Adam L. Wilding, DC

In this months issue we are going to detail the most recent, comprehensive, and authoritative Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain.

These guidelines were published in the October 2007 issue of the journal Annals of Internal Medicine.

An extensive panel of remarkably qualified experts constructed these clinical practice guidelines.

These experts performed a review of the literature on the topic and then graded the validity of each study.

The literature search for these guidelines included studies from MEDLINE (1966 through November 2006), the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and EMBASE.

This project was commissioned as a joint effort of the American College of Physicians and the American Pain Society. The results of their efforts are summarized below categorized by the SEVEN specific “recommendations” made by the panel…:

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

Annals of Internal Medicine
Volume 147, Number 7, October 2007, pp. 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; and Douglas K. Owens, MD, MS, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel

This article has 131 references.

Recommendation 1:

As a clinician you should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories:

1) Nonspecific low back pain

2) Back pain potentially associated with radiculopathy or spinal stenosis

3) 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.

Recommendation 2:

As a clinician you should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain.

Recommendation 3:

As a clinician you 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.

Recommendation 4:

As a clinician you 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).

Recommendation 5:

As a clinician you 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.

Recommendation 6:

For patients with low back pain, as a clinician you should consider the use of medications with proven benefits in conjunction with back care information and self-care.

As a clinician you should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy.

For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.

Recommendation 7:

For patients who do not improve with selfcare options, as a clinician you should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation.

For chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation.

The Authors/Panel Members Also Go Out Of Their Way To
Make The Following Points:

“Low back pain is the fifth most common reason for all physician visits in the United States.”

One quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months. The total direct health care costs attributable to low back pain in the U.S. was about $26.3 billion in 1998. Additional indirect costs related to days lost from work are substantial, with approximately 2% of the U.S. work force compensated for back injuries each year. About one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode, and 20% report substantial limitations in activity. Approximately 5% of the people with back pain disability account for 75% of the costs associated with low back pain.

When taking a history on the patients with low back pain, clinicians should inquire about:

Location of pain
Frequency of symptoms
Duration of pain
History of previous symptoms
Prior treatment and response to treatment

“More than 85% of patients who present to primary care have low back pain that cannot reliably be attributed to a specific disease or spinal abnormality.”

Specific disorders that cause low back pain include:

Ankylosing spondylitis 0.3% to 5% of cases

Compression fracture 4%

Symptomatic herniated disc 4%

Spinal stenosis 3%

Cancer 0.7%

Cauda equina syndrome 0.04%

Spinal infection 0.01%

All patients should be evaluated for rapidly progressive or severe neurologic deficits, fecal incontinence, and bladder dysfunction.

Cauda equina syndrome is most commonly associated with massive midline disc herniation, and this is rare. The most frequent finding in cauda equina syndrome is urinary retention (90% sensitivity). In patients without urinary retention, the probability of cauda equina syndrome is approximately 1 in 10,000.

Clinicians should also ask about risk factors for cancer and infection.

Risk factors for back pain caused by cancer include:

1) A history of cancer (positive likelihood ratio (9% increased risk)

2) Unexplained weight loss (positive likelihood ratio (1.2% increased risk)

3) Failure to improve after 1 month (1.2% increased risk)

4) Age older than 50 years (1.2% increased risk)

Clinical features predicting the presence of vertebral infection include:

 1) Fever

2) History of intravenous drug use

3) History of recent infection

Risk factors for vertebral compression fracture include:

1) Age older than 50 years.

2) History of osteoporosis

3) History of steroid use

4) Ankylosing spondylitis

More than 90% of symptomatic lumbar disc herniations (back and leg pain due to a prolapsed lumbar disc compressing a nerve root) occur at the L4/L5 and L5/S1 levels.

When lumbar disc herniation is suspected, a focused examination should include:

1) Straight-leg-raise testing:

A positive straight-leg-raise test is defined as reproduction of the patient’s     sciatica between 30 and 70 degrees of leg elevation, which has a 91% sensitivity but only a 26% specificity for diagnosing a herniated disc.

2) A neurological examination that includes:

Superficial sensation on the legs

    L4 nerve root 

Knee strength

Patellar reflex

    L5 nerve root

Great toe and foot dorsiflexion strength

    S1 nerve root

Foot plantarflexion

Ankle reflexes

“Evidence on the utility of history and examination for identifying lumbar spinal stenosis is sparse.”

