|
ONLINE EXCLUSIVE
GUIDELINE UPDATE:
What’s the best approach
to acute low back pain?
New guidelines provide management strategies for adults who have had low back pain or back-related leg symptoms for less than 6 weeks.
Son M. Bach, MD;
Premier Family Care of Mason, Mason, Ohio Keith B. Holten, MD, EditorClinton Memorial Hospital/University of Cincinnati, Family Medicine Residency, Wilmington, Ohio
keholtenmd@cmhregional.com
|
Practice recommendations for management of acute low back pain
Grade A recommendations
• Advise patients to:
- Stay active and continue ordinary activity within the limits permitted by pain. - Avoid bed rest. - Return to work early, which is associated with less disability.
• Consider McKenzie exercises, which are helpful for pain radiating below the knee.
• Recommend acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) if medication is necessary. COX-2 inhibitors, muscle relaxants, and opiate analgesics have not been shown to be more effective than NSAIDs for acute low back pain.
• Consider imaging if patients have no improvement after 6 weeks, although diagnostic tests or imaging is not usually required.
Grade B recommendations
• Reassure patients that 90% of episodes resolve within 6 weeks—regardless of treatment.
• Advise patients that minor flares-ups may occur in the subsequent year.
• Consider a plain lumbosacral spine x-ray if there is suspicion of spinal fracture or compression.
• Consider a bone scan after 10 days, if fracture is still suspected or the patient has multiple sites of pain.
• Suspect cauda equina syndrome or severe or progressive neurological deficit if red flags are present (TABLE).
• Obtain complete blood count, urinalysis, and sedimentation rate if cancer or infection are possibilities. If still suspicious, consider referral or perform other studies.
• Remember that a negative plain film x-ray does not rule out disease.
Grade C recommendations
• Recommend ice for painful areas and stretching exercises.
• Discuss the use of proper body mechanics and safe back exercises for injury prevention.
• Refer for goal-directed manual physical therapy if there is no improvement in 1 to 2 weeks, not modalities such as heat, traction, ultrasound, or transcutaneous electrical nerve stimulation.
• Do not refer for surgery in the absence of red flags.
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
|
|
FAST TRACK
Consider a bone scan after 10 days if fracture is still suspected or the patient has multiple pain sites.
|
|
-
What are the optimal initial therapies for treating low back pain?
-
What medications are recommended?
-
When should a patient be referred to a specialist?
-
What are the “red flags” of serious pathologies?
The answers to these questions are summarized on the next page and in the 2008 edition of Management of Acute Low Back Pain, published by the Michigan Quality Improvement Consortium (MQIC), a collaboration of physicians and representatives of Michigan health maintenance organizations and the Michigan State Medical Society, among others.
|
FAST TRACK
Reassure patients with acute low back pain that 90% of episodes resolve within 6 weeks.
|
|
Adult acute low back pain is commonly encountered in primary care practice, but the specific cause cannot always be identified. Low back pain has a benign course in 90% of patients. It is the fifth most common reason for all physician visits, and is responsible for direct health care expenditures of more than $20 billion annually.1
This guideline was developed to provide specific recommendations for consistent management of acute low back pain in an outpatient office setting. For our purposes, the evidence rating was updated to comply with the strength of recommendation taxonomy (SORT).2
TABLE“Red flags” for serious disease
| Cauda equina syndrome |
Cancer |
Fracture |
Infection |
• Severe or progressive neurological deficit
• Recent bowel or bladder dysfunction
• Saddle anesthesia |
• Age >50 years
• Cancer history
• Insidious onset
• No relief at bedtime or worsening when supine
• Constitutional symptoms (fever, weight loss)
• Male with diffuse osteoporosis or compression fracture |
• Traumatic injury or cumulative trauma
• Steroid use history
• Women age >50 years |
• Diabetes mellitus
• Immune suppression
• Human immunodeficiency virus (HIV)
• Intravenous drug use
• Steroid use history
• History of urinary tract infection or other infection
• Constitutional symptoms (fever, weight loss)
• No relief at bedtime or worsening when supine
• Previous surgery
• Insidious onset |
 Guideline relevance and limitations
Low back pain is commonly seen in primary care offices. The guideline was validated through an external and internal peer review. The limitations of the guideline were that it (1) did not describe the methods used to analyze the evidence, and (2) used expert consensus to formulate the recommendations.
Guideline development and evidence review
The MQIC project leader conducted a search of current literature regarding acute low back pain. Computer database searches were used to identify published studies, existing protocols, and/or national guidelines on the selected topic. When available, clinical practice guidelines from participating MQIC health plans and Michigan health systems were also used to develop a framework for the new guideline.
Using information obtained from literature searches and available health plan guidelines on the designated topic, the MQIC project leader prepared a draft guideline to be reviewed by the medical directors’ committee. They reviewed the guideline, evaluated the literature, and made multiple revisions.
The medical directors forwarded the guideline for external review to practitioners in MQIC health plans for comment. The guideline was also reviewed by state medical specialty societies for their input. After all feedback was received from external reviewers, it was presented for discussion by the medical directors. The MQIC medical directors approved this updated guideline in 2008.
Source for this guideline
Michigan Quality Improvement Consortium. Management of Acute Low Back Pain. Southfield, Mich: Michigan Quality Improvement Consortium; March 2008.
another guideline on low back pain
Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
This guideline from the American College of Physicians and the American Pain Society emphasizes a focused history and physical examination, first-line medication options of acetaminophen and/or NSAIDs, exercise therapy, and back-strengthening exercises. Routine imaging or other diagnostic tests in patients with nonspecific low back pain are not recommended.
- Patel AT,
Ogle AA.
Diagnosis and management of acute low back pain. Am Fam Physician 2000;61:1779–1790.
- Ebell M,
Siwek J,
Weiss BD, et al. Simplifying the language of evidence to improve patient care: Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. J Fam Pract. 2004;53:111–120.
The Journal of Family Practice ©2009 Quadrant HealthCom Inc.
|
