DiagnosisAcut Low Back Pain

8/10/2019 DiagnosisAcut Low Back Pain

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ACUTE LOW BACK PAIN 1

Clinical Treatment Pathway and Decision Support for

Treatment of Acute Uncomplicated Low Back Pain

Ryan D. Church FNP-C

University of Utah

In partial fulfillment of the requirements for the Doctor of Nursing Practice




Table of Contents

Page

Executive Summary ……………………………………………………………………… 4

Objectives ………………………………………………………………………………… 6

Clinical Significance …..…………………………………………………………………. 7

Theoretical Framework …………………………………………………………………... 9

Search Strategy …………………………………………………………………………… 11

Literature Review ………………………………………………………………………… 12

Barriers to Obtaining Adequate Care ……………………………………………. 13Treatment Options for Care of Acute Low Back Pain ………………………….. 14

Recommended Treatment for Acute Low Back Pain: National Guidelines ……. 15

Costs of Acute Low Back Pain ………………………………………………….. 18

Role of Advanced Practice Clinician s………………………………………….. 19

Guidelines and Pathways……………………………………………………….. 19

Development of a Treatment Pathway ………………………………………… 22

Implementation and Evaluation………………………………………………………… 23

Results ………………………………………………………………………………….. 25

The Essentials of Doctoral Education for Advanced Nursing Practice………………… 26

Recommendations.. .…………………………………………………………………….. 27

Conclusion……………………………………………………………………………….. 28

References………………………………………………………………………………. 30

Appendix A........................………………………………………………………… …… 33

Appendix B........................………………………………………………………………. 39




Appendix C....... .................………………………………………………………………. 43




Executive Summary

Acute uncomplicated low back pain is a very common problem in the United States.Acute low back pain is defined as pain present for up to 6 weeks. There is significant variabilityin the approach and treatment of acute uncomplicated low back pain and

unnecessary/inappropriate diagnostic studies and treatments are common. Healthcare providersneed a specific evidence-based clinical pathway to increase diagnostic accuracy and improve thedevelopment of treatment plans that will lead to improved outcomes.

The first objective of this project was to develop an evidence-based clinical decisionsupport pathway and algorithm to improve assessment and management of acute low back pain.The second objective of this project was to disseminate this information to providers byauthoring a scholarly article for publication consideration in the Journal of the AmericanAcademy of Nurse Practitioners.

The project objectives were met by the development of a treatment pathway and decisionsupport algorithms. Utilization of the clinical pathway and decision support algorithm will leadto decreased over utilization of diagnostic measures and treatments. Use of the pathway will also

improve diagnostic accuracy of spine related conditions. The clinical pathway and algorithmalso serve as a guide for training new healthcare providers who wish to improve knowledge andunderstanding regarding diagnosis and treatment of acute low back pain. The pathway assists

providers in presenting treatment options utilizing a shared decision making format. The clinicalalgorithm was developed to facilitate appropriate use of the pathway. The pathway and algorithmwere presented in a scholarly article submitted for publication consideration to the AmericanAcademy of Nurse Practitioners.

The Academic Center for Excellence (ACE) Star Model of Knowledge Transformation(2004) was selected as the theoretical framework for this project. This model helps to clarify thecycles and characteristics of knowledge that are used in evidence-based practice. It helps toorganize existing information as well as newly understood concepts that are designed to improve

care in the clinical setting. The Star Model of Knowledge Transformation depicts the relationship between the various phases of knowledge transformation from the discovery of new knowledgethrough integration into practice and subsequent evaluation of new practices.

The Essentials of Doctoral Education for Advanced Practice Nurses (2006) are made upof a number of key elements, many of which were integrated and used to guide this project.Included in this project were Essentials I. II, III, VII and VIII.

DNP Essential I provided an emphasis on patient education and shared decision-making.This project was chosen to improved access to care in the hopes that outcomes could beimproved. Nurses are in a unique position to improve this process and facilitate positive changewhich satisfies the second DNP Essential.

The criterion for the third DNP Essential is the process which focuses mainly on the

clinical scholarship and analytical methods of evidence based practice. DNP Essential VII,clinical prevention and population for improving the nation's health was addressed. Lastly, DNPEssential VIII, advanced nursing practice, was supported and met by improving education andexperience of the advanced practice clinician in the area of acute uncomplicated low back pain.




Acute low back pain is a common complaint in primary care settings across the country.

