low back pain: evaluation, management, and prognosis
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Low Back Pain: Evaluation, Management,
and Prognosis
Welcome to
Welcome and Overview
Bill McCarberg
FounderChronic Pain Management ProgramKaiser PermanenteSan Diego, California
Adjunct Assistant Clinical Professor University of CaliforniaSchool of MedicineSan Diego, California
Evidence-Based Evaluation of Patients With Low Back Pain
Learning Objective
Discuss the differential diagnosis for low back pain (LBP) and the importance of clinical red and yellow flags in evaluation of LBP
Low Back Pain Guidelines
In 2007, the American College of Physicians (ACP) and American Pain Society (APS) issued comprehensive joint clinical practice guidelines for diagnosis and treatment of LBP
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Guideline #1
Clinicians should conduct a focused history and physical examination to help place patients with LBP into 1 of 3 broad categories Nonspecific LBP Back pain potentially associated with radiculopathy
or spinal stenosis 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 evidenceChou R, et al. Ann Intern Med. 2007;147(7):478-491.
Focused History and Physical Examination Determine presence and level of
neurological involvement1,2
Classify patients into 3 broad categories Nonspecific LBP potentially associated with radiculopathy Spinal stenosis Back pain potentially associated with another specific
spinal cause Patients with serious or progressive neurologic deficits
or underlying conditions requiring prompt evaluation Tumor Infection Cauda equina syndrome
Patients with other conditions that may respond to specific treatments
Ankylosing spondylitis Vertebral compression fracture
1. Deyo RA, et al. JAMA. 1992;268(6):760-765. 2. Bigos SJ, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, No. 14 ; 1994.
Evaluation of Back Pain
Site
Length of illness
Spread
Quality
Intensity
Frequency
Duration
Time of onset
Mode of onset
Precipitating factors
Aggravating factors
Relieving factors
Associated features
McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1094-1105.
Epidemiology of Low Back Pain
90% of American adults experience an episode of back pain during their lifetime
Of patients who have acute back pain 90% to 95% have a non–life-threatening condition
Although up to 85% cannot be given an exact diagnosis, nearly all recover within 4 to 6 weeks
For 5% to 10% of patients, acute back pain is a manifestation of more serious pathology
Vascular catastrophes, malignancy, spinal cord compressive syndromes, and infectious disease processes
Winters ME, et al. Med Clin North Am. 2006;90(3):505-523.
What Is Seen in PrimaryCare Practice? In minority of patients presenting for initial evaluation
in primary care setting, LBP is caused by1
Cancer (approximately 0.7% of cases) Compression fracture (4%) Spinal infection (0.01%)
Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3%1 to 5%2
Spinal stenosis and symptomatic herniated disc are present in about 3% and 4% of patients, respectively
Cauda equina syndrome most commonly associated with massive midline disc herniation, but rare Estimated prevalence of 0.04%3
1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 2. Underwood MR, et al. Br J Rheumatol. 1995;34(11):1074-1077.3. Deyo RA, et al. JAMA. 1992;268(6):760-765.
Cost of Low Back Pain
LBP is one of top 10 reasons patients seek care from family physicians1
Prevalence of LBP has varied from 7.6% to 37% Peak prevalence between 45 and 60 years of age2
Also reported by adolescents and by adults of all ages
80% of adults seek care at some time for acute LBP3
One-third of US disability costs are due to lowback disorders3
Direct costs of diagnosing and treating LBP in United States estimated in 1991 to be $25* billion annually4
Indirect costs, including lost earnings, are even higher4
Proper diagnosis and appropriate treatment of LBP saves healthcare resources, relieves suffering
*40 billon in 2008 using Consumer Price Index to compute the relative value of money.1. AAFP. Facts About Family Practice; 1996. 2. Borenstein DG. Curr Opin Rheumatol. 1997;9(2):144-150. 3. Kuritzky L, et al. Prim Care Rep 1995;1:29-38. 4. Frymoyer JW, et al. Orthop Clin North Am. 1991;22(2):263-271.
Etiology of Low Back Pain
Nonspecific LBP
Back pain potentially associated with radiculopathy or spinal stenosis
Back pain potentially associated with another specific spinal cause
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Structural Sources of Low Back Pain
Muscles of the back1,2
Interspinous ligaments2-4
Zygapophyseal joints5-7
Sacroiliac joint(s)8
Intervertebral discs9-12
Mechanical12 or chemical irritation of dura mater13
1. Kellgren JH. Clin Sci. 1938;3:175-190. 2. Bogduk N. Med J Aust. 1980;2(10):537-541. 3. Kellgren JH. Clin Sci. 1939;4:35-46. 4. Feinstein B, et al. J Bone Joint Surg Am. 1954;36-A(5):981-997. 5. Mooney V, et al. Clin Orthop Relat Res. 1976(115):149-156. 6. McCall IW, et al. Spine (Phila Pa 1976). 1979;4(5):441-446. 7. Fukui S, et al. Clin J Pain. 1997;13(4):303-307.
8. Fortin JD, et al. Spine (Phila Pa 1976). 1994;19(13):1475-1482. 9. Wilberg G. Acta Orthop Scand. 1947;19:211-221. 10. Falconer MA, et al. J Neurol Neurosurg Psychiatry. 1948;11(1):13-26.11. Kuslich SD, et al. Orthop Clin North Am. 1991;22(2):181-187. 12. O'Neill CW, et al. Spine (Phila Pa 1976). 2002;27(24):2776-2781. 13. El-Mahdi MA, et al. Neurochirurgia (Stuttg). 1981;24(4):137-141.
