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. This also represents the first national guideline 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 approximately four weeks)—but only if they are considered candidates for surgery or epidural steroid injection.
Self-managing low back pain
Patient education is one key component of management (Figure 1). Clinicians should emphasize the usually benign and self-limiting course of acute episodes, even when accompanied by sciatica. They might also 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.