backPain.pdf

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Back Pain Assessment, Management, and Follow-up Guideline 1

Copyright 2012 Group Health Cooperative. All rights reserved.

Back PainAssessment, Management, and Follow-up Guideline

Background 2Terminology 2

AssessmentHistory 3Physical exam 4Recommended testing 5Warning signs requiring immediate or urgent evaluation 6Radiological exam 6Severity of pain and degree of activity interference 7

Diagnosis 7

Management of non-specific and radicular back painGoals 8Tips for communicating with patients 8Step 1. Self-management 8Step 2. Other management options 9Referrals to back specialists 10Pharmacologic options 10

Follow-up/Monitoring 12Comorbidity Screening 13

Evidence Summary 14References 16Clinician Lead and Guideline Development 17

Appendix 1. Evidence of effectiveness of non-pharmacologic strategies 18

Most recent :

Guidelinesare systematically developed statements to assist patients and providers in choosing appropriate healthcare for specific clinical conditions. While guidelines are useful aids to assist providers in determining appropriatepractices for many patients with specific clinical problems or prevention issues, guidelines are not meant to replacethe clinical judgment of the individual provider or establish a standard of care. The recommendations contained in theguidelines may not be appropriate for use in all circumstances. The inclusion of a recommendation in a guidelinedoes not imply coverage. A decision to adopt any particular recommendation must be made by the provider in light ofthe circumstances presented by the individual patient.


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BackgroundAcute and chronic back pain are common conditions that result in significant misery for patients andaccount for a large number of visits to primary care. There is considerable variation among primary careproviders about how to evaluate those patients, what options to offer them, how often to follow up, andunder what circumstances to refer them to specialists. For most patients with back pain, the condition willimprove within a few weeks or months; the initial focus should therefore be to offer counseling andsupport, simple analgesics as needed, and encouragement to stay active and focus on functionalrehabilitation.

This guideline is intended to help primary care teams do an effective initial assessment of back pain,maximize the patients chances for rehabilitation and functional improvement, and minimize the use ofunnecessary and potentially harmful interventions.

The treatment and follow-up recommendations in this guideline apply to patients with non-specific acuteor chronic low back pain or back pain associated with radiculopathy. This guideline does not address themanagement of patients with red flag conditions or back pain resulting from underlying systemic illness,beyond providing recommendations for initial assessment and referral.

Terminology

Acute back pain is pain lasting less than 4 weeks. Chronic back painis pain lasting longer than 3 months.

Non-specific back painis pain with no signs or symptoms of a serious underlying disorder (suchas cancer, infection, or cauda equina syndrome), spinal stenosis or radiculopathy, or otherspecific spinal cause (such as vertebral compression fracture or ankylosing spondylitis).Degenerative changes on lumbar imaging are usually considered non-specific, as they correlatepoorly with symptoms (Chou 2007). Note: For evaluation and referral recommendations forsuspected red flag conditions, see Table 4.

Radiculopathy,often referred to as sciatica, is a nerve root irritation resulting in a sharp orburning pain radiating down the posterior or lateral aspect of the lower limb, usually to the foot orankle. Pain radiating below the knee is more likely to represent true radiculopathy than proximalleg pain. Radicular nerve pain is often associated with numbness or tingling.

Neurogenic claudication,also referred to as pseudoclaudication, is nerve root entrapmentcaused by narrowing of the spinal canal or neural foramina; disc bulging and spondylolisthesismay contribute to the condition. Symptoms include back pain, transient tingling in the legs, andambulation-induced pain or fatigue in the lower extremities, resolving with rest. This pain withwalking is clinically distinguished from vascular claudication by the presence of normal arterialpulses.

Inflammatory back painis pain caused by inflammation in the spinal joints, with onset typicallyoccurring before age 45. It is characterized by improvement with exercise but not with rest and bymorning stiffness of longer than 30 minutes duration.


