Presentation on theme: "Low Back Pain: Evaluation, Management, and Prognosis"— Presentation transcript:
1Low Back Pain: Evaluation, Management, and Prognosis Welcome toLow Back Pain: Evaluation, Management, and Prognosis
2Welcome and Overview Bill McCarberg Founder Chronic Pain Management ProgramKaiser PermanenteSan Diego, CaliforniaAdjunct Assistant Clinical ProfessorUniversity of CaliforniaSchool of Medicine
3Evidence-Based Evaluation of Patients With Low Back Pain
4Learning ObjectiveDiscuss the differential diagnosis for low back pain (LBP) and the importance of clinical red and yellow flags in evaluation of LBP
5Low 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 LBPChou R, et al. Ann Intern Med. 2007;147(7):
6Guideline #1Clinicians should conduct a focused history and physical examination to help place patients with LBP into 1 of 3 broad categoriesNonspecific LBPBack pain potentially associated with radiculopathy or spinal stenosisBack pain potentially associated with another specific spinal causeThe history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back painStrong recommendationModerate-quality evidenceChou R, et al. Ann Intern Med. 2007;147(7):
7Focused History and Physical Examination Determine presence and level of neurological involvement1,2Classify patients into 3 broad categoriesNonspecific LBP potentially associated with radiculopathySpinal stenosisBack pain potentially associated with another specific spinal causePatients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluationTumorInfectionCauda equina syndromePatients with other conditions that may respond to specific treatmentsAnkylosing spondylitisVertebral compression fracture1. 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.
8Evaluation of Back Pain SiteLength of illnessSpreadQualityIntensityFrequencyDurationTime of onsetMode of onsetPrecipitating factorsAggravating factorsRelieving factorsAssociated featuresMcGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:
9Epidemiology of Low Back Pain 90% of American adults experience an episode of back pain during their lifetimeOf patients who have acute back pain90% to 95% have a non–life-threatening conditionAlthough up to 85% cannot be given an exact diagnosis, nearly all recover within 4 to 6 weeksFor 5% to 10% of patients, acute back pain is a manifestation of more serious pathologyVascular catastrophes, malignancy, spinal cord compressive syndromes, and infectious disease processesWinters ME, et al. Med Clin North Am. 2006;90(3):
10What Is Seen in Primary Care Practice? In minority of patients presenting for initial evaluation in primary care setting, LBP is caused by1Cancer (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%2Spinal stenosis and symptomatic herniated disc are present in about 3% and 4% of patients, respectivelyCauda equina syndrome most commonly associated with massive midline disc herniation, but rareEstimated prevalence of 0.04%31. 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):
11Cost of Low Back PainLBP is one of top 10 reasons patients seek care from family physicians1Prevalence of LBP has varied from 7.6% to 37%Peak prevalence between 45 and 60 years of age2Also reported by adolescents and by adults of all ages80% of adults seek care at some time for acute LBP3One-third of US disability costs are due to low back disorders3Direct costs of diagnosing and treating LBP in United States estimated in 1991 to be $25* billion annually4Indirect costs, including lost earnings, are even higher4Proper 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):
12Etiology of Low Back Pain Nonspecific LBPBack pain potentially associated with radiculopathy or spinal stenosisBack pain potentially associated with another specific spinal causeChou R, et al. Ann Intern Med. 2007;147(7):
13Structural Sources of Low Back Pain Muscles of the back1,2Interspinous ligaments2-4Zygapophyseal joints5-7Sacroiliac joint(s)8Intervertebral discs9-12Mechanical12 or chemical irritation of dura mater131. 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):
14Causes of Low Back PainPossible sources of back pain have been demonstrated; causes have been more elusiveRefuted: conditions traditionally considered to be possible causes are actually not causesEg, spondylolysis, spondylolisthesis, degenerative changes (spondylosis)Accepted: tumors and infectionsUntested: muscle sprain, ligament sprain, segmental dysfunction, and trigger pointsKnown source, unknown cause: sacroiliac joints, zygapophyseal joints, internal disc disruptionMcGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:
