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Exploring the NICE guidelines for low back pain

Margaret Flanagan
MSc BA (Hons) RGN ONC FETC
Nurse Clinician Western Avenue Medical Centre Chester

Low back pain is a common disorder affecting around one in three adults in the UK each year, with an estimated 2.5 million people seeking help from their GP or other primary healthcare professional. It represents a major cause of sickness absence from work and is exceeded only by mental health problems in the UK.

The National Institute for Health and Clinical Excellence (NICE) guideline for the early management of persistent non-specific low back pain, published in May 2009, recommends management for people who have been in pain for more than six weeks but less than a year, where the pain may be linked to structures in the back such as joints, muscles
and ligaments.1

The guidance sets out a range of effective mainstream and complimentary treatments, and recommends the care and advice that should be offered to people with low back pain.

Background
Why were the guidelines developed?
Previous evidence-based guidelines for the treatment of low back pain were published by the Royal College of General Practitioners over 10 years ago, so a further review of the evidence was overdue.
The recommendations for treatment of patients with low back pain were developed to:

  • Have a high impact on patient outcomes, especially pain, disability and psychological distress.
  • Have a high impact on reducing variation in the treatment offered to patients.
  • Lead to a more efficient use of NHS resources.

What does development of a guideline involve?

  • Working in accordance with a scope given by NICE.
  • Developing key clinical questions, which form a starting point for literature reviews.
  • Systematic literature searches.
  • Identification of evidence.
  • Critical appraisal of evidence.
  • Choice of outcomes.
  • Economic analysis.
  • Assigning levels to the evidence.
  • Forming recommendations.

Evidence is a key part of a guideline and healthcare as a whole (Table 1). In the field of back pain and its treatment there is a lack of evidence in many areas and to this end, the guideline development group made recommendations for research.1

[[Tab 1 back pain]]

Patient assessment and diagnosis
The most important consideration of the guideline is that the patient's diagnosis should be kept under review.

The initial diagnosis is made after a full assessment of the patient - many suitably trained and experienced nurses are now working as first point of contact clinicians in primary care, when assessment and diagnostic skills are paramount.

Historically, the nurse has been close to the patient as their advocate, providing them with a point of contact and a friendly ear if they run into problems. During the initial assessment it is important to exclude serious illness as the cause for back pain - malignancy, infection, fracture, ankylosing spondylitis and other inflammatory disorders - this is well within the remit of the primary care nurse.

Assessment of a patient presenting with back pain involves detailed history taking and examination, and it is essential that the examining clinician is aware of the anatomy and physiology of the spinal column.

The spine
The spine is composed of 33 vertebrae: seven cervical, 12 thoracic, five lumbar, five sacral (which are fused to form the sacrum) and four coccygeal (which are fused to form the coccyx).

The spinal cord runs from the base of the brain down the spinal canal with pairs of nerves leaving the cord at the levels of the vertebrae. The exception to this is the first cervical spinal nerve, which leaves the spinal cord above the first cervical vertebra - thus there are eight cervical spinal nerves.

Each spinal nerve supplies muscle (myotome) and skin (dermatome), and knowledge of the area supplied by each nerve enables the clinician to ascertain which nerve is affected by history taking and clinical examination.

Between the vertebrae are the intervertebral discs which act as shock absorbers and may prolapse, resulting in pressure on spinal nerves causing pain and paraesthesia in the legs. The whole of the spinal column is supported by muscles and ligaments and it is important to keep these strong and supple by regular exercise.

The consultation
Taking a history is vitally important when assessing a patient with back pain and the clinician must be aware of red flags:

  • Age less than 22 or over 55 at first presentation.
  • History of cancer, steroids or HIV.
  • Thoracic pain.
  • Unwell, weight loss.
  • Widespread neurology.
  • Structural deformity.
  • Persistent night pain.
  • Saddle anaesthesia or sphincter disturbance.