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Assessment: History

Table 1. Key elements in history for assessment of back pain

History of thispain episode

When did the pain start? How did the pain start (for example, while lifting or bending, or for no apparent cause)? Is the pain getting better or worse? What makes it better: activities such as standing, walking, and sitting, or over the

counter medications? Is the patient having any bladder or bowel dysfunction? How many days a week is the patient impacted by the pain? Pain and function

- Location of pain (e.g., limited to the low back? soft tissue? joints?)- Pain severity and degree of disability (See Tables 6a and 6b.)- When does it hurt?- Is there weakness?- Does the pain radiate to the leg/foot?

- Which leg(s)?- How is it distributed (above knee, below knee, both) and how does the patient

describe it (pins and needles, hot/burning, numb, worse with touch)?

Physicalactivity

Are there things the patient is not doing because of the pain, such as home chores,exercise, or activities of daily living (ADLs)?

Current level of activity? Activity level prior to this episode? What is the patient doing to cope with the pain and limitations?

Previousepisodes

History of prior episodes of back pain- Duration- Location(s) of pain- Severity of pain

What treatments or evaluations/exams have been tried in the past? What treatments have been helpful? What treatments have notbeen helpful?

Potential red

flags orunderlyingsystemicillness(Also seeTable 4.)

History of cancer

History of osteoporosis Immune suppression (steroid use, HIV, transplant, IV drug use) Cauda equina syndrome: saddle numbness, motor deficit at multiple levels, urinary

retention, and fecal incontinence Suspicious fracture Inflammatory disease, such as psoriasis, uveitis, or enthesitis (pain and swelling at the

heel involving the Achilles tendon and insertion of the plantar fascia) Unexpected weight loss Fever Pain at night Recent infection, such as a UTI Progressive neurological deficit Abnormal gait

Psychosocialrisk factors

Belief that the pain is due to a serious condition and being active would cause harm Fear that the pain is due to undiagnosed disease Illness behavior (extended rest, symptom magnification) Stress (e.g., family, job) Depression screen Employment status Days off work? Expected return date? Having or had problems with claims and compensation


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Assessment: Physical exam

Table 2. Key elements in physical exam for assessment of back pain

Presence andseverity ofneurologicdeficits

Patient affect

Standing Posture

Walk (heel walk, toe walk, partial squat, and Trendelenburg gait) Balance (stand on one foot) Range of motion (hip, spine, and Schber if indicated)

Sitting Reflexes: ankle, knee Sensory testing of lower limbs Manual muscle testing of lower extremities (hip and ankle extension and flexion,

dorsi- and plantar flexion, great toe dorsiflexion) Circulation Provocative testing (straight leg raising)


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Assessment: Recommended testing

Table 3. Recommended testing and interventions for assessment of back pain

Possible diagnosis Signs/symptoms Testing/intervention

Non-specific back

pain

Pain worsens with spine loading No imaging initially.

Consider X-ray after 6 weeks of self-

management if patient is over age 50. Consider referral to Physical Therapy.

Radiculopathy

(sciatica) without

weakness

Back pain with leg pain or sensorysymptoms in a lumbosacral nerveroot distribution

Positive straight-leg-raise test orcrossed-straight-leg-raise test

Consider early referral to Physical

Therapy.

After 4 weeks:

- Consider referral or consultation with

Physical Medicine and Rehabilitation.

- Consider MRI.

Radiculopathy with

weakness

Back pain with leg pain or sensorysymptoms in a lumbosacral nerveroot distribution

Positive straight-leg-raise test or

crossed-straight-leg-raise test

Consider early referral to Physical

Therapy.

Consider referral to Neurosurgery.

Consider referral to Physical Medicine &

Rehabilitation for chronic pain andimpaired function.

Lumbar spinal

stenosis

Radiating leg pain, sensorysymptoms

Older age Sometimes neurogenic claudation

After 4 weeks:

Consider referral to Physical Therapy.

Consider referral to Neurosurgery.

Consider MRI.

Inflammatory back

pain1

Age under 40 years Pain better with exercise Pain not better with rest Morning stiffness lasting longer

than 30 minutes (especially uponrising)

Significant response to NSAIDs

Lab testing

- HLA-B27

- ESR and/or CRP

Consider X-ray anteroposterior (AP) view

of sacroiliac joints.

Refer to Rheumatology for diagnosis and

management and/or Physical Medicine &

Rehabilitation for concerns about impaired

function.

