Nov 30, 1996 - guided by setting goals (even if there is some discomfort) rather than by the traditional dictum to "let pain be your guide." These newer concepts ...
LONDON, SATURDAY 30 NOVEMBER 1996
Acute low back pain: a new paradigm for management Limited imaging and an early return to normal activities The new clinical guidelines issued by Britain's Royal College of General Practitioners highlight new principles of back pain management that have emerged in the past decade.' The era of routine radiography, strict bed rest, corsets, and traction has passed. It has been replaced by parsimonious imaging, early return to normal activities, and greater emphasis on exercise to prevent recurrences or to treat chronic pain. Physical activity is guided by setting goals (even if there is some discomfort) rather than by the traditional dictum to "let pain be your guide." These newer concepts are based on steadily improving scientific evidence, and represent a major shift from the earlier paradigm of rest and pain contingent treatment. Many observers would now argue that back pain is a nearly ubiquitous part of human experience, is often the earliest sign of normal age related changes in the body, and has been over medicalised in this century. Back pain has always been with us (arguably even more prevalent in an earlier era of more physically demanding jobs), yet work disability due to back pain is a modem epidemic. Modem medical care has not prevented a steady rise in back related disability in most developed countries, and some fear that medicine may have contributed to the rise.2 In this context, the new clinical guidelines, and their American counterpart from the Agency for Health Care Policy and Research,' offer a breath of fresh air. The British guidelines explicitly built on the foundation of the earlier American effort, and their authors had the benefit of three additional years of research findings. This new research permitted refinement of earlier recommendations and some entirely new features. For example, a recent study suggests that both exercise and bed rest may slow recovery.4 In fact, this study and others s now suggest that nearly immediate return to normal activities may be the optimal recommendation for patients with acute back pain. Though specific exercise does not seem to be useful in acute management, 4 6 7 it does seem to reduce recurrences after the acute phase has subsided 8 and improve function for patients with chronic pain.9 10 A novel feature of the British guidelines is an algorithm for simple backache that recommends referring problematic cases to a general practitioner with special interest in back pain or a specialist physiotherapist. In the -absence of any surgical indications, such a referral pattern seems highly appropriate, and a similar strategy has proved satisfactory to both patients and physicians in a large American health maintenance organisation." With a plethora of emerging clinical guidelines on all aspects of medicine, practitioners may justifiably ask "How were these guidelines developed, and why should I follow them?" Traditionally, many guidelines were the product of expert consensus, which may or may not have been informed by a com-
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plete evaluation of available scientific evidence or a critical appraisal of its rigour. Happily, both the American and British guidelines were products of exhaustive literature searches, which began with computerised bibliographic databases and an explicit review of study quality based on sound principles of research design. Because even the best studies leave room for interpretation and debate, and because some important aspects of care have been too rarely studied for evidence based recommendations, the guideline panels sought broad multidisciplinary membership to encourage balanced deliberation. Both panels not only summarised their findings but rated the strength of evidence to support each conclusion. Successful implementation of new guidelines typically requires more than simply publishing and disseminating them. A local process of review and adaptation, which involves the practitioners of a particular locale or healthcare system, is often more persuasive than the edict of a national panel. Feedback to individual practitioners about their levels of compliance with specific recommendations, or comparison with their peers, may be valuable. One to one educational efforts by an influential peer and redesign of delivery systems to facilitate certain recommendations may be necessary. Finally, the new back pain guidelines represent such a substantial shift from the traditional approach that the public will need to be re-educated. We need to assure that the expectation of x ray films or other imaging is replaced by knowledge of their limited value; the habit of bed rest and "taking it easy" is replaced by rapid return to normal activities; and pain dependent recommendations for treatment and activity are replaced by recommendations based on goals. Medical knowledge is not static and so every guideline must be regularly updated. The British panel wisely set an explicit review date of April 1998. However, we should all stay alert to the developing online database being compiled by the
Managing acute low back pain For simple back ache (age 20-55 years, no radiation below the knee, "mechanical' pain, patient well): * Radiography, imaging, and specialist referral are unnecessary; psychosocial factors should be considered * Bed rest is not recommended; patients are advised to stay as active as possible and continue normal daily activities * Drugs should be prescribed at regular intervals, not as required, and should begin with paracetamol or non-steroidal antiinflammatory drugs, avoiding narcotics if possible * Spinal manipulation may be considered for relief of symptoms within six weeks of onset * Patients who have not returned to ordinary activities and work by six weeks should be referred for an exercise programme
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n al effort which seeks to Cochrane Collaboration synthesise and continually update the best available literature on efficacy of treatment. There is a large and active group evaluating studies of back pain, and the fruits of this effort should be available within the next few years. RICHARD A DEYO Professor Department of Medicine and the Department of Health Services, University of Washington, Seattle, WA 98195 USA
Supported in part by grant #HS-08 194 from the United States Agency for Health Care Policy and Research 1 Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Low back pain evidence review. London: Royal College of General Practitioners, 1996. 2 Waddell G. A new clinical model for the treatment of low back pain. Spine 1987;12:632-44. 3 Bigos S, Bowyer 0, Braen G, Brown K, Deyo R, Haldeman S, et al. Acute low back problems in adults. Clinical practice guideline No 14. Rockville, MD: Agency for Health Care Policy and
Research, Public Health Service, US Departnent of Health and Human Services, 1994. (AHCPR Publication No. 95-0642.) 4 Malmivaara A, Hakidnen U, Heinrichs ML, Aro T, Koskenniemi L, Kuosma E,et al. The treatment of acute low back pain - bed rest, exercises or ordinary activity? N Engl Y Med 1995;332:351-5. 5 Indahl A, Velund L, Reikeraas. Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine 1995;20:473-7. 6 Gilbert JR, Taylor DW, Hildebrand A, Evans C. Clinical trial of common treatments for low back pain in family practice. BMJ 1985;291:791-4. 7 Faas A, van Eijk JT, Chavannes AW, Gubbels JW. A randomized trial of exercise therapy in patients with acute low back pain. Efficacy on sickness absence. Spine 1995;20:941-7. 8 Lahad A, Malter AD, Berg AO, Deyo RA. The effectiveness of four interventions for the prevention of low back pain. JAMA 1994;272:1286-91. 9 Manniche C, Hesselsoe G, Bentzen L, Christensen I, Lundberg E. Clinical trial of intensive muscle training for chronic low back pain. Lancer 1988;2:1473-6. 10 Lindstrom I, Ohlund, Eek C, Wallin L, Peterson LE, Fordyce WE, Nachemson AL. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant conditioning behavioral approach. Phys Ther 1992;72:279-91. 11 Branthaven B, Stein GF, Mehran A. Impact of a medical back care program on utilization of services and primary care physician satisfaction in a large multi-specialty group practice health maintainance organization. Spine 1995;20:1165-9.