Acute low back pain is one of the leading reasons why people seek healthcare. According to

Chou et al., (2007), low back pain is the fifth most common reason for all provider visits in the

United States. Scott, Moga, and Harstall (2010) noted that Between 49% and 90% of people in developed countries will experience at least oneepisode of low back pain during their lifetime. Pain will resolve within two weeks for themajority of these individuals. However, 20% to 44% of patients, especially those with a

history of low back pain, will experience further episodes within a year, and more thanthree-quarters will experience a recurrence at some point in their lives. A small minorityof patients (2% to 7%) will develop chronic low back pain (p. 396).

There are millions of episodes of acute low back pain treated each year in the United

States. Waterman, Belmont, and Schoenfeld (2012) suggest that low back pain accounted for

3.15% of all emergency visits in the United States between 2004 and 2008.

Unfortunately, many who experience back pain undergo inappropriate and/or

unnecessary diagnostic studies and treatments. According to Taylor and Bussieres (2012), this is

due to provider lack of knowledge and experience. Diagnostic studies and treatment options

carry significant risk and cost; these risks and cost may be avoided by reducing unnecessary

diagnostic procedures and treatment. Time, money and other resources may be saved with proper

application of appropriate care. Srinivas, Deyo, and Berger (2012) document harm associated

with early imaging for low back pain, including patient “labeling,” unneeded follow -up tests for

incidental findings, irradiation exposure, unnecessary surgery, and significant cost. “Routine

imaging should not be pursued in acute low back pain. Not imaging patients with acute low back




pain will reduce harms and costs, without affecting clinical outcomes ” (Srinivas, et al., 2012 , p.

1016).

Objectives

This scholarly project was a portion of a much larger all-inclusive endeavor. The long-

term goal of this all-inclusive project was to develop a rapid care spine clinic, complete with a

24-hour call center and meticulously networked referral sources. The scope of this project is far

too large for a doctoral scholarly project in this setting. Therefore, a small portion of this work

was addressed.

The purpose of this scholarly project was to develop a patient treatment clinical guideline

including an algorithm based on evidenced literature to assist healthcare providers in managing

patient care as related to acute low back pain issues. These issues are related to acute low back

pain defined as low back pain present for up to six weeks (North American Spine Society, 2012).

The algorithm improves rates at which patients receive quality, evidence-based spinal care that is

timely and consistent with national guidelines.

A scholarly article was written and submitted for possible publication. The clinical

guideline along with the algorithm was to be the emphasis of the article.

The goal of this scholarly project initially was to develop a patient treatment clinical

guideline along with an algorithm for the treatment of acute low back pain as noted above.

However, after doing the extensive literature review and looking at all the evidence based

literature available it became obvious that what was needed was a patient treatment clinical

pathway including an algorithm. This clinical pathway was a means to bring the already

established guidelines to the clinician level for appropriate application. Thus the first objective




for the DNP project was changed to development of a patient treatment clinical pathway along

with an algorithm based on evidenced literature to assist healthcare providers in managing

patient care as related to acute uncomplicated low back pain.

Acute low back pain is to be defined as “low back pain present for up to six weeks”

(North American Spine Society, 2012). The treatment pathway and algorithm, when used

appropriately, will improve rates at which patients receive quality, evidence-based spinal care

that is timely and consistent with national guidelines. It will also facilitate training of new

providers regarding treatment of acute low back pain. A scholarly article was written and

submitted for publication consideration. The clinical pathway along with the algorithm was theemphasis of the article.

Clinical Significance

Implementation of a patient care pathway regarding diagnosis and treatment of acute

uncomplicated low back pain as well as other ailments of the spine are expected to have a

number of clinical implications. Of these, the most important will be homogenization of care.

For example, if a hospital or healthcare company that controls a number of outpatient clinics,

emergency rooms, clinical practice areas, and primary care clinics wishes to standardize care,

they could implement the treatment pathway and others like it for commonly encountered back

complaints. This is currently being done for cardiac complaints in emergency departments.

Lippi et al. (2012) state that “the preferable approach to deal with chest pain is to develop joint

protocols that will assist the clinical decision-making to quickly and accurately to rule-out

patients with non-life- threatening conditions” (p. 244).

Standardization of care has a number of possible benefits. Training all treating personnel

in the latest and most evidence based treatment pathways improves patient care by providing

decision -making support. Scott et al. (2010) points out that many providers lack current




education and training regarding appropriate treatment of low back pain. Providers continue to

avoid suggestion related to treatment in lieu of utilization of personal beliefs and outdated

training. If providers were held accountable to mandated treatment pathways, change would be

forthcoming.