15Diagnostic Triage Guides Subsequent Decision-Making Inquire aboutLocation of painFrequency of symptomsDuration of painHistory of previous symptoms, treatment, and response to treatmentConsider possibility of LBP due to problems outside the backPancreatitisNephrolithiasisAortic aneurysmSystemic illnesses (eg, endocarditis or viral syndromes)
16Differential Diagnosis for Acute Low Back Pain Disease or ConditionPatient Age (Years)Location of PainQuality of PainAggravating or Relieving FactorsSignsBack strain20-40Low back, buttock, posterior thighAche, spasmIncreased with activity or bendingLocal tenderness, limited spinal motionAcute disc herniation30-50Low back to lower legSharp, shooting, or burning pain; paresthesia in legDecreased with standing; increased with bending or sittingPositive straight leg raise test, weakness, asymmetric reflexesOsteoarthritis or spinal stenosisLow back to lower leg; often bilateralAche, shooting pain, “pins and needles” sensationIncreased with walking, especially up an incline; decreased with sittingMild decrease in extension of spine; may have weakness or asymmetric reflexesSpondylolisthesisAny ageBack, posterior thighAcheExaggeration of the lumbar curve, palpable “step off” (defect between spinous processes), tight hamstringsAnkylosing spondylitis15-40Sacroiliac joints, lumbar spineMorning stiffnessDecreased back motion, tenderness over sacroiliac jointsInfectionLumbar spine, sacrumSharp pain, acheVariesFever, percussive tenderness; may have neurologic abnormalities or decreased motionMalignancy>50Affected bone(s)Dull ache, throbbing pain; slowly progressiveIncreased with recumbency or coughMay have localized tenderness, neurologic signs, or feverAdapted from: Patel AT, et al. Am Fam Physician. 2000;61(6):
17Guideline #2Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific LBPStrong recommendationModerate-quality evidenceChou R, et al. Ann Intern Med. 2007;147(7):
18Plain 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 imaging1-3Exposure 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)4Routine 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 interventions7,81. 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):
19Plain 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 use1Evidence 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)2Thermography and electrophysiologic testing are not recommended for evaluation of nonspecific LBPJarvik JG, et al. Ann Intern Med. 2002;137(7):Chou R, et al. Ann Intern Med. 2007;147(7):
20Guideline #3Clinicians 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 examinationStrong recommendationModerate-quality evidenceChou R, et al. Ann Intern Med. 2007;147(7):
21CT 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 outcomes1-3MRI is generally preferred over CT if available; does not use ionizing radiation, provides better visualization of soft tissue, vertebral marrow, and the spinal canal41. 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):
22CT 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 compressionProposed strategies generally recommend plain radiography or measurement of erythrocyte sedimentation rate3, with MRI reserved for patients with abnormalities on initial testing1,2Alternative 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 option41. 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):
23Guideline #4Clinicians 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 recommendationModerate-quality evidenceChou R, et al. Ann Intern Med. 2007;147(7):
24Imaging 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 management1,2There is no compelling evidence that routine imaging effects treatment decisions or improves outcomes3For prolapsed lumbar disc with persistent radicular symptoms despite noninvasive therapy, discectomy or epidural steroids are potential treatment options4-8Surgery is also a treatment option for persistent symptoms associated with spinal stenosis9-121. 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):CD5. Gibson JN, et al. Cochrane Database Syst Rev. 2005(4):CD6. 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.