 Low back spinal stenosis patients may exhibit:

1) Claudication and radiating leg pain

2) Changing symptoms on downhill treadmill testing

3) Pain relieved by sitting

4) Age older than 65 years

Psychosocial factors that may predict poorer low back pain outcomes include:

1) Depression

2) Passive coping strategies

3) Job dissatisfaction

4) Higher disability levels

5) Disputed compensation claims

6) Somatization (the conversion of mental experiences into bodily symptoms)

Patients with initial acute low back pain should be reevaluated after one month if they have persistent, unimproved symptoms.

In patients with severe pain or functional deficits, older patients, or patients with signs of radiculopathy or spinal stenosis, earlier or more frequent reevaluation may be appropriate.

Low back x-rays are recommended for initial evaluation of possible vertebral compression fracture in selected higher-risk patients, such as those with a history of osteoporosis, age over 50, or steroid use. Low back x-rays are a reasonable initial option in patients with symptoms suggesting radiculopathy or spinal stenosis. X-rays cannot visualize discs or accurately evaluate the degree of spinal stenosis.

“Prompt work-up with MRI or CT is recommended in patients who have severe or progressive neurologic deficits or are suspected of having a serious underlying condition (such as vertebral infection, the cauda equina syndrome, or cancer with impending spinal cord compression) because delayed diagnosis and treatment are associated with poorer outcomes.” “Magnetic resonance imaging is generally preferred over CT if available because it does not use ionizing radiation and provides better visualization of soft tissue, vertebral marrow, and the spinal canal.” Suspicions of cancer at initial evaluation should be followed with MRI. It is acceptable “to directly perform MRI in patients with a history of cancer, the strongest predictor of vertebral cancer.”

General advice on self-management for nonspecific low back pain should include:

• Recommendations to remain active.
• In patients with chronic low back pain, a medium-firm mattress is generally better than a firm mattress.
• For acute low back pain (duration 4 weeks), spinal manipulation administered by providers with appropriate training is recommended.
• Unfortunately, “supervised exercise therapy and home exercise regimens are not effective for acute low back pain.”

For chronic low back pain, moderately effective nonpharmacologic therapies include

• acupuncture
• exercise therapy
• massage therapy
• yoga
• cognitive-behavioral therapy or progressive relaxation
• spinal manipulation
• intensive interdisciplinary rehabilitation.

Importantly, in this document, spinal manipulation is the only non-drug treatment recommendation for acute low back pain.

In addition, spinal manipulation is also recommended treatment for subacute and chronic low back pain.

At the end of this article, the authors make the following disclaimer:

“Note: Clinical practice guidelines are ‘guides’ only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians’ judgment.”

The following article, also published in the Annals of Internal Medicine, October 2007, is quite possibly the most comprehensive review of the literature concerning non-drug therapies used in the treatment of low back pain. It was prepared for the American Pain Society and the American College of Physicians Clinical Practice Guideline.

These authors note that there are many nonpharmacologic therapies available for treatment of low back pain. They therefore assessed the benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain).

Nonpharmacologic Therapies for Acute and Chronic Low Back Pain:
A Review of the Evidence for an American Pain Society
And
American College of Physicians Clinical Practice Guideline

 Annals of Internal Medicine

October 2007, Volume 147, Number 7, pp. 492-504

Roger Chou, MD, and Laurie Hoyt Huffman, MS

This article has 188 references

Intervention Definitions

Spinal manipulation

Manual therapy in which loads are applied to the spine using short- or long-lever methods. High-velocity thrusts are applied to a spinal joint beyond its restricted range of movement.

Spinal mobilization

Low-velocity, passive movements within or at the limit of joint range.

Massage

Soft tissue manipulation using the hands or a mechanical device through a variety of specific methods.

Acupuncture

An intervention consisting of the insertion of needles at specific acupuncture points.

Exercise therapy

A supervised exercise program or formal home exercise regimen, ranging from programs aimed at general physical fitness or aerobic exercise to programs aimed at muscle strengthening, flexibility, or stretching.

Yoga

An intervention distinguished from traditional exercise therapy by the use of specific body positions, breathing techniques, and emphasis on mental focus.

Back schools

An intervention consisting of an education and a skills program, including exercise therapy, in which all lessons are given to groups of patients and supervised by a paramedical therapist or medical specialist.

