Acute low back problems, the subject of this Clinical Practice Guideline, are experienced by almost everyone at some time in their adult lives. Back problems rank high among the reasons for physician office visits and are costly in terms of medical treatment, time lost from work, and nonmonetary costs such as diminished ability to perform or enjoy usual activities. For persons under age 45, low back problems are the most frequent cause of disability.
The US Department of Health & Human Services, Public Health Servic
e, Agency for Health Care Policy and Research (AHCPR) convened a 23-member
, multidisciplinary, private-sector panel to develop a guideline for the evaluation and treatment of acute low back problems in adults. The panel included physicians, nurses, chiropractors, experts in spine research, physical therapists, a psychologist, an occupational therapist, and a consumer representative. The panel defined "back problems" as activity intolerance due to back-related symptoms and "acute" as limitations of less than 3 months' duration. Back symptoms include pain, primarily in the back, as well as back-related leg pain (sciatica). The panel agreed that the guideline should provide primary care clinicians with information on the detection of serious spinal pathology (such as tumor or infection, spinal fracture or cauda equina syndrome) as well as nonspinal pathology that could be causing limitations due to low back symptoms, but that treatment of these conditions is outside the scope of the guideline.
Furthermore, the panel agreed that the assessment and treatment of patients younger than 18 years or those with chronic low back problems (back-related limitations lasting longer than 3 months) may be quite different than for adults with acute problems. For this reason, the panel decided that back problems in children as well as chronic low back problems are also outside the scope of the guideline.
The panel's overall intent was to change the paradigm of focusing care exclusively on the pain of low back problems to one of helping patients improve their activity tolerance. Findings and recommendation statements are based on an exhaustive and systematic review
and analysis of the scientific literature as well as information gathered from the clinical experience of the expert panel, public testimony, peer review, and pretesting in outpatient settings. This guideline is divided into an introduction and three chapters to correlate with the clinical approach: (1) Initial Assessment Methods; (2) Clinical Care Methods; and (3) Special Studies and Diagnostic Considerations.
Koes et al.`01
found the framework proposed by the AHCPR Back Guideline Panel published in 1994 had been adopted by nearly all subsequent back pain guidelines making systematic review of the literature the standard. Since the publication of the AHCPR Back guidelines, substantial new evidence on diagnosis and treatment of low back pain has become available. The AHCPR guidelines were evaluated in Shekelle et al., 2001
who found after 8 years the subsequent scientific publications did not reverse the findings in AHCPR Guide #14 systematic review of the literature while suggesting only minor update to be required. Specifically they suggested only tempering the (finding and recommendation) statements on back school, corsets, epidural steroids and addition of Primary Prevention. The Quality of Primary Care Guidelines for Acute Low Back Pain was assessed by van Tulder et al.,`04 finding the standard to be (17) Guidelines as the product of a systematic literature review methodology. Only the pre-dated Quebec Task Force in Canada in 1987 review was not based upon the AHCPR Guide #14 systematic review as the foundation for their guideline process.
Subsequent guidelines based upon systematic review have perhaps tempered, but not reversed, the finding and recommendation statement made in 1994 by the AHCPR Low Back Guideline. Subsequent scientific efforts have been supportive of those original findings without providing significantly different recommendations since 1994. Yet many subsequent guidelines have limited themselves by being Back Pain Guideline rather than Back Problem Guidelines. Part of this seems tethered to the mandate of the Cochrane Collaboration to use a medical model aimed at pain.van Tulder et al.,`06
Pain Guideline's inadvertent concentration on pain sometimes complicates the real problem of related reduced activity tolerance. Pain is an intermediate and extremely subjective issue while Guidelines for Back Problems target activity limitation due to back or related leg symptoms which is proven a more objective and real danger to the patient. Severe symptoms are usually fleeting. Limited activity tolerance is also fleeting and long term disability is usually avoidable unless the patient becomes debilitated by activity intended to reduce the patient's pain. It sounds reasonable enough that if the pain goes away there is no limitation - WRONG! Data suggests that medical decisions while concentrating on treating the pain rather avoiding disability seem to increase avoidable risks. Attempting to relieve pain by avoiding activity can be very debilitating depending upon age and duration of inactivity and foster frustration linked to poor decision making about risky procedures with results that have little impact on function. This clinical confusion targeting subjective pain in a strictly medical model, can endanger patients through debilitation from physical inactivity and risk loss of livelihood with its accompanying 50% increase in death rate of being unemployed before retirement age (See Off Work Risk). Thus, the original AHCPR not being a Back Pain Guideline but a Back Problem Guideline not suggests caring for the patient in pain but targets the more objective activity intolerance due to back or related leg symptoms that in the long run works to the advantage and safety of patient but good of society as a whole.
Initial Assessment Methods
The initial assessment of a patient with activity intolerance due to low back symptoms consists of a focused medical history and physical examination. The primary purpose is to seek medical history responses or physical examination findings that suggest a serious underlying spinal condition such as fracture, tumor, infection, or cauda equina syndrome. These responses or findings are referred to as "Red Flags
." The history and physical examination should also assess for nonspinal conditions (vascular, abdominal, urinary, or pelvic pathology) causing referred low back symptoms.
Once the clinician has ruled out red flags and nonspinal pathology, the symptoms can be categorized as either sciatica or nonspecific back pain. In the absence of red flags, neither routine nor special testing is required in the first month of symptoms for either category. Most of these patients will recover spontaneously from their activity limitations within 1 month.
Clinical Care Methods
In the absence of the red flags described above, most patients with activity intolerance due to an acute episode of low back symptoms can be treated similarly during the first month. The goals are to provide patients with accurate information about low back problems, assist with symptom relief, and make appropriate activity recommendations.
Once the history and physical examination are complete, the patient can be assured that there is no hint of a dangerous medical condition causing the back problem and that a rapid recovery is expected. Symptom control methods focus initially on providing the patient with a comfort level adequate to keep the patient as active as possible while awaiting spontaneous recovery. Later in treatment, symptom control is considered an adjunct in helping the patient overcome a specific activity intolerance. The primary methods of symptom control are oral pharmaceuticals and physical methods.
Among the oral medications available to control the discomfort of acute low back problems, the panel recommends acetaminophen as reasonably safe and acceptable. Nonsteroidal anti-inflammatory drugs (NSAID
s), including aspirin, are also acceptable despite the potential for side effects, most frequently gastrointestinal irritation. Muscle relaxants, including benzodiazepines, have been found no more effective than NSAID
s in treating patients with acute low back problems, and potential side effects of these drugs include drowsiness in up to 30 percent of patients. The panel recommended that opioids be avoided if possible because of significant risks of debilitation, drowsiness, decreased reaction time, clouded judgment, and potential misuse. If chosen, they should be used only for a short time. The panel also recommended against the use of oral steroids, colchicine, or antidepressant medications for acute low back problems.
The panel found manipulation to be a recommendable method of symptom control. Manipulation
seems helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms. If no symptomatic and functional improvement has been noted after 1 month of manipulative therapy, this treatment should be stopped and the patient reevaluated. The panel found no evidence of benefit from the application of physical agents and modalities such as ice, heat, massage, traction, ultrasound, cutaneous laser treatment, transcutaneous electrical nerve stimulation (TENS
), and biofeedback techniques. Self-application of heat or cold may be taught to patients who choose such options to provide temporary relief of symptoms. Evidence does not support the use of trigger point, ligamentous and facet joint injections, needle acupuncture, or dry needling as treatment for low back problems.
The panel found that prolonged bed rest (for more than 4 days) may lead to debilitation and is not appropriate in the treatment of low back problems. A gradual return to normal activities is advisable, although bed rest for 2 to 4 days may be an option for patients with severe initial symptoms of sciatica. The patient whose symptoms are aggravated by lifting or prolonged sitting may require specific advice and exploration of alternatives. For most patients, aerobic activities that minimally stress the back (such as walking, biking, or swimming) can be started during the first 2 weeks of acute low back problems. After this, conditioning exercises for trunk muscles (in particular back extensors) may be helpful, especially if the patient's acute low back problems persist, although such exercises may initially aggravate symptoms.
Special Studies and Diagnostic Considerations
The panel recommended that clinicians consider a diagnostic reevaluation that may include special studies if the patient continues to be limited by back symptoms for more than 1 month without improvement. Hestbaek et al.`03 and Pengel et al.`03 found significant improvement within the first month after initial presentation by patients with acute low back pain to suggest a reasonable approach of re-evaluateing patients with persistent, unimproved symptoms after one month. In patients with severe pain or functional deficits, older patients, or patients with neurogenic back pain, earlier or more frequent re-evaluation may also be appropriate.
This reevaluation begins with a review and update of the history and physical exam to look again for red flags or evidence of nonspinal conditions causing back symptoms. If none of these is found, an appropriate evaluation can be initiated for either patients with sciatica or those with nonspecific low back symptoms.
For patients limited by sciatica for more than 4 weeks without clear evidence on physical examination of nerve root compromise, electromyography (EMG
) and h-reflex tests of the lower limb may provide evidence of suspected neurologic dysfunction. Sensory evoked potentials (SEP
s) may be a useful adjunct for assessment of suspected spinal stenosis or spinal cord myelopathy. For patients limited by sciatica for more than 4 weeks with physiologic evidence of neurologic dysfunction, MRI
is an appropriate consideration to provide anatomic definition of suspected herniated disc before surgery. Anatomic abnormalities of the lumbar spine (such as degenerative changes or abnormal discs) can be confusing since they increase in frequency as patients age and are often noted on imaging tests in subjects with no symptoms of low back problems. Abnormalities on imaging should corroborate evidence from physical examination or physiologic testing. A referral for surgical consultation is reasonable for patients with sciatic symptoms who have (1) activity limitations for more than 1 month without improvement, (2) clear clinical or electrophysiological evidence of nerve root compromise, and (3) corroborative findings on imaging studies. Earlier emergency consultation is reserved for patients with findings of bowel and/or bladder dysfunction or progressive and/or severe neurologic impairment. Most patients with symptoms persisting beyond 4 weeks will not be surgical candidates since the majority will have nonspecific low back symptoms without evidence of a serious underlying condition.
Following diagnostic or surgical procedures, treatment for those patients who have not recovered focuses on graduated physical conditioning to gain tolerance for activities required at home and/or the workplace. To help patients who have extreme difficulty overcoming their personal activity intolerance, clinicians are encouraged to address any nonphysical factors (such as unrealistic expectations by patient or employer or other psychosocial problems) that can potentially be influenced in a positive manner. The goal is to help the patient recover normal activity tolerance and avoid the development of a chronic low back disability.
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