1 No rheumatologic testing or evaluation is needed for pain that is worsened with activity or relieved by

rest, or that starts after age 40. Anti-Nuclear Antibody (ANA) and Rheumatoid Factor Screen (RF)

tests provide no useful information in back pain.


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Assessment: Warning signs requiring immediate or urgent evaluation

Table 4. Warning signs requiring immediate or urgent evaluation, including red flag symptoms

Possible cause Signs/symptoms Testing/intervention

Cauda equina syndrome Saddle anesthesia Motor deficit at multiple levels

Urinary retention Fecal incontinence

MRI

Emergent referral to Neurosurgery

Significant or progressive

neurological deficits

Progressive motor weakness Severe leg pain

MRI

Urgent referral to Neurosurgery

History of cancer with new onsetlow back pain

MRI

ESR

Consider referral to Oncology

Cancer

Unexplained weight loss Failure to improve after 1 month 50 years old or older

Lumbosacral radiography or MRI

ESR

Consider referral to Oncology

Vertebral infection Fever IV drug use Recent infection

MRI

ESR and/or CRP

Consider referral to Infectious Disease

Vertebral compression

fracture

History of osteoporosis Use of corticosteroids Older age

Lumbosacral radiography

Consider referral to Neurosurgery

Assessment: Radiological exam

Table 5. Radiological exam for assessment of back pain

Testing Acute pain indications Chronic pain indications

X-ray Possible fracture (elderly, recent fall,severe pain, history of osteoporosisor steroid use)

After 6 weeks of self-management and ifindicated (e.g., age over 50 years, painincreasing)

Suspected inflammatory back pain (OrderAP pelvis of sacroiliac joint.)

Suspected structural deformities (e.g.,spondylolisthesis, scoliosis spondylitis)

MRI Red flags (suspicion of cancer orinfection, trauma, or cauda equinasyndrome)

Severe or incapacitating back or leg

pain (e.g., requiring hospitalization,precluding walking, or significantlylimiting ADLs)

Progressively severe back or leg pain Radiculopathy and major or progressive

neurological symptoms (e.g., foot drop,functionally limiting weakness)

Radiculopathy and sensory symptoms thatare not improving after 46 weeks

Surgery or epidural steroid injection beingconsidered

CT In acute and chronicpain: Contraindications to MRI or MRI results are inconclusive Suspected fracture or bone tumor


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Assessment: Severity of pain and degree of activity interferenceThere are a variety of tools for assessing pain and function. There is no evidence that one is superior toanother.

This two-item version of the Graded Chronic Pain Scale (Table 6a) is intended for brief and simpleassessment of pain severity in primary care settings. For score interpretation, see Table 6b. (Dunn 2010,Sullivan 2010)

Table 6a. Standard Questions: Pain interference and activity interference

1. In the last month, how much has pain interfered with your daily activities? Use a scale from 0 to10, where 0 is "no interference" and 10 is "unable to carry on any activities"?

Nointerference

Unable to carryon any activities

0 1 2 3 4 5 6 7 8 9 10

2. In the last month, on average, how would you rate your pain? Use a scale from 0 to 10, where 0is "no pain" and 10 is "pain as bad as could be"? [That is, your usual pain at times you were inpain.]

No pain

Pain as bad as

could be

0 1 2 3 4 5 6 7 8 9 10

Table 6b. Standard Questions: Interpretation of answers

Pain rating item Mild Moderate Severe

1. Pain-related interference with activities 13 46 710

2. Average/usual pain intensity 14 56 710

DiagnosisBased on assessment and additional testing, categorize the patient with back pain into one of three broaddiagnostic categories:

Non-specific back pain.

Back pain associated with radiculopathy or lumbar spinal stenosisapproximately 4% and 3% ofpatients, respectively.

Back pain associated with red flag conditions or possible underlying systemic illness. This guidelinedoes not address the management of patients with these conditions, apart from providingrecommendations for imaging and referral.


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Management of non-specific and radicular back pain: Goals Educate patient about the natural history of back pain. Ask about and address the patients concerns and goals. Maximize functional status. Reduce pain. Address associated symptoms, such as sleep or mood disturbances or fatigue. Do not expose the patient to unhelpful or possibly risky interventions.

