Why Focus on Low Back Pain? Care Pathway Roles and Responsibilities. The following table describes general role and responsibilities.

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1 Low Back Pain This CPM presents a model of care based on scientific evidence available at the time of publication. It is not a prescription for every physician or every patient, nor does it replace clinical judgment. All statements, protocols, and recommendations herein are viewed as transitory and iterative. Although physicians are encouraged to follow the CPM to help focus on and measure quality, deviations are a means for discovering improvements in patient care and expanding the knowledge base. If you have questions or concerns regarding this information, contact: Clinical Leaders David Arredondo, MD darredond@phs.org Dion Gallant, MD dgallant@phs.org Fauzia Malik fmalik@phs.org This CPM is part of Presbyterian s Clinical Care Model is a broad, enterprisewide body of documentation covering PHS functions, programs, and care pathways, intended to build organizational acumen, facilitate cross-system collaboration, and accelerate our implementation of clinical initiatives. Find all of PHS Care Model at March 2018 This Clinical Practice Model (CPM) is designed for patients: Over the age of 18 Presenting with low back pain Being seen in an outpatient setting (PMG Clinic or PHS Hospital) This CPM recommends an evidence-based protocol for diagnosis and treatment of low back pain. These recommendations represent the work of Presbyterian s Low Back Pain EBCD initiative. Why Focus on Low Back Pain? Low back pain (LBP) is the fifth most common reason that Americans visit their physicians (ACP, APS). It has a significant impact on the cost of care, as well as absenteeism in the workplace. Evaluation and treatment of LBP remains highly variable, often with an overreliance on imaging studies. Care Pathway Roles and Responsibilities The following table describes general role and responsibilities. Responsibility Initial diagnosis and treatment for mild, moderate, or severe low back pain Initial diagnosis and treatment for mild, moderate, or severe low back pain Evaluation and development of physical therapy treatment plan Guidance on resumption of daily and physical activities Support for lifestyle modification, stress management, depression due to chronic low back pain Consultations and administration of injections or other interventional procedures Surgical consultations and surgery Evidence/Resources American Academy of Family Physicians American College of Physicians American Pain Society Choosing Wisely Clinician Physician or Advanced Practice Clinician Physical Therapist Behavioral Health Clinician Interventional Pain Specialist Spine Surgeon jump to ALGORITHM 2018 Presbyterian Healthcare Services 1

2 Assessment, Diagnosis, and Treatment: Low Back Pain Diagnosis and Testing The recommended first step in diagnosis, regardless of care setting, is a detailed history, physical examination, and the identification of any red flags. This can assist in diagnosing the pain as one of three broad types: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. Typically, 85% of patients are diagnosed with nonspecific LBP (ACP & APS). Unless red flags are present or the pain has been ongoing for more than 6 weeks, imaging is not recommended. Diagnosis Administer Oswestry Low Back Pain Disability Questionnaire Document pain scale Conduct History & Physical Exam o This allows the provider to gain detailed information about the symptoms, potential cause, disabling factors, pre-injury work and health status, psychosocial risk factors, and the identification of any red flags. The focus of this exam should be on 2018 Presbyterian Healthcare Services 2

3 identifying any red flags (and the associated potential serious pathology) as opposed to developing a specific pathoanatomical diagnosis. Document presence or absence of red flags Assess for mental health concerns (sometimes referred to as yellow flags ) o Psychosocial risk factors are correlated with higher rates of chronicity o Addressing beliefs and fears regarding low back pain early on is key in avoiding chronicity o Screening for these yellow flags may include: Somatization Distress Depressive mood Passive coping strategies Fear of pain, movement, and re-injury High scores on measures such as the Fear-Avoidance Beliefs Questionnaire (FABQ) or the Pain Catastrophizing Scale (PCS) FABQ score <14 = low risk and >16 = high risk PCS score >30 = high risk Ascertain presence of radicular pain o May involve paresthesia in the lower extremities, numbness or weakness o Commonly co-presenting with related or referred lower extremity pain, such as buttock, thigh, or leg pain Refer to Physical Therapy, behavioral health clinician, interventional pain specialist, or surgical consultation as appropriate Imaging Tests Imaging tests are not recommended for low back pain within the first 6 weeks (source). Exceptions to this are when severe underlying conditions are suspected (see red flags, below). Imaging can have adverse effects through the overexposure to radiation and nocebic/iatrogenic effects due to the misinterpretation of age-related structural findings. In cases of nonspecific low back pain, there is no correlation between imaging and rate of recovery, and the cost of treatment is frequently higher when imaging is performed prior to other treatments. Red Flags & Possible Diagnoses Possible Diagnosis Red Flags/Risk Factors Imaging/other studies recommended Cancer History of cancer Unexplained weight loss Failure to improve after 1 month Age > 50 years Vertebral Infection/Epidural Abscess Fever IV drug use Recent infection Cauda equina Urinary retention Motor deficits Fecal incontinence Saddle anesthesia Vertebral compression fracture Older age History of osteoporosis Steroid use MRI ESR Lumbosacral plain radiography MRI ESR CRP MRI Lumbosacral plain radiography 2018 Presbyterian Healthcare Services 3

