Unequivocally, all good things come in trilogies: Lord of the Rings, The Matrix, The Dark Knight. It therefore comes as no shock to you, avid reader, that my opinions on the NICE LBP guidelines will culminate in this final, third instalment. Please, read over all three blogs and provide feedback, whether it be publicly or privately, as it all goes towards making the world a better place. It has been great to receive encouraging comments thus far, including clinicians using the info to support their practice, and journal editors suggesting its relevance to a wider readership. This one is nice (?!) and short!
In the absence of a study or studies investigating a specific population, guidelines often extrapolate findings from similar, or related, conditions. With the 2016 LBP guidelines, the caveat was that currently, there does not exist a breadth of evidence to cover LBP, and so the panel have considered it appropriate to use the findings of related outcomes in reviewed studies as an appropriate substitute. This is a logical, practical step which is supposed to help clinicians, whilst acknowledging the need to up the game in the research realm. As with the two previous Blog posts (The NICE Sham-bles & A NICE example of study quality consideration) I have yet again used those interventions included in the guidelines to illustrate the gross inconsistencies in the methods in which interventions were included.
So, self-management was recommended because the panel thought it sounded like a good idea (NICE, 2016, p.201). Furthermore, psychological therapies including a cognitive behavioral approach, and manual therapy, were recommended despite the absence of a clinically important improvement in quality of life. In addition, there was sufficient evidence of absence of effect in soft tissue techniques (e.g. massage), and therefore could not be recommended as a standalone intervention: ‘based on the limited clinical benefit seen for mobilisation/manipulation, the Guideline Development Group’s (GDG) felt this form of manual therapy could not be recommended for low back pain or sciatica as an independent intervention.’ (NICE, 2016, p.665). Despite the panel expressing difficulty in being able to state which manual therapy to recommend, they recommend it (and massage) on the proviso that it is in conjunction with other modalities (not stated which). Apologies for stating the obvious, but this is exactly the grounds in which contemporary acupuncture is taught, clinically reasoned and executed; it is rarely, if ever, a stand-alone intervention, and should always be used in conjunction with other modalities.
For NSAIDS, they were recommended for acute low back pain, despite the adverse event profile, and ‘that all the evidence [reviewed for the guideline] was drawn from people with chronic low back pain’ (NICE, 2016, p.665). In addition: ‘The GDG concluded that the potential harms of opioid treatment for chronic low back pain when used as a single agent outweighed the benefits and agreed a recommendation that opioids should not be used in the management of chronic low back pain.’ Yet, weak opioids are recommended when NSAIDS have not worked or are unsuitable. For comparison, here is what they say regarding the findings for acupuncture ‘Where clinically important effects were demonstrated, these were usually short-term.’ (NICE, 2016, p.497). So, acupuncture literature that was reviewed for this guideline, found clinically important short term benefits. Combined with its established extremely low adverse event risk profile, its exclusion for acute flare ups is does not add up.
The point of this short blog post is that the above approaches were considered appropriate to recommend despite several flaws. This seems to be logical in the absence of any stand out approach, but why acupuncture was excluded? The results of nearly every single study into acupuncture for LBP demonstrates it is effective for pain and/or function, regardless of what the proposed independent variable may be. To confound matters, there were studies that were shown to demonstrate a clear benefit compared to verum acupuncture, and as previously posted, a systematic review with meta-analysis by MacPherson et al (2017) demonstrated a clear benefit to receiving acupuncture in chronic pain populations. My hope is that those who make decisions on service provision, give this trilogy of blog posts serious thought. Maintaining a vibrant acupuncture service ensures clinicians can continue with an intervention that has a solid, supportive evidence base, whilst ensuring practitioner autonomy is preserved.
Dr. Carl Clarkson