Causes of Low Back Pain
Possible sources of back pain have been demonstrated; causes have beenmore elusive Refuted: conditions traditionally considered
to be possible causes are actually not causes Eg, spondylolysis, spondylolisthesis, degenerative
changes (spondylosis)
Accepted: tumors and infections Untested: muscle sprain, ligament sprain,
segmental dysfunction, and trigger points Known source, unknown cause: sacroiliac joints,
zygapophyseal joints, internal disc disruption
McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1105-1122.
Diagnostic Triage Guides Subsequent Decision-Making Inquire about
Location of pain Frequency of symptoms Duration of pain History of previous symptoms, treatment,
and response to treatment
Consider possibility of LBP due to problems outside the back Pancreatitis Nephrolithiasis Aortic aneurysm Systemic illnesses (eg, endocarditis or
viral syndromes)
Differential Diagnosis for Acute Low Back Pain
Disease or Condition
Patient Age
(Years)Location
of Pain Quality of PainAggravating or
Relieving Factors Signs
Back strain 20-40Low back, buttock,
posterior thighAche, spasm Increased with activity
or bendingLocal tenderness, limited
spinal motion
Acute disc herniation 30-50 Low back to
lower legSharp, shooting, or burning pain;
paresthesia in leg
Decreased with standing; increased
with bending or sitting
Positive straight leg raise test, weakness, asymmetric reflexes
Osteoarthritis or spinal stenosis 30-50
Low back to lower leg;
often bilateral
Ache, shooting pain, “pins and
needles” sensation
Increased with walking, especially up an
incline; decreased with sitting
Mild decrease in extension of spine; may have weakness
or asymmetric reflexes
Spondylolisthesis Any age Back, posterior thigh Ache Increased with activity
or bending
Exaggeration of the lumbar curve, palpable “step off” (defect between spinous
processes), tight hamstrings
Ankylosing spondylitis 15-40
Sacroiliac joints,
lumbar spineAche Morning stiffness
Decreased back motion, tenderness over sacroiliac joints
Infection Any age Lumbar spine, sacrum Sharp pain, ache Varies
Fever, percussive tenderness; may have
neurologic abnormalities or decreased motion
Malignancy >50 Affected bone(s)
Dull ache, throbbing pain;
slowly progressiveIncreased with
recumbency or coughMay have localized
tenderness, neurologic signs, or fever
Adapted from: Patel AT, et al. Am Fam Physician. 2000;61(6):1779-1786.
Guideline #2
Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific LBP
Strong recommendation
Moderate-quality evidence
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Plain X-Rays for Low Back Pain
There is no evidence that routine plain radiography in patients with nonspecific LBP is associated with a greater improvement in patient outcomes than selective imaging1-3
Exposure to unnecessary ionizing radiation should be avoided, particularly in young women (amount of gonadal radiation from obtaining a single plain radiograph [2 views] of the lumbar spine is equivalent to daily chest radiograph for more than 1 year)4
Routine advanced imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) is not associated with improved patient outcomes,5 identifies radiographic abnormalities poorly correlated with symptoms,6 and could lead to additional, possibly unnecessary interventions7,8
1. Deyo RA, et al. Arch Intern Med. 1987;147(1):141-145. 2. Kendrick D, et al. BMJ. 2001;322(7283):400-405. 3. Kerry S, et al. Br J Gen Pract. 2002;52(479):469-474. 4. Jarvik JG. Neuroimaging Clin N Am. 2003;13(2):293-305.
5. Gilbert FJ, et al. Radiology. 2004;231(2):343-351. 6. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 7. Jarvik JG, et al. JAMA. 2003;289(21):2810-2818. 8. Lurie JD, et al. Spine (Phila Pa 1976). 2003;28(6):616-620.
Plain X-Rays for Low Back Pain (cont.)
Plain radiography is recommended for initial evaluation of possible vertebral compression fracture in select high-risk patients, such as those with a history of osteoporosis or steroid use1
Evidence to guide optimal imaging strategies is not available for LBP that persists for more than 1 to 2 months if there are no symptoms suggesting radiculopathy or spinal stenosis, although plain radiography may be a reasonable initial option(see recommendation 4 for imaging recommendations in patients with symptoms suggesting radiculopathyor spinal stenosis)2
Thermography and electrophysiologic testing arenot recommended for evaluation of nonspecific LBP
1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.2. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Guideline #3
Clinicians should perform diagnostic imaging and testing for patients with LBP 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
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
CT or MRI Diagnostic Imaging
Prompt work-up with MRI or CT is recommended if severe or progressive neurologic deficits or suspected serious underlying condition; delayed diagnosis and treatment associated with poorer outcomes1-3
MRI is generally preferred over CT if available; does not use ionizing radiation, provides better visualization of soft tissue, vertebral marrow, and the spinal canal4
1. Loblaw DA, et al. J Clin Oncol. 2005;23(9):2028-2037. 2. Todd NV. Br J Neurosurg. 2005;19(4):301-306. 3. Tsiodras S, et al. Clin Orthop Relat Res. 2006;444:38-50. 4. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.
CT or MRI Diagnostic Imaging (cont.)
There is insufficient evidence to guide diagnostic strategies in patients who have risk factors for cancer but no signs of spinal cord compression
Proposed strategies generally recommend plain radiography or measurement of erythrocyte sedimentation rate3, with MRI reserved for patients with abnormalities on initial testing1,2
Alternative strategy is to directly perform MRI in patients with a history of cancer, the strongest predictor of vertebral cancer;2 for patients older than 50 without other risk factors for cancer, delaying imaging while offering standard treatments and reevaluating within 1 month may also be a reasonable option4
1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 2. Joines JD, et al. J Gen Intern Med. 2001;16(1):14-23. 3. van den Hoogen HM, et al. Spine (Phila Pa 1976). 1995;20(3):318-327. 4. Suarez-Almazor ME, et al. JAMA. 1997;277(22):1782-1786.
