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Low back pain

Low back pain. Implementing NICE guidance. 2009. NICE clinical guideline 88. What this presentation covers. Background Scope Key priorities for implementation Pharmacological therapies Non-pharmacological therapies Costs and savings Discussion Find out more. Background.

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Low back pain

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  1. Low back pain • Implementing NICE guidance • 2009 • NICE clinical guideline 88

  2. What this presentation covers • Background • Scope • Key priorities for implementation • Pharmacological therapies • Non-pharmacological therapies • Costs and savings • Discussion • Find out more

  3. Background • Low back pain affects around one-third of the UK adult population each year • Around 20% of people with low back pain will consult their GP • Helping people to self-manage their low back pain and return to their normal activities is a key focus

  4. Scope • 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 cover the management of severe disabling low back pain that has lasted over 12 months

  5. What is non-specific low back pain? • Non-specific low back pain is defined in the guideline as: • ‘tension, soreness and/or stiffness in the lower back region for which it isn’t possible to identify a specific cause of the pain’ • Specific causes of low back pain (not covered by the guideline) include malignancy, infection, fracture, and ankylosing spondylitis and other inflammatory disorders

  6. Principles of management • Keep diagnosis under review at all times • AND • Promote self-management • AND • Offer drug treatments as appropriate • AND • Offer one of the treatment options listed on the next slide  consider offering another of these if improvement is not satisfactory

  7. Information, education and patient preferences • Provide people with advice and information to promote self-management • Offer one of the following treatment options, taking patient preference into account: • an exercise programme • a course of manual therapy • a course of acupuncture • If improvement is not satisfactory, consider offering another of these

  8. Structured exercise programme • Consider offering a structured exercise programme: • up to 8 sessions over up to 12 weeks • supervised group exercise programme in a group of up to 10 people, tailored to the person • one-to-one supervised exercise programme only if a group programme is not suitable

  9. Manual therapy • Consider offering course of manual therapy: • including spinal manipulation • up to 9 sessions over up to 12 weeks • Manual therapy: a collective term that includes spinal manipulation, spinal mobilisation and massage

  10. 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.

  11. Combined physical and psychological treatment programme • Consider referral for combined physical and psychological treatment for people who: • have received at least one less intensive treatment • and • have high disability and/or significant psychological distress. • This treatment comprises around 100 hours over a maximum of 8 weeks

  12. Assessment and imaging • Do not offer X-ray of the lumbar spine • Only offer an MRI scan within the context of a referral for an opinion on spinal fusion

  13. Referral for surgery • Consider referral for an opinion on spinal fusion for people who: • have completed an optimal package of care • and • would consider surgery for their low back pain.

  14. Pharmacological therapies • Advise regular paracetamol as the first option • Offer NSAIDs and/or weak opioids when paracetamol alone is insufficient • Consider offering tricyclic antidepressants for pain relief if other medications are insufficient • Consider offering strong opioids for severe pain • For all medications: • consider risks and side effects • base decisions on continuation on individual response

  15. Non-pharmacological therapies • Do not offer • Laser therapy • Interferential therapy • Therapeutic ultrasound • TENS • Lumbar supports • Traction

  16. Costs per 100,000 population

  17. Savings per 100,000 population

  18. Discussion • How do local arrangements for imaging and assessment compare with the guideline recommendations? • How does local service provision for the exercise programme compare with the guidelinerecommendations? • What manual therapies are available locally and what care pathways lead to their use? • How can patients access combined physical and psychological treatment programmes locally?

  19. Find out more • Visit www.nice.org.uk/CG88 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing report and template • audit support • factsheet for commissioners • patient information leaflet

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