1. Low Back Pain: Evaluation, Management, and Prognosis
Welcome to
Low Back Pain: Evaluation, Management, and Prognosis

2. Welcome and Overview Bill McCarberg Founder
Chronic Pain Management Program
Kaiser Permanente
San Diego, California
Adjunct Assistant Clinical Professor
University of California
School of Medicine

3. Evidence-Based Evaluation of Patients With Low Back Pain

4. Learning Objective
Discuss the differential diagnosis for low back pain (LBP) and the importance of clinical red and yellow flags in evaluation of LBP

5. 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):

6. 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 evidence
Chou R, et al. Ann Intern Med. 2007;147(7):

7. 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):
2. Bigos SJ, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, No. 14; 1994.

8. 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:

9. 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):

10. What Is Seen in Primary Care 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):
2. Underwood MR, et al. Br J Rheumatol. 1995;34(11):
3. Deyo RA, et al. JAMA. 1992;268(6):

11. 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 low back 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):
3. Kuritzky L, et al. Prim Care Rep 1995;1:29-38.
4. Frymoyer JW, et al. Orthop Clin North Am. 1991;22(2):

12. 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):

13. 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:
2. Bogduk N. Med J Aust. 1980;2(10):
3. Kellgren JH. Clin Sci. 1939;4:35-46.
4. Feinstein B, et al. J Bone Joint Surg Am. 1954;36-A(5):
5. Mooney V, et al. Clin Orthop Relat Res. 1976(115):
6. McCall IW, et al. Spine (Phila Pa 1976). 1979;4(5):
7. Fukui S, et al. Clin J Pain. 1997;13(4):
8. Fortin JD, et al. Spine (Phila Pa 1976). 1994;19(13):
9. Wilberg G. Acta Orthop Scand. 1947;19:
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):
12. O'Neill CW, et al. Spine (Phila Pa 1976). 2002;27(24):
13. El-Mahdi MA, et al. Neurochirurgia (Stuttg). 1981;24(4):

14. Causes of Low Back Pain
Possible sources of back pain have been demonstrated; causes have been more 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:

15. 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)

16. Differential Diagnosis for Acute Low Back Pain
Disease or Condition
Patient Age (Years)
Location of Pain
Quality of Pain
Aggravating or Relieving Factors
Signs
Back strain
20-40
Low back, buttock, posterior thigh
Ache, spasm
Increased with activity or bending
Local tenderness, limited spinal motion
Acute disc herniation
30-50
Low back to lower leg
Sharp, 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
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
Exaggeration of the lumbar curve, palpable “step off” (defect between spinous processes), tight hamstrings
Ankylosing spondylitis
15-40
Sacroiliac joints, lumbar spine
Morning stiffness
Decreased back motion, tenderness over sacroiliac joints
Infection
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 progressive
Increased with recumbency or cough
May have localized tenderness, neurologic signs, or fever
Adapted from: Patel AT, et al. Am Fam Physician. 2000;61(6):

17. 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):

18. 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):
2. Kendrick D, et al. BMJ. 2001;322(7283):
3. Kerry S, et al. Br J Gen Pract. 2002;52(479):
4. Jarvik JG. Neuroimaging Clin N Am. 2003;13(2):
5. Gilbert FJ, et al. Radiology. 2004;231(2):
6. Jarvik JG, et al. Ann Intern Med. 2002;137(7):
7. Jarvik JG, et al. JAMA. 2003;289(21):
8. Lurie JD, et al. Spine (Phila Pa 1976). 2003;28(6):

19. 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 radiculopathy or spinal stenosis)2
Thermography and electrophysiologic testing are not recommended for evaluation of nonspecific LBP
Jarvik JG, et al. Ann Intern Med. 2002;137(7):
Chou R, et al. Ann Intern Med. 2007;147(7):

20. 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):

21. 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):
2. Todd NV. Br J Neurosurg. 2005;19(4):
3. Tsiodras S, et al. Clin Orthop Relat Res. 2006;444:38-50.
4. Jarvik JG, et al. Ann Intern Med. 2002;137(7):

22. 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):
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):
4. Suarez-Almazor ME, et al. JAMA. 1997;277(22):

23. 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):