4 Red Flags & Possible Diagnoses Possible Diagnosis Red Flags/Risk Factors Imaging/other studies recommended Ankylosing spondylitis Younger age Morning stiffness Improvement with exercise Alternating buttock pain Awaking due to back pain (second part of the night) Herniated disc Back and leg pain Positive straight-leg-raise test or crossed straight-leg-raise test Lumbar spinal stenosis Radiating leg pain Older age Changing symptoms on downhill treadmill Pain relieved when sitting Treatment Anterior-posterior pelvis plain radiography ESR CRP HLA-B27 If symptoms < 1 month: none If symptoms > 1 month: MRI or EMG/NCV If symptoms < 1 month: none If symptoms > 1 month: MRI or EMG/NCV Treatment of LBP may vary depending on if the symptoms are classified as mild, moderate, or severe, and if the LBP is acute, sub-acute or chronic. Acute describes pain occurring for less than 6 weeks, sub-acute for 6 to 12 weeks, and chronic for longer than 12 weeks. For scheduling purposes, back pain occurring for less than 90 days may be termed acute; chronic refers to pain occurring for more than 90 days. Mild Symptoms Pain without functional impairment/disability Core Treatment Plan First-line medication options include NSAIDs or acetaminophen See Medication Therapy for other options Heat or ice may be applied to provide short-term relief of symptoms With patient education, focus is on encouraging exercise, including walking or other aerobic activity, resumption of normal physical activities, avoiding bed rest for more than 48 hours, and ergonomics If appropriate, consider a referral to a behavioral health clinician Imaging is not recommended unless the symptoms are unresolved after 6 weeks Moderate Symptoms Pain with minimal functional impairment/disability Core Treatment Plan Mild Symptoms plan, and If a worker s compensation claim is involved, complete the necessary return to work assessment In acute cases, consider referral to Physical Therapy A short-term course of skeletal muscle relaxants (see Medication Therapy) may also be appropriate for acute LBP Severe Symptoms Pain with moderate-to-severe functional impairment/disability 2018 Presbyterian Healthcare Services 4

5 Core Treatment Plan Mild/Moderate Symptoms plan, and A short-term course of opioids may be appropriate in patients with acute LBP (see Medication Therapy) Medication Therapy Depending on the diagnosis and severity of the low back pain, various medication therapies may be used. The role of pharmacological therapy is to prevent and control symptoms and assist the patient in pursuing the lifestyle therapies and adjustments necessary. Most of the research supporting the choice of medication is based on short-term (<4 weeks) courses of treatment. NSAIDs and acetaminophen are the most commonly recommended medication options for patients suffering from low back pain. Medications Drugs 1 st Line NSAIDs Acetaminophen Notes Recommended as the first step in treating low back pain at home by Choosing Wisely Found to be a moderately effective short-term treatment for acute low back pain (ACP, APS) Acetaminophen may be slightly less effective than NSAIDs, though the results of studies are inconclusive, and the safety profile of acetaminophen is more favorable The possibility of adverse gastrointestinal or cardiovascular effects with NSAIDs should be considered 2 nd Line 3 rd Line Other Skeletal muscle relaxants Opioids Benzodiazepines Tricyclic antidepressants Limited evidence, but may be moderately effective as a short-term treatment for acute low back pain (ACP, APS) Some skeletal muscle relaxants may have adverse short-term effects, such as hepatotoxicity Baclofen is preferred, though cyclobenzaprine may be used in patients under 60 years old Carisoprodol is discouraged, given its potential for abuse. Moderately effective at treating low back pain May be appropriate for short-term use in patients complaining of severe pain Given the potential for abuse, use of opioids is not recommended as a long term solution Limited evidence, but may be moderately effective at treating low back pain in the short term in ED setting Not recommended for patients >65 years old Given the potential for abuse, use of benzodiazepines is not recommended as a long term solution Found to have a small to moderate effect on short-term pain relief (ACP, APS) At this point, only tricyclic antidepressants have been demonstrated to be effective in treating low back pain, though others have not been evaluated Antiepileptic drugs Gabapentin and topiramate may be effective for patients presenting with chronic low back pain with or without radiculopathy Physical Therapy The primary recommended treatment for acute LBP is physical therapy. Referral The PCP or the PT can refer a patient for outpatient physical therapy via Epic, which will then trigger a call to schedule an appointment from Presbyterian Customer Service Center (PCSC). There have been and continue to be efforts to simplify this process and make it more efficient, including adding acute slots into the PT schedule, which can allow patients to be seen sooner than they might otherwise be. Evaluation 1. Focus on Therapeutic Outcomes (FOTO) assessment, which includes 2018 Presbyterian Healthcare Services 5

6 a. Oswestry Low Back Pain Disability Questionnaire b. Fear-Avoidance Belief Questionnaire c. Pain Catastrophizing Scale 2. Patient vitals 3. History, which generally focuses on the following elements: a. Onset of pain b. Mechanism of injury c. Time frame of symptoms/injury d. Exacerbating and alleviating factors e. Location of symptoms f. Pain pattern g. Patient goals and expectations for outcomes h. Identification of red flags 4. Physical Exam, which typically includes various tests of measures, such as a. Range of motion b. Sensitivity c. Special tests as appropriate (e.g., straight leg raise test or slump test) Assessment Once the evaluation is completed, the PT provides their assessment of the issue and the best Plan of Care. Plan of Care The PT then develops an individualized Plan of Care, which is signed by the patient s PCP. Treatment Treatment typically takes place over the course of 7 to 9 weekly visits and may include: Manual therapy to reduce pain and disability and improve mobility Trunk coordination, strengthening and endurance exercises Centralization and directional preference exercises and procedures (McKenzie therapy) Flexion exercises (Williams flexion), per PT discretion Lower-quarter nerve mobilization procedures Recommendations for at-home stretching and exercise, as appropriate Cognitive behavioral intervention as needed to address psychosocial issues If the patient s symptoms do not improve with treatment, or if they appear to be in mental distress, the PT may decide to refer the patient back to their PCP with a recommendation to pursue treatment from a behavioral health clinician, interventional pain specialist, or surgeon. Therapeutic Lifestyle Changes Exercise/Activity Walking and other aerobic exercise should be encouraged Core strengthening exercises and flexion/extension movements can be helpful Mind-body exercises, such as yoga and pilates, can be helpful Bed rest is not recommended for >48 hours (Choosing Wisely) 2018 Presbyterian Healthcare Services 6

7 Other Non-pharmacological treatment Heat/ice may provide short-term pain relief Therapeutic massage, chiropractic work, and acupuncture may benefit some individuals Condition Progression Reoccurrence of LBP after an initial acute episode is very common, appearing in approximately 70% of patients. LBP may progress from acute to chronic if it is not resolved through treatment in either a primary care or physical therapy setting. If there is no improvement with non-invasive treatment of radicular LBP over the course of 9 to 10 weeks, or if the patient presents with several radiculopathy, it may be appropriate to refer the patient to an interventional pain specialist or to a surgical specialist. Interventional Procedures After an assessment and appropriate imaging, an interventional pain specialist may elect to use pharmacological treatment or one of several injections. The most commonly used injections are: Epidural Steroid Injection (may require a prior authorization) Facet Steroid injection Medial Branch Nerve Block Radiofrequency Discogram is less common, but also available. In some cases, these injections will provide short- or long-term relief for patients, and may be given up to 4 times per year. For patients with degenerative diseases, such as degenerative disc disease, treatment can continue for several years. Injections may also be used in conjunction with physical therapy or exercise programs. If the injections do not alleviate the symptoms, however, many providers choose to refer patients for surgical consultation. Both prior to and while undergoing pharmacological treatment of symptoms, patients may be assessed for potential misuse of opioids using either the Screener and Opioid Assessment for Patients with Pain- Revised (SOAPP -R) or the Current Opioid Misuse Measure (COMM). A pain psychologist is also available to treat those patients who struggle with psychosocial issues related to chronic pain. Surgery or Other Interventional Procedures If the patient is not able to manage their low back pain with the assistance of either physical therapy or treatment by an interventional pain specialist, a surgical consultation may be appropriate. Patient Education and Support Key aspects of patient education include helping patients Understand the generally favorable prognosis of low back pain Use active pain coping strategies for helping decrease fear and catastrophizing Rapidly resume vocational and daily activities, even if some pain persists Develop an appropriate self-care regimen that includes activities like walking and core strengthening exercise In many cases, it is also recommended to Discourage extended bed-rest (>48 hours) Avoid providing in-depth patho-anatomical explanations for the specific cause of the pain 2018 Presbyterian Healthcare Services 7

8 When dealing with chronic pain, some patients may benefit from treatment by a behavioral health clinician. Patient Education Materials In a primary care or urgent care setting, patient education materials provided by ExitCare are available on Epic. In PT, individualized patient education materials are created through Visual Health Information and Home Exercise To Go. Measurement and Reporting The key metric reported on LBP is the use of imaging studies. The percentage of patients with low back pain who receive imaging studies in less than 28 days are reported monthly via HEDIS and to CMS. Internal measures of success focus on the issues of access and improving patient outcomes, particularly with regard to physical therapy. The EBCD LBP initiative in 2014 resulted in a significant decrease in the average wait time for physical therapy services, from 40 days in January 2015 to 8 days in December There has also been a significant improvement in patients functional outcomes post-physical therapy according to pre- and post-treatment scores on the Oswestry Low Back Pain Disability Questionnaire. Clinical Definitions Access Evidence-Based Care Design (EBCD) Overuse The timely use of personal health services to achieve the best possible outcome. Key components of access: Gaining entry into the health care system. Getting access to sites of care where patients can receive needed services. Finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust. A formal, evidence-driven, cross-disciplinary method for clinical workflow development, redesign, or augmentation. When a drug or treatment is given without medical justification or strong scientific evidence. Overuse includes failing to follow effective options that cost less or cause fewer side effects. For example, antibiotics are prescribed for children s ear infections 80 percent of the time, despite the finding that these infections usually resolve within three days without antibiotics. Additional References Related Care Model Topics Chronic Opioid Therapy for Chronic Pain (pending) Evidence-Based Care Design Patient-Centered Medical Home (PCMH) Policies and Procedures [PHS login required] Epidural Corticosteroid Injections for Back Pain Other Resources Chou R, Qaseem A, Snow V, Casey D, Shekelle P, Owens DK. 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. 2007;147(7): doi: / Presbyterian Healthcare Services 8

9 Oswestry Low Back Pain Disability Questionnaire Patient Name: Date: Instructions: This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by checking ONE box in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem. Section 1 Pain Intensity I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the moment Section 2 Personal care (washing, dressing, etc) I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but manage most of my personal care I need help every day in most aspects of self-care I do not get dressed, I wash with difficulty and stay in bed Section 3 Lifting I can lift heavy weights without extra pain I can lift heavy weights but it gives extra pain Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently placed eg. on a table. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned I can lift very light weights I cannot lift or carry anything at all Section 4 Walking Pain does not prevent me walking any distance Pain prevents me from walking more than 2 kilometers Pain prevents me from walking more than 1 kilometer Pain prevents me from walking more than 500 meters I can only walk using a stick or crutches I am in bed most of the time 2018 Presbyterian Healthcare Services 9

10 Section 5 Sitting I can sit in any chair as long as I like I can only sit in my favorite chair as long as I like Pain prevents me sitting more than one hour Pain prevents me from sitting more than 30 minutes Pain prevents me from sitting more than 10 minutes Pain prevents me from sitting at all Section 8 Sex Life (if applicable) My sex life is normal and causes no extra pain My sex life is normal but causes some extra pain My sex life is nearly normal but is very painful My sex life is severely restricted by pain My sex life is nearly absent because of pain Pain prevents any sex life at all Section 6 Standing I can stand as long as I want without extra pain I can stand as long as I want but it gives me extra pain Pain prevents me from standing for more than 1 hour Pain prevents me from standing for more than 3 minutes Pain prevents me from standing for more than 10 minutes Pain prevents me from standing at all Section 7 Sleeping My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain I have less than 6 hours sleep Because of pain I have less than 4 hours sleep Because of pain I have less than 2 hours sleep Pain prevents me from sleeping at all Section 9 Social life My social life is normal and gives me no extra pain My social life is normal but increases the degree of pain Pain has no significant effect on my social life apart from limiting my more energetic interests eg, sport Pain has restricted my social life and I do not go out as often Pain has restricted my social life to my home I have no social life because of pain Section 10 Travelling I can travel anywhere without pain I can travel anywhere but it gives me extra pain Pain is bad but I manage journeys over two hours Pain restricts me to journeys of less than one hour Pain restricts me to short necessary journeys under 30 minutes Pain prevents me from travelling except to receive treatment 2018 Presbyterian Healthcare Services 10

11 Scoring Instructions: For each section the total possible score is 5. If the first statement is marked the section score = 0. If the last statement is marked, it=5. If all 10 sections are completed the score is calculated as follows: Example: 16 (patient score) / 50 (total possible score) x 100 = 32% If one section is missed or not applicable the score is calculated: Example: 16 (patient score) / 45 (total possible score) x 100 = 35.5% Minimum detectable change (90% confidence): 10% points (change of less than this may be attributable to error in the measurement) Interpretation of scores: 0 to 20%: minimal disability The patient can cope with most living activities. Usually no treatment is indicated apart from advice on lifting sitting and exercise %: moderate disability The patient experiences more pain and difficulty with sitting, lifting, and standing. Travel and social life are more difficult and they may be disabled from work. Personal care, sexual activity and sleeping are not grossly affected and the patient can usually be managed by conservative means %: severe disability Pain remains the main problem in this group but activities of daily living are affected. These patients require a detailed investigation %: crippled Back pain impinges on all aspects of the patient s life. Positive intervention is required %: These patients are either bed bound or exaggerating their symptoms Presbyterian Healthcare Services 11

12 Fear Avoidance Behavior Questionnaire (FABQ) Work Description: This module assesses fear-avoidance beliefs in respect to performing physical activities and work-related activities. Use to generate measures of the impact of fear-avoidance that may affect the outcomes for your patient. Originally, the fear- avoidance beliefs questionnaire (FABQ) was designed to assess fear-avoidance for patients with lumbar syndromes, but we have modified the questionnaire to be generic, i.e., no reference to the back or any other body part. This module can be used for any patient who has fear of activities or work. The FABQ-Work is also now being administered with Computer Adaptive Testing, so that all patients do not have to answer all questions. What will be reported: FOTO reports the Work Fear-Avoidance Behavior Questionnaire subscale both on an adjusted 100 point scale (first score) and on the standard scoring. The questionnaire has a score range from 0 (low fear) to 42 (high fear). High scores represent high fear. Low scores represent low levels of fear-avoidance, which is good. A useful cut point for clinical management is 35 or more for Work. When a patient has high (i.e. >35 Work FABQ), adjust treatment to manage the patient's fears of work activities to increase the probability of good functional status outcomes. Research Reference: Waddell G, Newton M, Henderson I, Somerville D, Main CJ, A Fear- Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low-back pain and disability. Pain, 1993;52: Responses for all questions: Completely disagree Somewhat disagree Unsure Somewhat agree Completely disagree Questions (possible -- not all questions will be asked of all patients): This is a statement other patients have made. Please rate your level of agreement. I cannot do my normal work with my present pain. I should not do my work with my present pain. I cannot do my normal work until my pain is treated. My work is too heavy for me. I do not think I will be back to my normal work within 3 months. I have a claim for compensation for my pain. My work might harm me. My work aggravated my pain Presbyterian Healthcare Services 12

13 Pain Catastrophizing Scale Description: This assessment asks the patient to reflect on past painful experiences, and to indicate the degree to which they experienced each of 13 thoughts or feelings when experiencing pain, which enables treatment plans to be more individually tailored. What is reported: The PCS yields a total score and three subscale scores assessing rumination, magnification, and helplessness, based on patient responses on a 5-point scale with the end points (0) not at all and (4) all the time. The total score is computed by summing responses to all 13 items and range from Subscales are computed by summing the responses of the following items: Rumination: Sum of items 8, 9, 10, 11 Magnification: Sum of Items 6, 7, 13 Helplessness: Sum of items 1, 2, 3, 4, 5, 12 Reference: Sullivan, Michael JL, Ph.D, Department of Psychology, Medicine and Neurology, School of Physical & Occupational Therapy McGill University, Montreal, Quebec H3A 181. Responses: 0 = not at all 1 = to a slight degree 2 = to a moderate degree 3 = to a great degree 4 = all the time Questions: When I'm in pain... I worry all the time about whether the pain will end. I feel I can't go on. It's terrible and I think it's never going to get any better. It's awful and I feel that it overwhelms me. I feel I can't stand it anymore. I become afraid that the pain will get worse. I keep thinking of other painful events. I anxiously want the pain to go away. I can't seem to keep it out of my mind. I keep thinking about how much it hurts. I keep thinking about how badly I want the pain to stop. There's nothing I can do to reduce the intensity of the pain. I wonder whether something serious may happen Presbyterian Healthcare Services 13