Education, self-management, and pharmacologic as well as nonpharmacologic therapies take center stage in new guidelines.
The American College of Physicians (ACP) and the American Pain Society (APS) have jointly issued a clinical practice guideline for the management of low back pain in primary care—the first such document for either organization. These also represent the first national guidelines of comparable scope since those published by the Agency for Health Care Policy and Research in 1994, according to Roger Chou, MD, associate professor of medicine at Oregon Health & Science University in Portland and director of clinical guidelines development for the APS.
“Compared with earlier guidelines, these are more positive about nonpharmacologic treatments,” observes Dr. Chou. The ACP/APS document also goes farther in addressing the needs of chronic as well as acute pain patients. “The most difficult-to-manage patients are those who don't get better in the first month,” Dr. Chou says.
Generally, the new Guideline represents radical departures from established practice less than it does evidence-based confirmation of what had been done on the basis of clinical philosophy and experience, he says.
Assessment—no rush to x-ray
The Guideline recommends an initial history and physical examination to help assign patients to one of three diagnostic categories:
• Nonspecific low back pain, by far the largest group, comprising 85% of patients who complain of back pain in primary care
• Pain possibly associated with radiculopathy or spinal stenosis, representing about 7% of cases
• Pain potentially due to another spinal cause, a group that includes the small proportion of patients with serious or progressive neurologic deficits or symptoms suggesting conditions that require prompt intervention (e.g., tumor or infection)
In any clinical evaluation, the key aspects to consider are location, frequency, and duration of pain; history of similar symptoms; and response to treatment.
The evaluation should also explore, when indicated, the possibility of problems outside the back, such as aortic aneurysm, pancreatitis, and viral syndromes. Risk factors for cancer and infection should be assessed.
Psychosocial factors (e.g., depression, job dissatisfaction, somatization) merit assessment because they predict outcome, including sustained disability, more reliably than pain history or physical examination. Identifying at-risk patients could help target appropriate interventions, such as intensive multidisciplinary rehabilitation, that are likely to be effective in this group.
Imaging and other diagnostic tests should not be ordered routinely to evaluate patients with nonspecific low back pain. “What had been a philosophical position has been confirmed by clinical trials showing that routine x-rays don't help, compared with selective x-rays, and may lead to more surgeries down the road,” Dr. Chou states.
Radiation is not insignificant, the Guideline points out: The amount of gonadal exposure from a single two-view plain x-ray of the spine is equivalent to a year of daily chest x-rays.
Prompt imaging evaluation is indicated, however, in the presence of severe or progressive neurologic deficits or when there are grounds to suspect a serious underlying condition. MRI, when available, is preferable to CT.
MRI or CT is indicated for patients with signs and symptoms of radiculopathy or spinal stenosis that do not resolve reasonably quickly (within about four weeks)—but only if they are candidates for surgery or epidural steroid injection.
Self-managing low back pain
Patient education is a key component of management (see algorithm). Physicians should emphasize the usually benign and self-limiting course of acute episodes, even when accompanied by sciatica. They might explain why x-rays and other tests are not being done and review the indications for such evaluation. Self-management counseling should stress remaining active and, if a period of bed rest is necessary, resuming normal activities as quickly as possible. Some specific recommendations can be made on the basis of data, albeit limited: The application of heat has been shown to provide short-term relief in acute episodes, but there is insufficient evidence to recommend cold packs or lumbar supports. Firm mattresses appear less helpful than medium-firm ones for chronic back pain.
The Guideline recommends self-help books as an economical source of more detailed information than the clinician can provide and notes that such books, when evidence-based, have been shown to be as effective or nearly so as interventions like yoga and supervised exercise therapy.
Medication
Pharmacotherapy has a limited role in low back pain management, generally in conjunction with self-care. The demonstrated benefits of diverse classes of medications have been, on the whole, modest and short-term.
Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are usually the mainstay of drug treatment, with a time-limited course of opioid analgesics or tramadol to be considered when pain is severe and disabling.
Muscle-relaxant medications are another option for short-term pain relief, and while there is little evidence of overall differences in efficacy or safety among agents, the risks associated with certain drugs (e.g., hepatotoxicity with dantrolene) should be taken into account.
Among novel treatments, the anticonvulsive drug gabapentin has been shown to have modest, short-term benefits for radiculopathy. There is limited evidence demonstrating small-to-moderate benefits with herbal therapies (e.g., devil's claw, capsicum), and they seem to be safe, the authors say.
Nonpharmacologic interventions
A number of modalities with proven benefits should be considered for patients who do not improve with self-care. During the acute phase (pain of less than four weeks), spinal manipulation has been associated with small-to-moderate benefits, while exercise, whether supervised or done at home, has not been shown effective.
For pain of longer duration, interventions with evidence of moderate efficacy include acupuncture, exercise therapy, cognitive behavior therapy, progressive relaxation, spinal manipulation, and intensive interdisciplinary rehabilitation. Exercise programs that are supervised, tailored to the individual, and involve stretching and strengthening appear to have the best outcomes.
Few trials have evaluated nonpharmacologic strategies specifically in patients with radicular pain or symptoms of spinal stenosis.
“A bunch of things seem to work, but there is no clear-cut first-line choice,” Dr. Chou says of nonpharmacologic interventions. Most have similar benefits—10-20 points on a 100-point pain scale. “Clinicians need to talk to patients about their preferences,” he says. “Studies show that if an individual believes acupuncture works, he or she will do better with it than with massage.” Cost and convenience are factors warranting consideration.
Specialty care
The Guideline suggests consultation with a back specialist when nonspecific low back pain doesn't respond adequately to noninvasive treatments but concedes that there are few data on timing or indications for referral. Although specialty interventions are not the province of this document, other guidelines suggest a three- to 24-month trial of nonsurgical interventions before considering surgery and note that participants in trials of surgery have generally had pain for at least one year.
Diagnosis and Treatment of Low Back Pain: a Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society was published in Annals of Internal Medicine (2007;147:478-491). It is available online at: http://www.annals.org/cgi/reprint/147/7/478.pdf. Reviews of evidence for medications and nonpharmacologic therapies for low back pain were published in the same issue (pages 505-514 and 492-504, respectively) and are available online at: http://www.annals.org/cgi/reprint/147/7/505.pdf and www.annals.org/cgi/reprint/147/7/492.pdf (all electronic documents were accessed April 4, 2008).
Mr. Sherman is a medical writer in New York City.