Health related issues associated with unnecessary testing are no small concern. Most

diagnostic tests carry some risk. Taylor and Bussieres (2012) explain “potential adverse

outcomes of overuse of imaging include inefficient and potentially inappropriate invasive

diagnosis and subsequent treatment, unnecessary ionizing radiation exposure, increased waiting

time for treatment, added costs, and poor utilization of human resources” (p. 2). Cost is another clinical implication. Many unnecessary diagnostic studies and treatments

are performed on patients each year. This leads to billions of dollars in lost assets yearly in the

United States (Ivanova et al., 2011). By reducing or eliminating unnecessary diagnostics studies

such as Magnetic Resonance Imaging (MRI) and by eliminating inappropriate treatments such as

facet joint injections, large sums of money could be saved by policy holders, insurance

companies, and government programs. There are other costs associated with these unnecessary

diagnostic and treatment measures that have immeasurable effects on human health and well-

being.

Access to service would be impacted. Patients and providers would not have to waste

time on unneeded treatments and tests, and time in the office for diagnostic work up and

treatment planning would decrease. As health care providers become better equipped to treat

common problems, such as acute low back pain, patients will spend less time in the health care

setting and more time on the job. This would decrease cost and increase outcome while

improving productivity.




As evidence based approved pathways are implemented, gaps in knowledge will be

clearly identified and directions for future study clarified. As protocols are developed for acute

uncomplicated low back pain and related complaints, such as acute low back pain with

radiculopathy, chronic low back pain, chronic low back pain with radiculopathy and others,

additional gaps will be identified and further research may be needed.

Theoretical Framework

In the modern healthcare model where patients seek treatments for expressed concerns,

there are many specific decisions in which the health care provider must engage and negotiate.

At the core of this scholarly project is the desire to provide decision support for the health care

provider treating acute low back pain. The Academic Center for Excellence (ACE) Star Model

of Knowledge Transformation (Stevens, 2004) was selected as the theoretical framework for this

project. This model helped to clarify the cycles and characteristics of knowledge that are used in

evidence-based practice. The model helped to organize existing information as well as newly

understood concepts that are designed to improve care in the clinical setting. The Star Model of

Knowledge Transformation (Stevens, 2004) is a simple depiction of the relationship between the

various phases of knowledge transformation from the discovery of new knowledge through

integration into practice and subsequent evaluation of new practices.

The ACE Star Model is organized into five distinct points. Discovery, Summary,

Translation, Integration, and Evaluation are the key elements of the Star Model. Discovery is the

leading point of the ACE Star Model. This is where new knowledge is generated. Knowledge is

discovered through the traditional research methods and through personal scientific inquiry.

This stage builds on existing knowledge and previous clinical practices.




Summary is the second point of the ACE Star. This is the process of synthesis of current

evidence-based research into meaningful concepts regarding the current state of scientific

knowledge.

There are two stages in the third point of the ACE Star of Translation. Phase 1 includes

translation of evidence into practice recommendations and then phase 2 is integration into

current practice. These packets of usable condensed evidence are directed for the use of

clinicians, and are generally called clinical practice guidelines. Clinical practice guidelines are

tools used to support the decision-making process of clinicians. To further refine these guidelines

and assist the clinician in the decision making process, clinical pathways are developed with thefurther guidance of a patient treatment algorithm. After reviewing the guidelines developed by

Chou et al. (2007) and the North American Spine Society it is noted that these are general

guidelines. The addition of a clinical pathway and its companion algorithm puts these guidelines

into context or in other words helps the clinician adapt this knowledge to a specific patient need.

For example, it is recommended that a patient that has been diagnosed with acute uncomplicated

low back pain should not have diagnostic imaging done of any kind (National Physicians

Alliance 2011). The clinical pathway with algorithm helps the clinician first; make the diagnosis

of uncomplicated low back pain, aids decision support at the point of care when diagnostic

images would be considered and points to evidence that the clinician may utilize to explain to the

patient why diagnostic imaging is not appropriate. In other words the clinical pathway puts

national guidelines in context and perspective.

The fourth point involves the changing of current practices of both individual clinicians

and entire health care systems. This process can be met with significant resistance. Changing

commonly held beliefs takes considerable time and energy.




Evaluation is the final stage of knowledge transformation. In evidence-based practice

there are many details that are evaluated. It includes identifying the impact of evidence-based

practice on outcomes. Satisfaction related to providers and patients are also evaluated along with

cost, efficacy, and health status impact.

By utilizing this theoretical framework, there will be better understanding of how health

care providers discover, synthesize, and utilize emerging data from evidence-based research.

This will ultimately improve outcome thereby reducing cost, improving efficacy, and reducing

risk (Stevens, 2004).

Search StrategyThe following research questions and search terms were utilized in developing research

parameters.

What is the incidence and prevalence of acute low back pain in the United States?

Research terms included: incidence, prevalence, acute low back pain, United States

What are the barriers for Americans to receive adequate appropriate timely evidence-

based care for acute low back pain? