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. 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 Principles of management

7. 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 Information, education and patient preferences

8. 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 Structured exercise programme

9. 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 Manual therapy

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. 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 Combined physical and psychological treatment programme

12. 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 Assessment and imaging

13. 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. Referral for surgery

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. Recommendations with significant costs Costs (£ per year) Acupuncture48,208 Manual therapy31,575 Group combined physical and psychological treatment programme20,635 Exercise programme1,708 Estimated cost of implementation102,126 Costs per 100,000 population

17. Recommendations with significant cost savings Savings (£ per year) Reduction in injections of therapeutic substances into the back66,546 Reduction in MRI scans23,389 Reduction in X-rays2,732 Reduction in use of radiofrequency facet joint denervation5,022 Reduction in other physical therapies3,501 Estimated saving from implementation101,190 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 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?

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