Copies of the guideline can be obtained from the Royal College of General Practitioners, 14 Princes Gate, Hyde Park, London SW7 1PU or at website http://www.rcgp.org.uk
Funding research in the NHS The creation of a unified budget is progressing well The NHS not only funds its own research but also provides the framework funding which allows many organisationsnotably the universities, the Medical Research Council, and medical research charities-to operate within it. The Culyer report, published in September 1994, recommended that the diversity of funding arrangements through which the NHS had supported research should be replaced by a single NHS budget.' Culyer perceived that much research in the NHS, especially that done outside teaching hospitals, was unrecognised and that the costs were subsumed in clinical prices. This covert research, from which the NHS as a whole benefits, might have been jeopardised as purchaserprovider contracting for patient care developed. The report therefore recommended that, in order to protect this research activity, it should be identified and costed and the money transferred into the new unified research and development budget. The identification by NHS providers of their research activity in the year up to 31 May 1996 has documented for the first time the total research enterprise and the professional vivacity of the NHS. Over 39 000 research projects have been identified (speech by secretary of state for health at the opening of the National Co-ordinating Centre for Health Technology Assessment, 8 July 1996). A substantial part of this research was being done in acute and community hospital trusts, demonstrating how the culture of research has become diffused within the NHS and how important it has been for the NHS to undertake this comprehensive exercise. Overall, trusts identified a total NHS spend of £330m supporting research and development (speech by secretary of state for health, 8 July 1996). The new single budget for NHS research and development will be in excess of C400m (speech by secretary of state for health, 8 July 1996). How will it be managed? The Culyer report insisted that bureaucracy should be minimised and that larger clinical research trusts should have both stability of funding and the autonomy to respond flexibly to changes in research direction. Equally important, trusts with smaller programmes of research-including primary care and community health services-should not be disadvantaged by any new system. An outline of the new funding system was published in June.2 Funding will be distributed from 1998-9 on a competitive basis. Providers with large scale, rolling research and development programmes will be able to bid for an inclusive 1344
portfolio funding. Other providers will bid for task limited funding to support particular lines of research. Universities will be interested in the rules for portfolio funding contracts, which will provide block funding for four years to cover the NHS costs of all their research and development activities not met from external sources, excluding costs of patient care. Bids for these contracts will be based on a robust local strategy and will require new alliances between the research community and universities on the one hand and a single NHS provider or consortium of providers on the other. These alliances will need to be negotiated soon, for the timetable is short: bids will be invited in December 1996, and final bids must be in by July 1997. The criteria for assessing bids have not yet been published, but scientific quality and continuity of substantial external grant support should be dominant; the capacity to manage a range of research programmes and resources is essential. However, there is no intention to run an assessment of NHS research but rather to depend on available indicators of the quality and quantity of institutional research. The same general principles and timetable will be followed for the allocation of task limited funding, but this is intended to support projects or programmes of work and, importantly, to enable providers who have not been players to enter research. The research community at large should welcome these proposals, for they are coherent, sit comfortably with patterns of activity as known and as revealed in the declaration exercise, and encourage local collaboration. The research community should also welcome the degree of subsidiarity inherent in the plans. But important questions remain to be addressed. Within trusts, how easy will it be to operate a hypothecated budget for research that requires underpinning across clinical services? How are the new funding arrangements to help areas such as general practice and public health research including epidemiology, where research is poorly funded yet fundamental to the operation of the NHS? The new funding system is intended to be redistributive. How will it be managed so as not to destabilise clinical units that are net losers? And, the greatest anxiety of all, in the longer term will the single research and development budget be exposed and vulnerable in a future crisis in NHS funding? Another contentious area in funding for clinical research was opened up for discussion in a second document released in June.' This paper sets out options for handling the BMJ VOLUME 313
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