NICE clinical guideline 88: Low back pain

Low back pain: early management of persistent non-specific low back pain

The development of this NICE clinical guideline on low back pain began before the Faculty of Pain Medicine of the Royal College of Anaesthetists was established in April 2007. The Royal College of Anaesthetists was registered as a stakeholder and a representative of the College attended an initial meeting about the scope of the guideline in February 2007. The College nominated an experienced pain specialist with a special interest in the management of low back pain to be part of the Guideline Development Group. There were 15 members on the Guideline Development Group but only one place was available for what NICE described as an "Expert in non-surgical interventional procedures such as: a Radiologist, Rheumatologist or Anaesthetist with experience and working knowledge of non-specific low back pain". Neither the person nominated by the RCoA nor any other anaesthetist or pain medicine specialist was selected by NICE. The other members of the Guideline Development Group included 2 general practitioners, 2 physiotherapists, a chiropractor, an osteopath, a clinical psychologist, an occupational health physician, an orthopaedic surgeon, a nurse, an occupational therapist, an acupuncturist and 2 patient representatives. The RCoA expressed disquiet about the membership of the Guideline Development Group in May 2007 and these comments can be viewed on the NICE website.

The Faculty of Pain Medicine submitted comments to the consultation on the draft guideline in November 2008. These Stakeholder Comments can be viewed in detail on the NICE website. The conclusion of the Faculty’s comments at that time stated:

"National guidelines for this common clinical problem would be very helpful but these current recommendations are seriously flawed and not suitable for a NICE publication. We believe that there are insurmountable problems with the methodology used by the Guideline Development Group, the strength of available evidence, the interpretation of the data and therefore the conclusions and recommendations. Significantly more work needs to be undertaken on this topic with input from others who will be able to assist in the appropriate interpretation of the available (but scant) evidence."

The Faculty of Pain Medicine is committed to improving the management of this major clinical problem and the Faculty supports any attempt to introduce evidence-based recommendations. There are elements of this NICE clinical guideline which will improve patient care but, as stated in the Stakeholder Comments in November 2008, other parts are based on insufficient evidence and are therefore inappropriate for inclusion in a national clinical guideline.

The Faculty will write to NICE to express disappointment that these recommendations have been published and that no heed was taken of our major reservations. The Faculty will suggest that NICE considers immediate withdrawal of the guideline to allow reconsideration of the evidence and the recommendations. The Faculty will offer to assist NICE in this process.

14 November 2011