Management: Tips for communicating with patients about their back pain Affirm/acknowledge the patients pain and suffering/loss of function. Address the patients specific fears or worries (e.g., undiagnosed serious disease, long-term

disability). Provide reassurance, noting the likelihood that the patients back pain will start improvingin the first month.

Activate:Help the patient identify enjoyable and meaningful activities that will increase strength,flexibility and endurance.

Management: Education and self-care (Step 1)

Table 7. Education and self-care for patients with non-specific back pain or radiculopathy(See Appendix 1 for the level of evidence supporting these recommendations.)

Educate patients on thenatural history of back pain.

Most patients with back pain experience significant improvementwithin 46 weeks; however, approximately two-thirds will experienceanother episode within 12 months.

Back pain is often recurrent or persistent. Early, routine imaging usually cannot determine a specific cause or

improve outcomes.

Promote self-care. In the absence of red flag symptoms, it is safe to resume activity. Encourage patient to stay active and to carry on with normal activities

as much as possible.-Advise continued routine activity while paying attention to correct

posture to minimize spine loading.-Advise the patient to temporarily limit or avoid specific activities

known to increase mechanical stress on the spine (e.g., prolongedunsupported sitting, heavy lifting, and bending or twisting theback, especially while lifting).

-Advise discontinuation of any activity or exercise that causesspread of symptoms (radiculopathy).

Build strength and endurance gradually. Move naturally and avoidguarded or bracing behavior.

Manage physical and emotional stressors.

Offer non-pharmacologictreatment.

Heat Stretching Walking

Offer pharmacologic treatment(see Table 10).

To manage pain and help patients stay active: Simple analgesics if not medically or otherwise contraindicated (e.g.,

NSAIDS, aspirin, acetaminophen) Prescription options (e.g., analgesics or, in acute cases, muscle

relaxants)

Minimize/prevent patients from getting therapies that have no proven benefit.


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Management: Options for those whose pain does not improve with education andself-care (Step 2)

Table 8. Options for patients with back pain that does not improve with education and self-care

Continue self-care strategies. If employing passivetreatments such as manipulation and mobilization, introduce activetreatment

(i.e., exercise) within a week.

Non-specific back pain

Acute back pain Active Walking Continue usual activities Physical therapy

Passive Spinal manipulation

1,2

Chronicback pain Active Physical therapy

Exercise (aerobic exercise, stretching, walking) Yoga

Passive Massage therapy

2

Acupuncture2

Spinal manipulation1,2

Radicular pain

Acute radicular pain Active Exercise/physical therapy

1Spinal manipulation may be done if pre-manipulative testing centralizes symptoms (supported byweak evidence).

2 Continued improvement should be documented for continued therapy. Typically no more than 4 to 6visits are needed.


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Management: Referrals to back specialists

Table 9. Referring patients to specialty for back pain

Specialty Reason for referral/recommendation of alternative practitioner

Physical therapy Non-specific back pain Radiculopathy (sciatica) with or without weakness

Lumbar spinal stenosisPhysical medicine andrehabilitation/painspecialist

Nonsurgical candidates such as radiculopathy, chronic pain, lumbar spinalstenosis

To develop detailed treatment plans to enable an individual to carry outrehabilitation, including exercise and self-care

Second opinion for surgical or nonsurgical patients with suboptimal responseto a conservative treatment regimen

Behavioral health Cognitive behavioral therapy for chronic pain

Neurosurgery Cauda equina syndrome (emergent referral) Acute or progressive neurologic deficit (urgent referral) Vertebral compression fracture

Oncology History of cancer with new onset back pain

Infectious disease When vertebral infection is suspected

Rheumatology When inflammatory disease is suspected

Treatment options that are not recommendedCheck coverage if considering treatment.

Discography Epidural steroid injections (for non-radicular pain) Inferential therapy Intradiscal electrothermal therapy (IDET) Kyphoplasty Laser therapy

Lumbar support Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) Percutaneous vertebroplasty (for vertebral fracture) Radiofrequency facet joint denervation Spinal cord stimulation Therapeutic ultrasound Traction Transcutaneous electrical nerve stimulation (TENS) Vertebral Axial Decompression (VAX-D System) for back pain X-stop for lumbar spinal stenosis

Management: Pharmacologic options

Consider the risks of any medication and prescribe the lowest effective dose for the shortestperiod of time.

