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Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

By Frank M. Painter|November 2, 2016|Guidelines, Low Back Pain|

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

SOURCE: Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491

Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross, Jr, MD, MPH; Paul Shekelle, MD, PhD; Douglas K. Owens, MD, MS

Clinical Efficacy Assessment Subcommittee
of the American College of Physicians
and the American College of Physicians/
American Pain Society Low Back Pain Guidelines Panel*

Review the complete Guideline for the Evaluation and Management of Low Back Pain: Evidence Review
(482 page Adobe Acrobat file)

From the FULL TEXT Article:

The Abstract

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).

Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).

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).

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).

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).

WARNING: Before following Recommendation #6,
please review the Contra-indications to NSAIDS use.

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Clinical Decision Rule for Primary Care Patient with Acute Low Back Pain at Risk of Developing Chronic Pain

By Frank M. Painter|November 1, 2016|Clinical Decision Rule, Low Back Pain|

Clinical Decision Rule for Primary Care Patient with Acute Low Back Pain at Risk of Developing Chronic Pain

The Chiro.Org Blog

SOURCE: Spine J. 2015 (Jul 1); 15 (7): 1577–1586

Wolf E. Mehling, MD, Mark H. Ebell, MD, MS, Andrew L. Avins, MD, MPH, Frederick M. Hecht, MD

Department of Family Medicine,
University of California-San Francisco,
1545 Divisadero St,
San Francisco, CA 94115, USA

BACKGROUND CONTEXT: Primary care clinicians need to identify candidates for early interventions to prevent patients with acute pain from developing chronic pain.

PURPOSE: We conducted a 2-year prospective cohort study of risk factors for the progression to chronic pain and developed and internally validated a clinical decision rule (CDR) that stratifies patients into low-, medium-, and high-risk groups for chronic pain.

STUDY DESIGN/SETTING: This is a prospective cohort study in primary care.

PATIENT SAMPLE: Patients with acute low back pain (LBP, ≤30 days duration) were included.

OUTCOME MEASURES: Outcome measures were self-reported perceived nonrecovery and chronic pain.

METHODS: Patients were surveyed at baseline, 6 months, and 2 years. We conducted bivariate and multivariate regression analyses of demographic, clinical, and psychosocial variables for chronic pain outcomes, developed a CDR, and assessed its performance by calculating the bootstrapped areas under the receiver-operating characteristic curve (AUC) and likelihood ratios.

RESULTS: Six hundred five patients enrolled: 13% had chronic pain at 6 months and 19% at 2 years. An eight-item CDR was most parsimonious for classifying patients into three risk levels. Bootstrapped AUC was 0.76 (0.70-0.82) for the 6-month CDR. Each 10-point score increase (60-point range) was associated with an odds ratio of 11.1 (10.8-11.4) for developing chronic pain. Using a less than 5% probability of chronic pain as the cutoff for low risk and a greater than 40% probability for high risk, likelihood ratios were 0.26 (0.14-0.48) and 4.4 (3.0-6.3) for these groups, respectively.

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Mechanisms of Low Back Pain: A Guide for Diagnosis and Therapy

By Frank M. Painter|October 30, 2016|Diagnosis, Low Back Pain|

Mechanisms of Low Back Pain: A Guide for Diagnosis and Therapy

The Chiro.Org Blog

SOURCE: F1000Res. 2016 (Oct 11); 5. pii: F1000

Massimo Allegri, Silvana Montella, Fabiana Salici,
Adriana Valente, Maurizio Marchesini, Christian Compagnone,
Marco Baciarello, Maria Elena Manferdini, and Guido Fanelli

Department of Surgical Sciences,
University of Parma,
Parma, Italy

Chronic low back pain (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 3 months. CLBP represents the second leading cause of disability worldwide being a major welfare and economic problem. The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the aging population, affecting both men and women in all ethnic groups, with a significant impact on functional capacity and occupational activities. It can also be influenced by psychological factors, such as stress, depression and/or anxiety. Given this complexity, the diagnostic evaluation of patients with CLBP can be very challenging and requires complex clinical decision-making.

Answering the question “what is the pain generator” among the several structures potentially involved in CLBP is a key factor in the management of these patients, since a mis-diagnosis can generate therapeutical mistakes. Traditionally, the notion that the etiology of 80% to 90% of LBP cases is unknown has been mistaken perpetuated across decades. In most cases, low back pain can be attributed to specific pain generator, with its own characteristics and with different therapeutical opportunity. Here we discuss about radicular pain, facet joint pain, sacro-iliac pain, pain related to lumbar stenosis, discogenic pain. Our article aims to offer to the clinicians a simple guidance to identify pain generators in a safer and faster way, relying a correct diagnosis and further therapeutical approach.