25MRI for Low Back PainMRI (preferred if available) or CT is recommended for evaluating patients with persistent back and leg pain who are potential candidates for invasive interventionsPlain radiography cannot visualize discs or accurately evaluate the degree of spinal stenosis1However, clinicians should be aware that findings on MRI or CT (such as bulging disc without nerve root impingement) are often nonspecificRecommendations 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 input21. Jarvik JG, et al. Ann Intern Med. 2002;137(7):2. Chou R, et al. Ann Intern Med. 2007;147(7):
26Critical 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 levels31. 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):
27Critical 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 dysfunctionChou R, et al. Ann Intern Med. 2007;147(7):
28Critical 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 discCrossed 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):
29Critical Clinical Indicators of Pathology (cont.) All patients should be evaluated forPresence of rapidly progressive or severe neurologic deficitsMotor deficits at more than 1 level, fecal incontinence, and bladder dysfunctionMost frequent finding in cauda equina syndrome is urinary retention (90% sensitivity)Without urinary retention, probability is approximately 1 in 10,000Chou R, et al. Ann Intern Med. 2007;147(7):Deyo RA, et al. JAMA. 1992;268(6):
30Yellow Flags Identify psychosocial problems in acute phase Slow progress to recovery may be due to undetected, or unrevealed psychosocial factorsPertain to patient's beliefs and behaviors concerning physical activity and domestic, social, and vocational responsibilitiesExample: patient believes physical activity might harm back, make pain worse, so avoids activitiesMost destructive is aversion to workBelief that work caused pain, work aggravates pain, work is too heavy, and work should not be doneMcGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:
31Psychosocial Factors of Low Back Pain Stronger predictors of LBP outcomes than either physical findings or severity/duration of pain1-3Assessment of psychosocial factors identifies patients who may have delayed recovery and could help target interventions1 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 disability4Direct evidence on effective primary care interventions for identifying and treating such factors in patients with acute LBP is lacking5,6Evidence is currently insufficient to recommend optimal methods for assessing psychosocial factors and emotional distress7However, psychosocial factors that may predict poorer LBP outcomes include presence of depression, passive coping strategies, job dissatisfaction, higher disability levels, disputed compensation claims, or somatization8-101. 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):E4. 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):
32Red Flags of Lower Back Pain HistoryGradual onset of back painAge <20 years or >50 yearsThoracic back painPain lasting longer than 6 weeksHistory of traumaFever/chills/night sweatsUnintentional weight lossPain worse with recumbencyPain worse at nightUnrelenting pain despite supratherapeutic doses of analgesicsHistory of malignancyHistory of immunosuppressionRecent procedure causing bacteremiaHistory of intravenous drug usePhysical ExaminationFeverHypotensionExtreme hypertensionPale, ashen appearancePulsatile abdominal massPulse amplitude differentialsSpinous process tendernessFocal neurologic signsAcute urinary retentionWinters ME, et al. Med Clin North Am. 2006;90(3):
33Risk for Chronicity Vertebral infection Vertebral compression fracture Intravenous drug use, recent infectionVertebral compression fractureOlder age, history of osteoporosis, and steroid useMusculoskeletalInactivityIn generalEmotional distress
34Cancer-Related Risk Factors Large, prospective study from a primary care settingHistory 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):
35Non-Cancer-Related Risk Factors Features predicting vertebral infection not well studied, but may include fever, intravenous drug use, or recent infection1Consider 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 only2Clinicians should be aware that criteria for diagnosing early ankylosing spondylitis (before the development of radiographic abnormalities) are evolving31. 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):
36Racial/Cultural Aspects of Assessment To communicate effectively with all patientsAlways use simple words, not medical jargonDetermine what the patient/caregiver already knows or believes about his/her health situationEncourage 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 meetingZacharoff KL. Cross-Cultural Pain Management: Effective Treatment of Pain in the Hispanic Population; 2009.
37Culturally 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 languageImplement 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 areaEnsure that staff, at all levels and across all disciplines, receives ongoing education and training in CLAS deliveryUSDHHS OMH. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care; 2001.
