Britain Releases Back Pain Guidelines

The United Kingdom has joined the United States and Sweden in recognizing the value of clinical practice guidelines for back pain with the publication of two documents: Back Pain and the Epidemiology and Cost of Back Pain. The documents are the product of the Clinical Standards Advisory Group (CSAG) established under the Community Care Act of 1990.

The Centre for Health Economics at York, commissioned by the CSAG, estimates the cost of back pain to Britain's National Health Service (NHS) at approximately 480 million pounds in 1993 (that's $755 million Yankee dollars). The cost to lost production was estimated at a very approximate 3.8 billion pounds (5.9 billion US); and DSS (Dept. of Social Services) benefits of an additional 1.4 billion pounds (2.18 billion US).

In Back Pain, it is noted that the British guidelines were produced "in collaboration with the US Panel and are broadly similar to current US and Swedish guidelines." They are said to refer "to low back pain but the same principles apply to other regions of the spine." The "US Panel" refers to the panel of experts that developed the guidelines for acute low back problems for the Agency for Health Care Policy and Research (under the US Department of Health and Human Services).

And indeed the conclusions of the United Kingdom's Clinical Standards Advisory Group were very similar to those of the low back panel of the US Agency for Health Care Policy and Research:

Early Management Strategy:

Prescribe simple analgesia, NSAIDS
(nonsteroidal anti-inflamatory drugs)

• avoid narcotics if possible and never for more than two weeks

Arrange physical therapy

• if symptoms last more than a few days
• manipulation
• active exercise and physical activity

Advise rest only if essential: 1-3 days

• prolonged bed rest is harmful

Encourage early activity

• activity is not harmful
• reduces pain
• physical fitness beneficial

Practice psychosocial management; this is fundamental

• promote positive attitudes to activity and work
• distress and depression

Advise absence from work only if unavoidable; early return to work

• prolonged sickness absence makes return to work increasingly difficult

The Clinical Standards Advisory Group that developed the back pain guidelines was a 10-member panel, that included Alan Breen, DC, PhD, research director for the Anglo-European College of Chiropractic, representing the chiropractic profession. In addition, the British Chiropractic Association was invited to be a "sounding board" on the guidelines, with their president, Dr. Hutchison, as a guest speaker.

We asked the British Chiropractic Association (BCA) for their take on the guidelines. BCA Executive Director Sue Wakefield stated:

"The Clinical Services Advisory Group (CSAG) is the UK equivalent of the American AHCPR. It's recommendations on back pain are less detailed than the AHCPR report. However, the main recommendation is that resources for the treatment of back pain in the National Health Service here should be shifted from hospital-based treatment to treatment in the community. The treatment in the community should include chiropractic, as well as manipulative physiotherapy and osteopathy.

"The publication of the report completes a series of events in the UK which brings chiropractic into the group of mainstream health professions. The other events leading to this were academic degree qualifications, registration under an Act of Parliament and a major clinical trial which established our effectiveness. The passage of the Chiropractors' Act has also been welcomed by the British Medical Association and the Royal College of General Practitioners, which in itself is very positive.

"The profession must now decide how quickly it wishes to move towards these activities and how to expand its recognition, building on its reputation for the treatment of low back pain, to other health care areas in which we are successful."

----------- * It should be noted that the term "physical therapy" in the British context is a general term that includes the care given by chiropractors, osteopaths and physiotherapists. "Greater professional and academic collaborations" between MDs, DCs, DOs and PTs is encouraged by the guidelines.