Guideline #4
Clinicians should evaluate patients with persistent LBP and signs or symptoms or radiculopathy or spinal stenosis with MRI (preferred) or CT only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy)
Strong recommendation
Moderate-quality evidence
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Imaging for Low Back Pain
The natural history of lumbar disc herniation with radiculopathy in most patients is for improvement within the first 4 weeks with noninvasive management1,2
There is no compelling evidence that routine imaging effects treatment decisions or improves outcomes3
For prolapsed lumbar disc with persistent radicular symptoms despite noninvasive therapy, discectomy or epidural steroids are potential treatment options4-8
Surgery is also a treatment option for persistent symptoms associated with spinal stenosis9-12
1. Vroomen PC, et al. Br J Gen Pract. 2002;52(475):119-123. 2. Weber H. Spine (Phila Pa 1976). 1983;8(2):131-140. 3. Modic MT, et al. Radiology. 2005;237(2):597-604. 4. Gibson JN, et al. Cochrane Database Syst Rev. 2000(3):CD001350. 5. Gibson JN, et al. Cochrane Database Syst Rev. 2005(4):CD001352. 6. Nelemans PJ, et al. Spine (Phila Pa 1976). 2001;26(5):501-515.
7. Peul WC, et al. N Engl J Med. 2007;356(22):2245-2256. 8. Weinstein JN, et al. JAMA. 2006;296(20):2451-2459. 9. Amundsen T, et al. Spine (Phila Pa 1976). 2000;25(11):1424-1435. 10. Atlas SJ, et al. Spine (Phila Pa 1976). 2005;30(8):936-943. 11. Weinstein JN, et al. N Engl J Med. 2007;356(22):2257-2270. 12. Malmivaara A, et al. Spine (Phila Pa 1976). 2007;32(1):1-8.
MRI for Low Back Pain
MRI (preferred if available) or CT is recommended for evaluating patients with persistent back and leg pain who are potential candidates for invasive interventions Plain radiography cannot visualize discs or accurately evaluate
the degree of spinal stenosis1
However, clinicians should be aware that findings on MRI or CT (such as bulging disc without nerve root impingement) are often nonspecific
Recommendations for specific invasive interventions, interpretation of radiographic findings, and additional work-up beyond scope of guideline, but decisions should be based on clinical correlation between symptoms and radiographic findings, severity of symptoms, patient preferences, surgical risks, and costs and will generally require specialist input2
1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.2. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Critical Clinical Indicators of Pathology In patients with back and leg pain, a typical
history for sciatica (back and leg pain in a typical lumbar nerve root distribution) has a fairly high sensitivity, but uncertain specificity for herniated disc1,2
>90% of symptomatic lumbar disc herniations (back and leg pain due to a prolapsed lumbar disc compressing a nerve root) occur at L4/L5 and L5/S1 levels3
1. van den Hoogen HM, et al. Spine (Phila Pa 1976). 1995;20(3):318-327. 2. Vroomen PC, et al. J Neurol. 1999;246(10):899-906. 3. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Critical Clinical Indicators of Pathology (cont.)
A focused examination that includes straight-leg-raise testing and a neurologic examination that includes evaluation of knee strength and reflexes (L4 nerve root), great toe and foot dorsiflexion strength (L5 nerve root), foot plantarflexion and ankle reflexes (S1 nerve root), and distribution of sensory symptoms should be done to assess the presence and severity of nerve root dysfunction
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Critical Clinical Indicators of Pathology (cont.)
A positive result on straight-leg-raise test (defined as reproduction of the patient’s sciatica between 30 and 70 degrees of leg elevation) has a relatively high sensitivity (91% [95% CI, 82% to 94%]), but modest specificity (26% [CI, 16% to 38%]) for diagnosing herniated disc
Crossed straight-leg-raise test is more specific (88% [CI, 86% to 90%]), butless sensitive (29% [CI, 24% to 34%])
Deville WL, et al. Spine (Phila Pa 1976). 2000;25(9):1140-1147.
Critical Clinical Indicators of Pathology (cont.)
All patients should be evaluated forPresence of rapidly progressive
or severe neurologic deficits Motor deficits at more than 1 level, fecal
incontinence, and bladder dysfunction
Most frequent finding in cauda equina syndrome is urinary retention (90% sensitivity)Without urinary retention, probability
is approximately 1 in 10,000
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.Deyo RA, et al. JAMA. 1992;268(6):760-765.
Yellow Flags
Identify psychosocial problems in acute phase
Slow progress to recovery may be due to undetected, or unrevealed psychosocial factors Pertain to patient's beliefs and behaviors
concerning physical activity and domestic, social, and vocational responsibilities
Example: patient believes physical activity might harm back, make pain worse, so avoids activities
Most destructive is aversion to work Belief that work caused pain, work aggravates pain,
work is too heavy, and work should not be done
McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1094-1105.
Psychosocial Factors of Low Back Pain Stronger predictors of LBP outcomes than either physical
findings or severity/duration of pain1-3
Assessment of psychosocial factors identifies patients who may have delayed recovery and could help target interventions
1 trial in referral setting found intensive multidisciplinary rehabilitation more effective than usual care in patients with acute or subacute LBP identified as having risk factors for chronic back pain disability4
Direct evidence on effective primary care interventions for identifying and treating such factors in patients with acute LBPis lacking5,6
Evidence is currently insufficient to recommend optimal methods for assessing psychosocial factors and emotional distress7
However, psychosocial factors that may predict poorer LBP outcomes include presence of depression, passive coping strategies, job dissatisfaction, higher disability levels, disputed compensation claims, or somatization8-10
1. Pengel LH, et al. BMJ. 2003;327(7410):323. 2. Fayad F, et al. Ann Readapt Med Phys. 2004;47(4):179-189. 3. Pincus T, et al. Spine (Phila Pa 1976). 2002;27(5):E109-120. 4. Gatchel RJ, et al. J Occup Rehabil. 2003;13(1):1-9. 5. Hay EM, et al. Lancet. 2005;365(9476):2024-2030.
