UK: NICE publishes long-awaited draft back pain guidelines...

[Blue Wode]

...and it looks like a win for the woos.

First line treatments are to include spinal manipulation and acupuncture:

Draft guidance issued jointly with the RCGP (Royal College of General Practitioners) advises GPs consider a number of non-pharmacological treatments for back pain alongside drug treatment, including manual therapies such as spinal manipulation, acupuncture or exercise programmes.

More…
http://www.pulsetoday.co.uk/story.asp?sectioncode=23&storycode=4120823&c=2

 

[Darat]

It's only a draft - still time for changes to be made.

 

[Blue Wode]

It's only a draft - still time for changes to be made.

That's exactly why I posted the link. A consultation on the draft guidance is open until the 26 November 2008, so it gives those with influence in the scientific community plenty of time to help ensure that the guidelines follow a stricter evidence base.

 

[Acleron]

The Guideline Development Group (GDG) that presumably wrote this draft includes Mr Peter Dixon, the Chiropractor Chairman of the General Chiropractic Council.

His understanding of the risks of this mostly useless treatment can be seen here.

It failed to specify the risks or establish that spinal manipulation was the cause and amounted to "simple scaremongering". Mr Dixon wrote: "There is a greater likelihood of suffering an adverse event as a result of getting into and out of the bath than there is in undergoing spinal manipulation."

He also justifies the use of chiropractic on the basis that it has been used by the NHS for a number of years. Just goes to show why letting them get their foot in the door is dangerous.

While he remains on the GDG, I see little hope for this part of the guideline to be removed.

 

[Ivor the Engineer]

Aren't NICE supposed to recommend treatments based on cost-effectiveness?

Last time I checked acupuncture and chiropractic treatments were a lot more expensive than a pack of Ibuprofen and gentle exercise.

 

[Blue Wode]

The Guideline Development Group (GDG) that presumably wrote this draft includes Mr Peter Dixon, the Chiropractor Chairman of the General Chiropractic Council.

His understanding of the risks of this mostly useless treatment can be seen here.

He also justifies the use of chiropractic on the basis that it has been used by the NHS for a number of years.

Yes, and the basis upon which that NHS usage was justified was appallingly flawed. See here:
http://www.skeptics.org.uk/forum/showpost.php?p=26449&postcount=203

As I’ve said before of Peter Dixon, how can a man who recently insisted that “there’s no available evidence to show that manipulation of the neck by chiropractors has ever caused a stroke” be a trusted member of a clinical excellence team? He clearly lacks a cautionary attitude. For those keen to learn more about his dubious claims, scroll down this link until you come to ‘Edzard Ernst again challenges chiropractors in UK’:
http://www.healthwatcher.net/chirowatch.com/cw-cervical.html

BTW, in view of this latest development, the Ministry of Truth doesn’t seem to have been too far off the mark with its views about the British Chiropractic Association (BCA) v. Simon Singh case:

…casting around for information presents a rather more enticing and plausible explanation as to why they [BCA] might want to prevent the publication of adverse commentary in the press and any kind of critical public debate surrounding the efficacy and risks of chiropractic…

…and to see that explanation first hand one need only take a short trip over to the website of NICE the National Institute for Clinical Evidence, where we find that one of things they’re working on is a new set of clinical guidelines for the treatement of non-specific lower back pain.

Yep, its the key to the NHS gravy train. If NICE approves the use of chiropractic manipulation as part of the treatment regime for lower back pain then the door opens to chiropractors taking referrals from the NHS under contracts in which the NHS pays their fees and before you can say ‘vested interest’ you’ve got a whole bunch of chiropractors on what is effectively the public payroll. Little wonder then that just about the last thing that the BCA want right now is science journalists asking all sorts of awkward questions like ‘is there any evidence to show that it works?’ and ‘what kind of risks might patients face when referred for a course of woo?’.

I’m speculating, of course, but the idea that this might all be motivated by nothing more than a desire to avoid adverse publicity and awkward question while the door to a taxpayer funded gravy train lies tantalising before them makes about as much sense as an explanation for the threat of legal action against Singh as anything else I can think of…

http://www.ministryoftruth.me.uk/2008/08/19/can-you-libel-woo/

Aren't NICE supposed to recommend treatments based on cost-effectiveness?

Last time I checked acupuncture and chiropractic treatments were a lot more expensive than a pack of Ibuprofen and gentle exercise.