Muscle relaxants are not indicated for treatment of chronic low back pain; limit use to 714 days.

Opioids are rarely indicated for the treatment of low back pain.Opioids appear to be similarlyefficacious to acetaminophen and NSAIDs, but have more risks and side effects. Patientsreceiving more than 7 days of opioids or more than one prescription within 6 weeks of the firstvisit for back pain had higher rates of work disability at 1 year. (See Chronic Opioid TherapySafety Guideline.)

The primary goal of treatment is maximal function, rather than complete relief from pain. Someongoing or recurrent pain is normal and not indicative of a serious problem.


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For information on side effects, contraindications, formulary status (e.g., prior authorization), and otherpharmacy-related issues, see the Group Health Drug Formulary online.

Table 10. Recommended pharmacologic options for the treatment of back pain

Line Medicationclass

Medication Initial dose Max. dailydose

Acute back pain

Acetaminophen 500650 mg three times daily 3,000 mg1

Ibuprofen 600800 mg three times dailywith food

2,400 mg

Naproxen 250500 mg twice daily with food 1,250 mg

Nabumetone3 500 mg two times daily with food 2,000 mg

1st NSAIDs2

Etodolac3 300400 mg two to three times daily

with food1,200 mg

Cyclobenzaprine 5 mg three times daily or

10 mg daily at bedtime

30 mg2nd Skeletal muscle

relaxants4

Methocarbamol 500 mg three to four times daily 4,000 mg

Hydrocodone-acetaminophen

5 mg/325 mg to 1 tab one to four times daily

3,000 mg1

(acetaminophencomponent)

3rd Opioids

Oxycodone 5 mg one to four times daily 80 mg

Chronic back pain

Acetaminophen 500650 mg three times daily 2,500 mg11

st NSAIDs

Consider other NSAIDs options listed above for acute back pain. For chronicuse, maximum dose for ibuprofen is 2,400 mg/day and for naproxen is

1,000 mg/day.

2nd

Opioids

See Chronic Opioid Therapy Safety Guideline.

1 Not to exceed 1,0001,500 mg daily for patients with liver disease or alcohol problems.

2 All patients over age 65 are considered at moderate risk for NSAID-induced GI toxicity and should

receive gastroprotective therapy. Use caution in patients with cardiovascular comorbidities, at riskfor GI bleed, or with hepatic or renal dysfunction. Chronic administration may increase the risk foradverse GI, cardiovascular, or renal effects.

3 Nabumetone and etodolac are partially selective NSAIDs. Moderate-strength evidence suggests

that nabumetone has decreased risk of GI adverse effects compared to non-selective NSAIDs inshort-term studies. The risk of GI adverse effects for etodolac compared to non-selective NSAIDsis unknown. Low-strength evidence suggests that etodolac has no increased risk of GI adverseeffects compared to nonuse.

4 Limit use to 714 days. Avoid use in patients over age 65 years. Use caution in patients withcardiovascular comorbidities or hepatic impairment.


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Pharmacologic options that are notrecommended

Acute back pain Systemic corticosteroids

Chronic back pain Gabapentin Celecoxib (NF)

Duloxetine Topiramate

Skeletal muscle relaxants

Follow-up/Monitoring

Table 11. Recommended follow-up for patients with acute and chronic back pain

Patient population Frequency of follow-up

Acute back pain

Have patient check back at 2 weeks, unless earlierfollow-up is advised. Options for follow-up includephone, secure e-mail message, or visit.

All

Additional follow-up as indicated.

Patients considered high-risk based onpsychosocial risk factor evaluation

Earlier and more frequent in-person follow-up maybe appropriate.

Older patientsorPatients with Symptom progression or no significant

improvement Severe pain or functional deficits

Signs of radiculopathy or lumbar spinal stenosis

Earlier and more frequent re-evaluations may beappropriate.

Patients referred to spinal manipulation,acupuncture, or massage

Have patient check back after 4 visits with referredspecialty to demonstrate improved functionality.