6. Jellema P, et al. BMJ. 2005;331(7508):84.7. Chou R, et al. Ann Intern Med. 2007;147(7):478-491. 8. Steenstra IA, et al. Occup Environ Med. 2005;62(12):851-860. 9. Deyo RA, et al. Spine (Phila Pa 1976). 2006;31(23):2724-2727. 10. Carey TS, et al. Spine (Phila Pa 1976). 1996;21(3):339-344.
Red Flags of Lower Back Pain
History Gradual onset of back pain Age <20 years or >50 years Thoracic back pain Pain lasting longer than 6 weeks History of trauma Fever/chills/night sweats Unintentional weight loss Pain worse with recumbency Pain worse at night Unrelenting pain despite
supratherapeutic doses of analgesics History of malignancy History of immunosuppression Recent procedure causing bacteremia History of intravenous drug use
Physical Examination Fever Hypotension Extreme hypertension Pale, ashen appearance Pulsatile abdominal mass Pulse amplitude differentials Spinous process tenderness Focal neurologic signs Acute urinary retention
Winters ME, et al. Med Clin North Am. 2006;90(3):505-523.
Risk for Chronicity
Vertebral infection Intravenous drug use, recent infection
Vertebral compression fracture Older age, history of osteoporosis,
and steroid use
Musculoskeletal Inactivity
In generalEmotional distress
Cancer-Related Risk Factors
Large, prospective study from a primary care setting History of cancer (positive likelihood ratio, 14.7) Unexplained weight loss (positive likelihood ratio, 2.7) Failure to improve after 1 month (positive likelihood
ratio, 3.0) Age >50 years (positive likelihood ratio, 2.7) Posttest probability of cancer increases from
approximately 0.7% to 9% in patients with a history of cancer (not including nonmelanoma skin cancer)
In patients with any 1 of the other 3 risk factors, the likelihood of cancer only increases to approximately 1.2%
Deyo RA, et al. J Gen Intern Med. 1988;3(3):230-238.
Non-Cancer-Related Risk Factors
Features predicting vertebral infection not well studied, but may include fever, intravenous drug use, or recent infection1
Consider risk factors for vertebral compression fracture, such as older age, history of osteoporosis, and steroid use; and for ankylosing spondylitis, such as younger age, morning stiffness, improvement with exercise, alternating buttock pain, and awakening due to back pain during the second part of the night only2
Clinicians should be aware that criteria for diagnosing early ankylosing spondylitis (before the development of radiographic abnormalities) are evolving3
1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 2. Rudwaleit M, et al. Arthritis Rheum. 2006;54(2):569-578. 3. Rudwaleit M, et al. Arthritis Rheum. 2005;52(4):1000-1008.
Racial/Cultural Aspectsof Assessment To communicate effectively with all patients
Always use simple words, not medical jargon Determine what the patient/caregiver already
knows or believes about his/her health situation Encourage questions by asking, “What
questions do you have?” (allows for an open-ended response), instead of “Do you have any questions?” (allows for a “no” response, ending the conversation)
Use the “teach-back” method to confirm the level of understanding: Ask patients/family members to restate what was just communicated in the appointment or meeting
Zacharoff KL. Cross-Cultural Pain Management: Effective Treatment of Pain in the Hispanic Population; 2009.
Culturally Competent Care
Ensure that patients/consumers receive effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language
Implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area
Ensure that staff, at all levels and across all disciplines, receives ongoing education and training in CLAS delivery
USDHHS OMH. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care ; 2001.
Avoiding Racial and Cultural Bias per Knox H. Todd, MD, MPHMake pain assessment mandatory
Give a nonopioid analgesic at triage
Track reasons for unscheduled returns
Audit for ethnic bias
Consider which pain scales should be used
Use multilingual laminated cardsTodd KH. Medical Ethics Advisor. 1999.
Pearls for Practice
Categorize patients into 1 of 3 broad groups: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause
Evaluate psychosocial risk factors to predict the risk for chronic, disabling low back pain
Provide patients with evidence-based information on expected course of low back pain, effective self-care options, and recommend that they be physically active
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Please pass your question cardto a staff member.
?Questions?
Treatment of Low Back Pain: Pharmacologic and Nonpharmacologic Options
Roger Chou, MD, FACPAssociate Professor of Medicine,Department of MedicineDepartment of Medical Informatics and Clinical EpidemiologyOregon Health & Science University
Disclosure: Roger Chou, MD, FACP
Dr. Chou has disclosed that he has no actual or potential conflict of interest in regard to this activity
His presentation will include off-label discussion of anticonvulsants, benzodiazepines, and tricyclic antidepressants for the treatment of low back pain (LBP)
Learning Objective
Integrate evidence-based pharmacologic and nonpharmacologic therapies into a comprehensive treatment plan for chronic LBP
Low Back Pain Burden
LBP is the fifth most common reason for US office visits, and the second most common symptomatic reason1-2
$90.7 billion dollars in total healthcare expenditures in 19983
LBP is the most common cause for activity limitations in persons under the age of 454
1. Hart LG, et al. Spine (Phila Pa 1976). 1995;20(1):11-19. 2. Deyo RA, et al. Spine (Phila Pa 1976). 2006;31(23):2724-2727.3. Luo X, et al. Spine (Phila Pa 1976). 2004;29(1):79-86.4. Von Korff M, et al. Spine (Phila Pa 1976). 1996;21(24):2833-2837.
Weinstein JN, et al. Spine (Phila Pa 1976). 2006;31(23):2707-2714.