You would appear to be correct about that:

Cost-Effectiveness of Complementary Therapies in the United Kingdom—A Systematic Review (December 2006)

Conclusions: Prospective, controlled, cost-effectiveness studies of complementary therapies have been carried out in the UK only for spinal manipulation (four studies) and acupuncture (two studies). The limited data available indicate that the use of these therapies usually represents an additional cost to conventional treatment.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17173105

What’s even more worrying about all of this is that because the scope of practice for chiropractors in the UK isn’t defined by law, increased referrals to them are likely to see many more GPs unwittingly sending their back pain patients into dens of woo:

Overall, mechanical conditions of the musculoskeletal system were felt to be treated effectively by chiropractic intervention and there was 100% agreement that it was beneficial in treating mechanical dysfunctions of the spine. Non-musculoskeletal conditions in adults, including asthma (64%), gastro-intestinal complaints (61%) and pre-menstrual syndrome (PMS) (70%), were considered conditions that can benefit from chiropractic management. Opinions on the treatment of osteoporosis (43%), obesity (26%), hypertension (42%) and infertility (30%) were less conclusive. Childhood musculoskeletal and muscular conditions, infantile colic, otitis media and asthma were perceived to benefit from chiropractic intervention by more than 50% of the respondents. Statistically significant differences between chiropractors of different associations in the UK were present, particularly regarding the benefits of chiropractic treatment for non-musculoskeletal conditions…..Traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of the respondents and 63% considered subluxation to be central to chiropractic intervention.

Aranka Pollentier and Jennifer M. Langworthy, The scope of chiropractic practice: A survey of chiropractors in the UK. Clinical Chiropractic, Volume 10, Issue 3, September 2007, pp147-155.
http://www.cam-research-group.co.uk...linical Chiropractic 2007 10 3 pg 147-155.pdf

Further reading:
http://www.skeptics.org.uk/article.php?dir=articles&article=chiropractic.php
http://www.skeptics.org.uk/acupuncture.php

 

[Acleron]

Yes, and the basis upon which that NHS usage was justified was appallingly flawed. See here:
http://www.skeptics.org.uk/forum/showpost.php?p=26449&postcount=203

As I’ve said before of Peter Dixon, how can a man who recently insisted that “there’s no available evidence to show that manipulation of the neck by chiropractors has ever caused a stroke” be a trusted member of a clinical excellence team? He clearly lacks a cautionary attitude. For those keen to learn more about his dubious claims, scroll down this link until you come to ‘Edzard Ernst again challenges chiropractors in UK’:
http://www.healthwatcher.net/chirowatch.com/cw-cervical.html

Yes, as the most experienced and qualified person in the UK to discuss altie treatments, Ernst should be on every Guideline Development Group that strays into the subject.

Dixon must be ecstatic with this guideline.

Key priorities for implementation
2 Consider offering a course of manual therapy including spinal manipulation

3 of up to 9 sessions over up to 12 weeks . [1.4.1]
4 Consider offering a course of acupuncture needling comprising up to

5 . [1.8.1]
10 sessions over a period of up to 12 weeks
6 Consider offering a structured exercise programme tailored to the

. [1.3.3]
7 individual

The rest of the priorities are mostly warnings against various modalities. Nowhere in this section is the use of paracetamol or ibuprofen mentioned.

Three pages later, under Guidance and sub sectioned Pharmacological Therapies comes :-

Advise the person to take regular paracetamol as the first
medication option.

I'm not sure what they mean by "Key priorities for implementation", at first reading it implies 'this is important' and 'must be done urgently'. This is reinforced by its positioning in the report.

If this report goes through without substantial changes, it will be held up as proof by all the woo mongers, that their treatments are not only valid but cost effective as well.

 

[jon]

Hm, where would physio fit into this?

As far as gentle exercise goes, I thought that keeping active should be the advice for most everyone with back pain? If they want needles etc. as well, that's another thing - but certainly not an alternative...

 

[Blue Wode]

NHS to promote acupuncture, chiropractic and osteopathy for back pain

It's happened.

Millions of people who suffer from back pain are to given the right to demand free acupuncture on the NHS, under controversial new guidance.

By Laura Donnelly, Health Correspondent
Last Updated: 5:42PM BST 23 May 2009

GPs will be told to offer their patients the traditional Chinese practice, as well as other treatments like osteopathy and chiropracty, as an alternative to conventional remedies like exercise.

Last night critics said the guidelines, which are due to be published by the National Institute for Health and Clinical Excellence (NICE) on Wednesday, amounted to an official endorsement of "mumbo jumbo" medicine with no good evidence to support it.

More...
http://www.telegraph.co.uk/health/healthnews/5374291/NHS-to-promote-acupuncture-for-back-pain.html

 

[Pipirr]

oh god damn it.

 

[Physiotherapist]

Hm, where would physio fit into this?

As far as gentle exercise goes, I thought that keeping active should be the advice for most everyone with back pain? If they want needles etc. as well, that's another thing - but certainly not an alternative...

Physio is part of main stream medicine and I see a lot of patients with back pain.

I give exercises, but a lot of the time as well as exercises, I do work with the soft tissues to correct muscle spasms and overall muscular balance. A lot of the time, back pain is caused by the muscles, rather than anything to do with bones directly and those mythical subluxations, as the chiros would have you believe.

If you work on the muscles to relax and lengthen them, then they don't pull bones out of place.

 

[Blue Wode]

The official NICE guidelines on low back pain published today (full details):
http://guidance.nice.org.uk/CG88

 

[The Don]

Already this morning on Radio 5 (the BBC) the presenters are coo-ing about what a wonderful thing acupuncture is. This now effecively legitimises all woo.