NICE scraps recommendations for paracetamol and acupuncture for low back pain

Exercise is the optimum way to manage low back pain, NICE experts have said in its latest draft guidance, which also downplays the use of paracetamol and retracts its endorsement of acupuncture.

Updated draft guidance from NICE on low back pain places exercise as the ‘first step’ for treating and alleviating symptoms of lower back pain.

The guideline, which replaces 2009 recommendations, says patients should be offered all forms of exercise including stretching, yoga, strengthening and aerobic exercise as the best way to manage low back pain. 

The guideline has been expanded to cover people with low back pain or sciatica for any length of time, whereas before it only covered management of back pain that lasted between six weeks and 12 months.

Acupuncture to relieve lower back pain has been stripped out completely from recommendations, after experts concluded it was no better than sham treatment.

Back pain treatment

Paracetamol is no longer the first recommended option for managing low back pain, and should not be offered on its own to manage low back pain, the guidance states.

Instead, NSAIDs are the recommended first-line pharmacological intervention. NICE says they should be offered at the lowest effective dose for the shortest possible period of time.

Opioids should not routinely offered, but weak opoids – such as codeine – can be recommended in conjunction with paracetamol or alone in instances where NSAIDs either fail to work or are not suitable.

Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants nor anticonvulsants should be offered to treat back pain, it says.

Therapeutic options

A raft of other therapies should not be prescribed including electrotherapies, belts, corset and foot orthotics.

Therapies such as massage and soft tissue manipulation by a therapist may be offered but only alongside exercise, as there is no evidence to suggest they are of benefit when used alone.

The guidance says psychological therapies could also be used alongside exercise.

Patients should be advised to try and continue with normal activities ‘as far as possible’ to help them self-manage their pain, its says, and should be encouraged to return to work.

Professor Mark Baker, clinical practice director for NICE, said: ‘Millions of people are affected every year by these often debilitating and distressing conditions.

‘Regrettably, there is a lack of convincing evidence of effectiveness for some widely used treatments. For example, acupuncture is no longer recommended for managing low back pain with or without sciatica. This is because there is not enough evidence to show that it is more effective than sham treatment.’

GP Dr Ian Bernstein, who helped develop the guideline, said: ‘The diagnosis of back pain includes a variety of patterns of symptoms. This means that one approach to treatment doesn’t fit all.

‘Therefore the draft guidance promotes combinations of treatments such as exercise with manual therapy or combining physical and psychological treatments. The draft guideline also promotes flexibility about the content and duration of treatments, and the choices made should take into account people’s preferences as well as clinical considerations.’

A recent study showed back pain caused more disability than any other condition, affecting one in 10 people. In the UK, it is estimated to be the root of 37% of chronic pain in men and 44% in women, costing £12bn a year.

Sciatica is relatively common, and estimated to affect as many as 40% of people at some point in their lives.

Photo: iStock

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