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How effective are guidelines for the management of low back pain?
  1. N J Sheehan
  1. Consultant Rheumatologist, Department of Rheumatology, Edith Cavell Hospital, Peterborough PE3 9GZ , UK njsheehan{at}

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    The National Institute for Clinical Effectiveness (NICE) recently published its first referral practice guide for general practitioners containing inter alia referral advice for acute low back pain.1 The NICE guidelines are to be evaluated in pilot schemes before being disseminated nationally. Six years have passed since the publication of the Clinical Standards Advisory Group (CSAG) report on back pain2 and it is four years since the Royal College of General Practitioners (RCGP) issued its own guidelines for the management of acute low back pain.3 Changes in practice introduced in response to these documents might give an indication of the likely success of the NICE guidelines in altering referral patterns and the clinical management of back pain.

    The CSAG report advocated that responsibility for back pain should be transferred from secondary to primary care. If this recommendation has been followed, there should have been a substantial reduction in the number of cases of back pain referred to hospital since 1994. Rheumatology encompasses a wide spectrum of musculoskeletal disorders and back pain accounts for a large proportion of referrals to many rheumatology departments. Amongst its recommendations, CSAG advised that domiciliary visits and hospital bed rest for back pain should be discontinued.

    I have audited the numbers, referral patterns, and management of patients with low back pain referred to me following publication of the CSAG and RCGP reports and compared them with previous practice.

    There was no overall reduction in the number of back pain cases referred to my main clinic during the period 1987–2000 (fig 1). In the last 5 years back pain has continued to account for an average of 22% of all new referrals, a proportion unchanged from the mean figure for the previous 8 years. The greatest change in practice was observed in the numbers of patients with back pain admitted to hospital for bed rest which fell from 53 in 1994 to two in 1997 before rising again to 10 in 1999. Domiciliary visits for back pain (table 1) roughly halved during the same period, but back pain still accounts for almost two thirds of requests for home visits.

    The nadir in both domiciliary visit requests and the number of admissions to hospital coincided with the appointment of a specialist back pain physiotherapist who provided an acute referral service in the community as well as conducting a fortnightly clinic in the rheumatology department, seeing patients with back pain who had been referred to the consultant. There was a rebound in the number of back pain admissions when this service suddenly ceased in 1998.

    The difference in the responses of secondary and primary care to the recommendations of the CSAG and RCGP reports may simply reflect the fact that it is easier to withdraw a service (inpatient bed rest) than to create a new one (efficient and effective primary care based treatment). The first saves money while the second demands additional resources which are not easily found.

    Until the will to demedicalise back pain and manage it in the community is matched by adequate funding, patients will continue to be referred inappropriately to hospitals. When it receives the results of the evaluation of its new guidelines, NICE is likely to be disappointed.

    Table 1

    Annual domiciliary visits (DV) for low back pain, 1994–2000

    Figure 1

    Annual new outpatient attendances for low back pain (LBP), 1987–2000. The data represent referrals to one consultant at his main hospital. The annual totals are for April–March.