24. 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):
2. Weber H. Spine (Phila Pa 1976). 1983;8(2):
3. Modic MT, et al. Radiology. 2005;237(2):
4. Gibson JN, et al. Cochrane Database Syst Rev. 2000(3):CD
5. Gibson JN, et al. Cochrane Database Syst Rev. 2005(4):CD
6. Nelemans PJ, et al. Spine (Phila Pa 1976). 2001;26(5):
7. Peul WC, et al. N Engl J Med. 2007;356(22):
8. Weinstein JN, et al. JAMA. 2006;296(20):
9. Amundsen T, et al. Spine (Phila Pa 1976). 2000;25(11):
10. Atlas SJ, et al. Spine (Phila Pa 1976). 2005;30(8):
11. Weinstein JN, et al. N Engl J Med. 2007;356(22):
12. Malmivaara A, et al. Spine (Phila Pa 1976). 2007;32(1):1-8.

25. 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):
2. Chou R, et al. Ann Intern Med. 2007;147(7):

26. 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):
2. Vroomen PC, et al. J Neurol. 1999;246(10):
3. Chou R, et al. Ann Intern Med. 2007;147(7):

27. 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):

28. 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%]), but less sensitive (29% [CI, 24% to 34%])
Deville WL, et al. Spine (Phila Pa 1976). 2000;25(9):

29. Critical Clinical Indicators of Pathology (cont.)
All patients should be evaluated for
Presence 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):
Deyo RA, et al. JAMA. 1992;268(6):

30. 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:

31. 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 LBP is 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):
3. Pincus T, et al. Spine (Phila Pa 1976). 2002;27(5):E
4. Gatchel RJ, et al. J Occup Rehabil. 2003;13(1):1-9.
5. Hay EM, et al. Lancet. 2005;365(9476):
6. Jellema P, et al. BMJ. 2005;331(7508):84.
7. Chou R, et al. Ann Intern Med. 2007;147(7):
8. Steenstra IA, et al. Occup Environ Med. 2005;62(12):
9. Deyo RA, et al. Spine (Phila Pa 1976). 2006;31(23): Carey TS, et al. Spine (Phila Pa 1976). 1996;21(3):

32. 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):

33. Risk for Chronicity Vertebral infection Vertebral compression fracture
Intravenous drug use, recent infection
Vertebral compression fracture
Older age, history of osteoporosis, and steroid use
Musculoskeletal
Inactivity
In general
Emotional distress

34. 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):

35. 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):
2. Rudwaleit M, et al. Arthritis Rheum. 2006;54(2):
3. Rudwaleit M, et al. Arthritis Rheum. 2005;52(4):

36. Racial/Cultural Aspects of 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.

37. 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.

38. Avoiding Racial and Cultural Bias per Knox H. Todd, MD, MPH
Make 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 cards
Todd KH. Medical Ethics Advisor

39. 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):

40. Please pass your question card to a staff member.?
Questions?
Please pass your question card to a staff member.

41. Treatment of Low Back Pain: Pharmacologic and Nonpharmacologic Options
Roger Chou, MD, FACP
Associate Professor of Medicine, Department of Medicine Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University

42. 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)

43. Learning Objective
Integrate evidence-based pharmacologic and nonpharmacologic therapies into a comprehensive treatment plan for chronic LBP

44. 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):
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):

45. Increasing Rates of Back Surgery
Trends in Rates of Discectomy/Laminectomy and Fusion in
US Average Rate of Discharges per 1000 Medicare Enrollees
Weinstein JN, et al. Spine (Phila Pa 1976). 2006;31(23):

46. Increasing Rates of Back Injections
Lumbosacral Injection Rates by Year: Age- and Sex-Adjusted per 100,000
2055.2
553.4
263.9
212.3
79.7
SI=sacroiliac. Friedly J, et al. Spine (Phila Pa 1976). 2007;32(16):

