Regimental Therapy

NICE guidelines development
Low back pain and sciatica:

Management of non-specific low
back pain and sciatica
Steven Vogel
Vice Principal (Research),
The British School of Osteopathy
Editor-in-Chief,
The International Journal of Osteopathic Medicine
Aims of the presentation
• Brief overview of clinical guidelines
• Summary of current NICE guidelines for
the management of persistent non specific
low back pain
• Scope of the new guideline currently in
development
• Brief description of the development
process
Guidelines and back pain
• Clinical guidelines aim
to improve quality of
care by translating
best evidence into
practice
• Provide guidance for
clinicians
• Provide guidance for
purchasers
A clinical guideline is not the

same as a protocol….
• Reviewed guidelines from 13 countries
and 2 international guidelines
Diagnosis
Treatment
2009 NICE guidelines persistent
non specific back pain
Keep diagnosis under review at all times

AND
Promote self-management
AND
Offer drug treatments as appropriate
AND
Follow the care pathway
Key points for implementation
• Provide people with advice and information to promote
self-management: Nature of back pain, encourages
normal activities, stay physically active and to exercise
• Offer one of the following treatment options, taking

patient preference into account:
 an exercise programme
 a course of manual therapy
 a course of acupuncture
If improvement is not satisfactory, consider offering
another of these
Combined physical and psychological
treatment programme
CPP
• Consider referral for combined physical and
psychological treatment for people who:
 have received at least one less intensive treatment

and
 have high disability and/or significant psychological
distress.
Do not
• Offer injections of therapeutic substances into
the back for non-specific low back pain.
• Refer for intradiscal electrothermal therapy
(IDET)
• Refer for radiofrequency facet jt denervation
• Refer for percutaneous intradiscal
radiofrequency thermocoagulation (PIRFT)
• SSRIs, Laser, Interferential therapy, Ultrasound,
TENS, Supports, Traction
Assessment and imaging
• Do not offer X-ray of the

lumbar spine
• Only offer an MRI scan within

the context of a referral for an
opinion on spinal fusion
Referral for surgery
• Consider referral for an opinion on spinal fusion for

people who:
 have completed an
optimal package
of care
and
 would consider
surgery for their
low back pain.
Controversy
• Injections
• Acupuncture
• Manipulation
• Unclear to what extent the guideline has

been implemented
Update in progress
Low back pain and sciatica: management

of non-specific low back pain and sciatica
This is an update of Low back pain: early

management of persistent non-specific
low back pain (NICE clinical guideline 88).
Scope
• The scope:
• NHS England – topic selection
• Update after 3 year review (GDG and high level
review)
• Identifies the key clinical issues
• Sets the boundaries of the development work
• Provides information to healthcare professionals
about the expected content of the guideline
• Informs the development of the detailed review
questions from the key clinical issues
Population
• Groups that will be included:
• People aged 16 or older presenting with
symptoms of ‘non-specific’ low back pain. The
pain may (or may not) radiate to the limbs and
is not associated with progressive neurological
deficit
• People aged 16 or older with suspected
sciatica
Settings
• All settings in which NHS-funded care is

received.
Groups that will not be covered
low back pain or sciatica related to specific spinal pathologies,
including:
• inflammatory causes of back pain (for example, ankylosing

spondylitis or diseases of the viscera)
• serious spinal pathology (for example, neoplasms, infections
or osteoporotic collapse)
• neurological disorders (including cauda equina syndrome or
mononeuritis)
• adolescent scoliosis.
• People aged under 16 years.
Key issues that will be covered
• Assessment to identify ‘non-specific’ low back pain and sciatica
and any prognostic factors that could guide management.
• Use of pharmacological treatments for low back pain.
• Non-pharmacological interventions.
• Manual therapies
• CAM therapies
• Orthotics and appliances
• Patient education
• Electrotherapy
• Self management
• continued
Key issues that will be covered
• Combined therapies
• The use of invasive procedures
• Psychological interventions
• Surgery
Key issues that will not be
covered
• post-surgery care
• spinal cord stimulation
• Pharmacological treatments for sciatica.

Main outcomes
• Pain severity (for example, visual analogue scale [VAS] or
numeric rating scale [NRS])
• Function measured by disability scores (for example, the

