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 5 th 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 selfcare. 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 1 st 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 selfcare 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.