Increasing Rates of Back Surgery
Trends in Rates of Discectomy/Laminectomy and Fusion in 1992-2003
US
Aver
age
Rat
e of
Dis
char
ges
per 1
000
Med
icar
e En
rolle
es
Increasing Rates of Back Injections
SI=sacroiliac.Friedly J, et al. Spine (Phila Pa 1976). 2007;32(16):1754-1760.
Lumbosacral Injection Rates by Year: Age- and Sex-Adjusted per 100,000
553.4
79.7
2055.2
263.9212.3
Increasing Costs
Martin BI, et al. JAMA. 2008;299(6):656-664.
Year
Mea
n ($
)
Rising Prevalence of Chronic LBP
CI=confidence interval. PRR=prevalence rate ratio.*The PRRs and CI were estimated via bootstrapping; 97.5% CIs were reported rather than to assume normality.**Unable to estimate owing to scall cell count (n<5).Freburger JK, et al. Arch Intern Med. 2009;169(3):251-258.
Characteristic1992
(n=8067)2006
(n=9924) % IncreasePRR
(2.5-97.5% CI)*Total 3.9 (3.4-4.4) 10.2 (9.3-11.0) 162 2.62 (2.21-3.13)
Sex
Male 2.9 (2.2-3.6) 8.0 (6.8-9.2) 176 2.76 (2.11-3.75)
Female 4.8 (4.0-5.6) 12.2 (10.9-13.5) 154 2.54 (2.13-3.08)
Age (Years)
21-34 1.4 (0.8-2.0) 4.3 (3.0-5.6) 201 3.01 (1.95-5.17)
35-44 4.8 (3.3-6.3) 9.2 (7.2-11.2) 92 1.92 (1.35-2.86)
45-54 4.2 (3.0-5.5) 13.5 (11.4-15.7) 219 3.19 (2.29-4.59)
55-64 6.3 (4.2-8.3) 15.4 (12.8-17.9) 146 2.46 (1.73-3.50)
65 5.9 (4.5-7.3) 12.3 (10.2-14.4) 109 2.09 (1.62-2.84)
Race/Ethnicity
Non-Hispanic White 4.1 (3.5-4.7) 10.5 (9.4-11.5) 155 2.55 (2.13-3.05)
Non-Hispanic Black 3.0 (2.0-4.0) 9.8 (8.2-11.4) 226 3.26 (2.32-4.96)
Hispanic ** 6.3 (3.8-8.9)
Other 4.1 (1.4-6.8) 9.1 (6.0-12.0) 120 2.20 (1.16-6.99)
Prevalence of Chronic Low Back Pain in North Carolina, 1992 and 2006% Prevalence (95% CI)
1992: 3.9% 2006: 10.2%
Practice Patterns
Spine surgery rates in the US are the highest in the world Rates in the US 5 times higher than in the UK 20-fold variation in fusion: 4.6 per 1000 in
Idaho Falls to 0.2 per 1000 in Bangor, Maine
Interventional therapies are also widely used Intradiscal electrothermal therapy estimated
at 7000-10,000 annually 20-fold variation in epidural steroid injections:
104 per 1000 in Palm Springs to 5.6 per 1000in Honolulu
Deyo RA, et al. Clin Orthop Relat Res. 2006;443:139-146.Weinstein JN, et al. Spine (Phila Pa 1976). 2006;31(23):2707-2714.
“7 Back Pain Breakthroughs: Are you hurting? Here’s help.” Reader’s Digest
July 2007
End Back Pain Agony(Michael J. Weiss)
Weiss MJ. Reader's Digest. July, 2007.
Reader’s Digest “Cures” for Low Back Pain “Cures” based on anecdotal evidence, not
yet approved, and/or only in animal studies Infrared belt: $2335 “Magic Spinal Wand”
Percutaneous automatic discectomy
Flexible fusion Stem cells Site-directed bone growth New bed
Based on an unpublished observational study funded by a sleep products trade group
Weiss MJ. Reader's Digest. July, 2007.
Low Back Pain Guidelines ProjectOverview and Timeline Began 2004; primary care guidelines published
October 2007 Address both acute and chronic LBP, and nonspecific
LBP and LBP with radiculopathy or spinal stenosis Guideline for interventional therapies/surgery
published May 2009 Partnership between the American Pain Society
and the American College of Physicians (ACP) Funded by the American Pain Society
Multidisciplinary panel with 25 members; over 15 specialties/organizations represented
Series of 3 face-to-face meetings to develop guidelines Consensus achieved for all recommendations
Recommendation GridACP Methods
Quality of Evidence
Benefits Do or Do Not Clearly Outweigh Risks
Benefits and Risks and Burdens Finely Balanced
High Strong Weak
Moderate Strong Weak
Low Strong Weak
Insufficient I
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Strength of Recommendation
Basic Principles of Selecting Therapy for Low Back Pain For most LBP, labeling with a specific
etiology doesn’t help inform therapy choices
Most patients with acute LBP will improve regardless of which therapy is chosen
For chronic LBP, therapies are moderately effective at best
Use interventions with proven efficacy
Noninvasive approaches to most LBP
Consider psychosocial factors
RecommendationTreatment of Low Back PainProvide patients with evidence-based
information about their expected course, advise patients to remain active, and provide information about effective self-care optionsStrong recommendationModerate-quality evidence
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Advice and Self-Care for Low Back Pain Inform patients of generally favorable
prognosis of acute LBP with or without sciatica
Discuss need for re-evaluation if not improved
Advise to remain active
Consider self-care education books
Superficial heat moderately effective for acute LBP
No evidence to support use of lumbar supports
Firm mattresses inferior to medium-firm mattresses (1 RCT)
RCT=randomized controlled trial.
RecommendationTreatment of Low Back PainConsider the use of medications with
proven benefits in conjunction with back care information and self-care … for most patients, first-line medication options are acetaminophen or NSAIDsStrong recommendationModerate-quality evidence
NSAIDs=nonsteroidal anti-inflammatory drugs.Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Pharmacologic Interventions
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.Chou R, et al. Ann Intern Med. 2007;147(7):505-514.This information includes a use that has not been approved by the US FDA.
