1. CLINICAL PRACTICE GUIDELINES FOR ACUTE LOW BAC K PAIN AETNA USHEALTHCARE

2. PATIENT GOALS Prevent or minimize daily symptoms/recurrent exacerbations with return to baseline function. Foster optimal use of specialty and ancillary services. Minimize the need for acute care services (ER/urgent care visits, hospitalizations.

3. DIAGNOSIS Initial assessment includes a focused history, physical, and neurological exam. Exclude “Red Flags” which include fracture, cancer, infection, and Cauda Equina Syndrome. Cauda Equina syndrome is diagnosed when there is saddle anesthesia, loss of bladder or bowel sphincter tone and/or rapidly progressive neurological deficit.

4. ASSESSMENT With a symptomatic herniated disc leg pain usually outweighs back pain. 90% of patients will recover within four weeks, regardless of treatment, unless there are “Red Flags”.

5. ASSESSMENT X-rays and lab tests (CBC, U/A, ESR) should be considered when there is no response to an initial four weeks of conservative therapy, to further evaluate potentially serious pathology, or when surgery is being considered. MRI/CT should be requested on the basis of clinical findings since 1/3 of asymptomatic adults may show a bulging disc on MRI/CT

6. THERAPY Acetaminophen is the safest drug treatment for common acute low back pain. Salicylates or NSAIDs can be used alone or added to acetaminophen therapy. Muscle relaxants and narcotics should be reserved for severe cases in the first week only.

7. THERAPY A short course of physical therapy may be beneficial. A short course of oral steroids may be considered after failure of initial conservative therapy. Surgery is primarily for unrelenting sciatica with signs of nerve root compression and a concordantly abnormal imaging study.

8. PATIENT INSTRUCTIONS Activity as tolerated: there is no relationship between activity level, rest, and recovery. Resume daily activities and support return to work with initial improvement. Patient does not have to be completely pain- free before returning to work.

9. PATIENT INSTRUCTIONS Events and activities that “trigger” acute low back pain should be identified and avoided, and “safe lifting” techniques should be taught. Develop a long-term daily program of flexibility and back-strengthening exercises as soon as symptoms resolve.

10. WARNING SIGNS Re-evaluate if symptoms do not improve after 4 weeks of initial therapy and consider imaging studies and/or referral to specialist. Depression is a barrier that may confound the symptoms and assessment of chronic back pain.

11. SPECIALIST INVOLVEMENT If symptoms do not improve after 4 weeks of conservative therapy. If new or progressive neurological deficits and/or if any “Red Flags” are recognized at any time. Recurrent symptoms (more than two episodes in a 6-month period). Recurrent symptoms after low back surgery.