47. Increasing Costs Mean ($) Year
Martin BI, et al. JAMA. 2008;299(6):

48. Rising Prevalence of Chronic LBP
Prevalence of Chronic Low Back Pain in North Carolina, 1992 and 2006
% Prevalence (95% CI)
1992: 3.9%
2006: 10.2%
Characteristic
1992
(n=8067)
2006
(n=9924)
% Increase
PRR
( % CI)*
Total
3.9 ( )
10.2 ( )
162
2.62 ( )
Sex
Male
2.9 ( )
8.0 ( )
176
2.76 ( )
Female
4.8 ( )
12.2 ( )
154
2.54 ( )
Age (Years)
21-34
1.4 ( )
4.3 ( )
201
3.01 ( )
35-44
4.8 ( )
9.2 ( ) 92
1.92 ( )
45-54
4.2 ( )
13.5 ( )
219
3.19 ( )
55-64
6.3 ( )
15.4 ( )
146
2.46 ( )
65
5.9 ( )
12.3 ( )
109
2.09 ( )
Race/Ethnicity
Non-Hispanic White
4.1 ( )
10.5 ( )
155
2.55 ( )
Non-Hispanic Black
3.0 ( )
9.8 ( )
226
3.26 ( )
Hispanic **
6.3 ( )
Other
4.1 ( )
9.1 ( )
120
2.20 ( )
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):

49. 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 ,000 annually
20-fold variation in epidural steroid injections: 104 per 1000 in Palm Springs to 5.6 per in Honolulu
Deyo RA, et al. Clin Orthop Relat Res. 2006;443:
Weinstein JN, et al. Spine (Phila Pa 1976). 2006;31(23):

50. “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.

51. 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.

52. Low Back Pain Guidelines Project Overview 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

53. Recommendation Grid ACP Methods
Quality of Evidence
Benefits Do or Do Not Clearly Outweigh Risks
Benefits and Risks and Burdens Finely Balanced
High
Strong
Weak
Moderate
Low
Insufficient I
Strength of Recommendation
Chou R, et al. Ann Intern Med. 2007;147(7):

54. 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

55. Recommendation Treatment of Low Back Pain
Provide patients with evidence-based information about their expected course, advise patients to remain active, and provide information about effective self-care options
Strong recommendation
Moderate-quality evidence
Chou R, et al. Ann Intern Med. 2007;147(7):

56. 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.

57. Recommendation Treatment of Low Back Pain
Consider 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 NSAIDs
Strong recommendation
Moderate-quality evidence
NSAIDs=nonsteroidal anti-inflammatory drugs.
Chou R, et al. Ann Intern Med. 2007;147(7):

58. Pharmacologic Interventions
Drug
Net Benefit
Level of Evidence
Acetaminophen
Small to moderate
Fair
Skeletal muscle relaxants
Moderate (for acute LBP only)
Good
NSAIDs
Moderate
Tricyclic antidepressants
Small to moderate (for chronic LBP only)
Chou R, et al. Ann Intern Med. 2007;147(7):
Chou R, et al. Ann Intern Med. 2007;147(7):
This information includes a use that has not been approved by the US FDA.

59. Pharmacologic Interventions (cont.)
Drug
Net Benefit
Level of Evidence
Opioids and tramadol
Moderate
Fair
Benzodiazepines
Antiepileptic medications
Small (for radiculopathy only)
Systemic steroids
No benefit
Good
Chou R, et al. Ann Intern Med. 2007;147(7):
Chou R, et al. Ann Intern Med. 2007;147(7):
This information includes a use that has not been approved by the US FDA.

60. Recommendation Treatment 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 recommendation
Moderate-quality evidence
Chou R, et al. Ann Intern Med. 2007;147(7):

61. Noninvasive Interventions for Chronic or Subacute LBP
Net Benefit
Level of Evidence
Behavioral therapy
Moderate
Good
Exercise therapy
Spinal manipulation
Acupuncture
Fair
Chou R, et al. Ann Intern Med. 2007;147(7):

62. Noninvasive Interventions for Chronic or Subacute LBP (cont.)
Net Benefit
Level of Evidence
Massage
Moderate
Fair
Yoga
Fair (for Viniyoga)
Back schools
Small
Traction
No benefit
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):

63. Recommendation Interventional 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):

64. 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):

65. Placebo-Controlled Trials of RFDN for Presumed Facet Joint Pain
Study
Sample Size
Selection
Quality
Benefits
Gallagher, 1994 41
Uncontrolled block
Poor quality
Can’t tell
Leclaire, 2001 70
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
<1 point for pain, 0.5 points for function
van Kleef, 1999 30
1-2 point for pain and function
van Wijk, 2005 81
Technical issues?
NS=not significant.

66. Placebo-Controlled Trials of RFDN for Presumed Facet Joint Pain
Study
Sample Size
Selection
Quality
Benefits
Gallagher, 1994 41
Uncontrolled block
Poor quality
Can’t tell
Leclaire, 2001 70
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
<1 point for pain, 0.5 points for function
van Kleef, 1999 30
1-2 point for pain and function
van Wijk, 2005 81
Technical issues?

