Nice guidelines for back pain draw criticism from sceptics

cartoon Chiropractic has been been the recommended for the management of back pain in Denmark for over 15 years, in Cuba acupuncture is usually the primary intervention, the blockade forbids American chiropractors to go to Cuba, some Europeans like myself have worked with great success in their health system. I was seeing twelve patients an hour, it does not take long to get a stiff spinal joint moving again.

The NICE guidelines are hardly rocket science, but it will be interesting how many NHS trusts will implement them and start commissioning chiropractic services. Now the chiropractic profession has been handed this ball will the drop it. There are many medics and pharmacologists with a vested interest ( highlighted by the House of Commons Health Committee in 2005) who are up in arms. A Pharmacology Professor David Colquhoun  who is very antagonistic towards any alternatives to orthodox medicine, has articulated these objections on his blog in two postings,Rawlins should withdraw guidance and start again Too many vested interests, not enough honesty

I think Professor Colquhoun can rest assured and stop whinging. Medical and pharmacological interests will dominate the commissioning process and I am sure pharmaceuticals will continue to account for 15% of the NHS budget and all those deaths from side effects. These are challenging times for drug safety professionals. In the USA, drug-related adverse reactions (ADRs) result in an estimated 100,000 deaths per year, and up to 5% of all hospitalisations involve some of the most widely prescribed drugs. Less than 10% of ADRs are currently reported back to the manufacturer or the regulatory authorities. This is the equivalent of three Jumbo plane crashes each week die from adverse reactions to pharmaceuticals  and no one is looking for those planes. In 15 years I have never even hurt one patient.

On top of this the General Chiropractic Council forbids registered chiropractors to criticise medical professionals for prescribing all these dangerous drugs. In recent years the chiropractors professional conduct committee was chaired by a former president of the Royal Pharmaceutical Society Linda Stone OBE. Chiropractors are constantly reminded that as long as they don’t criticise the biomedical approach to health care they wont have to pay VAT. I can speak out because I am not a registered chiropractor


New NICE guidelines to help millions of people with low back pain

Millions of people with low back pain will benefit from new guidance issued to the NHS on the most effective ways to treat this often painful and distressing condition.

The National Institute for Health and Clinical Excellence (NICE) and the National Clinical Guideline Centre today (Wednesday 27 May) publish a guideline to improve the early management of persistent non-specific low back pain. This covers people who have been in pain longer than six weeks but less than one year, where the pain may be linked to structures in the back such as the joints, muscles and ligaments. Setting out a range of effective mainstream and complementary treatments, the guideline recommends what care and advice the NHS should offer to people affected by low back pain.

Affecting around 1 in 3 adults in the UK each year, low back pain is a very common disorder, with an estimated 2.5 million people seeking help from their GP about their condition. For many people the pain goes away in days or weeks. However for some, the pain can be distressing and persist for a long time. It is difficult to ‘cure’ low back pain, but the treatments recommended in this guideline can reduce its effect on people’s lives.

Professor Peter Littlejohns, NICE Clinical and Public Health Director, said: “Most people will be affected by low back pain at some stage in their lives, so it’s good news that the NHS now has evidence-based guidance on how to treat the condition effectively. There is variation in current clinical practice, so this new NICE guideline means that for the first time we now have the means for a consistent national approach to managing low back pain. Importantly patients whose pain is not improving should have access to a choice of different therapies including acupuncture, structured exercise and manual therapy. The recommendations will enable health professionals to provide the best care and advice for people seeking help for low back pain, which should reduce the impact of the condition on patients’ day-to-day lives.”

Recommendations from the guideline for health professionals include:

• Advise people with low back pain that staying physically active as much as possible is likely to help and provide people with advice and information to help them manage their low back pain
• Offer one of the following treatment options, taking into account the patient’s preference: an exercise programme, a course of manual therapy including manipulation, or a course of acupuncture (more details on each below). Consider offering another of these options if the chosen treatment does not result in satisfactory improvement
• Consider offering a structured exercise programme tailored to the individual that may include exercises to strengthen muscles, improve posture and stretching
• Consider offering a course of manual therapy, including spinal manipulation, spinal mobilisation and massage. Treatment may be provided by a range of health professionals including chiropractors, osteopaths, manipulative physiotherapists or doctors who have had specialist training
• Consider offering a course of acupuncture needling, up to a maximum of 10 sessions over a period of up to 12 weeks
• Injections of therapeutic substances into the back for non-specific low back pain are not recommended
• Offer a combined intensive exercise and psychological treatment programme for people who have had at least one less intensive treatment already, but who still have disabling pain which causes significant distress or seriously impacts on daily life
• Do not offer X-ray of the lumbar spine for the management of non-specific low back pain, and only offer an MRI scan within the context of a referral for an opinion on spinal fusion.

Professor Martin Underwood, Chair of the Guideline Development Group and GP, said: “This guideline heralds a sea-change in the treatment of low back pain. I am delighted that now, as a GP, I’ll be able to offer my patients a choice of therapies for persistent low back pain that have been shown to work. For those patients who don’t improve, I will be able to refer them for intensive treatment that will reduce the misery of living for years with disabling low back pain. Importantly, this guideline also gives doctors and other health professionals clear and consistent advice on how to help their patients with persistent back pain.”

Steve Vogel, Guideline Developer and NHS Osteopath, said: “Having been one of a small minority of osteopaths working in an NHS general practice for the last fifteen years, I am excited that many more of the millions of people who suffer from back pain can benefit from the sort of hands-on treatment I provide. The guideline recommendations combine giving advice about exercise and activity, with options including hands on treatment by osteopaths, chiropractors, manipulating physiotherapists and acupuncturists. This choice, alongside traditional pain treatments like paracetamol, is essential in enabling people to find something that works for them."

Dr Dries Hettinga, Head of Policy and Research at BackCare, and Patient Representative on the Guideline said: “This guideline is an important step forward in raising the standards of care for people with low back pain, and providing a choice of effective treatments. Fortunately most people with back pain recover within weeks without specialised treatments, but a significant group need a bit more help with their condition. This guideline is aimed at people who haven’t got better after six weeks, offering them a comprehensive treatment programme that should help prevent a long term problem from developing. This guideline will help patients understand what treatment and care can help them with their back pain, and shows that there can be a positive outlook for treating this condition.”

Elaine Buchanan, Guideline Developer and Consultant Physiotherapist said: “This guideline provides an essential opportunity for physiotherapists and other health professionals to ensure that people with low back pain benefit from evidence-based treatment. In addition to advice and medication, people who have back pain persisting beyond six weeks now have the choice of three effective treatments: acupuncture, exercise and manual therapy. The small number of people who continue to have problematic back pain following these therapies will have access to an intensive treatment programme, run by a team of specialists.

These programmes combine physical and cognitive behavioural approaches to help people maximise their quality of life, by teaching them skills and techniques which reduce the disability and distress caused by their condition.”

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