Are we providing the multimodality treatments advocated within current guidelines when managing patients with lower back pain?

Low back pain (LBP) is a common disorder, affecting around one-third of the UK adult population annually. Usually, this is a benign, self- limiting disorder not requiring professional advice or specific treatment.¹ Around 20% of people with LBP will consult their GP.² Annually LBP in the UK costs about £10,668 million.³

The National Institute of Clinical Excellence (NICE) published guidelines in 2009 on the &Early management of persistent non specific lower back pain' outlining the initial care of LBP using current and complementary treatment modalities.

Recommendations include a multidisciplinary approach employing manual therapy with spinal manipulation or massage, physiotherapy with a structured exercise programme, and acupuncture. Information literature is recommended to encourage patients' involvement in their care. They suggest referral to a combined physical and psychological treatment programme, which is not available in all regions.

We constructed a questionnaire for patients attending a single spinal surgeons outpatient department over a 2-month period, with a history of non-specific LBP of less than 12 months.

Age, gender and duration of symptoms were determined, together with all treatment options/information provided to patients. 50 consecutive patients were questioned. The mean duration of LBP was 8.7 months. Average age was 45 years. The percentage of patients attending each modality is shown in table 1. No patients received all the treatment modalities, and 4% had failed to receive any prior to consultation. 78% had received two modalities at time of referral.

Table 1.

Percentage of individual modality uptake in patients.

Modality	%
Physiotherapy	82
Chiropractor/ Osteopath	72
Acupuncture	12
Combined Physical ' Psychological Therapy	0
NHS Documentation	18

The NICE guidelines provide evidence-based best practice for managing acute persistent LBP. They offer a strategy for primary care management prior to spinal outpatients referral. Surgery is considered only after other modalities have failed. Appropriate management of this complex patient group has the potential to minimize those with disabling long-term back pain, and reduce the personal, social and economic impact of LBP.²

NICE identifies various multidisciplinary treatments including promoting patient self-management through advice and information. They aim to reduce the impact on a patient's dayto- day life, even if the pain cannot be relieved completely.² Only 18% of patients had received written information or advice. NICE advise referral to a combined physical and psychological treatment programme but such a service is not provided by healthcare trusts within Northern Ireland.

Table 2.

Percentage of combined modalities offered to patients.

Total number of modalities utilised	% of patients undertaking
5	0
4	2
3	16
2	52
1	26
0	4

NICE recommends acupuncture. Systematic reviews have found it a useful adjunct to conventional care.⁴ In this cohort, only 12% received acupuncture. Availability of NHS acupuncture is limited in our region.

Referral to a surgeon may be for advice and reassurance, and the assumption that all patients being referred should have undertaken all modalities would be unfair. Referral pathways may reflect longstanding traditional routes, possibly explaining the large percentage receiving physiotherapy compared to complementary therapies.

Despite a full complement of treatments there will always be patients refractory to conservative management who may benefit from spinal outpatients referral. Further studies may determine whether greater awareness and adherence to such guidelines improves clinical outcome. At present the adherence to the guidelines is inconsistent. New guidance must be effectively disseminated among healthcare professionals to offer patients the best evidence based care and ultimately reduced the morbidity and economic impact of the condition. Treatment options proposed need to be available to the primary care physician, perhaps explaining why, within our region, such guidelines cannot be fully observed.

The author has no conflict of interest.