Lower back pain is one of the most common health problems around the world and healthcare professionals are continuously reviewing how best to treat it. Putting aside the individual for a moment, millions of productive hours are lost in the workplace and, with the loss of earnings that represents, there are serious implications for national economies as many find their ability to work restricted or completely finished. This puts pressure on national agencies to set best practice standards to keep the majority of adults in productive work.

Although the UK often gets a bad press for its National Health Service (NHS), one of the more successful features of the service is the National Institute for Health and Clinical Excellence (NICE). This agency is responsible for co-ordinating national healthcare planning and directing individual agencies through clinical guidelines. It reviews all the available scientific information to decide which treatments are sufficiently cost-effective to be adopted across the whole of the NHS. The idea is to ensure that everyone gets the same quality of treatment no matter where they live. More importantly, the evidence-based approach is designed to produce better patient outcomes.

NICE has just published its guidelines for the treatment of lower back pain. It treats the issue as multidisciplinary, i.e. one that should be approached using a variety of different forms of treatment supplied by different groups of health professionals. The basic assumption is that patients benefit from maintaining mobility, i.e. everyone should remain physically active. So the key recommendation is for therapists to design home-based exercise programs which run in conjunction with spinal manipulation and massage sessions at clinics and hospitals. The conclusion is that intensive exercise is the best treatment, particularly if combined with cognitive behavioral therapy to teach coping strategies and reduce depression. The evidence shows that patients who have a good understanding of their condition manage the pain more effectively and make better lives for themselves. No injections or investigations using X-rays or MRI scans are considered cost-effective.

This does not deny the use of drugs to support the exercise programs. Indeed, nursing staff are considered vital in helping patients understand how to manage the more common side effects to using medication like tramadol. Constipation can make back pain more severe so learning how to prevent the side effects from worsening the underlying problem is necessary. The focus is therefore on front-line nursing staff and therapists rather than doctors and surgeons. The aim is to show patients that back pain is not a life-threatening condition and that, within the new physical limitations, they should get on with their lives as normally as possible. Although tramadol and, where appropriate, more powerful pain killers can be prescribed, their use should be kept to a minimum. Curiously, this contrasts sharply with the doctor-led approach in the US where expensive diagnostic testing and surgery are commonly used even though there is no reliable evidence that this approach is better value to the patients. Doctors in the US are powerful and protect their status and role in delivering health care. The only common feature between the two systems is the reliance on tramadol as the first-response for pain relief. No matter where you live, doctors agree tramadol is the best.