A team of researchers from Australia, Brazil, and the U.K. recommended several changes to the NICE (National Institute for Health and Care Excellence) guidelines for low back pain and sciatica because some of the guidelines “are not in line with the most recent evidence.”

According to their editorial published in the British Journal of Sports Medicine, the team suggested five changes:

  1. Remove the statement about risk stratification for acute low back pain in primary care.
  2. Remove the statement about self-management for low back pain with or without sciatica.
  3. Remove the “radiofrequency denervation” exception from the statement regarding not recommending spinal injections for low back pain with or without sciatica.
  4. Offer an alternative to not giving paracetamol alone, gabapentinoids, antiepileptics, or antidepressants to treat low back pain without sciatica.
  5. Offer an alternative to not giving opioids to treat chronic low back pain without sciatica.

They also suggested that the guidelines offer an equal number of “do offers” and “don’t offers” because the current ones offer “don’ts” without offering an alternative.

Risk stratification

Risk stratification is a process used in healthcare systems to categorize patients based on their likelihood of experiencing poor outcomes or needing more intensive treatment. It helps clinicians tailor care plans by identifying high, medium, or low-risk patients based on specific factors.

The researchers wrote that although risk stratification was slightly more effective than usual care in the original STarT Back trial in the U.K., “several subsequent trials have failed to show any benefit of risk stratification when managing patients with low back pain or sciatica.”

Self-management

The researchers wrote that recent trials have shown that self-management for low back pain and sciatica results in “modest effects.”

While they did not cite which specific trials, a 2023 narrative review found that research in self-management in low back pain had “inconsistencies” in interventions, characteristics, and outcome measures. The authors of the review found that current self-management approaches “do not consider the complex biopsychosocial nature” of chronic low back pain.

“It is hard to argue that these two interventions [including risk stratification] should be considered standard care for low back pain,” Oliveira and his colleagues wrote.

Radiofrequency denervation

Radiofrequency denervation uses heat generated by radio waves to disable specific nerves from transmitting nociceptive signals in the spine. While it is often used to relieve chronic pain, Oliveira and his colleagues wrote that radiofrequency denervation “current evidence shows mixed results regarding its efficacy.”

Therefore, they suggested removing the phrase about using radiofrequency denervation as an exception for spinal injections.

However, they added there is a radiofrequency denervation for low back pain trial that is currently evaluating the effectiveness of the treatment, and its findings could influence the existing effect estimates and the level of certainty in the evidence. 

“Once the results are known, this statement may also require some revision,” they wrote.

Offer alternatives

The existing NICE guidelines suggest clinicians avoid recommending four medications: gabapentinoids, antiepileptics, antidepressants, and paracetamol alone. The researchers wrote that while this recommendation is aligned with the existing evidence, “there are effective pharmacological and non-pharmacological options for pain control that were ignored.”

Oliveira and his colleagues wrote that non-steroidal anti-inflammatory drugs (NSAIDs) “are widely recommended as first-line treatment by low back pain guidelines, including the NICE and WHO guidelines. Therefore, if any medication is prescribed/advised for low back pain with or without sciatica, the prescription/advice should be for an NSAID.”

They warned that this recommendation may not be suitable for older people.

“Failing to provide alternative treatment options may reduce the chances of deimplementing the use of those four medications,” they wrote.

Offer exercise and physical and psychological therapies

The existing NICE guidelines suggest clinicians avoid recommending opioids except for acute low back pain with weak opioids. The researchers recommended that supervised exercise and psychological therapies, such as cognitive behavioural therapy (CBT), should be offered for persistent low back pain and sciatica.

Several systematic reviews have shown that exercise of almost any kind can reduce chronic low back pain with varying degrees of evidence.

  • A 2021 Cochrane review of 249 trials found that exercise has “moderate-certainty evidence” that exercise may be effective for treating chronic low back pain compared to no treatment, usual care, or placebo. While these researchers found that exercise has improved pain (with low-certainty evidence) and function (with moderate-certainty evidence), they concluded that the effect sizes were “small and not clinically important when considering all comparisons together.”
  • A 2022 systematic review of 58 trials with a total of more than 10,000 people found that individualized exercise programs have “small to medium effects” for chronic low back pain compared to groups with active or passive treatments in the long-term. Clinical effects are larger when exercise is combined with CBT, the researchers reported.
  • A 2023 systematic review of 75 trials with more than 5,200 people found that tai chi, yoga, Pilates, sling exercise, motor control exercise, and core or stabilization exercises “significantly improved” chronic low back pain compared with conventional care or no intervention groups.

CBT also has shown similar results in treating low back pain.

  • A 2022 systematic review and meta-analysis of 20 trials found that CBT as an adjunct to other types of therapy may be more effective than CBT or other therapies alone in reducing chronic low back pain and disability. The researchers noted that 10 of the studies reported CBT “ induced a clinically significant reduction in pain intensity or disability level” while seven studies reported “limited or no clinical effects” and five studies did not report any clinical significance.
  • A 2023 systematic review and meta-analysis of 16 trials with a total of 2,527 people found CBT “was superior to other treatments in improving social participation” but not so much on improving depression, anxiety, sleep quality, and controlling negative emotions when compared to physical therapy, exercise, and other psychological interventions.

The NICE (National Institute for Health and Care Excellence) clinical guidelines are evidence-based recommendations developed in the U.K. to help healthcare professionals, patients, and policymakers make informed decisions. They are based on the best available scientific evidence, which requires regular updates.

“If the NICE standard for low back pain was followed, most patients would miss out on the right care but stand a good chance of receiving low-value care,” they wrote.

 

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Nick Ng is the editor of Massage & Fitness Magazine and the managing editor for My Neighborhood News Network.

An alumni from San Diego State University with a bachelor’s in graphic communications, Nick also completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014. In 2021, he earned an associate degree in journalism at Palomar College.

When he gets a chance, he enjoys weightlifting at the gym, salsa dancing, and exploring new areas in the Puget Sound area in Washington state.