Lower back pain is a very common condition, around 60–85 per cent of the population will experience a period of lower back pain during their lifetime. Most of these cases are so-called ‘non-specific lower back pain’, where there is no identifiable physical cause of the pain. This is an area of medicine where a plethora of different treatments exist for this condition, but not all of them are based on solid evidence: an area where one would expect guidelines to fill a gap by providing advice on which treatments to avoid and which treatments to recommend. We will first consider the English guidelines on this topic before considering the Dutch guidelines. Both these guidelines present a path of care for patients and make several choices on which treatments to offer and in which order to provide them.

THE ENGLISH GUIDELINE ON LOWER BACK PAIN

The focus of our analysis will be the 2009 guideline on persistent non- specific lower back pain (hereafter: back pain) drafted by the NCCP and authorised by NICE. The guideline was drafted by a group of medical professionals from a diverse background including GPs, physiotherapists, a spinal surgeon, nurses and patients. They were supported by a technical team provided by the NCCP consisting of a healthcare economist, information specialists and health fellows.

Before the guideline group was established, the chair for the group was recruited to work with a clinical advisor and the technical team in preparing the scope of the guideline. The chair and clinical advisor were approached informally by NICE and agreed to participate. The reason they were approached was because they had done work for NICE in the past on back pain and related areas and were therefore well-known and well- regarded in this medical field.

The scope sets the limits of the medical condition the guideline will provide recommendations on. In this case, the scope only included back pain from six weeks to one year. So acute back pain that lasted less than six weeks was not included, nor was chronic back pain that lasted longer than a year. This decision was made during discussions between the chair and clinical advisor of the guideline group and the technical team at NICE. NICE had recently published a guideline on acute lower back pain and wanted to draft a separate guideline that had a duration longer than a year.