Early management of persistent nonspecific low backpain

ntroduction

This guideline covers the early treatment and management of persistent or recurrent low back pain, defined as non-specific low back pain that has lasted for more than 6 weeks, but for less than 12 months. It does not address the management of severe disabling low back pain that has lasted over 12 months.上海仁济医院疼痛科王祥瑞

Non-specific low back pain is tension, soreness and/or stiffness in the lower back region for which it is not possible to identify a specific cause of the pain. Several structures in the back, including the joints, discs and connective tissues, may contribute to symptoms.

The lower back is commonly defined as the area between the bottom of the rib cage and the buttock creases. Some people with non-specific low back pain may also feel pain in their upper legs, but the low back pain usually predominates.

A clinician who suspects that there is a specific cause for their patient"s low back pain (see box 1) should arrange the relevant investigations. However, the diagnosis of specific causes of low back pain is beyond the remit of this guideline.

Box 1 Specific causes of low back pain (not covered in this guideline)

Malignancy

Infection

Fracture

Ankylosing spondylitis and other inflammatory disorders

The management of the following conditions is not covered by this guideline:

• radicular pain resulting from nerve root compression
• cauda equina syndrome (this should be treated as a surgical emergency requiring immediate referral).

Low back pain is a common disorder, affecting around one-third of the UK adult population each year. Around 20% of people with low back pain (that is, 1 in 15 of the population) will consult their GP about it.

There is a generally accepted approach to the management of back pain of less than 6 weeks" duration. What has been less clear is how low back pain should be managed in people whose pain and disability has lasted more than 6 weeks. Appropriate management has the potential to reduce the number of people with disabling long-term back pain, and so reduce the personal, social and economic impact of low back pain.

A key focus is helping people with persistent non-specific low back pain to self-manage their condition. Providing advice and information is an important part of this. The aim of the recommended treatments and management strategies is to reduce the pain and its impact on the person"s day-to-day life, even if the pain cannot be cured completely.

The guideline will assume that prescribers will use a drug"s summary of product characteristics to inform their decisions for individual patients. This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use (see section 1.8).

Patient-centred care

This guideline offers best practice advice on the care of people with non-specific low back pain.

Treatment and care should take into account patients" needs and preferences. People with non-specific low back pain should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If patients do not have the capacity to make decisions, healthcare professionals should follow the Department of Health guidelines ? "Reference guide to consent for examination or treatment" (2001) (available from www.dh.gov.uk). Healthcare professionals should also follow the code of practice that accompanies the Mental Capacity Act (summary available from www.publicguardian.gov.uk).

Good communication between healthcare professionals and patients is essential. It should be supported by evidence-based written information tailored to the patient"s needs. Treatment and care, and the information patients are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.

If the patient agrees, families and carers should have the opportunity to be involved in decisions about treatment and care.

Families and carers should also be given the information and support they need.

Key priorities for implementation

Information, education and patient preferences

• Provide people with advice and information to promote self-management of their low back pain.
• Offer one of the following treatment options, taking into account patient preference: an exercise programme (see section 1.3.3), a course of manual therapy (see section 1.4.1) or a course of acupuncture (see section 1.6.1). Consider offering another of these options if the chosen treatment does not result in satisfactory improvement.

Physical activity and exercise

• Consider offering a structured exercise programme tailored to the person:
  • This should comprise up to a maximum of eight sessions over a period of up to 12 weeks.
  • Offer a group supervised exercise programme, in a group of up to 10 people.
  • A one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.

Manual therapy ^[1]

• Consider offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks.

Invasive procedures

• Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of up to 12 weeks.
• Do not offer injections of therapeutic substances into the back for non-specific low back pain.

Combined physical and psychological treatment programme

• Consider referral for a combined physical and psychological treatment programme, comprising around 100 hours over a maximum of 8 weeks, for people who:
  • have received at least one less intensive treatment (see section 1.2.5) and
  • have high disability and/or significant psychological distress.

Assessment and imaging

• Do not offer X-ray of the lumbar spine for the management of non-specific low back pain.
• Only offer an MRI scan for non-specific low back pain within the context of a referral for an opinion on spinal fusion (see section 1.9).

Referral for surgery

• Consider referral for an opinion on spinal fusion for people who:
  • have completed an optimal package of care, including a combined physical and psychological treatment programme (see section 1.7) and
  • still have severe non-specific low back pain for which they would consider surgery.