Drug Net Benefit Level of Evidence
Acetaminophen Small to moderate Fair
Skeletal muscle relaxants
Moderate (for acute LBP only) Good
NSAIDs Moderate Good
Tricyclic antidepressants
Small to moderate (for chronic LBP only) Good
Pharmacologic Interventions (cont.)
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.Chou R, et al. Ann Intern Med. 2007;147(7):505-514.This information includes a use that has not been approved by the US FDA.
Drug Net Benefit Level of Evidence
Opioids and tramadol Moderate Fair
Benzodiazepines Moderate Fair
Antiepileptic medications
Small (for radiculopathy only) Fair
Systemic steroids No benefit Good
RecommendationTreatment of Low Back Pain For patients who do not improve with
self-care options, consider the addition of nonpharmacologic therapy with proven benefits
For chronic or subacute LBP, options include Intensive interdisciplinary
rehabilitation Exercise therapy Acupuncture Massage therapy
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Spinal manipulation Yoga Cognitive-behavioral
therapy Progressive relaxation
Weak recommendationModerate-quality evidence
Noninvasive Interventions for Chronic or Subacute LBP
Intervention Net Benefit Level of Evidence
Behavioral therapy Moderate Good
Exercise therapy Moderate Good
Spinal manipulation Moderate Good
Acupuncture Moderate Fair
Chou R, et al. Ann Intern Med. 2007;147(7):492-504.
Noninvasive Interventions for Chronic or Subacute LBP (cont.)
Intervention Net Benefit Level of Evidence
Massage Moderate Fair
Yoga Moderate Fair(for Viniyoga)
Back schools Small Fair
Traction No benefit Fair
Interferential therapy,lumbar supports, short-wave diathermy, TENS, ultrasound
Unclear Poor
TENS=transcutaneous electrical nerve stimulation.Chou R, et al. Ann Intern Med. 2007;147(7):492-504.
RecommendationInterventional Therapies for Nonradicular Low Back Pain In patients with persistent nonradicular LBP,
facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injection are not recommended Strong recommendation Moderate-quality evidence
There is insufficient evidence to adequately evaluate benefits of other interventional therapies for nonradicular LBP
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Interventional Therapies for Nonradicular Low Back Pain Interventional therapies not proven to be effective
in placebo-controlled, randomized trials No trials (SI joint injection), trials showing no benefit
(facet joint injection), inconsistent results (IDET, RFDN), or poor-quality evidence (trigger point injections)
Promising results from nonrandomized studies not replicated in randomized trials IDET Facet joint steroid injection
Not clear if interventions are ineffective, or if patients were not accurately selected
IDET=intradiscal electrothermal therapy. RFDN=radiofrequency denervation.Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Placebo-Controlled Trials of RFDN for Presumed Facet Joint Pain
StudySample
Size Selection Quality Benefits
Gallagher, 1994 41 Uncontrolled block Poor quality Can’t tell
Leclaire, 2001 70 Uncontrolled block No major issues No
Nath, 2008 40 Controlled block
Baseline differences (1.6 points
for pain)
1.5 points for leg pain, NS for back pain
Tekin, 2007 60 Clinical criteria Poor quality <1 point for pain,
0.5 points for function
van Kleef, 1999 30 Uncontrolled block No major issues 1-2 point for pain
and function
van Wijk, 2005 81 Uncontrolled block
Technical issues? No
NS=not significant.
Placebo-Controlled Trials of RFDN for Presumed Facet Joint Pain
StudySample
Size Selection Quality Benefits
Gallagher, 1994 41 Uncontrolled block Poor quality Can’t tell
Leclaire, 2001 70 Uncontrolled block No major issues No
Nath, 2008 40 Controlled block
Baseline differences (1.6 points
for pain)
1.5 points for leg pain, NS for back pain
Tekin, 2007 60 Clinical criteria Poor quality <1 point for pain,
0.5 points for function
van Kleef, 1999 30 Uncontrolled block No major issues 1-2 point for pain
and function
van Wijk, 2005 81 Uncontrolled block
Technical issues? No
Placebo-Controlled Trials of RFDN for Presumed Facet Joint Pain (cont.)
StudySample
Size Selection Quality Benefits
Leclaire, 2001 70 Uncontrolled block No major issues No
Nath, 2008 40 Controlled block
Baseline differences (1.6 points
for pain)
1.5 points for leg pain, NS for back pain
van Kleef, 1999 30 Uncontrolled block No major issues 1-2 point for pain
and function
RecommendationSurgery for Nonradicular Low Back Pain In patients with nonradicular LBP,
common degenerative spinal changes, and persistent and disabling symptoms … discuss risks and benefits of surgery as an optionWeak recommendation
High-quality evidence
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Surgery for Nonradicular Low Back Pain With Degenerative Changes Benefits vary depending on comparator
Benefits of fusion vs standard nonsurgical therapy less than 15 points on a 100-point pain or function scale (1 RCT)
No difference vs intensive interdisciplinary rehabilitation (3 RCTs)
All enrollees failed >1 year of nonsurgical management and are not at higher risk for poor surgical outcomes
Fewer than half experience optimal outcomes (relief of pain, return to work, decreased analgesic use)
No evidence that instrumentation improves outcomes Shared decision-making approach recommended
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1094-1109.