38Avoiding Racial and Cultural Bias per Knox H. Todd, MD, MPH Make pain assessment mandatoryGive a nonopioid analgesic at triageTrack reasons for unscheduled returnsAudit for ethnic biasConsider which pain scales should be usedUse multilingual laminated cardsTodd KH. Medical Ethics Advisor
39Pearls for PracticeCategorize 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 causeEvaluate psychosocial risk factors to predict the risk for chronic, disabling low back painProvide patients with evidence-based information on expected course of low back pain, effective self-care options, and recommend that they be physically activeChou R, et al. Ann Intern Med. 2007;147(7):
40Please pass your question card to a staff member. ?Questions?Please pass your question card to a staff member.
41Treatment of Low Back Pain: Pharmacologic and Nonpharmacologic Options Roger Chou, MD, FACPAssociate Professor of Medicine, Department of Medicine Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University
42Disclosure: Roger Chou, MD, FACP Dr. Chou has disclosed that he has no actual or potential conflict of interest in regard to this activityHis presentation will include off-label discussion of anticonvulsants, benzodiazepines, and tricyclic antidepressants for the treatment of low back pain (LBP)
43Learning ObjectiveIntegrate evidence-based pharmacologic and nonpharmacologic therapies into a comprehensive treatment plan for chronic LBP
44Low Back Pain BurdenLBP is the fifth most common reason for US office visits, and the second most common symptomatic reason1-2$90.7 billion dollars in total healthcare expenditures in 19983LBP is the most common cause for activity limitations in persons under the age of 4541. Hart LG, et al. Spine (Phila Pa 1976). 1995;20(1):11-19.2. Deyo RA, et al. Spine (Phila Pa 1976). 2006;31(23):3. Luo X, et al. Spine (Phila Pa 1976). 2004;29(1):79-86.4. Von Korff M, et al. Spine (Phila Pa 1976). 1996;21(24):
45Increasing Rates of Back Surgery Trends in Rates of Discectomy/Laminectomy and Fusion inUS Average Rate of Discharges per 1000 Medicare EnrolleesWeinstein JN, et al. Spine (Phila Pa 1976). 2006;31(23):
46Increasing Rates of Back Injections Lumbosacral Injection Rates by Year: Age- and Sex-Adjusted per 100,0002055.2553.4263.9212.379.7SI=sacroiliac. Friedly J, et al. Spine (Phila Pa 1976). 2007;32(16):
47Increasing Costs Mean ($) Year Martin BI, et al. JAMA. 2008;299(6):
48Rising 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%Characteristic1992(n=8067)2006(n=9924)% IncreasePRR( % CI)*Total3.9 ( )10.2 ( )1622.62 ( )SexMale2.9 ( )8.0 ( )1762.76 ( )Female4.8 ( )12.2 ( )1542.54 ( )Age (Years)21-341.4 ( )4.3 ( )2013.01 ( )35-444.8 ( )9.2 ( )921.92 ( )45-544.2 ( )13.5 ( )2193.19 ( )55-646.3 ( )15.4 ( )1462.46 ( )655.9 ( )12.3 ( )1092.09 ( )Race/EthnicityNon-Hispanic White4.1 ( )10.5 ( )1552.55 ( )Non-Hispanic Black3.0 ( )9.8 ( )2263.26 ( )Hispanic**6.3 ( )Other4.1 ( )9.1 ( )1202.20 ( )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):
49Practice PatternsSpine surgery rates in the US are the highest in the worldRates in the US 5 times higher than in the UK20-fold variation in fusion: 4.6 per 1000 in Idaho Falls to 0.2 per 1000 in Bangor, MaineInterventional therapies are also widely usedIntradiscal electrothermal therapy estimated at ,000 annually20-fold variation in epidural steroid injections: 104 per 1000 in Palm Springs to 5.6 per in HonoluluDeyo 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 2007End Back Pain Agony (Michael J. Weiss)Weiss MJ. Reader's Digest. July, 2007.
