Diagnosis and Treatment of Low

Back Pain: A Joint Clinical Practice Guideline

from the American College of Physicians and the

American Pain Society

Annals of Internal Medicine

October 2007

Volume 147, No 7

Terry Rochon, RNP

Fundamentals of Geriatrics

December 4, 2008

APS-ACP Collaboration

• The first comprehensive, evidence-based

clinical practice guideline to assist clinicians in

managing low-back pain

• Recommends less reliance on diagnostic

imaging

• Provides evidence supporting the benefits of

several therapies with and without medication

AMDA Chronic Pain Management in the Long-Term

Care Setting.

Clinical Practice Guideline 1999

• 45% to 80% of nursing facility residents

with chronic pain

• Treatment for chronic non-cancer pain

among those with non-terminal illness has

been neglected

AGS The Management of Persistent Pain in Older

Persons. JAGS 50:S205-S224, 2002.

• The healthcare system has an obligation to provide

comfort and pain management for older adults

• Overview of the principles of pain management as

they apply specifically to older people

• Specific recommendations to aid in decision

making about pain management for this

population

Pain Management in Nursing Homes

1999 Brown Study

• Found nearly 30% of NH residents with daily pain were not receiving pain medications

• Among those who die, we found nearly one in four did not have their pain treated. This varied between 15% and 30%

JAMA 2001

Pain Management in NH

• As high as 83% of NH

resident experience pain

• Many times pain goes

undetected and untreated

• If left untreated it can

impair mobility, cause

depression and diminish

quality of life.

JAMA 2001

Variations across states www.chcr.brown.edu/dying/factsondying

Medical Guidelines

• Screening and recognition

• Assessment and reassessment

• Treatment interventions

• Documentation

• Consultation

• Compliance with Laws and Regulations

Why the Importance on

Low Back Pain

• 5th most common reason for all primary care visits

• Approximately ¼ of US adults reported low back pain lasting at least 1 whole day in the past 3 months

• 7.6% of US adults reported 1 episode of severe acute low back pain within a 1 year period

Costs of Low Back Pain

• Accounts for $26.3 billion in direct health

care costs

• Indirect costs related to days lost from work

– approximately 2% of the US work force

compensated for back injuries each year

Pain Severity and Duration Among

Those Who Seek Medical Care

• Most return to work in 1 month

• 1/3 report persistent pain of at least

moderate intensity 1 year after an acute

episode

• 1 in 5 report substantial limitations in

activity

Purpose of the Guidelines

• Present available evidence for evaluation and

management of acute and chronic low back

pain in primary care settings

• To help clinicians be more confident when

suggesting therapies for low back pain

Target Audience

• All clinicians caring for patients with low

(lumbar) back pain of any duration, either

with or without leg pain

Target Patient Population

• Adults with acute and chronic low back

pain not associated with major trauma

• Excluded: non-spinal low back pain:

fibromyalgia, myofascial pain syndrome,

thoracic or cervical back pain

Literature Search

• Medline 1966 – 11/2006

• Cochrane Database of Systemic Reviews

• Cochrane Central Register of Controlled

Trials

• EMBASE

Literature Search

• Non-pregnant adults with LBP of any duration

that evaluated a target medication and reported at

least one of the following outcomes

– Back-specific function

– Generic health status

– Pain

– Work disability

– Patient satisfaction

Grading Recommendations

• ACP’s clinical practice guidelines grading

system

• Guideline considered interventions to have

proven benefits

– Supported by at least fair-quality evidence

– Associated with at least moderate benefits

Basis of Recommendations

• Systematic evidence review summarized in

2 background papers

• Evidence report by the American Pain

Society

• Multidisciplinary panel’s review and

analysis of evidence related to diagnosis

and treatment of low back pain

Summary of Recommendations

• Less reliance on expensive diagnostic

imaging

• Strong evidence supporting the benefits of

several therapies, with and without

medication

Scope of Recommendations

• Non-invasive procedures

• Complete guideline including invasive

treatments for low back pain will be

published later in 2008

Recommendation 1

• Clinicians should conduct a focused history and physical examination to triage patients with low back pain into one of three categories

– Non-spcific low back pain

– Back pain potentially associated with radiculopathy or spinal stenosis

– Back pain associated with another specific spinal cause

Frequency of Low Back Pain Causes

• More than 85% of patients with LBP cannot reliably be attributed to a specific disease or spinal abnormality

• 5% Ankylosing spondylosis

• 4% spinal stenosis and herniated disc

• 4% compression fractures

• 0.7% cancer

• 0.01% spinal infection

• 0.04% massive midline disc herniation

Recommendation 1: Focused

history and physical

• Determine specific underlying disease

conditions

• Measure the presence of neurological

involvement

• Assess for the presence of rapidly progressive

or severe neurological deficits at more than one

level, fecal incontinence, bladder dysfunction

Recommendation 1: Focused

history and physical

• Classify patients into 1 of 3 broad categories

• Non-specific low back pain

• Back pain associated with radiculopathy

• Spinal stenosis

• Specific spinal cause

• Tumor

• Infection

• Cauda equina syndrome

Recommendation 1: Focused

history and physical

• Ask about cancer risk factors

• History of cancer ( increases the probability

of cancer cause from 0.7% to 9%)

• Unexplained weight loss

• Failure to improve after 1 month

• Older than 50 yo

Recommendation 1: Focused

history and physical

• Risk factor for vertebral compression

fractures

• Older age

• History of osteoporosis

• History of steroid use

Recommendation 1: Focused

history and physical

• Risk factor for ankylosing spondylitis

• Younger age

• Morning stiffness

• Improvement with exercise

• Alternating buttock pain

• Awakening due to back pain during the

second part of the night

Recommendation 1: Focused

history and physical

• Herniated disc

• Back pain with leg pain in an L4, L5 or S1

nerve root distribution

• Positive straight leg raise test or crossed

straight leg raise test

Recommendation 1: Focused

history and physical

• Spinal stenosis

• Radiating leg pain

• Older age

Recommendation 1: Focused

history and physical

• History should include assessment of

psychosocial risk factors which predict risk

for chronic disabling back pain

– Noted to be stronger predictors of outcomes

than either physical examination findings or

severity and duration of pain

• Factors of depression, passive coping, job

dissatisfaction, higher disability levels, disputed

compensation claims, somatization

Recommendation 2

• Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain

– Radiography recommended for initial evaluation of possible vertebral compression fracture in those with OP or steroid use

– Not recommended for LBP that existed more than 1 to 2 months if there are no symptoms suggesting radiculopathy or spinal stenosis

Recommendation 3

• Clinicians should perform diagnostic

imaging and testing for patients with LBP

when severe or progressive neurological

deficits are present or when serious

underlying conditions are suspected on the

basis of history and physical examination

MRI preferred over CTS

• Does not use ionizing radiation

• Provides better visualization of soft tissue,

vertebral marrow, and the spinal canal

Recommendation 4

• Clinicians should evaluate patients with

persistent LBP and signs or symptoms of

radiculopathy or spinal stenosis with MRI

(preferred) or CT only if they are potential

candidates for surgery or epidural steroid

injection (for suspected radiculopathy)

Prolapsed lumbar disc or Spinal

stenosis

• Non-invasive management improves

radiculopathy in 4 weeks for most patients

• With persistent radicular symptoms

despite non-invasive treatment consider

discectomy or epidural steroids

Recommendation 5

• Clinicians should provide patients with

evidence-based information on LBP with

regard to:

– expected course

– advise patients to remain active

– provide information about effective self-care

options

Evidence-based Information

• Expect improvement within 1 month

• Imaging does not improve patient outcomes and increase costs

• Remain active

• Acupuncture

• Spinal manipulation

• Massage

• Heat

• Medium - Firm mattress

Recommendation 6

• For patients with LBP, clinicians should consider

the use of medications with proven benefits in

conjunction with back care information and self-

care.

• Clinicians should assess severity of baseline pain

and functional deficits, potential benefits, risks,

and relative lack of long-term efficacy and safety

before initiating therapy.

Medications

• 1st line options

– Acetaminophen

– NSAIDS

• Severe or disabling pain: opioids

• Tricyclic antidepressants

• Gabapentin for short term use

Recommendation 7

• For patients who do not improve with self-

care options, clinicians should consider the

addition on nonpharmacological therapy

with proven benefits.

Nonpharmacological Therapy

• For acute LBP: spinal manipulation

• Chronic or subacute LBP: intensive

interdisciplinary rehab, exercise therapy

acupuncture, massage therapy, spinal

manipulation, yoga, cognitive-behavioral

therapy, progressive relaxation

Expanded Guidelines

Interventional Procedures

• Evidence from randomized controlled trials

is mixed, sparse, not available, or showed

no benefits

• Invasive diagnotics

• Epidural stenosis injections

• Surgery

Not yet published

Invasive Diagnostics

• Not proven to be accurate for diagnosisng

spinal conditions

• Ability to effectively guide therapeutic

choices and improve outcomes uncertain

– Provocative discography

– Facet joint block

– Sacroiliac joint block

Epidural Stenosis Injections

• Option for short-term pain relief for

persistent radiculopathy

– Radiating low-back pain caused by herniated

disc

Other injections

• Not supported by convincing, consistent evidence

of benefits from randomized trials

– Local injections

– Prolotherapy

– Botulinum toxin (botox) injections

– Facet joint injections

– Sacroiliac joint injection

– Radiofrequency denervation

– Intradiscal electrothermal therapy

Surgery

• Effective though the benefits are diminished

over time in treatment for:

– Spinal stenosis

– radiculopathy

Surgery Non-radicular LBP

• Some studies show no benefit compared to

interdisciplinary rehabilitation

• Sub-optimal outcomes including

– Persistent pain

– Functional deficits

Gold standard for LBP

• Stay active

• Talk honestly about self care options

• “Non-invasive therapies supported by

evidence showing benefits should be tried

before considering interventional

therapies.” Roger Chou, MD May 2008

Interventional Techniques:

evidence-based guidelines

• www.guideline.gov

• Interventional techniques in the

management of chronic spinal pain:

evidence-based guidelines in the

management o chronic spinal pain. Pain

Physician 2007 Jan:10(1):7-111.