Research Review by Dr. Shawn Thistle©

Date:

Dec. 2007

Study Title:

Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society

Authors:

Chou R et al.

Publication Information:

Annals of Internal Medicine 2007; 147: 478-491.

Summary:

It is well known that low back pain (LBP) is common and costly. Although many cases of acute LBP are self-limiting, patients who do seek medical care often improve in pain and disability, and return to work within 4-6 weeks. The biggest clinical and economic challenge continues to be the (approximately) one third of LBP patients that report persistent pain at a moderate or higher level up to a year after onset. To illustrate, it is estimated that 5% of LBP patients account for 75% of the cost of this condition, which approaches $30 billion in the USA alone each year!

Treatment options for LBP are plentiful, however there is still no definitive evidence-based treatment approach for primary care and manual medicine providers to rely on. There are wide variations in practice patterns, and cost of treatment for LBP. However, as a whole, patients experience broadly similar outcomes.

The purpose of this guideline was to synthesize the available evidence for assessment and management of acute and chronic LBP. The target audience for this guideline is all clinicians caring for LBP patients, with or without leg pain, in a primary care setting. The target patient population was adults with acute (< 4 weeks), subacute (4-8 weeks) or chronic (> 8 weeks) LBP not associated with major trauma, children or adolescents with LBP, and pregnant women. Patients with LBP caused by non-spinal sources, fibromyalgia/myofascial pain, and with concomitant thoracic and cervical back pain were also included.

This guideline emerged from a systematic literature review carried out by Chou and colleagues, initially created as an evidence report for the American Pain Society. In combination with the American College of Physicians, a multi-disciplinary panel of experts was formed, creating key questions and scope to guide the evidence review. All English-language articles reporting on randomized, controlled trials of non-pregnant adults (> 18 yoa) with LBP (with or without leg pain) of any duration were included. Trials had to report on at least one of the following outcomes: back specific function, generic health status, pain, work disability, or patient satisfaction.

7 recommendations arose from this project, each of which will be quoted directly below, with additional relevant points added under each one.

Recommendation #1: “Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).” [pg. 479]
  • > 85% of patients with back pain cannot reliably have an exact pain generator identified
  • no evidence suggests that providing a specific anatomical diagnosis improves patient outcomes – making “mechanical” or “non-specific” LBP a prudent diagnosis
  • best estimates for the minority of patients with specific disorders are: cancer (0.7%), compression fractures (4%), spinal infection (0.01%), Ankylosing Spondylitis (0.3%-5%), spinal stenosis and symptomatic disc herniation (~3%), cauda equina syndrome (0.04%)
Recommendation #2: “Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).” [pg. 483]
  • there is no evidence that routine plain film radiography improves patient outcomes in those with non-specific LBP
  • routine advanced imaging is also not associated with improved outcomes, and potentially identifies many abnormalities that correlate poorly with symptoms, but may lead to additional needless interventions
  • in those at high risk of vertebral compression fracture (history of osteoporosis or corticosteroid use), plain films are recommended
  • thermography and electro-physiological testing is not recommended for the evaluation of non-specific LBP
Recommendation #3: “Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).” [pg. 483]
  • MRI is generally preferable over CT scanning if available due to superior visualization of soft tissue structures
  • in patients with a previous history of cancer, the value of utilizing advanced imaging early is increased
Recommendation #4: “Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).” [pg. 483]
  • natural history for lumbar disc herniation with radiculopathy is generally favorable, and no compelling evidence suggests that utilizing advanced imaging in these patients improves outcomes
  • only those with persistent or progressive neurological deficits should undergo advanced imaging
Recommendation #5: “Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).” [pg. 484]
  • the probability of significant improvement in acute LBP within the first month is high
  • bed rest should be limited, and is generally not recommended
  • there is insufficient evidence to guide recommendations regarding modifying duties for return-to-work
  • heat application may help for short-term relief of acute LBP
  • for those with chronic LBP – there is some evidence to suggest that medium-firm mattresses are better than firm mattresses
  • there is insufficient evidence to recommend lumbar supports or ice application for acute LBP as self-care options
Recommendation #6: “For patients with low back pain, 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 data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.” [pg. 484]
  • each class of medications has unique profiles of risk/benefit/cost
  • there is insufficient evidence to recommend for or against the use of therapeutic doses of Aspirin for patients with LBP
  • use of opioid analgesics needs to be carefully considered due to the high risk of aberrant drug-related behaviors, and potential for abuse or addiction
  • evidence is limited on the risks and benefits of long-term use of any medication for LBP – therefore extended use should be limited to those patients who experience significant clinical benefit without adverse reaction
Recommendation #7: “For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).” [pg. 486]
  • for acute LBP – SMT performed by trained professionals is associated with small to moderate short-term benefits
  • supervised exercise and home exercise programs are not effective for acute LBP
  • the optimal time to start exercise therapy after symptom onset is uncertain
  • for subacute LBP (4-8 weeks) – interdisciplinary rehabilitation (involving a family physician consultation and involving physical therapy, psychological, social, or vocational intervention) is moderately effective, while functional restoration with cognitive behavioral therapy reduced work absenteeism in occupational settings
  • for chronic LBP – moderate effectiveness is seen with acupuncture, exercise therapy, massage therapy, spinal manipulation, some types of yoga, cognitive behavioral therapy or progressive relaxation, and intensive interdisciplinary therapy (although the levels of evidence for individual therapies ranges between fair to good)
  • for chronic LBP – exercise programs that are individualized and supervised that include stretching and strengthening exercise work best
  • intermittent traction, although oft advertised and with claims of high success rates, has NOT been shown to be effective for patients with radicular symptoms or spinal stenosis
  • there is insufficient evidence to guide recommending exact times for specialist referral in those with persistent symptoms, or those who do not respond to various therapies
  • according to existing guidelines, referral for surgical consult could occur after patients are non-responsive for 3 months up to 2 years depending of the guideline referenced – this expert panel recommends at least 1 year of non-responsiveness prior to surgical referral

Conclusions & Practical Application:

These guidelines represent a substantial undertaking by two large and influential medical groups. From a manual therapy perspective, these guidelines reinforce and support most best-practice approaches we already use, while emphasizing the uncertainty of the state of the literature as a whole in this topic area.

Recommendation #1 emphasizes the importance of sub-classifying LBP patients by historical and examination findings, and may fit nicely with our existing knowledge of the clinical prediction rule (CPR) previously reviewed by the RRS. This guideline recommends a slightly more simplistic model including only three categories, but still makes intuitive sense.

After reviewing the references provided in this paper, it appears the literature regarding the LBP CPR (DeLitto, Fritz, Childs et al) was not included – likely because most of this work is not in the form of a RCT. This omission represents a potential weakness of this guideline, but readers should keep in mind that those who produced it are family physicians, with presumably little interest in the specifics of manual medicine management of this condition (aside from which therapy works best of course).

The other recommendations provide a good review of existing knowledge, and effectively synthesize the existing literature on low back pain as a whole. It should be noted that this guideline is, by its nature, an overview, and is not meant to be taken as a comprehensive review of any specific treatment approach.

Further, it did not have the ability to evaluate the potential benefit of combining various treatment modalities, as is common in clinical practice.