51Reader’s Digest “Cures” for Low Back Pain “Cures” based on anecdotal evidence, not yet approved, and/or only in animal studiesInfrared belt: $2335“Magic Spinal Wand”Percutaneous automatic discectomyFlexible fusionStem cellsSite-directed bone growthNew bedBased on an unpublished observational study funded by a sleep products trade groupWeiss MJ. Reader's Digest. July, 2007.
52Low Back Pain Guidelines Project Overview and Timeline Began 2004; primary care guidelines published October 2007Address both acute and chronic LBP, and nonspecific LBP and LBP with radiculopathy or spinal stenosisGuideline for interventional therapies/surgery published May 2009Partnership between the American Pain Society and the American College of Physicians (ACP)Funded by the American Pain SocietyMultidisciplinary panel with 25 members; over 15 specialties/organizations representedSeries of 3 face-to-face meetings to develop guidelinesConsensus achieved for all recommendations
53Recommendation Grid ACP Methods Quality of EvidenceBenefits Do or Do Not Clearly Outweigh RisksBenefits and Risks and Burdens Finely BalancedHighStrongWeakModerateLowInsufficientIStrength of RecommendationChou R, et al. Ann Intern Med. 2007;147(7):
54Basic Principles of Selecting Therapy for Low Back Pain For most LBP, labeling with a specific etiology doesn’t help inform therapy choicesMost patients with acute LBP will improve regardless of which therapy is chosenFor chronic LBP, therapies are moderately effective at bestUse interventions with proven efficacyNoninvasive approaches to most LBPConsider psychosocial factors
55Recommendation 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 optionsStrong recommendationModerate-quality evidenceChou R, et al. Ann Intern Med. 2007;147(7):
56Advice and Self-Care for Low Back Pain Inform patients of generally favorable prognosis of acute LBP with or without sciaticaDiscuss need for re-evaluation if not improvedAdvise to remain activeConsider self-care education booksSuperficial heat moderately effective for acute LBPNo evidence to support use of lumbar supportsFirm mattresses inferior to medium-firm mattresses (1 RCT)RCT=randomized controlled trial.
57Recommendation 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 NSAIDsStrong recommendationModerate-quality evidenceNSAIDs=nonsteroidal anti-inflammatory drugs.Chou R, et al. Ann Intern Med. 2007;147(7):
58Pharmacologic Interventions DrugNet BenefitLevel of EvidenceAcetaminophenSmall to moderateFairSkeletal muscle relaxantsModerate (for acute LBP only)GoodNSAIDsModerateTricyclic antidepressantsSmall 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.
59Pharmacologic Interventions (cont.) DrugNet BenefitLevel of EvidenceOpioids and tramadolModerateFairBenzodiazepinesAntiepileptic medicationsSmall (for radiculopathy only)Systemic steroidsNo benefitGoodChou 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.
60Recommendation Treatment of Low Back Pain For patients who do not improve with self-care options, consider the addition of nonpharmacologic therapy with proven benefitsFor chronic or subacute LBP, options includeIntensive interdisciplinary rehabilitationExercise therapyAcupunctureMassage therapySpinal manipulationYogaCognitive-behavioral therapyProgressive relaxationWeak recommendationModerate-quality evidenceChou R, et al. Ann Intern Med. 2007;147(7):
61Noninvasive Interventions for Chronic or Subacute LBP Net BenefitLevel of EvidenceBehavioral therapyModerateGoodExercise therapySpinal manipulationAcupunctureFairChou R, et al. Ann Intern Med. 2007;147(7):
62Noninvasive Interventions for Chronic or Subacute LBP (cont.) Net BenefitLevel of EvidenceMassageModerateFairYogaFair (for Viniyoga)Back schoolsSmallTractionNo benefitInterferential therapy, lumbar supports, short-wave diathermy, TENS, ultrasoundUnclearPoorTENS=transcutaneous electrical nerve stimulation.Chou R, et al. Ann Intern Med. 2007;147(7):
63Recommendation Interventional Therapies for Nonradicular Low Back Pain In patients with persistent nonradicular LBP, facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injection are not recommendedStrong recommendationModerate-quality evidenceThere is insufficient evidence to adequately evaluate benefits of other interventional therapies for nonradicular LBPChou R, et al. Spine (Phila Pa 1976). 2009;34(10):
64Interventional Therapies for Nonradicular Low Back Pain Interventional therapies not proven to be effective in placebo-controlled, randomized trialsNo 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 trialsIDETFacet joint steroid injectionNot clear if interventions are ineffective, or if patients were not accurately selectedIDET=intradiscal electrothermal therapy.RFDN=radiofrequency denervation.Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):
65Placebo-Controlled Trials of RFDN for Presumed Facet Joint Pain StudySample SizeSelectionQualityBenefitsGallagher, 199441Uncontrolled blockPoor qualityCan’t tellLeclaire, 200170No major issuesNoNath, 200840Controlled blockBaseline differences (1.6 points for pain)1.5 points for leg pain, NS for back painTekin, 200760Clinical criteria<1 point for pain, 0.5 points for functionvan Kleef, 1999301-2 point for pain and functionvan Wijk, 200581Technical issues?NS=not significant.
66Placebo-Controlled Trials of RFDN for Presumed Facet Joint Pain StudySample SizeSelectionQualityBenefitsGallagher, 199441Uncontrolled blockPoor qualityCan’t tellLeclaire, 200170No major issuesNoNath, 200840Controlled blockBaseline differences (1.6 points for pain)1.5 points for leg pain, NS for back painTekin, 200760Clinical criteria<1 point for pain, 0.5 points for functionvan Kleef, 1999301-2 point for pain and functionvan Wijk, 200581Technical issues?
67Placebo-Controlled Trials of RFDN for Presumed Facet Joint Pain (cont StudySample SizeSelectionQualityBenefitsLeclaire, 200170Uncontrolled blockNo major issuesNoNath, 200840Controlled blockBaseline differences (1.6 points for pain)1.5 points for leg pain, NS for back painvan Kleef, 1999301-2 point for pain and function
68Recommendation 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 optionWeak recommendationHigh-quality evidenceChou R, et al. Spine (Phila Pa 1976). 2009;34(10):
69Surgery for Nonradicular Low Back Pain With Degenerative Changes Benefits vary depending on comparatorBenefits 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 outcomesFewer than half experience optimal outcomes (relief of pain, return to work, decreased analgesic use)No evidence that instrumentation improves outcomesShared decision-making approach recommendedChou R, et al. Spine (Phila Pa 1976). 2009;34(10):Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):
70Recommendation 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 optionWeak recommendationModerate-quality evidenceChou R, et al. Spine (Phila Pa 1976). 2009;34(10):
71Interventional Therapies for Radiculopathy/Prolapsed Disc Epidural steroid injectionShort-term benefits in some higher-quality trials, but data are inconsistent (could be related to comparator used in trials)No long-term benefitsNo route clearly superiorLimited evidence of no benefit for spinal stenosisShared decision-making approach recommendedChou R, et al. Spine (Phila Pa 1976). 2009;34(10):
72Recommendation 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 optionStrong recommendationHigh-quality evidenceChou R, et al. Spine (Phila Pa 1976). 2009;34(10):
73Surgery for Herniated Disc With Radiculopathy Discectomy associated with more rapid improvement in symptoms than nonsurgical therapyPatients improved either with or without surgeryNo progressive neurologic deficits without immediate surgeryLong-term (after 1-2 years) outcomes similar in some trialsMost trials evaluated standard open discectomy or microdiscectomyShared decision-making approach recommendedChou R, et al. Spine (Phila Pa 1976). 2009;34(10):Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):
74Surgery for Spinal Stenosis Decompressive laminectomy associated with superior outcomes vs nonsurgical therapyMild improvement with nonsurgical therapyNo severe neurologic deficits without immediate surgeryBenefits may diminish with long-term (>2 years) follow-upShared decision-making approach recommendedChou R, et al. Spine (Phila Pa 1976). 2009;34(10):Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):
75Conclusions The quality of evidence for different LBP therapies varies A number of therapies appear similarly and moderately effective for LBPGuidelines can provide clinicians with a useful framework for choosing therapiesFactors that influence choices from recommended therapies include patient preferences, availability, and costsShared decision-making can help make decisions consistent with patient values and preferences
76Please pass your question card to a staff member. ?Questions?Please pass your question card to a staff member.
77Current 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
78Disclosure: Bill McCarberg, MD TypeCompanySpeakers BureauAbbott 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 LPDr. McCarberg’s presentation will not include discussion of off-label, experimental, and/or investigational uses of drugs or devices
79Learning ObjectiveEvaluate early interventions for acute back pain in patients considered at high risk for transition to chronic low back pain (CLBP)
80Disability from Back Pain The minority of cases which involve disability account for a disproportionate percentage of overall healthcare costsThe most cost-effective approach is to more aggressively pursue secondary prevention efforts on subacute patients before chronic disability is fully established1Acute: <3 weeksSubacute: >3 weeks but <3 monthsChronic: >3 months, or more than 6 episodes in 12 months1. Waddell G, et al. Occup Med (Lond). 2001;51(2):
81Adverse Prognostic Indicators Yellow flags are psychosocial indicators suggesting increased risk of progression to long-term distress, disability, and painCan be applied more broadly to assess likelihood of development of persistent problems from acute pain presentationYellow flags can relate to the patient’s attitudes and beliefs, emotions, behaviors, family, and workplaceKendall NA. Baillieres Best Pract Res Clin Rheumatol. 1999;13(3):
82Risk Factors for Chronic Low Back Pain: Yellow Flags Belief that pain and activity are harmful“Sickness behavior” such as extended restBodily preoccupation and catastrophic thinkingLow or negative mood, anxiety, social withdrawalPersonal problems (eg, marital, financial, etc)History of substance abuseProblems/dissatisfaction with work (“blue flags”)Overprotective family/lack of supportHistory of disability and other claimsInappropriate expectations of treatmentLow expectation of active participationThe presence of yellow flags highlights the need to address specific psychosocial factors as part of a multimodal management approach
83Additional Risk Factors for Chronicity Previous history of low back painAgeNerve root involvementPoor physical fitnessSelf-rated health poorHeavy manual labor, inability for light duty upon return to work (“black flags”)Ongoing medico-legal actionsObesity*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):
84Interventional Therapies Do Not Prevent Chronicity Level of Evidence and Summary Grades for Interdisciplinary Rehabilitation, Injections, Other Interventional Therapies, and Surgery for Patients With Nonradicular LBPInterventionConditionLevel of EvidenceNet BenefitGradeInterdisciplinary rehabilitationNonspecific LBPGoodModerateBProlotherapyNo benefitDIntradiscal steroid injectionPresumed discogenic painFusion surgeryNonradicular LBP with common dengerative changesFairModerate vs standard nonsurgical therapy, no difference vs intensive rehabilitationFacet joint steroid injectionPresumed facet joint painBotulinum toxin injectionPoorUnable to estimateILocal injectionsEpidural steroid injectionMedial branch block (therapeutic)Presumed facet joint painSacroiliac joint steroid injectionPresumed sacroiliac joint painAdditionally, regardless of the comparator intervention, there is no convincing evidence that epidural steroids are associated with long-term benefits or reduced rates of subsequent surgeryChou R, et al. Spine (Phila Pa 1976). 2009;34(10):
85The Fear-Avoidance Model of Chronic Pain InjuryDisuseDisabilityDepressionRecoveryAvoidanceEscapeArousalPreventativeMotivationPainAnxietyConfrontationPain ExperienceDefensiveMotivationHypervigilanceArousalFearof PainThreat PerceptionCatastrophizingLow FearNegative AffectivityThreatening Illness InformationLeeuw M, et al. J Behav Med. 2007;30(1):77-94.Vlaeyen JW, et al. Pain. 2000;85(3):
86Assessment of Fear-Avoidance Behaviors Pain Catastrophizing Scale (PCS)113 itemsFear of Pain Questionnaire (FPQ)230 itemsFear-Avoidance Beliefs Questionnaire (FABQ)316 itemsCoping Strategies Questionnaire (CSQ)442 items1. 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.
87Reducing Catastrophizing Numerous interventions appear effectiveCognitive-behavioral therapies1-4Physiotherapy and other activity- based interventions5Intensive patient education and exposure interventions6, 7Limited understanding of the mechanisms by which changes in catastrophizing occur1. 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):
88Comprehensive Interventions With High-Risk Patients Show Promise High-risk patients identified with SCIDIntensive interdisciplinary team intervention4 major components: psychology, physical therapy, occupational therapy, and case managementPhysical therapy sessions: both individual and group exercise classesBiofeedback/pain management sessionsGroup didactic sessionsCase manager/occupational therapy sessionsInterventions spaced over a 3-week periodSCID=Structured Clinical Interview for DSM-IV Disorders.Gatchel RJ, et al. J Occup Rehabil. 2003;13(1):1-9.
89Early Intensive Intervention Effectiveness Long-Term Outcome Results at 12-Month Follow-UpOutcome MeasureHR-I(n=22)HR-NI(n=48)LR(n=54)p-Value% return to work at follow-up*91%69%87%.027Average number of healthcare visits regardless of reason**25.628.812.4.004Average number of healthcare visits related to LBP**17.027.39.3Average number of disability days due to back pain**38.2102.420.8.001Average of self-rated most “intense pain” at 12-month follow-up (0-100 scale)**46.467.344.8Average of self-rated pain over last 3 months (0-100 scale)**26.843.125.7% currently taking narcotic analgesics*27.3%43.8%18.5%.020% currently taking psychotropic medication4.5%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.
90Most Recent Preventing Chronicity Study (April 2009) First-onset, subacute LBP patientsBehavioral medicine intervention (n=34)Four 1-hour individual treatment sessions includedEducation about back function and painSystematic graduated increases in physical exercise to quota with feedbackPlanning and contracting activities of daily livingSelf-management and problem-solving training to cope with painContingent reinforcement of active functioning and nonreinforcement of pain behaviorsVocational counseling, as neededCompared to “attention control” group (n=33)Slater MA, et al. Arch Phys Med Rehabil. 2009;90(4):
91Most 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 LBPSlater MA, et al. Arch Phys Med Rehabil. 2009;90(4):
92Key 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=.0552. Recovery Expectation} p=.0453. Fears4. Knowledge5. Appropriate Care6. Disability Management7. Self-Management8. Case Management9. Temporary Duties} p<.00110. Alternative Care} p<.00111. Back Supports24681012Rankings by PanelGuzman J, et al. Spine (Phila Pa 1976). 2007;32(7):
93Provider Reassurance Tell patients your plan and your expectations Set reasonable expectations with patient buy-inReassure severity of acute pain does not correlate with outcome or durationFollow up regularly to check response to treatmentReassess for further diagnostic of therapeutic options
94SummaryPsychosocial aspects of pain and pain perception significantly influence patient outcomesAssessing for yellow flags and identifying patients at high risk of chronicity early in pain process (subacute) yields best chance for intervention and possible preventionMultiple psychosocial and physical interventions appear promising; aggressive/ intensive intervention seems most importantNurture the therapeutic relationship with shared expectations and goals of treatment