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NICE back pain recommendations

NICE Back Pain Recommendations

NICE (National Institute for Health and Care Excellence) is the British National Health System’s agency that creates their care guidelines.  NICE’s strong focus is evidence based care, and their committees are historically conservative with respect to mainstream medicine.

England’s NICE Back Pain Recommendations = StrongPosture® philosophy for Back Pain Care?

The News: On November 30, 2016 NICE came out with new Back Pain guidelines for assessment and care, both non-invasive and surgical (1)… and their recommendations for non-invasive care largely parallel what I personally have been recommending for years! 

Here’s a summary of what they recommend for non-invasive care, where we differ, and why I like their general perspective. 

For low back pain both with and without sciatica, if there are no red flag indicators and the pain doesn’t appear likely to improve by itself quickly with a good outcome, NICE recommends beginning with non-invasive care that includes: (My summary and comments in italics below) 

1.2.1  Self-management –  Clinicians and therapists should advise people to care for self-limited problems themselves, give info on the nature of the back pain and encouragement to stay normally active.

1.2.2 Exercise –  group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches)  (i.e.. StrongPosture classes)

1.2.3-1.2.6 &.8  Not recommended: Belts, corsets, rocker shoes, traction, acupuncture and foot orthotics –  I’d personally differ somewhat on orthotics… I’ve seen inexpensive orthotics often help, but my hunch is the health system’s problem here is economic as orthotics can mean expensive fittings and fabrications.  

I believe focused intersegmental traction with spinal manipulation can be helpful, but again, I see the system wide economic problem with ineffective long axis traction often recommended for back pain.

And directly from the NICE guidelines:

1.2.7  “Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy”.

The StrongPosture® Philosophy of Back Pain Care:

First Relieve the pain & Regain motion – As in spinal manipulation + soft tissue techniques, both suggested by NICE.  Personally I might sometimes suggest therapies to accelerate pain relieve & healing…but understand the British perspective on minimizing cost.

Then retrain with Balance, Alignment and Motion (the BAM StrongPosture® rehab exercise protocols) towards functional symmetry –  

Plus, the Attentional Focus cueing baked into the StrongPosture® BAM protocols integrates mindful movement with a simple Cognitive Behavior Therapy (CBT),  making a case for psychological benefit as well by empowering people with progressive improvement and awareness of objectively observable incremental changes (1). Completing NICE’s recommended “treatment package including exercise…. with or without psychological therapy”.

And while group classes are great, especially for chronic or recurrent problems there’s no substitute for one-on-one training with a CPEP® (certified Posture Exercise Professional).

Reason? The StrongPosture framework makes it systematic to retrain subtle motion compensations (functional) towards symmetry, and advise specific peel-backs or progressions, or focuses to individualize for adaptations (structural).

Note for doctors of chiropractic: The Journal of Chiropractic and Manual Therapy recently published a plan for the profession’s modernization along evidence supported lines, “The New Chiropractic Roadmap”.  The author advised the profession to “develop a generalised special interest”, suggesting the possibility of “improved posture through motor control”.

80% of low back pain is non-specific

Since 80% of low back pain is non-specific (2) and often attributed to posture (3) and loss of postural control (4), we believe all DCs should incorporate posture control retraining to synergize with the widely agreed upon benefit of SMT to unlock potential segmental motion (5) to restore control lost arcs of postural kinetic chain function.

1. Weiniger, S, StrongPosture Rehab Professional Training Manual, BodyZone Press, 2000-2016

2. Low back pain and sciatica in over 16s: Assessment and Management/ NICE guideline [NG59] Published date: November 2016

3. Kent, P., Mjøsund, H. L., & Petersen, D. H. (2010). Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review. BMC Medicine, 8(1), 22. doi:10.1186/1741-7015-8-22

4. Christie, H. J., Kumar, S., & Warren, S. A. (1995). Postural aberrations in low back pain. Archives of Physical Medicine and Rehabilitation, 76(3), 218-24.

5. Schelldorfer, S., Ernst, M. J., Rast, F. M., Bauer, C. M., Meichtry, A., & Kool, J. (2014). Low back pain and postural control, effects of task difficulty on centre of pressure and spinal kinematics. Gait & Posture. doi:10.1016/j.gaitpost.2014.09.004

6. Fritz, J. M., Koppenhaver, S. L., Kawchuk, G. N., Teyhen, D. S., Hebert, J. J., & Childs, J. D. (2011). Preliminary investigation of the mechanisms underlying the effects of manipulation: Exploration of a multivariate model including spinal stiffness, multifidus recruitment, and clinical findings. Spine, 36(21), 1772-81. doi:10.1097/BRS.0b013e318216337d

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