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Back pain in Britain: an alternative approach

If you have low back pain (and if you don’t, you probably will, for four of five of us develop an achy lower back at some point in our lives), you’ll be interested to learn that three alternative therapies — acupuncture, manual therapy (massage and/

If you have low back pain (and if you don’t, you probably will, for four of five of us develop an achy lower back at some point in our lives), you’ll be interested to learn that three alternative therapies — acupuncture, manual therapy (massage and/or spinal manipulation) and exercise — are now the officially recommended first line of treatment in the United Kingdom.

The recommendations, which raised a few doubting eyebrows among some of Britain’s more staid physicians (more about that in a second), were issued late last month by the U.K.’s National Institute for Health and Clinical Excellence (NICE). This is the group that evaluates the evidence for various medical practices, determines which ones actually work, performs a cost-benefit analysis, and then decides if the practices should be offered through Britain’s National Health Service (NHS).

According to The Guardian newspaper, which offers a thorough summary of the evidence for and against the recommendations here, this is the first time NICE has given a positive thumbs up to alternative treatments.

First, do no harm
What this trio of alternative therapies share is a relatively inexpensive price tag as well as some evidence (perhaps a bit lukewarm) that they provide some symptom relief. Also, they’re unlikely to cause harm.

That last factor is important, for most nonspecific low back pain (defined as stiffness, pain and tension in the lower back for which no specific cause can be pinpointed) gets resolved within a month or so on its own.

What’s also interesting, however, is what the recommendations tell doctors not to do when a patient has non-specific low back pain: no X-rays of the lumbar spine and no MRIs (magnetic resonance imaging) unless something more sinister is suspected, such as a spinal malignancy, infection or fracture.

The recommendations also nix laser or ultrasound therapy and transcutaneous electrical nerve simulation (TENS).

Doubting Thomases
According to reports in the British press, doubts about these recommendations seem to be coming from two main sources.

Some doctors are adamant that corticosteroid injections are the way to go (despite the lack of any good studies). Other doctors are concerned that spinal manipulation poses more risks than benefits.

The steroid advocates seem particularly angry about the NICE recommendations. “I have never known so many pain medicine specialists to be so furious,” a doctor told The Daily Mail. “More patients will end up having more expensive surgery, which is unnecessary, risky and has worse results.”

Coming to a medical clinic near you?
NICE estimated that stopping the use of steroid injections will by itself save $53 million. But the alternative therapies don’t come cheap. NICE also estimated NHS will spend $39 million extra on acupuncture, for example.

If we get some kind of national health care here in the United States, we’ll have a similar group figuring out our best medical practices. As President Obama stated last week, reforming health care includes “promoting best practices, not just the most expensive practice.”

Get ready for the pushback.