two main predictors of developing chronic pain are fear avoidance and task persistence with vigilance, guarding and altered movement patterns underpinning the one and increasing peripheral and central sensitization underpinning the other. So a brief, good, hands on examination, some clear feedback about negative findings and advice about pacing activity might be just what the nice doctor can do! Additionally using a measure such as the STarT Back Tool to assess risk of chronicity and very early signposting to MDTs or CBT trained and supervised physiotherapists would be appropriate for those at high risk. A great resource is Peter O’Sullivans talk available at or YouTube “Back Pain – Separating fact from fiction” A real eye opener for patients. In short IMHO get doctors doctoring not acting as clinical pharmacists.

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder