low back pain: evaluation, management, and prognosis

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


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


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


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




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)




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



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.


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


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


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


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


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


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


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


Gallagher, 1994 41 Uncontrolled block Poor quality Can’t tell




for pain)


Tekin, 2007 60 Clinical criteria Poor quality <1 point for pain,

0.5 points for function


and function

van Wijk, 2005 81 Uncontrolled block

Technical issues? No

Placebo-Controlled Trials of RFDN for Presumed Facet Joint Pain (cont.)

StudySample





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


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



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


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


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


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


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


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

low back pain: evaluation, management, and prognosis

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