Transcript Using this template - British Osteopathic Association

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
• 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
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
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
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
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
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
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
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 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
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
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.
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
Non-pharmacological therapies
Do not offer
• Laser therapy
• Interferential therapy
• Therapeutic ultrasound
• TENS
• Lumbar supports
• Traction
Costs per 100,000 population
Recommendations with significant costs
Costs
(£ per year)
Acupuncture
48,208
Manual therapy
31,575
Group combined physical and psychological treatment
programme
20,635
Exercise programme
Estimated cost of implementation
1,708
102,126
Savings per 100,000 population
Recommendations with significant cost savings
Savings
(£ per year)
Reduction in injections of therapeutic substances into the
back
66,546
Reduction in MRI scans
23,389
Reduction in X-rays
2,732
Reduction in use of radiofrequency facet joint denervation
5,022
Reduction in other physical therapies
3,501
Estimated saving from implementation
101,190
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 guideline
recommendations?
• 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?
Find out more
Visit www.nice.org.uk/CG88 for:
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•
•
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the guideline
the quick reference guide
‘Understanding NICE guidance’
costing report and template
audit support
factsheet for commissioners
patient information leaflet