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National Collaborating Centre for Primary Care (UK). Low Back Pain: Early Management of Persistent Non-specific Low Back Pain [Internet]. London: Royal College of General Practitioners (UK); 2009 May. (NICE Clinical Guidelines, No. 88.)

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  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

2Introduction

2.1. Background

Low back pain is a common disorder. Nearly everyone is affected by it at some time. For most people affected by low back pain substantial pain or disability is short lived and they soon return to normal activities regardless of any advice or treatment they receive. A small proportion, however, develop chronic pain and disability. Once low back pain has been present for more than a year few people with long-term pain and disability return to normal activities. It is this group who account for the majority of the health and social costs associated with low back pain.

There is a generally accepted approach to the management of back pain of less than 6 weeks’ duration (acute low back pain). What has been less clear is how low back pain should be managed in people whose pain and disability has lasted more than six weeks. Appropriate management has the potential to reduce the number of people with disabling long-term back pain; and so reduce the personal, social, and economic impact of low back pain to society.

This guideline covers the management of persistent or recurrent low back pain defined as non-specific low back pain that has lasted for more than 6 weeks, but for less than 12 months. It does not address the management of severe disabling low back pain that has lasted longer than 12 months.

Non-specific low back pain

Non-specific low back pain is tension, soreness and/or stiffness in the lower back region for which it isn’t possible to identify a specific cause of the pain. Several structures in the back, including joints, discs and connective tissues, may contribute to symptoms. The diagnosis of non-specific low back pain is dependent on the clinician being satisfied that there is not a specific cause for their patient’s pain. A clinician who suspects that there is a specific cause for their patient’s low back pain (see box 1) should arrange the relevant investigations. However, the diagnosis of specific causes of low back pain is beyond the remit of this guideline.

The lower back is commonly defined as the area bounded by the bottom of the rib cage and the buttock creases. Some people with non-specific low back pain may also feel pain in their upper legs, but the low back pain usually predominates. Several structures, including the joints, discs and connective tissues, may contribute to symptoms.

The management of the following conditions is not covered by this guideline:

  • radicular pain resulting from nerve root compression (sometimes called sciatica).
  • cauda equina syndrome (this should be treated as a surgical emergency requiring immediate referral).

Conventionally low back pain is categorised according to its duration as acute (<6 weeks), sub-acute (6 weeks – 12 weeks) and chronic (>12 weeks) (Spitzer, W. O. and Leblanc, F. E., 1987). Since many people affected by low back pain find that their symptoms wax and wane it may not always be appropriate to use such a rigid classification system.(Croft, P. R., Macfarlane, G. J., Papageorgiou, A. C. et al, 1998)

Epidemiology of low back pain

Estimates of the prevalence of low back pain vary considerably between studies - up to 33% for point prevalence, 65% for 1- year prevalence, and 84% for lifetime prevalence.(Walker, B. F., 2000) There is no convincing evidence that age affects the prevalence of back pain.(Airaksinen, O., Brox, J. I., Cedraschi, C. et al, 2006) There are few epidemiological data that are directly relevant to the target population for these guidelines. Published data do not distinguish between low back pain that persists for over a year and less than a year.

Low back pain probably affects around one-third of the UK adult population each year. Of these, around 20% (1 in 15 of the population) will consult their GP about their back pain. (Macfarlane, G. J., Jones, G. T., and Hannaford, P. C., 2006). This results in 2.6 million people, in the UK, seeking advice about back pain from their GP each year(Arthritis Research Campaign., 2002).

One year after a first episode of back pain 62% of people still have pain and 16% of those initially unable to work are not working after one year (Hestbaek, L., Leboeuf-Yde, C., and Manniche, C., 2003). Typically, pain and disability improve rapidly during the first month; (58% reduction from initial scores for both pain and disability) with little further improvement being observed after three months(Pengel, L. H., Herbert, R. D., Maher, C. G. et al, 2003). Estimates for the adult population burden of chronic back pain include; 11% for disabling back pain in the previous three months, 23% for low back pain lasting more than three months and, 18% for at least moderately troublesome pain in the previous month (Andersson, H. I., Ejlertsson, G., Leden, I. et al, 1993; Cassidy, J. D., Carroll, L. J., and Cote, P., 1998; Parsons, S., Breen, A., Foster, N. E. et al, 2007).

Cost of back pain

The direct and indirect financial costs of back pain are substantial in all developed countries. Estimates for the cost of back pain in different health and social systems are not directly comparable (Dagenais, S., Caro, J., and Haldeman, S., 2008). The most recent cost of illness study for the UK is based on 1998 estimates. (Maniadakis, N. and Gray, A., 2000) The economic climate has changed and there has been inflation since then. It is difficult to estimate effect of the first two of these factors on current cost of back pain. The UK retail price index, however, increased by 28.8% in the ten years to July 2008 ((Office for National Statistics., 2008). http://www.statistics.gov.uk/downloads/theme_economy/RP04.pdf accessed 03.02.09) suggesting that current direct health care costs are likely to be substantially greater than the published figures.

In 1998 the health care costs due to back pain were £1,632M, of which £565M was the cost of non-NHS health care costs (Maniadakis, N. and Gray, A., 2000). These large non-NHS costs are mainly accounted for by the use of private therapists (acupuncturists, chiropractors, occupational therapists, osteopaths, physiotherapists and others). This large private sector involvement in the care of back pain is unusual within the UK health care system. Although NICE guidance is developed for the NHS these guidelines may also be relevant to purchasing decisions made by individuals with back pain and private insurers.

The indirect costs of back pain, due to lost production are larger. The 1998 estimates for this was either £3,440M, or £9,090M depending on the approach used for this costing. (Maniadakis, N. and Gray, A., 2000).

Diagnosis

For patients presenting with a new episode, or exacerbation, of low back pain consideration needs to be given to the possibility that there is a specific cause for their pain. For acute back pain, malignancy, infection, osteoporotic and non-osteoporotic fractures need to be considered. Malignancy is more common in older people and those with a past history of tumours known to metastasise to bone (e.g. breast, lung and prostate). Infection should be considered in those who may have an impaired immune system, e.g. people living with HIV, or who are systemically unwell. Osteoporotic fractures typically affect older people (women more than men) and those with other chronic illnesses; particularly if they have used long term oral steroids. Apart from osteoporotic fractures in older people these are all uncommon; very few patients presenting with back pain will need further investigation before making a diagnosis of acute non-specific low back pain. The general approach to the treatment for acute non-specific low back pain is advice to stay active and to avoid bed rest, plus pain relieving medications such as paracetamol, weak opioids or NSAIDs.(Koes, B. and van Tulder, M., 2006)

For those with pain that continues for longer than six weeks or who further deteriorate between six weeks and one year, the possibility of a specific cause needs to be re-considered. In addition to the specific causes of acute low back pain, the possibility of chronic inflammatory conditions such as ankylosing spondylitis or other inflammatory disorders need to be considered.

Objective for treatment of non-specific low back pain

The overall objective of the early management of non-specific low back pain (lasting six weeks to one year) is to ensure that an episode of low back pain does not result in long-term withdrawal from normal activities, including sickness absence from paid employment. It is improving these outcomes (pain, disability and distress) that are the focus for the management of non-specific low back pain and thus the focus of this guideline. More severe pain and back pain-related disability, and psychological distress predict a poor long term outcome for people with non-specific back pain.(Pincus, T., Santos, R., Breen, A. et al, 2008)

Available treatments for non-specific low back pain

There are a plethora of treatments available for the treatment of non-specific low back pain. Not all of the treatments used have a strong theoretical underpinning. The differences and similarities between different therapeutic approaches are not always clearly explicated in the literature. Furthermore, for many of the individual treatment approaches used any therapeutic benefit is the result of both the specific treatment modality used and the non-specific effects of the therapist delivering the treatment. For therapist-delivered interventions the guideline development group took the pragmatic decision that it was the effect of the package of care delivered by the therapist or therapists that is of interest rather than the individual components of the treatment package. The packages of care may be delivered by health professional from a range of clinical backgrounds. The guideline development group explicitly considered the nature of the intervention packages, not professional background of the therapists involved. It is anticipated that any therapist delivering these therapies will be adequately trained for this activity.

Broadly speaking the treatments that have been used for non-specific low back pain are:

  • Education/information
    Including advice from practitioners regarding exercise and/or causes of back pain, formal education sessions, and written educational material.
  • Exercise
    Including group and individual supervised exercise; both land and water based
  • Manual therapies
    Including manipulation, massage, mobilisation
  • Other non-pharmacological interventions
    Including, interferential, laser, lumbar supports, transcutaneous electrical nerve stimulation, traction, ultrasound,
  • Psychological interventions
    These including a variants of cognitive behavioural therapy and self management
  • Combined physical and psychological interventions (CPP)
    These include the components seen in some types of back school and multidisciplinary rehabilitation programmes
  • Pharmacological interventions
    Including antidepressants, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and paracetamol
  • Invasive procedures
    Including acupuncture, electro-acupuncture, nerve blocks, neuroreflexotherapy, percutaneous electrical nerve stimulation (PENS), injection of therapeutic substance into the spine.
  • Surgical referral
    For this guideline the evidence supporting different therapeutic approaches and the evidence on the decision making process for selecting therapeutic approaches has been reviewed.

2.2. Aim of the guideline

Clinical guidelines are defined as ‘systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances’.

This guideline gives recommendations to clinicians and others about clinical assessment, pharmacological and non-pharmacological treatments and referral to surgery.

2.3. How the guideline is set out

The recommendations for all the topics in each clinical chapter are listed at the start of the chapter. Both the evidence statements and narratives of the research studies on which our recommendations are based are found within each topic section. The evidence statements follow the narrative for each topic. Also included in each chapter is a brief explanation of why the GDG made the specific recommendations. The evidence tables with details of the research studies that describe the studies reviewed are found in Appendix C.

Unless otherwise indicated, recommendations are relevant for individuals with non specific low back pain.

2.4. Scope

The guideline was developed in accordance with a scope given by the National Institute for Health and Clinical Excellence (NICE, ‘the Institute’). The scope set the remit of the guideline and specified those aspects of the management of low back pain to be included and excluded. The scope was published in May 2007 and is reproduced here in Appendix A.

The scope was originally titled’ Low back pain: the acute management of patients with chronic (longer than 6 weeks) non-specific low back pain’. In response to feedback at the consultation stage for the draft guideline this was changed to ‘ Low back pain: early management of persistent low back pain’ to make its remit clearer.

Whom the guideline is intended for

This guideline is of relevance to those who work in or use the National Health Service (NHS) in England and Wales:

  • Primary and secondary care settings dealing with assessment, treatment and management of non-specific low back pain in adults
  • People with non-specific low back pain who are considering purchasing treatment privately may also find these guidelines useful when choosing treatment options

Areas outside the remit of the guideline

  • Individuals who have LBP because of specific spinal pathologies, including:
    • –Malignancy
    • –Infection
    • –Osteoporotic Collapse
    • –Fracture
    • –Ankylosing Spondylitis or other inflammatory disorders
    • –Cauda equina compression
  • People with radiculopathy and/or nerve root pain.
  • Children under the age of 18 years
  • People with acute LBP (less than 6 weeks duration)
  • People with non-specific LBP of greater than 12 months duration.

2.5. Responsibility and support for guideline development

2.5.1. The National Collaborating Centre for Primary Care (NCC-PC)

The NCC-PC is a partnership of primary care professional associations and was formed as a collaborating centre to develop guidelines under contract to NICE. It is entirely funded by NICE. The NCC-PC is contracted to develop four guidelines at any one time, although there is some overlap at start and finish. Unlike many of the other centres which focus on a particular clinical area, the NCC-PC has a broad range of topics relevant to primary care. However, it does not develop guidelines exclusively for primary care. Each guideline may, depending on the scope, provide guidance to other health sectors in addition to primary care.

The Royal College of General Practitioners (RCGP) acts as the host organisation. The Royal Pharmaceutical Society and the Community Practitioners and Health Visitors’ Association are partner members with representation from other professional and lay bodies on the Board. The RCGP holds the contract with the Institute for the NCC-PC.

2.5.2. The development team

The development team had the responsibility for this guideline throughout its development. They were responsible for preparing information for the Guideline Development Group (GDG), for drafting the guideline and for responding to consultation comments. The development team working on this guideline consisted of the:

  • Guideline lead
    who is a senior member of the NCC-PC team who has overall responsibility for the guideline
  • Information scientist
    who searched the bibliographic databases for evidence to answer the questions posed by the GDG
  • Reviewer (Health Services Research Fellow)
    who appraised the literature and abstracted and distilled the relevant evidence for the GDG
  • Health economist
    who reviewed the economic evidence, constructed economic models in selected areas and assisted the GDG in considering cost effectiveness
  • Project manager
    who was responsible for organising and planning the development, for meetings and minutes and for liaising with the Institute and external bodies
  • Clinical advisor
    A clinician with an academic understanding of the research in the area and its practical implications to the service, who advised the development team on searches and the interpretation of the literature
  • Chair
    who was responsible for chairing and facilitating the working of the GDG meetings

Applications were invited for the post of Clinical Advisor, who was recruited to work on average, a half a day a week on the guideline. The members of the development team attended the GDG meetings and participated in them. The development team also met regularly with the Chair of the GDG and the Clinical Advisor during the development of the guideline to review progress and plan work.

2.5.3. The Guideline Development Group (GDG)

A Chair was chosen for the group and his primary role was to facilitate and chair the GDG meetings.

Guideline Development Groups (GDGs) are working groups consisting of a range of members with the experience and expertise needed to address the scope of the guideline. Nominations for GDG members were invited from the relevant stakeholder organisations which were sent the draft scope of the guideline with some guidance on the expertise needed. Two patient representatives and nine healthcare professionals were invited to join the GDG.

Nominees who were not selected for the GDG were invited to act as Expert Peer Reviewers and were sent drafts of the guideline by the Institute during the consultation periods and invited to submit comments using the same process as stakeholders.

Each member of the GDG served as an individual expert in their own right and not as a representative of their nominating organisation, although they were encouraged to keep the nominating organisation informed of progress.

In accordance with guidance from NICE, all GDG members’ interests were recorded on a standard declaration form that covered consultancies, fee-paid work, share-holdings, fellowships, and support from the healthcare industry. Details of these can be seen in Appendix F.

The names of GDG members appear listed below.

Full GDG members

  • Professor Martin Underwood (Chair)
    Professor of Primary Care Research
    Warwick Medical School, University of Warwick
  • Professor Paul Watson (Clinical Advisor)
    Professor of Pain Management and Rehabilitation
    Department of Health Sciences, University of Leicester
  • Mrs Elaine Buchanan
    Consultant Physiotherapist, Nuffield Orthopaedic Centre, Oxford
  • Dr Paul Coffey
    General Practitioner, Eynsham Medical Group, Whitney, Oxon
  • Mr Peter Dixon
    Chiropractor Chairman General Chiropractic Council, London
  • Mrs Christine Drummond
    Patient member
  • Mrs Margaret Flanagan
    Nurse Clinician, Western Avenue Medical Centre, Chester
  • Professor Charles Greenough
    Consultant Spinal Surgeon, James Cook University, Middlesbrough
  • Dr Mark Griffiths (PhD),
    Consultant Clinical Psychologist
    NHS Halton & St Helens, Cheshire
  • Dr Jacqueline Halliday Bell
    Medical Inspector Health and Safety Executive, Birmingham
  • Dr Dries Hettinga (PhD)
    Patient member, BackCare
  • Mr Steven Vogel
    Vice Principal (Research and Quality), British School of Osteopathy, London
  • Dr David Walsh
    Associate Professor University of Nottingham

Members of the GDG from the NCC-PC were

  • Gill Ritchie
    Guideline Lead, NCC-PC
  • Pauline Savigny
    Health Services Research Fellow, NCC-PC
  • Nicola Brown
    Health Services Research Fellow, NCC-PC (from May 2007 to October 2007)
  • Stefanie Kuntze
    Health Economist, NCC-PC
  • David Hill
    Project Manager, NCC-PC
  • Chris Rule
    Project Manager, NCC-PC (from August 2006 to September 2007)
  • Marian Cotterell
    Information Scientist, NCC-PC

Co-opted GDG Members

  • Dr Michael Cummings
    Medical Director, British Medical Acupuncture Society
  • Mr Ray Langford
    Clinical Specialist Occupational Therapist, St Helens, Knowsley Hospitals NHS Teaching Trust

Observers

  • Ms Colette Marshall
    Commissioning Manager, National Institute for Health and Clinical Excellence (until August 2007)
  • Ms Sarah Willett
    Commissioning Manager, National Institute for Health and Clinical Excellence (from December 2007)

2.5.4. Guideline Development Group meetings

The GDG met at 5 to 6 weekly intervals for 16 months to review the evidence identified by the development team, to comment on its quality and relevance, and to develop recommendations for clinical practice based on the available evidence. The recommendations were agreed by the full GDG.

2.6. Care pathway

A clinical care pathway (see next page) has been developed to indicate the key components in the treatment and management of non-specific LBP in adults. This is reproduced from the quick reference guide of the guideline, which is available at www.nice.org.uk/CG88.

Flowchart Icon

Care pathway. (PDF, 175K)

2.7. Research recommendations

What is the clinical and cost effectiveness of using screening protocols to target treatments for patients with 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 (Haldorsen, Håland. E. M., Grasdal, Astrid. L., Skouen, Jan. Sture. et al, 2002). 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.

How can education be effectively delivered for people with chronic 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:

  • identify appropriate goals and techniques for the education of people with low back pain
  • determine efficacy in achieving educational goals
  • determine effects on clinical outcomes, including pain, distress and disability.

What is the effectiveness and cost effectiveness of sequential interventions (manual therapy, exercise and acupuncture) compared with single interventions on pain, functional disability and psychological distress, in people with chronic non-specific back pain of between six weeks and one year?

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:

  • test the effect of providing a subsequent course of a different therapy (manual therapy, exercise or acupuncture) in the management of persistent non-specific low back pain, when the first-choice therapy has been inadequately effective.
  • determine the cost effectiveness of providing more than one of these interventions to people with persistent non-specific low back pain.

What is the effectiveness and cost effectiveness of psychological treatments for non-specific low back pain greater than six weeks?

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:

  • use randomised controlled trials to test the effect of adding psychological treatment to other treatments for non-specific low back pain
  • test individual and/or group treatments
  • clearly describe the psychological treatments tested and provide a robust theoretical justification for them.

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.

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.

Is Transcutaneous Electrical Nerve Stimulation (TENS) an effective therapy for the management of non-specific chronic low back pain?

Why this is important,

TENS is a widely used modality in the management of chronic low back pain; it can be used as an analgesic modality on its own or in combination with analgesic medication. Despite the long history of use of TENS for back pain the quality of research studies is poor. There is evidence from cohort studies that TENS is well tolerated and those who find it effective continue to use it successfully for many years. These guidelines have failed to recommend TENS as a treatment, not because of evidence that it does not work, but because there is no evidence that it is effective. The guideline development group did not find any large well-conducted large randomised controlled studies.

TENS research should

  • Establish the most effective stimulation parameters for effective use.
  • Assess pain relief when using TENS, overall daily pain, medication usage and healthcare consulting as outcomes in addition to disability.

2.8 Acknowledgements

We gratefully acknowledge the contributions of Joanne Lord (NICE) for her advice and work on the health economic modelling. Anne Morgan for her work on the cost effectiveness and clinical evidence reviews. Chris Rule for project managing the guideline through the scoping and development phases. Chris Tack for his work on the guideline scope and developing the clinical questions this guideline should address; Angela Cooper, Neill Calvert; Julie Neilson and Katrina Sparrow from the NCC-PC for their help and advice with regard to the clinical and cost effectiveness reviews. Finally we are also very grateful to all those who advised the development team and GDG and so contributed to the guideline process.

2.9 Glossary

Acupuncture

Acupuncture refers to the insertion of a solid needle into any part of the human body for disease prevention, therapy or maintenance of health. There are various other techniques often used with acupuncture, which may or may not be invasive.

From: Acupuncture Regulation Working Group report published in September 2003

Alexander Technique

The Alexander Technique is a taught self-care discipline that enables an individual to recognise, understand and avoid habits adversely affecting muscle tone, coordination and spinal functioning. Priority is given to habits that affect freedom of poise of the head and neck and that lead to stiffening and shortening of the spine, often causing or aggravating pain

Autotraction

Traction performed by utilising the patient’s own body weight (for example by suspension via the lower limb) or through movement

Bio-psychological model

The bio-psychosocial model of illness is an explanatory model for illness that hypothesizes that biological, psychological, and social factors all have role in explaining human disease. This contrasts with the traditional reductionist medical model of illness seeks to identify a single, usually physical cause for illness. The bio-psychosocial assessments are part of approach used of many clinicians, from a range of professional backgrounds, who treat back pain

Cognitive Behavioural Therapy (CBT)

A range of therapies based on psychological models of human cognition, learning and behaviour

Chiropractic treatment

The diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the functions of the nervous system and general health. There is an emphasis on manual treatments including spinal adjustment and other joint and soft-tissue manipulation. (World Federation of Chiropractic 2001)

Cost effectiveness acceptability curve (CEAC)

The cost-effectiveness acceptability curve (CEAC) is a method for summarising the uncertainty in estimates of cost-effectiveness. The CEAC, derived from the joint distribution of costs and effects, illustrates the (Bayesian) probability that the data are consistent with a true cost-effectiveness ratio falling below a specified ceiling ratio. (Fenwick et al., 2006 BMC)

Cost-benefit analysis

A type of economic evaluation where both costs and benefits of healthcare treatment are measured in the same monetary units. If benefits exceed costs, the evaluation would recommend providing the treatment

Cost-consequences analysis

A type of economic evaluation where various health outcomes are reported in addition to cost for each intervention, but there is no overall measure of health gain

Cost-effectiveness analysis

An economic study design in which consequences of different interventions are measured using a single outcome, usually in ‘natural’ units (for example, life-years gained, deaths avoided, heart attacks avoided, cases detected). Alternative interventions are then compared in terms of cost per unit of effectiveness

Cost-effectiveness model

An explicit mathematical framework, which is used to represent clinical decision problems and incorporate evidence from a variety of sources in order to estimate the costs and health outcomes. See also Markov model

Cost-minimisation analysis

An economic evaluation that finds the least costly alternative therapy after the proposed interventions has been demonstrated to be no worse than its main comparator(s) in terms of effectiveness and toxicity

Cost-utility analysis

A form of cost-effectiveness analysis in which the units of effectiveness are quality-adjusted life-years (QALYs)

Counselling

Counselling takes place when a counsellor sees a client in a private and confidential setting to explore a difficulty the client is having, distress they may be experiencing or perhaps their dissatisfaction with life, or loss of a sense of direction and purpose. It is always at the request of the client as no one can properly be ’sent’ for counseling

COX-2 inhibitors

A type of NSAID thought to be less likely to produce gastro-intestinal adverse effects than traditional NSAIDs example include celecoxib and etoricoxib

CPP

Combined physical and psychological interventions

Decision analysis

A systematic way of reaching decisions, based on evidence from research. This evidence is translated into probabilities, and then into diagrams or decision trees which direct the clinician through a succession of possible scenarios, actions and outcomes

Decision problem

A clear specification of the interventions, patient populations and outcome measures and the perspective adopted in an evaluation, with an explicit justification, relating these to the decision which the analysis is to inform

Discounting

Costs and benefits incurred today have a higher value than costs and benefits occurring in the future. Discounting health benefits reflects individual preference for benefits to be experienced in the present rather than the future. Discounting costs reflects individual preference for costs to be experienced in the future rather than the present. For NICE economic evaluations, health outcomes will be discounted at 3.5% and costs at 3.5% per annum, following the recommendations of the UK Treasury

Dominance

An intervention is said to be dominant if it is both less costly and more effective than an alternative intervention. See also extended dominance

Economic evaluation

Comparative analysis of alternative health strategies (interventions or programmes), in terms of both their costs and consequences

Extended dominance

An intervention is extendedly dominated when it can be dominated by a combination of two alternative interventions (i.e. if x% of the population are treated with intervention A, and y% are treated with intervention C, the overall result will be an intervention strategy that is both cheaper and more effective than intervention B). See also dominance

Extrapolation

In data analysis, predicting the value of a parameter outside the range of observed values

Facet Joint denervation

Removal of nerve supply to the synovial joints between zygapophyses or articular processes of the vertebrae, usually by heating, cutting or crushing the axons

Facet joint injection

Injection of therapeutic substances into the facet joint

Health economics

The study of the allocation of resources among alternative healthcare treatments. Health economists are concerned with both increasing the average level of health in the population and improving the distribution of healthcare resources

Health-related quality of life

A combination of an individual’s physical, mental and social well-being not merely the absence of disease.

Health related quality of life (HRQoL) is a subdivision of quality of life and most commonly refers to people’s experience of their global health. It may also refer to health-related subjective well-being, functional status or self-perceived health multi-dimensional concept that encompasses the physical, emotional and social components associated with an illness or treatment

Hydrotherapy

An exercise treatment conducted within a specially designed pool so that water supports the patient’s body weight

ICER Incremental cost effectiveness ratio

Incremental cost effectiveness ratio – this is the difference between the mean costs in the Incremental Cost population of interest divided by the difference in effectiveness ratio the mean outcomes in the population of interest

For instance if A and B are being compared: Cost of A minus costs of B divided by effects of A minus effects of B.This the mathematical derivation of the QALY (see below)

Interferential therapy

An electrical treatment that uses two medium frequency currents, simultaneously, so that their paths cross. Where they cross a beat frequency is generated which mimics a low frequency stimulation

Intra-Discal Electrothermal Therapy (IDET)

Use of a heating wire passed through a hollow needle into the lumbar disc intended to seal any ruptures in the disc

Laser therapy

The use of lasers to generate heat and non-heat energy within the body

Life-year

A measure of health outcome that shows the number of years of remaining life expectancy

Life-years gained

Average years of life gained per person as a result of an intervention

Lumbar supports

External devices designed to reduce spinal mobility, e.g. corsets

Manipulation

Small amplitude high velocity movement at the limit of joint range taking the joint beyond the available range of movement

Manual Therapy

A general term for treatments such as chiropractic, osteopathy or physiotherapy that involve manipulation, massage, soft tissue and joint mobilisation

Markov model

A modelling technique used when more than two health states needs to be considered. They are particularly useful for disease in which events can occur repeatedly over time

McKenzie

A system of assessment and management for all musculoskeletal problems that uses classification into non-specific mechanical syndromes. Assessment involves the monitoring of symptomatic and mechanical responses during the use of repeated movements and sustained postures

Mobilisation

Therapist delivered joint movements within the available range of motion

MRI

Magnetic resonance imaging an imaging technique used to image internal structures of the body, particularly the soft tissues without use of radiation

Neuroreflexotherapy

Temporary implantations of epidermal devices into trigger points at the site of each subject’s clinically involved dermatomes on the back and into referred tender points in the ear

Non-specific low back pain

Pain muscle tension or stiffness affecting the lower back for which there is not a recognised patho-anatomic cause

NSAIDS

Non-steroidal anti-inflammatory drugs. Examples include naproxen, ibuprofen and diclofenac

ODI

Oswestry Disability index

Opioid

A type of painkiller used for moderate to severe pain. Examples of weak opioids are codeine and dihydrocodeine (these are sometimes combined with paracetamol as co-codamol or co-dydramol, respectively). Examples of strong opioids are buprenorphine, diamorphine, pethidine and fentanyl. Some opioids, such as tramadol, are difficult to classify because they can act like a weak or strong opioid depending on the dose used and the circumstances

Opportunity cost

The opportunity cost of investing in a healthcare intervention is the other healthcare programmes that are displaced by its introduction. This may be best measured by the health benefits that could have been achieved had the money been spent on the next best alternative healthcare intervention

Osteopathy

Osteopaths specialise in the diagnosis, treatment, prevention and rehabilitation of musculoskeletal conditions. Osteopathic manual therapy, including manipulation, is an important part of most treatment

Percutaneous Electrical Nerve Stimulation (PENS)

The electrical stimulation, using needles inserted into the skin, of sensory nerves serving pain generating structures

Physiotherapy

Physiotherapy aims to improve human function and movement and maximising potential: it uses physical approaches to promote, maintain and restore physical, psychological and social well-being, through the use of manual therapy, electro therapy and exercise

Prepared Patient Information

Prepared patient information booklets as opposed to written report of verbal information given during the consultation

Probabilistic sensitivity analysis

Probability distributions are assigned to the uncertain parameters and are incorporated into evaluation models based on decision analytical techniques (for example, Monte Carlo simulation)

Prolotherapy

Injections of irritant solutions to strengthen lumbosacral ligaments

Proton pump inhibitor

A type of drug that reduces the production of acid in the stomach, and is used to treat indigestion and stomach ulcers. Examples include omeprazole and lansoprazole

Psychological treatment

Psychological treatments include a range of talking therapies including both psychotherapy and counselling there a several different broad psychological approaches, including, for example cognitive behavioural therapy (CBT). The focus of these treatments is usually on health promotion rather than treating specific disorders

Quality adjusted life-years (QALYS)

An index of survival that is adjusted to account for the person’s quality of life during this time. QALYs have the advantage of incorporating changes in both quantity (longevity/mortality) and quality (morbidity, psychological, functional, social and other factors) of life. Used to measure benefits in cost-utility analysis, QALYS are calculated by estimating the number of years of life gained from a treatment and weighting each year with a quality-of-life score between zero and one

radiofrequency facet joint denervation

The use of radio-frequency energy to generate heat to destroy nerves supplying the lumbar facet joints

RMDQ

Roland Morris Disability Questionnaire

Spinal Fusion

A procedure that involves fusing together two or more vertebrae in the spine using either bone grafts or metal rods

SSRI

Selective Serotonin reuptake inhibitor. A class of drug that are used as an antidepressant

TENS

Transcutaneous electrical nerve stimulation. A method of producing electroanalgesia through electrodes applied to the skin

The Back Book

A widely used advice booklet for people with back pain

Therapeutic ultrasound

The use of, externally applied sound waves to generate heat within specific parts of the body

Time horizon

The time span used in the NICE appraisal that reflects the period over which the main differences between interventions in health effects and use of healthcare resources are expected to be experienced, and taking into account the limitations of supportive evidence

Traction

The use of externally applied force to stretch and mobilise the spine

Tricyclic antidepressant (TCA)

A type of drug that can be used to treat back pain –this use is different from its action in treating depression, which usually requires a much higher dose. Examples include amitriptyline and imipramine

Usual Care

Typical advice and other treatments offered in within general practice

Utility

This concept is applied in health care to mean the individual’s valuation of their state of well-being deriving from the use of health care interventions. In brief, utility is a measure of the preference for, or desirability of, a specific level of health status or specific health outcome

VAS

Visual analogue score - a score for measuring pain

Willingness to pay (WTP) threshold

WTP refers to the amount that a decision maker is willing to pay for an additional unit of outcome (e.g. an additional QALY). If the WTP is higher than the ICER, the intervention is cost effective. If not, the intervention is not cost effective.

Boxes

Box 1Specific causes of low back pain (not covered in this guideline)

Malignancy

Infection

Fracture

Ankylosing Spondylitis and other inflammatory disorders

Copyright © 2009, Royal College of General Practitioners.

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Bookshelf ID: NBK11709
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