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NHS highlights new back pain advice featuring Warwick expertise

The NHS website NHS Choices has published details of recommended changes to treatment of low back pain following a series of papers which featured expertise from the University of Warwick’s Medical School.

Professor Martin Underwood of Warwick Medical School contributed to a series of papers in The Lancet which highlighted the extent to which low back pain is mistreated, often against best practice treatment guidelines.


Evidence suggests that low back pain should be managed in primary care, with the first line of treatment being education and advice to keep active and at work. However, in reality, a high proportion of patients worldwide are treated in emergency departments, encouraged to rest and stop work, are commonly referred for scans or surgery, or prescribed pain killers including opioids, which are discouraged for treating low back pain.

The series reviewed evidence from high- and low-income countries that suggests that many of the mistakes of high-income countries are already well established in low-income and middle-income countries. Rest is frequently recommended in low and middle income countries, and resources to modify workplaces are scarce.

Prof Underwood, who is one of the 31 authors of The Lancet papers, said: "Our current treatment approaches are failing to reduce the burden of back pain disability.

"We need to change the way we approach back pain treatment in the UK and help low- and middle-income countries to avoid developing high-cost services of limited effectiveness.

"Quite a lot of people get exposed to high-tech medical and invasive procedures. There's very little evidence base to support their use."

The NHS Choices website states that the researchers looked at guidelines and studies from around the world to see what they had in common. They found that exercise, with or without supportive education, was effective at managing back pain, but a lot of other treatments were not.

Comparing NICE guidelines with other guidelines from countries such as Denmark and the US, overall they concluded that paracetamol was not recommended, and glucocorticoid steroids were only recommended in a small number of patients with herniated discs and radiculopathy (compressed nerve) causing pain which had lasted 12 weeks or more. They found that surgery is only considered appropriate for people with long-term pain and only after other types of treatment have been tried.

The researchers also looked at how well guidelines are applied in practice. They described how UK GPs participating in a research study had taken appropriate action to reduce the number of people they were sending for spinal X-rays, in line with recommendations. They also described how a questionnaire (the STarT Back tool) has been helping to identify the right treatment for each person based on their symptoms.

The authors of the study highlighted that not much work has been done on how to prevent low back pain in the first place, and that more research in this area could be beneficial. They also noted that most existing research on treatments is in adults in high-income countries, and that there is very little evidence base on what works for other groups, including children.

Professor Underwood has a substantial track record of community based research into the improved diagnosis and management of musculoskeletal disorders, particularly back pain and osteoarthritis. He is currently Chief Investigator of CHESS a randomised controlled trial which is comparing a headache education and self-management programme with usual GP care plus a relaxation CD. The results of the study will be used to help patients with chronic headaches in the future.

29 March 2018

For further details contact

Nicola Jones,

Media Relations Manager

University of Warwick