Roland-Morris disability questionnaire or the Oswestry
disability index)
• Health-related quality of life (for example, SF-12 or EQ-5D)
• Adverse events
• Healthcare utilisation
Developing clinical guidelines
overview
• Scoping: Identify and refine the subject area
• Convene multi disciplinary guideline
development groups (GDGs)
• Develop clinical questions
• Retrieve, analyse and present the evidence to
the GDG
• Translate the evidence into recommendations
• Consultation: external review of the guideline
Guideline Development
Group (GDG)
• Multidisciplinary group, including health care
professionals and patient/carer members.
• Should represent the perspectives of the health
care professionals involved in the care of
patients affected by the condition
• Not expected to represent the views of their
professional organisations
• Are required to declare conflicts of interest and
follow a code of conduct
Appointment to the GDG
• Open application: statement and CV
• Interview
• Appointment
• No remuneration
• Approximately one meeting per month for
2 years
Name Background
Dr Stephen Ward Consultant in Pain Medicine, Chair
Prof. Gary McFarlane Epidemiologist
Dr Ian Bernstein General Practitioner
Dr Simon Somerville General Practitioner
Mr Steven Vogel Manual Therapist
Mr Babak Arvin Neurosurgeon
Mrs Helen Taylor Clinical Nurse Specialist
Dr Chris Wells Pain Medicine Specialist
Dr Neil O’Connell Physiotherapist
Dr Patrick Hill Clinical Psychologist
Prof. David Walsh Rheumatologist
Mr Phillip Sell Spinal Surgeon
Mr Mark Mason Patient Member
Ms Wendy Menon Patient Member
GDG
• Supported by technical team
• Research fellows
• Health economists
• Information scientist
• Project manager, and
• Guideline lead.
• Technical team are members of the
group with voting rights
Clinical questions
• Each recommendation needs to relate to a
question
• Each question has to be addressed with a
systematic review of the evidence
• The most widely used structure is PICO
– Population
– Intervention
– Comparison
– Outcome
• This implies the minimum requirements for a
clinical question
Example from the 2009 clinical guideline
Question: What is the effectiveness of manual
therapies compared with usual care on
functional disability, pain, or distress?
Population Adults presenting with non specific back pain > than
6 weeks duration and < one year
Intervention Manual therapies
Comparison Usual care
Outcome Disability scores

Pain scores
Psychological distress
Determine type
of review Assess quality
Present results
question by outcome
to GDG
(GRADE)
Produce review Analysis:

protocol including meta- Interpret the
analysis where evidence and apply
appropriate context
Recommendations
Search medical
literature Extract data
databases
“Sift” search
results; then obtain Include /exclude full
full papers papers
Assessing the quality of the evidence
for interventions using GRADE
Randomised trials are best study design for
• Study design
intervention reviews
• Study limitations Consider randomisation method, allocation
(risk of bias) concealment, blinding, missing data, etc
• Indirectness Patient population and intervention do not fit
directly with those of the guideline
• Inconsistency Differences in effect size between studies and
explanations by subgroup analysis
• Imprecision Results are consistent with more than one conclusion,
relative to the clinically important effect
May be funding issue or only publishing studies
• Publication bias with significant results
GRADE classifies evidence quality as:
• High: We are very confident that the true effect lies
close to that of the estimate of the effect
• Moderate: We are moderately confident in the effect
estimate: The true effect is likely to be close to the
estimate of the effect, but there is a possibility that it is
substantially different
• Low: Our confidence in the effect estimate is limited:
The true effect may be substantially different from the
estimate of the effect
• Very low: We have very little confidence in the effect
estimate: The true effect is likely to be substantially
different from the estimate of effect
What information do the GDG
consider?
• Evidence report
• Exclusion list
• Forest plots (meta-analysis)

Paperwork
• GRADE Evidence profiles
• Evidence statements (sent out prior to each GDG

meeting)
• Evidence tables
• Health economic evidence

Why consider cost-effectiveness?
• The NHS does not
have enough
resources to do
everything
• If it spends more on
one thing, it has to do
less of something else
• Could we do more
good by spending
money differently?
• Prioritise interventions
with a high health gain
per £ spent (QALY)
Recommendations and NICE principles:
• Recommendations must reflect the evidence
• ‘Offer’ vs ‘Consider’
• Clinical and cost effectiveness considered
• Can make recommendation for a subgroup of
population if clear evidence for effectiveness
• Must consider equalities issues
• Transparency
Options when poor quality / no evidence
• Expert group discussion (informal consensus / vote)

• Extrapolate if possible (indirect evidence)
• Formal consensus decision making
• Transparency and acknowledgement
• No recommendation
Validation
• Draft guideline sent out for stakeholder
consultation as part of the clinical guideline
development
• Key part of the quality assurance and peer-
review processes
• Important that stakeholder comments are
addressed appropriately
Acknowledgements
Grateful acknowledgement is given to the
following people who have kindly allowed
me to use their slides as part this
presentation.
• Dr Stephen Ward – Chair, Consultant in Pain

Medicine, Brighton & Sussex University
Hospitals NHS trust
• Serena Carville – Associate Director, Guideline
Lead, National Clinical Guideline Centre
Thank you for your attention
Questions?
• https://www.nice.org.uk/
• http://www.ncgc.ac.uk/

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NICE guidelines development

Low back pain and sciatica:

A clinical guideline is not the

Keep diagnosis under review at all times

• Offer one of the following treatment options, taking

 have received at least one less intensive treatment

• Do not offer X-ray of the

• Only offer an MRI scan within

• Consider referral for an opinion on spinal fusion for

• Unclear to what extent the guideline has

Low back pain and sciatica: management

This is an update of Low back pain: early

• All settings in which NHS-funded care is

• inflammatory causes of back pain (for example, ankylosing

• Use of pharmacological treatments for low back pain.

• The use of invasive procedures

• spinal cord stimulation

• Pharmacological treatments for sciatica.

• Function measured by disability scores (for example, the

• Health-related quality of life (for example, SF-12 or EQ-5D)

Comparison Usual care

Outcome Disability scores

Produce review Analysis:

• Forest plots (meta-analysis)

• Evidence statements (sent out prior to each GDG

• Health economic evidence

• Expert group discussion (informal consensus / vote)

• Dr Stephen Ward – Chair, Consultant in Pain

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