Friday, May 29, 2009

A NICE approach to treating low back pain

NICE which is the UK's National Institute for Clinical Excellence has just released guidelines for treating low back pain (LBP).

The first recommendation is to promote self-management. This means to suggest to patients with LBP to exercise and try to continuing doing ones normal activity, as possible. The next one is pain medication - first acetaminophen. The final recommendation is exercise or manual therapy (i.e. spinal manipulation) or acupuncture.

Another interesting feature is what the guidelines proscribe. All of the following are treatments/diagnostic tests that are NOT allowed (because they either don't work or aren't needed):
Medical/Surgical treatments
  • SSRIs for pain management
  • Facet injections
  • Radiofrequency facet joint denervation
  • IDET (Intradiscal Electrothermal Annuloplasty)
  • PIRFT (Percutaneous Intradiscal Radiofrequency Thermocoagulation)
Physical therapy
  • Laser therapy (AKA Cold Laser)
  • Interferential electrical stimulation
  • Therapeutic ultrasound
  • TENS (another kind of electical stimulation)
  • Lumbar supports or belts - back braces
  • Traction
Diagnostic tests
  • Plain film x-ray under any circumstances
  • MRI to be offered only to rule out red flags or for surgical referral
    • I think of an MRI for a a back pain patient, a road map for a surgeon. Keep that in mind if you are pushing your doctor to get one.
    • Red Flags are signs of:
    • Spinal cancer
    • Cauda equina syndrome
    • Infection
    • Ankylosing spondylitis or another inflammatory disorder
    • Fracture
Of course as I noted in previous blogs, it is likely that your health care provider will ignore these recommendations and do what they have always done, even if the scientific evidence is that it is not effective.

These new guidelines are is not particularly new but nice to see.


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