- 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
Skip to [ Story Content and jump story attachments ]
Newsletter sign up
Advertisement
Advertisement
Advertisement
Advertisement
Advertisement
Advertisement
Advertisement
Main Page Content:
Controversy over NICE back pain guidelines
06 Oct 08
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Draft guidance issued jointly with the RCGP advises GPs consider a number of non-pharmacological treatments for back pain alongside drug treatment, including manual therapies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
-
Readers' comments
This article is poorly written. It is completely misleading to link spinal manipulation for low back pain and the possible risks of cervical manipulation leading to stroke and death. Can you explain what is 'a small majority of patients.? My view is that lumbar spinal manipulation has a clear role in some cases of low back pain but back pain is a symptom and not a diagnosis. Guidelines for treating symptoms and not diagnoses are bound to cause mixed opinions as no one treatment is correct for all causes of back pain.
Does paracetamol really help anyone unable to walk due to back pain? It certainly did not touch mine!
There is a great deal of evidence supporting the use of spinal manipulative therapy for mechanical back pain. I would urge anyone concerned about this to read the full draft guidelines in which issues such as effectiveness, safety and cost effectiveness are clearly addressed. It is true that not all treaments would be suitable for everyone but the recommendations allow for a package of care that could be adapted according to patient choice.
NICE has totally ignored the expert views of Pain Physicians and the wealth of literature about the usefulness, effectiveness and safety of injection techniques compared to complementary therapy and surgical procedures.
The most affected due to this guideline will be our patients. I request NICE to have a neutral evidence based approach when ever it brings out a guideline.
Ernst's paper deselects more recent statistically sound papers by its arbitary cut off date for paper selection. The minimal risk of manipulation is for cervical manipulation and if your author looks closely they will see that the guideline is for back pain not neck pain. Manual therapy is not just a quick manipulation. Osteopaths etc provide the full mix of intervention, information, advice, exercise, massage, often dry needle acupuncture and some manipulation. They provide a non-medicalised experience that keeps patients out of the GP surgery and out of the sick role. It's cheap, the capital costs are included in the treatment price, it's better than 'standard care', it's safe, patients like it, they feel empowered, there's not much wait. So what else can I say? Please read the full guideline if you want to get interested in this.