Psychological therapies

Includes biofeedback (the use of auditory and visual signals reflecting muscle tension or activity to inhibit or reduce the muscle activity), progressive relaxation (a technique that involves the deliberate tensing and relaxation of muscles to facilitate the recognition and release of muscle tension), and standard cognitive-behavioral and operant therapy.

Interdisciplinary therapy (also called multidisciplinary therapy)

An intervention that combines and coordinates physical, vocational, and behavioral components and is provided by multiple health care professionals with different clinical backgrounds.

Functional restoration (also called physical conditioning, work hardening, or work conditioning)

An intervention that involves simulated or actual work tests in a supervised environment in order to enhance job performance skills and improve strength, endurance, flexibility, and cardiovascular fitness in injured workers.

Interferential therapy

The superficial application of a medium-frequency alternating current modulated to produce low frequencies up to 150 Hz.

Low-level laser therapy

The superficial application of lasers at wavelengths of 632–904 nm.

Lumbar supports

A back brace or orthotic device worn to passively support the back.

Shortwave diathermy

Therapeutic elevation of the temperature of deep tissues by application of shortwave electromagnetic radiation with a frequency range of 10–100 MHz.

Superficial heat

The superficial application of heat to the lumbar area.

Traction

An intervention involving drawing or pulling to stretch the lumbar spine.

Transcutaneous electrical nerve stimulation (TENS)

Use of a small battery-operated device to provide continuous electrical impulses via surface electrodes, with the goal of relieving symptoms by modifying pain perception.

Ultrasonography

The therapeutic application of high-frequency sound waves up to 3 MHz.

The Following Chart Summarizes The Treatment Benefit For Low Back Pain

These authors did not review the evidence of benefit / harm in trials of low back pain associated with acute major trauma, cancer, infection, the cauda equina syndrome, fibromyalgia, and osteoporosis or vertebral compression fracture.

In addition to the chart provided above, these authors note:

There is “good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (4 weeks’ duration) low back pain.”

There is “fair evidence that acupuncture, massage, yoga, and functional restoration are also effective for chronic low back pain.”

“For acute low back pain (4 weeks’ duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat and spinal manipulation.”

“Massage seemed more effective in trials that used a trained massage therapist with many years of experience or a licensed massage therapist.”

There is fair evidence that massage is similar in efficacy to other noninvasive interventions for chronic low back pain.

“For chronic low back pain, the Cochrane review found exercise slightly to moderately superior to no treatment for pain relief.”

“The authors of the Cochrane review also conducted a meta-regression analysis and found that exercise therapy using individualized regimens, supervision, stretching, and strengthening was associated with the best outcomes.” There is fair evidence that yoga is slightly superior to traditional exercises for functional status and use of analgesic medications.

There is fair evidence that acupuncture is more effective than sham acupuncture.

Intensive interdisciplinary rehabilitation is moderately more effective than non-interdisciplinary rehabilitation for improving pain and function.

In this review, the only non-drug treatment that has proven evidence to benefit acute, subacute, and chronic back pain is spinal manipulation.

Manipulation was defined as “Manual therapy in which loads are applied to the spine using short- or long-lever methods. High-velocity thrusts are applied to a spinal joint beyond its restricted range of movement.”

Clinical Conditions Glossary

Acute low back pain: Low back pain present for fewer than 4 weeks.

Cauda equina syndrome: Compression on nerve roots from the lower cord segments, usually due to a massive, centrally herniated disc, which can result in urinary retention or incontinence from loss of sphincter function, bilateral motor weakness of the lower extremities, and saddle anesthesia.

Chronic low back pain: Low back pain present for more than 3 months.

Herniated disc: Herniation of the nucleus pulposus of an intervertebral disc through its fibrous outer covering, which can result in compression of adjacent nerve roots or other structures.

Neurogenic claudication: Symptoms of leg pain (and occasionally weakness) on walking or standing, relieved by sitting or spinal flexion, associated with spinal stenosis.

Nonspecific low back pain: Pain occurring primarily in the back with no signs of a serious underlying condition (such as cancer, infection, or cauda equina syndrome), spinal stenosis or radiculopathy, or another specific spinal cause (such as vertebral compression fracture or ankylosing spondylitis). Degenerative changes on lumbar imaging are usually considered nonspecific, as they correlate poorly with symptoms.

Radiculopathy: Dysfunction of a nerve root associated with pain, sensory impairment, weakness, or diminished deep tendon reflexes in a nerve root distribution.

Sciatica: Pain radiating down the leg below the knee in the distribution of the sciatic nerve, suggesting nerve root compromise due to mechanical pressure or inflammation. Sciatica is the most common symptom of lumbar radiculopathy.

Spinal stenosis: Narrowing of the spinal canal that may result in bony constriction of the cauda equina and the emerging nerve roots.

Straight-leg-raise test: A procedure in which the hip is flexed with the knee extended in order to passively stretch the sciatic nerve and elicit symptoms suggesting nerve root tension. A positive test is usually considered reproduction of the patient’s sciatica when the leg is raised between 30 and 70 degrees. Reproduction of the patient’s sciatica when the unaffected leg is lifted is referred to as a positive “crossed” straight-leg-raise test.

Subacute low back pain: Low back pain present from between 4 weeks to 3 months.

Clinical Interventions Glossary

Acupressure: An intervention consisting of manipulation with the fingers instead of needles at specific acupuncture points.

Acupuncture: An intervention consisting of the insertion of needles at specific acupuncture points.

Back school: An intervention consisting of education and a skills program, including exercise therapy, in which all lessons are given to groups of patients and supervised by a paramedical therapist or medical specialist.

Brief individualized educational interventions: Individualized assessment and education about low back pain problems without supervised exercise therapy or other specific interventions. As we defined them, brief educational interventions differ from back schools because they do not involve group education or supervised exercise.

Exercise: A supervised exercise program or formal home exercise regimen, ranging from programs aimed at general physical fitness or aerobic exercise to programs aimed at muscle strengthening, flexibility, stretching, or different combinations of these elements.

Functional restoration (also called physical conditioning, work hardening, or work conditioning): An intervention that involves simulated or actual work tests in a supervised environment in order to enhance job performance skills and improve strength, endurance, flexibility, and cardiovascular fitness in injured workers.

Interdisciplinary rehabilitation (also called multidisciplinary therapy): An intervention that combines and coordinates physical, vocational, and behavioral components and is provided by multiple health care professionals with different clinical backgrounds.

Interferential therapy: The superficial application of a medium-frequency alternating current modulated to produce low frequencies up to 150 Hz. It is thought to increase blood flow to tissues and provide pain relief and is considered more comfortable for patients than

transcutaneous electrical nerve stimulation.

Low-level laser therapy: The superficial application of lasers at wavelengths between 632 and 904 nm to the skin in order to apply electromagnetic energy to soft tissue. Optimal treatment parameters (wavelength, dosage, dose-intensity, and type of laser) are uncertain.

Massage: Soft tissue manipulation using the hands or a mechanical device through a variety of specific methods.

Neuroreflexotherapy: A technique from Spain characterized by the temporary implantation of staples superficially into the skin over trigger points in the back and referred tender points in the ear. Neuroreflexotherapy is believed to stimulate different zones of the skin than acupuncture.

Percutaneous electrical nerve stimulation (PENS): An intervention that involves inserting acupuncture-like needles and applying low-level electrical stimulation. It differs from electroacupuncture in that the insertion points target dermatomal levels for local pathology, rather than acupuncture points.

Progressive relaxation: A technique which involves the deliberate tensing and relaxation of muscles, in order to facilitate the recognition and release of muscle tension.

Self-care options: Interventions that can be readily implemented by patients without seeing a clinician or that can be implemented on the basis of advice provided at a routine clinic visit.

Self-care education book: Reading material (books, booklets, or leaflets) that provide education and self-care advice for patients with low back pain.

Shortwave diathermy: Therapeutic elevation of the temperature of deep tissues by application of short-wave electromagnetic radiation with a frequency range from 10–100 MHz.

Spa therapy: An intervention involving several interventions, including mineral water bathing, usually with heated water, typically while staying at a spa resort.

Spinal manipulation: Manual therapy in which loads are applied to the spine by using short- or long-lever methods and high-velocity thrusts are applied to a spinal joint beyond its restricted range of movement. Spinal mobilization, or low-velocity, passive movements within or at the limit of joint range, is often used in conjunction with spinal manipulation.

Traction: An intervention involving drawing or pulling in order to stretch the lumbar spine.

Transcutaneous electrical nerve stimulation (TENS): Use of a small, battery-operated device to provide continuous electrical impulses via surface electrodes, with the goal of providing symptomatic relief by modifying pain perception.

Yoga: An intervention distinguished from traditional exercise therapy by the use of specific body positions, breathing techniques, and an emphasis on mental focus.