The NICE guideline is very clear about what is does not address and annotates certain conditions that require further assessment and investigation, some of which are discussed above. It also promotes patient choice and recommends providing information and advice to enable self-management of back pain.

Simple, non-specific back pain
Simple non-specific backache (which is the focus of the NICE guideline) normally presents with the following:

  • Presentation between ages 20-55.
  • Lumbosacral region, buttocks and thighs.
  • Pain mechanical in nature:
    - Varies with physical activity.
    - Varies with time.
  • Patient is well.
  • Prognosis is good.

Patient examination follows the "inspection, palpation, percussion" principles, although in orthopaedics this is adapted to the "look, feel, move" progression. If possible, it is advised to watch the patient walking to assess gait. It is important that the patient is unaware of this and if the clinician can collect the patient from the waiting room, this is good practice.

Examination of the spine involves assessing movement in all planes, assessing power and bulk of muscles and testing of sensation and reflexes.

Cauda equina syndrome
It is important that clinicians are aware of cauda equina syndrome, a very rare condition that can leave the patient with devastating consequences. The signs and symptoms of this are:

  • Difficulty with micturition (urination).
  • Loss of anal sphincter tone or faecal incontinence.
  • Saddle anaesthesia about the anus, perineum or genitals.
  • Widespread (>one nerve root) or progressive motor weakness in the legs or gait disturbance.
  • Sensory level.

If this condition is suspected, the patient requires urgent admission to hospital, scanning and possible surgery.

Inflammatory back pain
Inflammatory disorders commonly present with:

  • Gradual onset before age 40.
  • Marked morning stiffness lasting more than one hour.
  • Persistent limitation of spinal movements in all directions.
  • Peripheral joint involvement.
  • Iritis, skin rashes (psoriasis), colitis, urethral discharge.
  • Family history.

If any clinician is unsure about what action to take following detailed assessment, then advice must be sought as soon as possible.

Treatment
The review of the evidence has resulted in the following recommendations for treatment, taking into account patient choice:

  • Exercise programme.
  • Course of manual therapy.
  • Course of acupuncture.
  • Combined physical and psychological programme after the patient has received at least one less intensive treatment or if the patient has significant disability and/or significant psychological distress.

X-rays are not recommended for the management of
non-specific low back pain and MRI scans are only to be considered if the patient is to be referred for surgery.

Injections of therapeutic substances into the back for non-specific low back pain are not recommended.

Analgesia
Medication management is an important aspect in the treatment of low back pain. Many nurses are now supplementary and independent prescribers, and pain management is of great importance to the patient with this problem. The WHO pain ladder
(www.who.int/cancer/palliative/painladder/en/) should be followed and analgesia increased or altered according to response.

There is opportunity for nurses to explain the potential complications of pain medication to patients - evidence suggests that a common side-effect of constipation caused by opioids can cause back pain to deteriorate, for example. If this is made clear to the patient, steps can be taken to prevent side-effects. 

An important concept is that back pain, while a life-limiting condition, is not a life-threatening condition and the patient should try to live life as normally as possible. This can be difficult if they are in pain and many people still believe the older treatment of rest curing back pain - explanation and discussion with the well-informed nurse can help to change this concept.

Conclusion
The publication of this guideline by NICE offers many opportunities for nurses. There are personal research and training opportunities suggested within the document developed according to the lack of evidence.

During their careers, nurses develop their skills of assessing, planning and implementing care; these skills can be used with great success in the in the treatment of low back pain and the nurse is in an ideal position to coordinate that care.

Being a member of a guideline development group for NICE is an excellent experience. It involves a lot of time, energy and effort but it enables participation in the systematic review of current evidence to ensure that treatments are based on the best available evidence and outcomes.

Reference
1. Savigny P, Kuntze S, Watson P et al. Low back pain: early management of persistent non-specific low back pain. Full guideline. May 2009. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners; 2009.