Back Pain Assessment, Management, and Follow-up Guideline 1
Copyright 2012 Group Health Cooperative. All rights reserved.
Back Pain Assessment, Management, and Follow-up Guideline
Background 2 Terminology 2 Assessment History 3 Physical exam 4 Recommended testing 5 Warning signs requiring immediate or urgent evaluation 6 Radiological exam 6 Severity of pain and degree of activity interference 7 Diagnosis 7 Management of non-specific and radicular back pain Goals 8 Tips for communicating with patients 8 Step 1. Self-management 8 Step 2. Other management options 9 Referrals to back specialists 10 Pharmacologic options 10 Follow-up/Monitoring 12 Comorbidity Screening 13
Evidence Summary 14 References 16 Clinician Lead and Guideline Development 17 Appendix 1. Evidence of effectiveness of non-pharmacologic strategies 18
Most recent guideIine approvaI: February 2012
Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health care for specific clinical conditions. While guidelines are useful aids to assist providers in determining appropriate practices for many patients with specific clinical problems or prevention issues, guidelines are not meant to replace the clinical judgment of the individual provider or establish a standard of care. The recommendations contained in the guidelines may not be appropriate for use in all circumstances. The inclusion of a recommendation in a guideline does not imply coverage. A decision to adopt any particular recommendation must be made by the provider in light of the circumstances presented by the individual patient.
Back Pain Assessment, Management, and Follow-up Guideline 2 Background Acute and chronic back pain are common conditions that result in significant misery for patients and account for a large number of visits to primary care. There is considerable variation among primary care providers about how to evaluate those patients, what options to offer them, how often to follow up, and under what circumstances to refer them to specialists. For most patients with back pain, the condition will improve within a few weeks or months; the initial focus should therefore be to offer counseling and support, simple analgesics as needed, and encouragement to stay active and focus on functional rehabilitation.
This guideline is intended to help primary care teams do an effective initial assessment of back pain, maximize the patients chances for rehabilitation and functional improvement, and minimize the use of unnecessary and potentially harmful interventions.
The treatment and follow-up recommendations in this guideline apply to patients with non-specific acute or chronic low back pain or back pain associated with radiculopathy. This guideline does not address the management of patients with red flag conditions or back pain resulting from underlying systemic illness, beyond providing recommendations for initial assessment and referral.
Terminology Acute back pain is pain lasting less than 4 weeks. Chronic back pain is pain lasting longer than 3 months. Non-specific back pain is pain with no signs or symptoms of a serious underlying disorder (such as cancer, infection, or cauda equina syndrome), spinal stenosis or radiculopathy, or other specific spinal cause (such as vertebral compression fracture or ankylosing spondylitis). Degenerative changes on lumbar imaging are usually considered non-specific, as they correlate poorly with symptoms (Chou 2007). Note: For evaluation and referral recommendations for suspected red flag conditions, see Table 4. Radiculopathy, often referred to as sciatica, is a nerve root irritation resulting in a sharp or burning pain radiating down the posterior or lateral aspect of the lower limb, usually to the foot or ankle. Pain radiating below the knee is more likely to represent true radiculopathy than proximal leg pain. Radicular nerve pain is often associated with numbness or tingling. Neurogenic claudication, also referred to as pseudoclaudication, is nerve root entrapment caused by narrowing of the spinal canal or neural foramina; disc bulging and spondylolisthesis may contribute to the condition. Symptoms include back pain, transient tingling in the legs, and ambulation-induced pain or fatigue in the lower extremities, resolving with rest. This pain with walking is clinically distinguished from vascular claudication by the presence of normal arterial pulses. Inflammatory back pain is pain caused by inflammation in the spinal joints, with onset typically occurring before age 45. It is characterized by improvement with exercise but not with rest and by morning stiffness of longer than 30 minutes duration. Back Pain Assessment, Management, and Follow-up Guideline 3 Assessment: History
Table 1. Key elements in history for assessment of back pain History of this pain episode When did the pain start? How did the pain start (for example, while lifting or bending, or for no apparent cause)? Is the pain getting better or worse? What makes it better: activities such as standing, walking, and sitting, or over the counter medications? Is the patient having any bladder or bowel dysfunction? How many days a week is the patient impacted by the pain? Pain and function - Location of pain (e.g., limited to the low back? soft tissue? joints?) - Pain severity and degree of disability (See Tables 6a and 6b.) - When does it hurt? - Is there weakness? - Does the pain radiate to the leg/foot? - Which leg(s)? - How is it distributed (above knee, below knee, both) and how does the patient describe it (pins and needles, hot/burning, numb, worse with touch)? Physical activity Are there things the patient is not doing because of the pain, such as home chores, exercise, or activities of daily living (ADLs)? Current level of activity? Activity level prior to this episode? What is the patient doing to cope with the pain and limitations? Previous episodes History of prior episodes of back pain - Duration - Location(s) of pain - Severity of pain What treatments or evaluations/exams have been tried in the past? What treatments have been helpful? What treatments have not been helpful? Potential red flags or underlying systemic illness (Also see Table 4.) History of cancer History of osteoporosis Immune suppression (steroid use, HIV, transplant, IV drug use) Cauda equina syndrome: saddle numbness, motor deficit at multiple levels, urinary retention, and fecal incontinence Suspicious fracture Inflammatory disease, such as psoriasis, uveitis, or enthesitis (pain and swelling at the heel involving the Achilles tendon and insertion of the plantar fascia) Unexpected weight loss Fever Pain at night Recent infection, such as a UTI Progressive neurological deficit Abnormal gait Psychosocial risk factors Belief that the pain is due to a serious condition and being active would cause harm Fear that the pain is due to undiagnosed disease Illness behavior (extended rest, symptom magnification) Stress (e.g., family, job) Depression screen Employment status Days off work? Expected return date? Having or had problems with claims and compensation
Back Pain Assessment, Management, and Follow-up Guideline 4 Assessment: Physical exam
Table 2. Key elements in physical exam for assessment of back pain Presence and severity of neurologic deficits Patient affect
Standing Posture Walk (heel walk, toe walk, partial squat, and Trendelenburg gait) Balance (stand on one foot) Range of motion (hip, spine, and Schber if indicated)
Sitting Reflexes: ankle, knee Sensory testing of lower limbs Manual muscle testing of lower extremities (hip and ankle extension and flexion, dorsi- and plantar flexion, great toe dorsiflexion) Circulation Provocative testing (straight leg raising) Back Pain Assessment, Management, and Follow-up Guideline 5 Assessment: Recommended testing
Table 3. Recommended testing and interventions for assessment of back pain Possible diagnosis Signs/symptoms Testing/intervention Non-specific back pain Pain worsens with spine loading No imaging initially. Consider X-ray after 6 weeks of self- management if patient is over age 50. Consider referral to Physical Therapy. Radiculopathy (sciatica) without weakness Back pain with leg pain or sensory symptoms in a lumbosacral nerve root distribution Positive straight-leg-raise test or crossed-straight-leg-raise test Consider early referral to Physical Therapy. After 4 weeks: - Consider referral or consultation with Physical Medicine and Rehabilitation. - Consider MRI. Radiculopathy with weakness Back pain with leg pain or sensory symptoms in a lumbosacral nerve root distribution Positive straight-leg-raise test or crossed-straight-leg-raise test Consider early referral to Physical Therapy. Consider referral to Neurosurgery. Consider referral to Physical Medicine & Rehabilitation for chronic pain and impaired function. Lumbar spinal stenosis Radiating leg pain, sensory symptoms Older age Sometimes neurogenic claudation After 4 weeks: Consider referral to Physical Therapy. Consider referral to Neurosurgery. Consider MRI. Inflammatory back pain 1
Age under 40 years Pain better with exercise Pain not better with rest Morning stiffness lasting longer than 30 minutes (especially upon rising) Significant response to NSAIDs Lab testing - HLA-B27 - ESR and/or CRP Consider X-ray anteroposterior (AP) view of sacroiliac joints. Refer to Rheumatology for diagnosis and management and/or Physical Medicine & Rehabilitation for concerns about impaired function. 1 No rheumatologic testing or evaluation is needed for pain that is worsened with activity or relieved by rest, or that starts after age 40. Anti-Nuclear Antibody (ANA) and Rheumatoid Factor Screen (RF) tests provide no useful information in back pain.
Back Pain Assessment, Management, and Follow-up Guideline 6 Assessment: Warning signs requiring immediate or urgent evaluation
Table 4. Warning signs requiring immediate or urgent evaluation, including red flag symptoms Possible cause Signs/symptoms Testing/intervention Cauda equina syndrome Saddle anesthesia Motor deficit at multiple levels Urinary retention Fecal incontinence MRI Emergent referral to Neurosurgery Significant or progressive neurological deficits Progressive motor weakness Severe leg pain MRI Urgent referral to Neurosurgery History of cancer with new onset low back pain MRI ESR Consider referral to Oncology Cancer
Unexplained weight loss Failure to improve after 1 month 50 years old or older Lumbosacral radiography or MRI ESR Consider referral to Oncology Vertebral infection Fever IV drug use Recent infection MRI ESR and/or CRP Consider referral to Infectious Disease Vertebral compression fracture History of osteoporosis Use of corticosteroids Older age Lumbosacral radiography Consider referral to Neurosurgery
Assessment: Radiological exam
Table 5. Radiological exam for assessment of back pain Testing Acute pain indications Chronic pain indications X-ray Possible fracture (elderly, recent fall, severe pain, history of osteoporosis or steroid use) After 6 weeks of self-management and if indicated (e.g., age over 50 years, pain increasing) Suspected inflammatory back pain (Order AP pelvis of sacroiliac joint.) Suspected structural deformities (e.g., spondylolisthesis, scoliosis spondylitis) MRI Red flags (suspicion of cancer or infection, trauma, or cauda equina syndrome) Severe or incapacitating back or leg pain (e.g., requiring hospitalization, precluding walking, or significantly limiting ADLs) Progressively severe back or leg pain Radiculopathy and major or progressive neurological symptoms (e.g., foot drop, functionally limiting weakness) Radiculopathy and sensory symptoms that are not improving after 46 weeks Surgery or epidural steroid injection being considered CT In acute and chronic pain: Contraindications to MRI or MRI results are inconclusive Suspected fracture or bone tumor
Back Pain Assessment, Management, and Follow-up Guideline 7 Assessment: Severity of pain and degree of activity interference There are a variety of tools for assessing pain and function. There is no evidence that one is superior to another.
This two-item version of the Graded Chronic Pain Scale (Table 6a) is intended for brief and simple assessment of pain severity in primary care settings. For score interpretation, see Table 6b. (Dunn 2010, Sullivan 2010)
Table 6a. Standard Questions: Pain interference and activity interference 1. In the last month, how much has pain interfered with your daily activities? Use a scale from 0 to 10, where 0 is "no interference" and 10 is "unable to carry on any activities"? No interference
Unable to carry on any activities 0 1 2 3 4 5 6 7 8 9 10 2. In the last month, on average, how would you rate your pain? Use a scale from 0 to 10, where 0 is "no pain" and 10 is "pain as bad as could be"? [That is, your usual pain at times you were in pain.] No pain Pain as bad as could be 0 1 2 3 4 5 6 7 8 9 10
Table 6b. Standard Questions: Interpretation of answers Pain rating item Mild Moderate Severe 1. Pain-related interference with activities 13 46 710 2. Average/usual pain intensity 14 56 710
Diagnosis Based on assessment and additional testing, categorize the patient with back pain into one of three broad diagnostic categories: Non-specific back pain. Back pain associated with radiculopathy or lumbar spinal stenosisapproximately 4% and 3% of patients, respectively. Back pain associated with red flag conditions or possible underlying systemic illness. This guideline does not address the management of patients with these conditions, apart from providing recommendations for imaging and referral.
Back Pain Assessment, Management, and Follow-up Guideline 8 Management of non-specific and radicular back pain: Goals Educate patient about the natural history of back pain. Ask about and address the patients concerns and goals. Maximize functional status. Reduce pain. Address associated symptoms, such as sleep or mood disturbances or fatigue. Do not expose the patient to unhelpful or possibly risky interventions.
Management: Tips for communicating with patients about their back pain Affirm/acknowledge the patients pain and suffering/loss of function. Address the patients specific fears or worries (e.g., undiagnosed serious disease, long-term disability). Provide reassurance, noting the likelihood that the patients back pain will start improving in the first month. Activate: Help the patient identify enjoyable and meaningful activities that will increase strength, flexibility and endurance.
Management: Education and self-care (Step 1)
Table 7. Education and self-care for patients with non-specific back pain or radiculopathy (See Appendix 1 for the level of evidence supporting these recommendations.) Educate patients on the natural history of back pain. Most patients with back pain experience significant improvement within 46 weeks; however, approximately two-thirds will experience another episode within 12 months. Back pain is often recurrent or persistent. Early, routine imaging usually cannot determine a specific cause or improve outcomes. Promote self-care. In the absence of red flag symptoms, it is safe to resume activity. Encourage patient to stay active and to carry on with normal activities as much as possible. - Advise continued routine activity while paying attention to correct posture to minimize spine loading. - Advise the patient to temporarily limit or avoid specific activities known to increase mechanical stress on the spine (e.g., prolonged unsupported sitting, heavy lifting, and bending or twisting the back, especially while lifting). - Advise discontinuation of any activity or exercise that causes spread of symptoms (radiculopathy). Build strength and endurance gradually. Move naturally and avoid guarded or bracing behavior. Manage physical and emotional stressors. Offer non-pharmacologic treatment. Heat Stretching Walking Offer pharmacologic treatment (see Table 10). To manage pain and help patients stay active: Simple analgesics if not medically or otherwise contraindicated (e.g., NSAIDS, aspirin, acetaminophen) Prescription options (e.g., analgesics or, in acute cases, muscle relaxants) Minimize/prevent patients from getting therapies that have no proven benefit. Back Pain Assessment, Management, and Follow-up Guideline 9
Management: Options for those whose pain does not improve with education and self-care (Step 2)
Table 8. Options for patients with back pain that does not improve with education and self-care Continue self-care strategies. If employing passive treatments such as manipulation and mobilization, introduce active treatment (i.e., exercise) within a week. Non-specific back pain Acute back pain Active Walking Continue usual activities Physical therapy
Passive Spinal manipulation 1,2
Chronic back pain
Active Physical therapy Exercise (aerobic exercise, stretching, walking) Yoga
Passive Massage therapy 2
Acupuncture 2
Spinal manipulation 1,2
Radicular pain Acute radicular pain Active Exercise/physical therapy 1 Spinal manipulation may be done if pre-manipulative testing centralizes symptoms (supported by weak evidence). 2 Continued improvement should be documented for continued therapy. Typically no more than 4 to 6 visits are needed.
Back Pain Assessment, Management, and Follow-up Guideline 10 Management: Referrals to back specialists
Table 9. Referring patients to specialty for back pain Specialty Reason for referral/recommendation of alternative practitioner Physical therapy Non-specific back pain Radiculopathy (sciatica) with or without weakness Lumbar spinal stenosis Physical medicine and rehabilitation/pain specialist Nonsurgical candidates such as radiculopathy, chronic pain, lumbar spinal stenosis To develop detailed treatment plans to enable an individual to carry out rehabilitation, including exercise and self-care Second opinion for surgical or nonsurgical patients with suboptimal response to a conservative treatment regimen Behavioral health Cognitive behavioral therapy for chronic pain Neurosurgery Cauda equina syndrome (emergent referral) Acute or progressive neurologic deficit (urgent referral) Vertebral compression fracture Oncology History of cancer with new onset back pain Infectious disease When vertebral infection is suspected Rheumatology When inflammatory disease is suspected
Treatment options that are not recommended Check coverage if considering treatment. Discography Epidural steroid injections (for non-radicular pain) Inferential therapy Intradiscal electrothermal therapy (IDET) Kyphoplasty Laser therapy Lumbar support Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) Percutaneous vertebroplasty (for vertebral fracture) Radiofrequency facet joint denervation Spinal cord stimulation Therapeutic ultrasound Traction Transcutaneous electrical nerve stimulation (TENS) Vertebral Axial Decompression (VAX-D System) for back pain X-stop for lumbar spinal stenosis
Management: Pharmacologic options Consider the risks of any medication and prescribe the lowest effective dose for the shortest period of time. Muscle relaxants are not indicated for treatment of chronic low back pain; limit use to 714 days. Opioids are rarely indicated for the treatment of low back pain. Opioids appear to be similarly efficacious to acetaminophen and NSAIDs, but have more risks and side effects. Patients receiving more than 7 days of opioids or more than one prescription within 6 weeks of the first visit for back pain had higher rates of work disability at 1 year. (See Chronic Opioid Therapy Safety Guideline.) The primary goal of treatment is maximal function, rather than complete relief from pain. Some ongoing or recurrent pain is normal and not indicative of a serious problem. Back Pain Assessment, Management, and Follow-up Guideline 11
For information on side effects, contraindications, formulary status (e.g., prior authorization), and other pharmacy-related issues, see the Group Health Drug Formulary online.
Table 10. Recommended pharmacologic options for the treatment of back pain Line Medication class Medication Initial dose Max. daily dose Acute back pain Acetaminophen 500650 mg three times daily 3,000 mg 1
Ibuprofen 600800 mg three times daily with food 2,400 mg Naproxen 250500 mg twice daily with food 1,250 mg Nabumetone 3 500 mg two times daily with food 2,000 mg 1st NSAIDs 2
Etodolac 3 300400 mg two to three times daily with food 1,200 mg Cyclobenzaprine 5 mg three times daily or 10 mg daily at bedtime 30 mg 2nd Skeletal muscle relaxants 4
Methocarbamol 500 mg three to four times daily 4,000 mg Hydrocodone- acetaminophen 5 mg/325 mg to 1 tab one to four times daily 3,000 mg 1 (acetaminophen component) 3rd Opioids Oxycodone 5 mg one to four times daily 80 mg Chronic back pain Acetaminophen 500650 mg three times daily 2,500 mg 1 1 st NSAIDs
Consider other NSAIDs options listed above for acute back pain. For chronic use, maximum dose for ibuprofen is 2,400 mg/day and for naproxen is 1,000 mg/day.
2 nd Opioids
See Chronic Opioid Therapy Safety Guideline.
1 Not to exceed 1,0001,500 mg daily for patients with liver disease or alcohol problems. 2 All patients over age 65 are considered at moderate risk for NSAID-induced GI toxicity and should receive gastroprotective therapy. Use caution in patients with cardiovascular comorbidities, at risk for GI bleed, or with hepatic or renal dysfunction. Chronic administration may increase the risk for adverse GI, cardiovascular, or renal effects. 3 Nabumetone and etodolac are partially selective NSAIDs. Moderate-strength evidence suggests that nabumetone has decreased risk of GI adverse effects compared to non-selective NSAIDs in short-term studies. The risk of GI adverse effects for etodolac compared to non-selective NSAIDs is unknown. Low-strength evidence suggests that etodolac has no increased risk of GI adverse effects compared to nonuse. 4 Limit use to 714 days. Avoid use in patients over age 65 years. Use caution in patients with cardiovascular comorbidities or hepatic impairment.
Back Pain Assessment, Management, and Follow-up Guideline 12 Pharmacologic options that are not recommended
Table 11. Recommended follow-up for patients with acute and chronic back pain Patient population Frequency of follow-up Acute back pain Have patient check back at 2 weeks, unless earlier follow-up is advised. Options for follow-up include phone, secure e-mail message, or visit. All Additional follow-up as indicated. Patients considered high-risk based on psychosocial risk factor evaluation Earlier and more frequent in-person follow-up may be appropriate. Older patients or Patients with Symptom progression or no significant improvement Severe pain or functional deficits Signs of radiculopathy or lumbar spinal stenosis Earlier and more frequent re-evaluations may be appropriate. Patients referred to spinal manipulation, acupuncture, or massage Have patient check back after 4 visits with referred specialty to demonstrate improved functionality. Chronic back pain Stable As needed. With fluctuating pain Periodic. On medications Periodic. (See the Chronic Opioid Therapy Safety Guideline if applicable.)
Back Pain Assessment, Management, and Follow-up Guideline 13 Comorbidity screening
Table 12. Recommended comorbidity screening for patients with back pain Condition Test(s) Depression Consider screening for depression with the Patient Health Questionnaire (PHQ-9). 1,2
Alcohol or drug abuse Consider screening with the AUDIT Alcohol Use Questionnaire (adults), the DAST-10 Drug Use Questionnaire (adults), or the CRAFFT Drug and Alcohol Use Survey (adolescents). 1 See the Adult Depression Guideline for additional guidance. Patients with major depression can be treated in primary care or offered a referral to Behavioral Health Services for counseling and/or drug therapy. 2 Evidence suggests that patients with depression are less likely to be adherent to recommended management plans and less likely to be effective at self-management of chronic conditions.
Back Pain Assessment, Management, and Follow-up Guideline 14 Evidence summary This guideline was adapted from the following sources: Agency for Healthcare Research and Quality. Complementary and Alternative Therapies for Back Pain II. 2011; Evidence Report/Technology Assessment Number 194. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/backpaincam/backcam2.pdf. Accessed January 2012.
Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):492504.
Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009 May;34(1):10661077.
National Institute for Health and Clinical Excellence (NICE). Low back pain: early management of persistent non-specific low back pain. 2009; Clinical guidelines CG88. Available at: http://www.nice.org.uk/nicemedia/live/11887/44345/44345.pdf. Accessed January 2012.
Washington State Health Care Authority. Spinal Injections: Health Technology Assessment. 2011. Available at: http://www.hta.hca.wa.gov/documents/updated_final_report_spinal_injections_0310- 1.pdf. Accessed January 2012.
The Group Health guideline team reviewed additional evidence in the following areas of non-pharmacologic treatment. Spinal manipulation A recent Cochrane review that included 26 randomized controlled trials (RCTs) and 6,070 participants examined the effectiveness of spinal manipulative therapy (SMT) on pain and functional status compared to control treatments for adults with chronic low back pain. Results from this analysis suggest that there was no significant difference in pain relief between SMT and simulated (sham) SMT. Compared to other interventions such as exercise and physiotherapy, evidence suggests that SMT provides significantly better pain relief at 1, 3, and 6 months; however, there was no significant difference in pain relief at 12 months. Results also suggest that compared to another intervention, SMT significantly improves functional status at 1 month. There was no significant difference in functional status at 3, 6, and 12 months (Rubinstein 2011). Acupuncture A recent RCT that included 638 subjects evaluated the effectiveness of three different types of acupuncture (individualized, standardized, or simulated [sham]) for the treatment of chronic low back pain compared to usual care. The primary outcome was back-related dysfunction and symptom bothersomeness at 8 weeks. After 8 weeks, participants who received one of the acupuncture treatments had significant improvements in back-related dysfunction and symptom bothersomeness compared to usual care; however, there was no significant difference between the acupuncture treatment groups in back-related dysfunction or symptom bothersomeness. After 1 year, there was no significant difference in symptom bothersomeness between the four treatment groups; however, participants who received real acupuncture continued to have less dysfunction compared to those who received usual care. The number needed to treat (NNT) with acupuncture to improve function ranged from 5 for short-term benefit to 8 for long-term benefit (Cherkin 2009).
Another RCT that included 84 subjects examined whether treatment with acupuncture or the muscle relaxant baclofen alone or in combination would alleviate symptoms of chronic non-specific low back pain in men. Results from this study suggest that after 5 and 10 weeks of follow-up the combined Back Pain Assessment, Management, and Follow-up Guideline 15 group and the acupuncture alone group experienced significantly greater reductions in pain and disability compared to the control group or the baclofen alone. The combined group also experienced significantly greater reductions in pain and disability compared to the group that received only acupuncture (Zaringhalam 2010). Massage A Cochrane meta-analysis that included 13 RCTs with 1,596 participants assessed the effectiveness of massage therapy for low back pain. Results from this meta-analysis suggest that massage therapy may be beneficial for patients with subacute (pain lasting 4 to 12 weeks) and chronic back pain (pain lasting more than 12 weeks); however, more research is needed to determine the ideal massage therapy method, duration, and frequency (Furlan 2008).
A recent RCT that was published after the meta-analysis and included 401 participants evaluated whether massage (relaxation or structural) would reduce pain and improve function in patients with chronic low back pain compared to usual care. The primary outcome measures were back pain related dysfunction (Roland Morris Disability Questionnaire [RMDQ]) and symptom bothersomeness at 10 weeks. Secondary outcome measures evaluated the primary outcome measures at 26 and 52 weeks. Results suggest that after 10 weeks of follow-up, treatment with relaxation or structural massage significantly improved function and symptom bothersomeness in patients with chronic low back pain compared to usual care. There was no significant difference in function or symptom bothersomeness between the two massage groups. Effects decreased after the 10-week treatment; however, at 26 weeks patients who received massage therapy still had statistically significant differences in functional improvement compared to the usual care group. At 52 weeks, relaxation massage was modestly more effective than structural massage and usual care. There were no significant differences in symptom bothersomeness at 26 or 52 weeks (Cherkin 2011). Interdisciplinary rehabilitation A recent RCT followed 286 subjects for 24 months to compare the efficacy of a multidisciplinary biopsychosocial rehabilitation program with an intensive therapist-assisted individual back muscle exercise program for the treatment of chronic low back pain. Outcome measures were change in pain (100 mm VAS) and disability (RMDQ) at 3 months. There was no significant difference in pain between the two groups at any time point. Compared to patients in the exercise program, patients in the multidisciplinary rehabilitation program experienced significantly greater reductions in disability at 3 months (3.0 vs. 1.5, P < 0.05). This improvement was maintained throughout the 24-month follow- up period; however, it should be noted that this difference may not be clinically significant (Dufour 2010).
Another RCT that followed 109 patients for 12 months compared the effects of functional multidisciplinary rehabilitation with those of physiotherapy on functional status and work status in patients with subacute or chronic low back pain. Results suggest that compared to outpatients, physiotherapy patients who received functional multidisciplinary rehabilitation were more likely to be working full time and had less disability at 12 months. Results should be interpreted with caution as baseline characteristics were not similar and there were a large number of patients lost to follow-up. Additionally, when the analysis method for disability outcomes was changed, the between-group differences were no longer significant (Henchoz 2010). Mindfulness-based stress reduction There is insufficient evidence to make a recommendation for or against mindfulness-based stress reduction for the treatment of chronic low back pain.
Back Pain Assessment, Management, and Follow-up Guideline 16 References Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009 May 11;169(9):858866.
Cherkin DC, Sherman KJ, Kahn J, et al. A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2011 Jul 5;155(1):19.
Dufour N, Thamsborg G, Oefeldt A, Lundsgaard C, Stender S. Treatment of chronic low back pain: a randomized, clinical trial comparing group-based multidisciplinary biopsychosocial rehabilitation and intensive individual therapist-assisted back muscle strengthening exercises. Spine (Phila Pa 1976). 2010 Mar 1;35(5):469476. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010 Jan 19;152(2):8592.
Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD001929.
Henchoz Y, de Goumoens P, So AK, Paillex R. Functional multidisciplinary rehabilitation versus outpatient physiotherapy for non specific low back pain: randomized controlled trial. Swiss Med Wkly. 2010 Dec 22;140:w13133.
Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev. 2011 Feb 16;(2):CD008112. Sullivan MD, Von Korff M, Banta-Green C, Merrill JO, Saunders K. Problems and concerns of patients receiving chronic opioid therapy for chronic non-cancer pain. Pain. 2010 May;149(2):345353.
Zaringhalam J, Manaheji H, Rastqar A, Zaringhalam M. Reduction of chronic non-specific low back pain: a randomised controlled clinical trial on acupuncture and baclofen. Chin Med. 2010 Apr 24;5:15.
Back Pain Assessment, Management, and Follow-up Guideline 17 Clinician lead and guideline development
Clinician Lead David K. McCulloch, MD Medical Director, Clinical Improvement
Content Expert Randi Beck, MD Service Line Chief, Physical Medicine & Rehabilitation
Guideline Team Members Rosemary Agostini, MD, Sports Medicine Hugh Allen, MD, Anesthesiology Arne Andersen, MD, Family Medicine, Neurosciences Beth Arnold , PharmD, Pharmacy Administration Ben Balderson, PhD, Psychologist, Group Health Research Institute Jo-Ellen Callahan, Manager, Radiology Services Dan Cherkin, PhD, Group Health Research Institute Rebecca Doheny, Clinical Epidemiologist, Clinical Improvement & Prevention Abid Haq, MD, Occupational Medicine Bill Huff, MD, Family Medicine, Sports Medicine Steve Lavine, MD, Anesthesiology Jennifer Macuiba, Guideline Coordinator, Clinical Improvement & Prevention Robyn Mayfield, Patient Health Education Resources, Clinical Improvement & Prevention Donna Moore, MD, Physiatry/Physical Medicine Ina Oppliger, MD, Rheumatology Tom Paulson, MD, Medical Director, Care Review and Utilization Grant Scull, MD, Family Medicine Michelle Seelig, MD, Family Medicine Rajiv Sethi, MD, Neurosurgery Karen Severson, RN, Nursing Ann Stedronsky, Clinical Publications, Clinical Improvement & Prevention John Vandergrift, MD, Emergency Medicine Michael Von Korff, ScD, Group Health Research Institute
Most Recent Guideline Approval: February 2012
Process of Development The recommendations in this guideline were adapted from externally developed, evidence-based guidelines from the Agency for Healthcare Research and Quality, the American Pain Society and American College of Physicians, the National Institute for Health and Clinical Excellence, and the Washington State Health Care Authority. (See Evidence Summary for details.)
The following specialties were represented on the development and/or update teams: anesthesiology, behavioral health, complementary and alternative medicine, emergency medicine, family medicine, Group Health Research Institute, neurosurgery, nursing, occupational medicine, orthopedics, pharmacy, physiatry and rehabilitation, and rheumatology.
Back Pain Assessment, Management, and Follow-up Guideline 18 Appendix 1. Evidence of effectiveness for non-pharmacologic strategies for the management of back pain
Definitions Small benefit = Mean 5- to 10-point improvement in pain on a 100-point VAS Mean 5- to 10-point improvement in function on the Oswestry Disability Index Mean 1- to 2-point improvement in function on the Roland-Morris Disability Questionnaire
Moderate benefit = Mean 10- to 20-point improvement in pain on a 100-point VAS Mean 10- to 20-point improvement in function on the Oswestry Disability Index Mean 2- to 5-point improvement in function on the Roland-Morris Disability Questionnaire
Table a. Level of evidence supporting SELF-CARE options for ACUTE back pain Treatment Small/moderate benefit No benefit Unable to estimate benefit Active treatment Advice to remain active X Passive treatment Superficial heat X Bed rest (limit to less than 48 hours) X Lumbar support X Superficial cold X
Table b. Level of evidence supporting SELF-CARE options for CHRONIC back pain Treatment Small/moderate benefit No benefit Unable to estimate benefit Advice to remain active X
Progressive relaxation 1 X Lumbar support X 1 Progressive relaxation requires intensive initial training.
Table c. Level of evidence supporting NON-PHARMACOLOGIC options for ACUTE back pain Treatment Small/moderate
benefit No benefit Unable to estimate benefit Spinal manipulation X Exercise therapy X Acupuncture X Back school X Interferential therapy X Low-level laser therapy X Massage X Transcutaneous electrical nerve stimulation (TENS) X Back Pain Assessment, Management, and Follow-up Guideline 19
Table d. Level of evidence supporting NON-PHARMACOLOGIC options for CHRONIC back pain Treatment Small/moderate
benefit No benefit Unable to estimate benefit Exercise X Education X Spinal manipulation X Massage X Acupuncture X Intensive interdisciplinary rehabilitation X Psychological therapy (cognitive behavioral therapy or progressive relaxation) X Yoga X Traction X Back school X Interferential therapy X Low-level laser therapy X Transcutaenous electric nerve stimulation (TENS) X Therapeutic ultrasound X Mindfulness-based stress reduction X
Table e. Level of evidence supporting INVASIVE TREATMENT options for CHRONIC NON-SPECIFIC back pain Treatment Recommended Not recommended/insufficient evidence Nerve root blocks X Intra-discal electrothermal therapy (IDET) X Lumbar (spinal) fusion 1 X Prolotherapy X Radiofrequency facet joint denervation X Sacroiliac joint injections X Trigger point/soft tissue injections X Epidural steroid injections 2 X Spinal cord stimulation X 1 Referral for an opinion on spinal fusion may be appropriate for a small group of selected individuals who have failed to respond to a combined physical and psychological intervention (NICE 2009). 2 There is insufficient evidence for epidural steroid injections. Only consider epidural steroid injections after initial appropriate conservative treatment programs have failed. Successful epidural steroid injections may allow patients to advance in a conservative treatment program. Patients should be made aware of the general risks of short-term and long-term use of steroids (ICSI 2010).
Back Pain Assessment, Management, and Follow-up Guideline 20