RecommendationInterventional Therapies for Radicular LBP In patients with persistent radiculopathy
due to herniated lumbar disc … discuss risks and benefits of epidural steroid injection as an option Weak recommendation
Moderate-quality evidence
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Interventional Therapies for Radiculopathy/Prolapsed DiscEpidural steroid injection
Short-term benefits in some higher-quality trials, but data are inconsistent (could be related to comparator used in trials)
No long-term benefits No route clearly superior Limited evidence of no benefit for
spinal stenosis Shared decision-making
approach recommended
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
RecommendationSurgery for Radicular Low Back Pain and Spinal Stenosis In patients with persistent radiculopathy
due to herniated lumbar disc or persistent and disabling leg pain dueto spinal stenosis … discuss risks and benefits of surgery as an option Strong recommendation
High-quality evidence
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Surgery for Herniated Disc With Radiculopathy Discectomy associated with more
rapid improvement in symptoms than nonsurgical therapy
Patients improved either with or without surgery No progressive neurologic deficits without
immediate surgery Long-term (after 1-2 years) outcomes similar
in some trials
Most trials evaluated standard open discectomy or microdiscectomy
Shared decision-making approach recommended
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1094-1109.
Surgery for Spinal Stenosis
Decompressive laminectomy associated with superior outcomes vs nonsurgical therapy
Mild improvement with nonsurgical therapy
No severe neurologic deficits without immediate surgery
Benefits may diminish with long-term (>2 years) follow-up
Shared decision-making approach recommended
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1094-1109.
Conclusions
The quality of evidence for different LBP therapies varies
A number of therapies appear similarlyand moderately effective for LBP
Guidelines can provide clinicians with a useful framework for choosing therapies
Factors that influence choices from recommended therapies include patient preferences, availability, and costs
Shared decision-making can help make decisions consistent with patient valuesand preferences
Please pass your question cardto a staff member.
?Questions?
Current Understanding of the Prevention of Chronicity of Low Back Pain
Bill McCarberg, MD Founder, Chronic Pain Management ProgramKaiser Permanente San DiegoAdjunct Assistant Clinical Professor, University of California, San Diego
Disclosure: Bill McCarberg, MD
Dr. McCarberg’s presentation will not include discussion of off-label, experimental, and/or investigational uses of drugs or devices
Type Company
Speakers Bureau
Abbott Laboratories; Cephalon, Inc.; Eli Lilly and Company; Endo Pharmaceuticals; Forest Pharmaceuticals; King Pharmaceuticals; Ligand Pharmaceuticals, Inc.; Merck & Co., Inc.; Mylan Pharmaceuticals, Inc.; Pfizer, Inc.; PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc.; Purdue Pharma LP
Learning Objective
Evaluate early interventions for acute back pain in patients considered at high risk for transition to chronic low back pain (CLBP)
Disability from Back Pain
The minority of cases which involve disability account for a disproportionate percentage of overall healthcare costs
The most cost-effective approach is to more aggressively pursue secondary prevention efforts on subacute patients before chronic disability is fully established1
Acute: <3 weeks Subacute: >3 weeks but <3 months Chronic: >3 months, or more than 6 episodes
in 12 months
1. Waddell G, et al. Occup Med (Lond). 2001;51(2):124-135.
Adverse Prognostic Indicators
Yellow flags are psychosocial indicators suggesting increased risk of progression to long-term distress, disability, and pain
Can be applied more broadly to assess likelihood of development of persistent problems from acute pain presentation
Yellow flags can relate to the patient’s attitudes and beliefs, emotions, behaviors, family, and workplace
Kendall NA. Baillieres Best Pract Res Clin Rheumatol. 1999;13(3):545-554.
Risk Factors for Chronic Low Back Pain: Yellow Flags Belief that pain and activity are harmful “Sickness behavior” such as extended rest Bodily preoccupation and catastrophic thinking Low or negative mood, anxiety, social withdrawal Personal problems (eg, marital, financial, etc) History of substance abuse Problems/dissatisfaction with work (“blue flags”) Overprotective family/lack of support History of disability and other claims Inappropriate expectations of treatment
Low expectation of active participation
The presence of yellow flags highlights the need to address specific psychosocial factors as part of a multimodal management approach
Additional Risk Factors for Chronicity Previous history of low back pain Age Nerve root involvement Poor physical fitness Self-rated health poor Heavy manual labor, inability for light duty
upon return to work (“black flags”) Ongoing medico-legal actions Obesity* Smoking**No evidence for efficacy of smoking cessation or nonoperative weight loss as interventions for CLBP.Wai EK, et al. Spine J. 2008;8(1):195-202.
Interventional Therapies Do Not Prevent Chronicity
Additionally, regardless of the comparator intervention, there is no convincing evidence that epidural steroids are associated with long-term benefits or reduced rates of subsequent surgery
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Level of Evidence and Summary Grades for Interdisciplinary Rehabilitation, Injections, Other Interventional Therapies, and Surgery for Patients With Nonradicular LBP
Intervention Condition Level of Evidence Net Benefit Grade
Interdisciplinary rehabilitation Nonspecific LBP Good Moderate B
Prolotherapy Nonspecific LBP Good No benefit D
Intradiscal steroid injection Presumed discogenic pain Good No benefit D
Fusion surgeryNonradicular LBP
with common dengerative changes
FairModerate vs standard nonsurgical
therapy, no difference vs intensive rehabilitation
B
Facet joint steroid injection Presumed facet joint pain Fair No benefit D
Botulinum toxin injection Nonspecific LBP Poor Unable to estimate I
Local injections Nonspecific LBP Poor Unable to estimate I
Epidural steroid injection Nonspecific LBP Poor Unable to estimate I
Medial branch block (therapeutic)
Presumed facet joint pain Poor Unable to estimate I
Sacroiliac joint steroid injection
Presumed sacroiliac joint pain Poor Unable to estimate I
The Fear-Avoidance Model of Chronic Pain
Leeuw M, et al. J Behav Med. 2007;30(1):77-94.Vlaeyen JW, et al. Pain. 2000;85(3):317-332.