Chronic back pain

Stable As needed.

With fluctuating pain Periodic.

On medications Periodic.(See the Chronic Opioid Therapy Safety Guidelineif applicable.)


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Comorbidity screening

Table 12. Recommended comorbidity screening for patients with back pain

Condition Test(s)

Depression Consider screening for depression with the

Patient Health Questionnaire (PHQ-9).

1,2

Alcohol or drug abuse Consider screening with the AUDIT Alcohol Use Questionnaire (adults),

the DAST-10 Drug Use Questionnaire (adults), or

the CRAFFT Drug and Alcohol Use Survey (adolescents).

1 See the Adult Depression Guideline for additional guidance. Patients with major depression can be treated in

primary care or offered a referral to Behavioral Health Services for counseling and/or drug therapy.2

Evidence suggests that patients with depression are less likely to be adherent to recommended managementplans and less likely to be effective at self-management of chronic conditions.


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Evidence summary

This guideline was adapted from the following sources:

Agency for Healthcare Research and Quality. Complementary and Alternative Therapies for BackPain II.2011; Evidence Report/Technology Assessment Number 194. Available at:http://www.ahrq.gov/downloads/pub/evidence/pdf/backpaincam/backcam2.pdf. Accessed January

2012.

Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review ofthe evidence for an American Pain Society/American College of Physicians clinical practice guideline.

Ann Intern Med. 2007 Oct 2;147(7):492504.

Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinaryrehabilitation for low back pain: an evidence-based clinical practice guideline from the American PainSociety. Spine (Phila Pa 1976). 2009 May;34(1):10661077.

National Institute for Health and Clinical Excellence (NICE). Low back pain: early management ofpersistent non-specific low back pain.2009; Clinical guidelines CG88. Available at:http://www.nice.org.uk/nicemedia/live/11887/44345/44345.pdf. Accessed January 2012.

Washington State Health Care Authority. Spinal Injections: Health Technology Assessment.2011.Available at: http://www.hta.hca.wa.gov/documents/updated_final_report_spinal_injections_0310-1.pdf. Accessed January 2012.

The Group Health guideline team reviewed additional evidence in the following areas of non-pharmacologictreatment.

Spinal manipulation

A recent Cochrane review that included 26 randomized controlled trials (RCTs) and 6,070 participantsexamined the effectiveness of spinal manipulative therapy (SMT) on pain and functional status

compared to control treatments for adults with chronic low back pain. Results from this analysissuggest that there was no significant difference in pain relief between SMT and simulated (sham)SMT. Compared to other interventions such as exercise and physiotherapy, evidence suggests thatSMT provides significantly better pain relief at 1, 3, and 6 months; however, there was no significantdifference in pain relief at 12 months. Results also suggest that compared to another intervention,SMT significantly improves functional status at 1 month. There was no significant difference infunctional status at 3, 6, and 12 months (Rubinstein 2011).

Acupuncture

A recent RCT that included 638 subjects evaluated the effectiveness of three different types ofacupuncture (individualized, standardized, or simulated [sham]) for the treatment of chronic low backpain compared to usual care. The primary outcome was back-related dysfunction and symptombothersomeness at 8 weeks. After 8 weeks, participants who received one of the acupuncture

treatments had significant improvements in back-related dysfunction and symptom bothersomenesscompared to usual care; however, there was no significant difference between the acupuncturetreatment groups in back-related dysfunction or symptom bothersomeness. After 1 year, there was nosignificant difference in symptom bothersomeness between the four treatment groups; however,participants who received real acupuncture continued to have less dysfunction compared to thosewho received usual care. The number needed to treat (NNT) with acupuncture to improve functionranged from 5 for short-term benefit to 8 for long-term benefit(Cherkin 2009).

Another RCT that included 84 subjects examined whether treatment with acupuncture or the musclerelaxant baclofen alone or in combination would alleviate symptoms of chronic non-specific low backpain in men. Results from this study suggest that after 5 and 10 weeks of follow-up the combined


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group and the acupuncture alone group experienced significantly greater reductions in pain anddisability compared to the control group or the baclofen alone. The combined group also experiencedsignificantly greater reductions in pain and disability compared to the group that received onlyacupuncture (Zaringhalam 2010).