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An Updated Overview of Clinical Guidelines for the Management of Non-specific Low Back Pain in Primary Care

By Frank M. Painter|October 28, 2016|Guidelines, Low Back Pain|

An Updated Overview of Clinical Guidelines for the Management of Non-specific Low Back Pain in Primary Care

The Chiro.Org Blog

SOURCE: Eur Spine J. 2010 (Dec); 19 (12): 2075–2094

Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C.

Department of General Practice,
Erasmus MC, P.O. Box 2040, 3000 CA,
Rotterdam, The Netherlands

This review of national and international guidelines conducted by Koes et. al. points out the disparities between guidelines with respect to spinal manipulation and the use of drugs for both chronic and acute low back pain. Another review of guidelines published in June 2010 also noted a great degree of similarity between guidelines and that:“Recommendations for management of acute LBP emphasized patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy.”Although there is always a need for more evidence, the evidence over the last few years is providing much stronger support for SMT and that evidence is slowly finding its way into major clinical guidelines both in the United States and internationally.

The Abstract

The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000.

Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity.

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Estimating the Risk of Chronic Pain: Development and Validation of a Prognostic Model (PICKUP) for Patients with Acute Low Back Pain

By Frank M. Painter|October 27, 2016|Low Back Pain|

Estimating the Risk of Chronic Pain: Development and Validation of a Prognostic Model (PICKUP) for Patients with Acute Low Back Pain

The Chiro.Org Blog

SOURCE: PLoS Med. 2016 (May 17); 13 (5): e1002019

Adrian C. Traeger, Nicholas Henschke, Markus Hübscher,
Christopher M. Williams, Steven J. Kamper,
Christopher G. Maher, G. Lorimer Moseley,
James H. McAuley

Prince of Wales Clinical School,
University of New South Wales,
Sydney, New South Wales, Australia

BACKGROUND: Low back pain (LBP) is a major health problem. Globally it is responsible for the most years lived with disability. The most problematic type of LBP is chronic LBP (pain lasting longer than 3 mo); it has a poor prognosis and is costly, and interventions are only moderately effective. Targeting interventions according to risk profile is a promising approach to prevent the onset of chronic LBP. Developing accurate prognostic models is the first step. No validated prognostic models are available to accurately predict the onset of chronic LBP. The primary aim of this study was to develop and validate a prognostic model to estimate the risk of chronic LBP.

METHODS AND FINDINGS: We used the PROGRESS framework to specify a priori methods, which we published in a study protocol. Data from 2,758 patients with acute LBP attending primary care in Australia between 5 November 2003 and 15 July 2005 (development sample, n = 1,230) and between 10 November 2009 and 5 February 2013 (external validation sample, n = 1,528) were used to develop and externally validate the model. The primary outcome was chronic LBP (ongoing pain at 3 mo). In all, 30% of the development sample and 19% of the external validation sample developed chronic LBP. In the external validation sample, the primary model (PICKUP) discriminated between those who did and did not develop chronic LBP with acceptable performance (area under the receiver operating characteristic curve 0.66 [95% CI 0.63 to 0.69]). Although model calibration was also acceptable in the external validation sample (intercept = -0.55, slope = 0.89), some miscalibration was observed for high-risk groups. The decision curve analysis estimated that, if decisions to recommend further intervention were based on risk scores, screening could lead to a net reduction of 40 unnecessary interventions for every 100 patients presenting to primary care compared to a “treat all” approach. Limitations of the method include the model being restricted to using prognostic factors measured in existing studies and using stepwise methods to specify the model. Limitations of the model include modest discrimination performance. The model also requires recalibration for local settings.

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Cost-Effectiveness Of General Practice Care For Low Back Pain: A Systematic Review

By Frank M. Painter|October 25, 2016|Cost-Effectiveness|

Cost-Effectiveness Of General Practice Care For Low Back Pain: A Systematic Review

The Chiro.Org Blog

SOURCE: Eur Spine J. 2011 (Jul); 20 (7): 1012–1023

Chung-Wei Christine Lin, Marion Haas, Chris G. Maher,
Luciana A. C. Machado, Maurits W. van Tulder

The George Institute for Global Health and
Sydney Medical School,
The University of Sydney,
PO Box M201, Missenden Rd,
Sydney, NSW 2050, Australia.

Care from a general practitioner (GP) is one of the most frequently utilised healthcare services for people with low back pain and only a small proportion of those with low back pain who seek care from a GP are referred to other services. The aim of this systematic review was to evaluate the evidence on cost-effectiveness of GP care in non-specific low back pain. We searched clinical and economic electronic databases, and the reference list of relevant systematic reviews and included studies to June 2010. Economic evaluations conducted alongside randomised controlled trials with at least one GP care arm were eligible for inclusion. Two reviewers independently screened search results and extracted data.

Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual GP care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone.

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