PainAnxiety
Hypervigilance
Preventative
Motivation
Arou
sal
Fearof Pain
Threat Perception
Defensive
MotivationAr
ousa
l
Confrontation
Recovery
Injury
DisuseDisabilityDepression
Avoidance
Escape
Catastrophizing
Negative AffectivityThreatening Illness Information
Low Fear
Pain Experience
Assessment of Fear-Avoidance Behaviors Pain Catastrophizing Scale (PCS)1
13 items
Fear of Pain Questionnaire (FPQ)2
30 items
Fear-Avoidance Beliefs Questionnaire (FABQ)3
16 items
Coping Strategies Questionnaire (CSQ)4
42 items
1. Sullivan MJL, et al. Psychological Assessment. 1995;7(4):524-532.2. McNeil DW, et al. J Behav Med. 1998;21(4):389-410.3. Waddell G, et al. Pain. 1993;52(2):157-168.4. Rosenstiel AK, et al. Pain. 1983;17(1):33-44.
Reducing Catastrophizing
Numerous interventions appear effective Cognitive-behavioral therapies1-4
Physiotherapy and other activity-based interventions5
Intensive patient education and exposure interventions6, 7
Limited understanding of the mechanisms by which changes in catastrophizing occur
1. Linton SJ, et al. Pain. 2001;90(1-2):83-90.2. Basler HD, et al. Patient Educ Couns. 1997;31(2):113-124.3. Vlaeyen JW, et al. Pain Res Manag. 2002;7(3):144-153.4. Hoffman BM, et al. Health Psychol. 2007;26(1):1-9.
5. Smeets RJ, et al. J Pain. 2006;7(4):261-271.6. Moseley GL, et al. Clin J Pain. 2004;20(5):324-330.7. Leeuw M, et al. Pain. 2008;138(1):192-207.
Comprehensive Interventions With High-Risk Patients Show Promise High-risk patients identified with SCID
Intensive interdisciplinary team intervention 4 major components: psychology, physical therapy,
occupational therapy, and case management Physical therapy sessions: both individual and group
exercise classes Biofeedback/pain management sessions Group didactic sessions Case manager/occupational therapy sessions
Interventions spaced over a 3-week period
SCID=Structured Clinical Interview for DSM-IV Disorders.Gatchel RJ, et al. J Occup Rehabil. 2003;13(1):1-9.
Early Intensive Intervention Effectiveness
*Chi-square analysis. **ANOVA.HR-I=high-risk intervention group. HR-NI=high-risk nonintervention group. LR=low-risk group.Gatchel RJ, et al. J Occup Rehabil. 2003;13(1):1-9.
Long-Term Outcome Results at 12-Month Follow-Up
Outcome Measure HR-I (n=22)
HR-NI(n=48)
LR(n=54) p-Value
% return to work at follow-up* 91% 69% 87% .027
Average number of healthcare visits regardless of reason** 25.6 28.8 12.4 .004
Average number of healthcare visits related to LBP** 17.0 27.3 9.3 .004
Average number of disability days due to back pain** 38.2 102.4 20.8 .001
Average of self-rated most “intense pain” at 12-month follow-up (0-100 scale)** 46.4 67.3 44.8 .001
Average of self-rated pain over last 3 months (0-100 scale)** 26.8 43.1 25.7 .001
% currently taking narcotic analgesics* 27.3% 43.8% 18.5% .020
% currently taking psychotropic medication 4.5% 16.7% 1.9% .019
Most Recent Preventing Chronicity Study (April 2009) First-onset, subacute LBP patients Behavioral medicine intervention (n=34)
Four 1-hour individual treatment sessions included Education about back function and pain Systematic graduated increases in physical exercise
to quota with feedback Planning and contracting activities of daily living Self-management and problem-solving training to cope
with pain Contingent reinforcement of active functioning and
nonreinforcement of pain behaviors Vocational counseling, as needed
Compared to “attention control” group (n=33)Slater MA, et al. Arch Phys Med Rehabil. 2009;90(4):545-552.
Most Recent Preventing Chronicity Study (April 2009) (cont.)
Chi square analysis comparing proportions recovered at 6 months after pain onset for behavioral medicine and attention control participants found rates 54% vs 23% for those completing all 4 sessions and 6-month follow-up (p=.02)
Conclusions: early intervention using a behavioral medicine rehabilitation approach may enhance recovery and reduce chronic pain and disability in patients with first-onset, subacute LBP
Slater MA, et al. Arch Phys Med Rehabil. 2009;90(4):545-552.
Key Impact Factors in Back Disability Prevention
Spread of Rankings for Impact Provided by Key Stakeholders (N=33) at the End of a Consensus Process (Round 3)
Guzman J, et al. Spine (Phila Pa 1976). 2007;32(7):807-815.
2 12104 6 80
1. Provider Reassurance
2. Recovery Expectation
3. Fears
4. Knowledge
5. Appropriate Care
6. Disability Management
7. Self-Management
8. Case Management
9. Temporary Duties
10. Alternative Care
11. Back Supports
Rankings by Panel
} p=.055
} p=.045
} p<.001
} p<.001
Provider Reassurance
Tell patients your plan and your expectations
Set reasonable expectations with patient buy-in
Reassure severity of acute pain does not correlate with outcome or duration
Follow up regularly to check response to treatment
Reassess for further diagnostic of therapeutic options
Summary
Psychosocial aspects of pain and pain perception significantly influence patient outcomes
Assessing for yellow flags and identifying patients at high risk of chronicity early in pain process (subacute) yields best chance for intervention and possible prevention
Multiple psychosocial and physical interventions appear promising; aggressive/intensive intervention seems most important
Nurture the therapeutic relationship with shared expectations and goals of treatment
?Questions?
Question and Answer Session
Low Back Pain: Evaluation, Management,
and Prognosis
Thank You for Attending
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