67. Placebo-Controlled Trials of RFDN for Presumed Facet Joint Pain (cont
Study
Sample 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
1-2 point for pain and function

68. Recommendation Surgery 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 option
Weak recommendation
High-quality evidence
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):

69. 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):
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):

70. Recommendation Interventional 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):

71. Interventional Therapies for Radiculopathy/Prolapsed Disc
Epidural 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):

72. Recommendation Surgery for Radicular Low Back Pain and Spinal Stenosis
In patients with persistent radiculopathy due to herniated lumbar disc or persistent and disabling leg pain due to 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):

73. 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):
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):

74. 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):
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):

75. Conclusions The quality of evidence for different LBP therapies varies
A number of therapies appear similarly and 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 values and preferences

76. Please pass your question card to a staff member.?
Questions?
Please pass your question card to a staff member.

77. Current Understanding of the Prevention of Chronicity of Low Back Pain
Bill McCarberg, MD Founder, Chronic Pain Management Program
Kaiser Permanente San Diego
Adjunct Assistant Clinical Professor,
University of California, San Diego

78. Disclosure: Bill McCarberg, MD
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
Dr. McCarberg’s presentation will not include discussion of off-label, experimental, and/or investigational uses of drugs or devices

79. Learning Objective
Evaluate early interventions for acute back pain in patients considered at high risk for transition to chronic low back pain (CLBP)

80. 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):

81. 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):

82. 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

83. 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):

84. Interventional Therapies Do Not Prevent Chronicity
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
No benefit D
Intradiscal steroid injection
Presumed discogenic pain
Fusion surgery
Nonradicular LBP with common dengerative changes
Fair
Moderate vs standard nonsurgical therapy, no difference vs intensive rehabilitation
Facet joint steroid injection
Presumed facet joint pain
Botulinum toxin injection
Poor
Unable to estimate I
Local injections
Epidural steroid injection
Medial branch block (therapeutic)
Presumed facet joint pain
Sacroiliac joint steroid injection
Presumed sacroiliac joint pain
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):

85. The Fear-Avoidance Model of Chronic Pain
Injury
Disuse
Disability
Depression
Recovery
Avoidance
Escape
Arousal
Preventative
Motivation
Pain
Anxiety
Confrontation
Pain Experience
Defensive
Motivation
Hypervigilance
Arousal
Fear
of Pain
Threat Perception
Catastrophizing
Low Fear
Negative Affectivity
Threatening Illness Information
Leeuw M, et al. J Behav Med. 2007;30(1):77-94.
Vlaeyen JW, et al. Pain. 2000;85(3):

86. 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):
2. McNeil DW, et al. J Behav Med. 1998;21(4):
3. Waddell G, et al. Pain. 1993;52(2):
4. Rosenstiel AK, et al. Pain. 1983;17(1):33-44.

87. 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):
3. Vlaeyen JW, et al. Pain Res Manag. 2002;7(3):
4. Hoffman BM, et al. Health Psychol. 2007;26(1):1-9.
5. Smeets RJ, et al. J Pain. 2006;7(4):
6. Moseley GL, et al. Clin J Pain. 2004;20(5):
7. Leeuw M, et al. Pain. 2008;138(1):

88. 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.

89. Early Intensive Intervention Effectiveness
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
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
Average of self-rated pain over last 3 months (0-100 scale)**
26.8
43.1
25.7
% currently taking narcotic analgesics*
27.3%
43.8%
18.5%
.020
% currently taking psychotropic medication
4.5%
16.7%
1.9%
.019
*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.

90. 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):

91. 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):

92. 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)
1. Provider Reassurance
} p=.055
2. Recovery Expectation
} p=.045
3. Fears
4. Knowledge
5. Appropriate Care
6. Disability Management
7. Self-Management
8. Case Management
9. Temporary Duties
} p<.001
10. Alternative Care
} p<.001
11. Back Supports 2 4 6 8 10 12
Rankings by Panel
Guzman J, et al. Spine (Phila Pa 1976). 2007;32(7):

93. 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

94. 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

95. ?
Questions?

96. Question and Answer Session

97. Low Back Pain: Evaluation, Management, and Prognosis
Thank You for Attending
Low Back Pain: Evaluation, Management, and Prognosis