How to Treat Back Pain
There is in Britain a government-run organisation with the rather self-congratulatory name of ‘The National Institute for Health and Clinical Excellence’, usually referred to as NICE.
One of its functions is to ‘provide recommendations for the treatment and care of people by health professionals’.
So far so good. But what does NICE have to say about a disorder that causes widespread suffering and a huge economic burden – low back pain?
They published a ‘guideline’ on this matter in May 2009 running to 240 pages, with the repetitious title: Low back pain: early management of persistent non-specific low back pain.
A summary of the guideline was published in the British Medical Journal (13 June 2009, p1441) which left me feeling rather bemused as to why they had bothered.
The very title contains a contradiction: ‘early’ management (i.e., treatment) of ‘persistent’ …pain.
If the pain is persistent, how can treatment for it be described as early? Persistent pain is defined in the guideline as that which has lasted from between 6 weeks to 1 year. So, if a patient has had pain for, say, five weeks, what then? This doesn’t count as persistent? Is the patient told to wait till the six weeks have elapsed and then one can apply the guideline? And if the pain has lasted for, say, 11 months, one can still regard this stretch of time as sufficiently short so that if treatment is started at this point it is still considered early?
Let us stick just with the title of the paper a little longer. What is ‘non-specific low back pain’ anyway? Apart from the relatively rare serious disorders which can affect the lower back, such as cancer or tuberculosis, it seems to mean undiagnosed back pain. Then it should be so called, and doctors’ ignorance should not be covered up this sort of pseudo-diagnosis. Then at least our minds might be focussed on the need to try and make some sense of these ubiquitous disorders.
The title could more honestly, and concisely, be written: Treatment of persistent undiagnosed low back pain.
But this won’t do. It violates the first rule of therapeutics: no treatment without diagnosis.
Now, let us get to the meat of the recommendations. We should ‘Offer educational advice that includes information on the benign nature of non-specific low back pain…’
It includes such information? So, what information besides should be offered? Considering that the doctor (I’m sorry, I mean the health professional) – apart from realising (or hoping) that the patient’s ‘non-specific’ pain is not life-threatening – is abysmally ignorant of the cause and treatment of the patient’s condition, how can he or she presume to offer ‘educational advice’? It is the blind leading the blind.
Then, we are supposed to ‘Encourage the person to be physically active and continue with normal activities (what’s the difference?) as far as possible’. Oh, great. Isn’t this what the patient is struggling to do anyway?
Now we get down to the nitty gritty: ‘Take into account the person’s expectation and preferences…’ Don’t we do this as a matter of course? Isn’t this passing the buck? Let the patient (I’m sorry, the person) decide! Suppose the person responds: ‘I don’t know, doctor, what would you recommend?’ Or, ‘I leave it up to you, doctor.’ Or – no passing the buck here – ‘If you had my back pain, what would you do, doctor?’
The next paragraph is titled: ‘Therapies for low back pain’. This looks more hopeful!
‘Offer one of the following treatment options, taking into account the patient’s preference (they’ve said that already): an exercise programme, a course of manual therapy, or a course of acupuncture.’
What a let down. Here is the patient, suffering from low back pain for at least the last six weeks, coming to a ‘health professional’ for help, and all that should be done, according to this guideline, is to offer – not forgetting the person’s preference of course – one of these non-specific ways of passing the time. Why should the patient bother at all? What is the reasoning behind any of these treatments having any effect whatsoever on the back pain? Will somebody please enlighten me.
Not to worry, there’s more: ‘Combined physical and psychological treatment programme’.
Now we’re getting somewhere! ‘[F]or people who have received at least one less intensive treatment and who also have high disability and/or substantial psychological distress’, a mere ‘100 hours over a maximum of eight weeks’ should sort it out. I kid you not – this is actually what it says.
What about drug treatments? Surely, here must be some nuggetts of wisdom. Let’s see: ‘Advise regular paracetamol (acetoaminophen, Tyelenol®, Panadol®) as the first medication option.’ Well, I could have thought of that. However, ‘When paracetamol alone provides insufficient pain relief, offer non-steroidal anti-inflammatory drugs (commonly used for painful conditions of the moving parts of the body, referred to as NSAIDs for short) or weak opioids (related to morphine), or both.’ Wow, real rocket science! And, for those with poor memories, don’t forget to ‘Take into account…the patient’s preference’!
All right, let’s not be cynical. After all, these are experts who are offering guidance to us lesser forms of medical life, so they presumably know what they are talking about. Don’t they?
After exhorting us to ‘Give due consideration to the risk of side-effects from NSAIDs’, (thank you, that would never have occurred to me) next on the list is the advice that ‘Either an oral NSAID…or a cyclo-oxygenase-2 (COX2) inhibitor (such as celecoxib) may be offered when an anti-inflammatory painkiller is recommended.’
Now hang on a minute. Isn’t there something about cyclo-oxygenase-2 inhibitors of which one should be careful? Oh yes, it’s in my September 2009 edition of the British National Formulary, page 561, in the box:
Cyclo-oxygenase-2 inhibitors are associated with an increased risk of thrombotic events (e.g. myocardial infarction and stroke) and should not be used in preference to non-selective NSAIDs except when specifically indicated…
The anti-arthritis drug celecoxib belongs to the same chemical group as rofecoxib, one trade name of which is Vioxx®, which was withdrawn in 2004 because it was suspected of causing heart attacks in thousands of users.
If all this hasn’t cured you, and if you haven’t had a heart attack or a stroke from the COX-2 drug, there is still hope: spinal fusion (an operation using bone grafts or metal rods and screws to fix together two or more vertebrae). Now, I ask you. In patients with undiagnosed back pain what is the logic of recommending spinal fusion? It is most curious, because in the list of ‘Treatments not recommended’ is the item ‘Lumbar supports (devices to reduce spinal movement) such as corsets.’ It would be hard to think of a more effective way of reducing spinal movement than an operation for spinal fusion.
Another treatment helpfully listed among the not-recommended sort, is ‘Injection of therapeutic substances into the back’. Should one inject them into the front, then, or perhaps the side? This patronising prohibition appears to have been thought up by people who have had no experience in actually treating patients with back pain.
It seems to me the writers of this guideline should go back to the drawing board.