NICE guidelines for low back pain and sciatica: a clarification

The recently published NICE guidelines for low back pain and sciatica are clear and unambiguous. However, they seem to have been misinterpreted by some people. One area where this has happened is the part about manual therapy. Here is what the guideline says:

“Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy.”

I have seen this misinterpreted as:

  • “Select just the bits you like”
  • “Manual therapy with exercise or psychological therapy”
  • “Exercise and manual therapy is the choice for low back pain”
  • “Osteopathy or manual therapy continues to be the treatment of choice for low back pain with the proviso that it is provided with exercise”

It’s important to understand that the wording from the guideline above makes it clear that exercise is a mandatory part of a treatment package. Manual therapy and psychological therapy are optional add-ons but exercise is compulsory. That means that the treatment options are: exercise alone, exercise plus manual therapy, exercise plus psychological therapy, exercise plus manual therapy and psychological therapy. Using a treatment package that consists of manual therapy alone, psychological therapy alone or manual therapy plus psychological therapy does not comply with the guidance. It’s also important to understand that there is no requirement to provide a multimodal treatment package and in some cases exercise alone will be the most appropriate treatment. You certainly can’t “select just the bits you like” as exercise is not an optional component.

Now let’s look at what the NICE guidelines say about exercise:

“Consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica. Take people’s specific needs, preferences and capabilities into account when choosing the type of exercise.”

One important point from this guidance is that NICE recommends a “group exercise programme”. This presents something of a problem for pure manual therapists such as osteopaths and chiropractors as they don’t normally have access to a group exercise programme for their patients. I have already highlighted the fact that osteopathy and chiropractic are no longer first line treatment choices for low back pain and sciatica. NICE have made it clear in their own press release that exercise is the “first step in managing the condition”. The right person to deliver an exercise programme is of course a physiotherapist.

Ultimately, the purpose behind these guidelines is to bring about improvement in care for patients. Views such as “Osteopathy or manual therapy continues to be the treatment of choice for low back pain with the proviso that it is provided with exercise” give an interesting insight into the goals of the osteopathic profession. This statement is far too obviously in conflict with the guidelines to be a mere “misunderstanding”. These kinds of statements appear to be more focused on promoting the businesses of the osteopaths. In so doing, osteopaths seem to have forgotten the most important thing of all: looking after the best interest of their patients.

The new NICE guidelines are something of a problem for osteopaths and chiropractors as their treatments are no longer first line choices and they are not well placed to offer a suitable exercise programme. Some of them may opt to continue treating patients the way the always have and not take the NICE guidelines into account. However, that is a potentially risky strategy for two reasons:

  1. It doesn’t seem to be in the best interest of their patients
  2. They risk being found in breach of their “Practice Standards” which could result in formal complaints to either the GOsC or GCC.
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