Massage

A Cochrane meta-analysis that included 13 RCTs with 1,596 participants assessed the effectiveness

of massage therapy for low back pain. Results from this meta-analysis suggest that massage therapymay be beneficial for patients with subacute (pain lasting 4 to 12 weeks) and chronic back pain (painlasting more than 12 weeks); however, more research is needed to determine the ideal massagetherapy method, duration, and frequency (Furlan 2008).

A recent RCT that was published after the meta-analysis and included 401 participants evaluatedwhether massage (relaxation or structural) would reduce pain and improve function in patients withchronic low back pain compared to usual care. The primary outcome measures were back painrelated dysfunction (Roland Morris Disability Questionnaire [RMDQ]) and symptom bothersomenessat 10 weeks. Secondary outcome measures evaluated the primary outcome measures at 26 and 52weeks. Results suggest that after 10 weeks of follow-up, treatment with relaxation or structuralmassage significantly improved function and symptom bothersomeness in patients with chronic lowback pain compared to usual care. There was no significant difference in function or symptombothersomeness between the two massage groups. Effects decreased after the 10-week treatment;however, at 26 weeks patients who received massage therapy still had statistically significantdifferences in functional improvement compared to the usual care group. At 52 weeks, relaxationmassage was modestly more effective than structural massage and usual care. There were nosignificant differences in symptom bothersomeness at 26 or 52 weeks (Cherkin 2011).

Interdisciplinary rehabilitation

A recent RCT followed 286 subjects for 24 months to compare the efficacy of a multidisciplinarybiopsychosocial rehabilitation program with an intensive therapist-assisted individual back muscleexercise program for the treatment of chronic low back pain. Outcome measures were change in pain(100 mm VAS) and disability (RMDQ) at 3 months. There was no significant difference in painbetween the two groups at any time point. Compared to patients in the exercise program, patients inthe multidisciplinary rehabilitation program experienced significantly greater reductions in disability at

3 months (3.0 vs. 1.5, P < 0.05). This improvement was maintained throughout the 24-month follow-up period; however, it should be noted that this difference may not be clinically significant (Dufour2010).

Another RCT that followed 109 patients for 12 months compared the effects of functionalmultidisciplinary rehabilitation with those of physiotherapy on functional status and work status inpatients with subacute or chronic low back pain. Results suggest that compared to outpatients,physiotherapy patients who received functional multidisciplinary rehabilitation were more likely to beworking full time and had less disability at 12 months. Results should be interpreted with caution asbaseline characteristics were not similar and there were a large number of patients lost to follow-up.

Additionally, when the analysis method for disability outcomes was changed, the between-groupdifferences were no longer significant (Henchoz 2010).

Mindfulness-based stress reductionThere is insufficient evidence to make a recommendation for or against mindfulness-based stressreduction for the treatment of chronic low back pain.


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Clinician lead and guideline development

Clinician LeadDavid K. McCulloch, MDMedical Director, Clinical Improvement

Content ExpertRandi Beck, MD

Service Line Chief, Physical Medicine & Rehabilitation

Guideline Team Members

Rosemary Agostini, MD, Sports Medicine

Hugh Allen, MD, Anesthesiology

Arne Andersen, MD, Family Medicine, Neurosciences

Beth Arnold ,PharmD, Pharmacy AdministrationBen Balderson, PhD, Psychologist, Group Health Research Institute

Jo-Ellen Callahan, Manager, Radiology Services

Dan Cherkin, PhD, Group Health Research Institute

Rebecca Doheny, Clinical Epidemiologist, Clinical Improvement & Prevention

Abid Haq, MD, Occupational Medicine

Bill Huff, MD, Family Medicine, Sports MedicineSteve Lavine, MD, Anesthesiology

Jennifer Macuiba, Guideline Coordinator, Clinical Improvement & Prevention

Robyn Mayfield, Patient Health Education Resources, Clinical Improvement & Prevention

