Low back pain: Early management of persistent non-specific low back pain

4.1 Screening protocols

What is the clinical and cost effectiveness of using screening protocols to target treatments for people with persistent non-specific low back pain?

Why this is important

People with poorer physical function and, in particular, those with psychological factors such as increased fear of activity, psychological distress, and negative feelings about back pain, are more disabled by their pain, and are more likely to have a poor outcome.

One randomised controlled trial has demonstrated the value of screening in improving outcome with respect to return to work. No UK study to date has demonstrated that targeting treatments based on a risk-factor profile leads to improved outcome or cost effectiveness.

Research into matching people with low back pain to the specific treatments recommended is needed. The role of both psychological and physical factors should be considered.

This should include studies to identify which people are likely to gain the greatest benefit from treatments that are recommended in this guideline, and studies to identify which people are likely to benefit from treatments that are not currently recommended.

4.2 Delivery of patient education

How can education be delivered effectively for people with persistent
non-specific low back pain?

Why this is important

Improved understanding of low back pain and its management are identified as key components of care by both patients and healthcare professionals. This guideline emphasises the importance of patient choice, which can only be exercised effectively if people have an adequate understanding of the available options. Extensive research literature addresses the education of adults using a wide variety of techniques, but studies of patient education for people with low back pain have focused almost exclusively on written information. Little evidence is available as to whether such materials are the most effective way to deliver educational goals. Interdisciplinary projects combining educational and healthcare research methodologies should:

4.3 Use of sequential therapies

What is the effectiveness and cost effectiveness of sequential therapies (manual therapy, exercise and acupuncture) compared with single interventions with respect to pain, functional disability and psychological distress in people with persistent non-specific low back pain?

Why this is important

There is evidence that manual therapy, exercise and acupuncture individually are cost-effective management options compared with usual care for persistent non-specific low back pain. The cost implications of treating people who do not respond to initial therapy and so receive multiple back care interventions are substantial. It is unclear whether there is added health gain for this subgroup from either multiple or sequential use of therapies.

Research should:

4.4 Psychological treatments

What is the effectiveness and cost effectiveness of psychological treatments as monotherapy for persistent non-specific low back pain?

Why this is important

The effectiveness and cost effectiveness of psychological treatments for people with persistent non-specific low back pain is not known. Data from randomised controlled trials studying people with a mixture of painful disorders, and other research, suggest that such treatments may be helpful for non-specific low back pain, but there are few robust data relating specifically to back pain.

Research should:

If possible, the comparative effectiveness and cost effectiveness of different psychological treatments should be tested; for example, group compared with individual treatment, or treatment approaches based on different theories.

4.5 Invasive procedures

What is the effectiveness and cost-effectiveness of facet joint injections and radiofrequency lesioning for people with persistent non-specific low back pain?

Why this is important

Many invasive procedures are performed on people with persistent non-specific low back pain. These are usually undertaken after the condition has lasted a long time (more than 12 months). Procedures such as facet joint injections and radiofrequency lesioning are performed regularly in specialist pain clinics. There is evidence that pain arising from the facet joints can be a cause of low back pain, but the role of specific therapeutic interventions remains unclear. Case studies provide some evidence for the effectiveness of facet joint injections and medial branch blocks, but randomised controlled trials give conflicting evidence.

Robust trials, including health economic evaluations, should be carried out to determine the effectiveness and cost effectiveness of invasive procedures – in particular, facet joint injections and radiofrequency lesioning. These should include the development of specific criteria for patient selection and a comparison with non-invasive therapies.