New British Low Back Pain Guidelines Released

Royal College of General Practitioners Update AHCPR Guideline

By Editorial Staff

As health care research progresses, so does the need to update practice guidelines. The Mercy chiropractic guidelines were updated by the Canadian guidelines (Glenerin), and soon will be amended by the Australian chiropractic guidelines. Meanwhile Britain's Royal College of General Practitioners has produced Clinical Guidelines for the Management of Acute Low Back Pain, which updates those developed by the Agency for Health Care Policy and Research (AHCPR).

While the AHCPR guidelines were based upon the available research at the time (through 1992), the new British guidelines consider additional and more recent studies (through April of 1996).

Another important difference is that the British effort was led by the Royal College of General Practitioners, rather than an agency of the British government. For medical practitioners, this makes the recommendations even stronger and gives them more credibility.

The chiropractic profession had some involvement in the new British guidelines. The development group for the guidelines included one chiropractor, Dr. Alan Breen, research director at the Anglo European College of Chiropractic. The British Chiropractic Association is also listed as one of the contributing organizations.

The British guideline's group "started from the AHCPR review" as their base. Where little evidence or only consensus was available, the guideline group "generally reproduced the original recommendations from the AHCPR (1994) and the Royal College for Radiologists."

These are the principal recommendations enunciated in the brief pamphlet version of the British guidelines:

Assessment

• Carry out diagnostic triage.
• X-rays are not routinely indicated in simple backache.
• Consider psychosocial factors.

Drug Therapy

• Prescribe analgesics at regular intervals, not p.r.n.
• Start with paracetamol. If inadequate, substitute NSAIDs

(e.g., ibuprofen or diclofenac) and then paracetamol-weak opioid compound (e.g., codydramol or coproxamol). Finally, consider adding a short course of muscle relaxant (e.g., diazepam or baclofen).

• Avoid narcotics if possible.

Bed Rest

• Do not recommend or use bed rest as a treatment for simple back pain.
• Some patients may be confined to bed for a few days as a consequence of their pain, but this should not be considered a treatment.

Advice on Staying Active

• Advise patients to stay as active as possible and to continue normal daily activities.
• Advise patients to increase their physical activities progressively over a few days or weeks.
• If a patient is working, then advice to stay at work or return to work as soon as possible is probably beneficial.

Manipulation

• Consider manipulative treatment within the first 6 weeks for patients who need additional help with pain relief or who are failing to return to normal activities.

Back Exercises

• Patients who have not returned to ordinary activities and work by 6 weeks should be referred for reactivation/ rehabilitation.

The guidelines additionally assessed psychosocial factors and came to the following conclusions:

• Psychological, social and economic factors play an important role in chronic low back pain and disability.
• Psychosocial factors are important at a much earlier stage than previously believed.
• Psychosocial factors influence a patient's response to treatment and rehabilitation.

While the support for "manipulation" is not as strong as the chiropractic profession would like to see, the British guidelines do continue to establish the efficacy of chiropractic manipulation for acute low back pain, particularly to a much less doubtful medical profession. The address and phone number are below to obtain a copy of the guidelines:

Royal College of General Practitioners
Sales Office
14 Princess Gate
Hyde Park, London SW7 1PU
England

Telephone: 011-44-171-823-9698
Fax: 011-44-171-225-0629

Price: L10 (The current exchange rate for the British pound (L) is $1.67 U.S. dollars.)