Donna Moore, MD, Physiatry/Physical Medicine

Ina Oppliger, MD, Rheumatology

Tom Paulson, MD, Medical Director, Care Review and Utilization

Grant Scull, MD, Family Medicine

Michelle Seelig, MD, Family Medicine

Rajiv Sethi, MD, Neurosurgery

Karen Severson, RN, Nursing

Ann Stedronsky, Clinical Publications, Clinical Improvement & Prevention

John Vandergrift, MD, Emergency Medicine

Michael Von Korff, ScD, Group Health Research Institute

Most Recent Guideline Approval: February 2012Process of DevelopmentThe recommendations in thisguideline were adapted from externally developed, evidence-basedguidelines from the Agency for Healthcare Research and Quality, the American Pain Society and

American College of Physicians, the National Institute for Health and Clinical Excellence, and theWashington State Health Care Authority. (See Evidence Summary for details.)

The following specialties were represented on the development and/or update teams: anesthesiology,behavioral health, complementary and alternative medicine, emergency medicine, family medicine, GroupHealth Research Institute, neurosurgery, nursing, occupational medicine, orthopedics, pharmacy,physiatry and rehabilitation, and rheumatology.


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Appendix 1. Evidence of effectiveness for non-pharmacologic strategies for themanagement of back pain

DefinitionsSmall benefit =

Mean 5- to 10-point improvement in pain on a 100-point VASMean 5- to 10-point improvement in function on the Oswestry Disability IndexMean 1- to 2-point improvement in function on the Roland-Morris Disability Questionnaire

Moderate benefit =Mean 10- to 20-point improvement in pain on a 100-point VASMean 10- to 20-point improvement in function on the Oswestry Disability IndexMean 2- to 5-point improvement in function on the Roland-Morris Disability Questionnaire

Table a. Level of evidence supporting SELF-CARE options for ACUTE back pain

Treatment Small/moderatebenefit

Nobenefit

Unable to estimatebenefit

Active treatment

Advice to remain active XPassive treatment

Superficial heat X

Bed rest (limit to less than 48 hours) X

Lumbar support X

Superficial cold X

Table b. Level of evidence supporting SELF-CARE options for CHRONIC back pain

Treatment Small/moderate

benefit

No

benefit

Unable to estimate

benefit

Advice to remain active X

Progressive relaxation1 X

Lumbar support X

1 Progressive relaxation requires intensive initial training.

Table c. Level of evidence supporting NON-PHARMACOLOGIC options for ACUTE back pain


benefitNo benefit Unable to estimate

benefit

Spinal manipulation X

Exercise therapy X

Acupuncture X

Back school X

Interferential therapy X

Low-level laser therapy X

Massage X

Transcutaneous electrical nervestimulation (TENS)

X


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Table d. Level of evidence supporting NON-PHARMACOLOGIC options for CHRONIC back pain


benefitNo benefit Unable to estimate

benefit

Exercise X

Education X

Spinal manipulation X

Massage X

Acupuncture X

Intensive interdisciplinary rehabilitation X

Psychological therapy (cognitivebehavioral therapy or progressiverelaxation)

X

Yoga X

Traction X

Back school X

Interferential therapy X

Low-level laser therapy X

Transcutaenous electric nervestimulation (TENS)

X

Therapeutic ultrasound X

Mindfulness-based stress reduction X

Table e. Level of evidence supporting INVASIVE TREATMENT options for CHRONIC NON-SPECIFIC

back pain

Treatment Recommended Not recommended/insufficient

evidence

Nerve root blocks X

Intra-discal electrothermal therapy (IDET) X

Lumbar (spinal) fusion1

X

Prolotherapy X

Radiofrequency facet joint denervation X

Sacroiliac joint injections X

Trigger point/soft tissue injections X

Epidural steroid injections 2 X

Spinal cord stimulation X

1 Referral for an opinion on spinal fusion may be appropriate for a small group of selected individuals who

have failed to respond to a combined physical and psychological intervention (NICE 2009).2 There is insufficient evidence for epidural steroid injections. Only consider epidural steroid injections after

initial appropriate conservative treatment programs have failed. Successful epidural steroid injections mayallow patients to advance in a conservative treatment program. Patients should be made aware of thegeneral risks of short-term and long-term use of steroids (ICSI 2010).


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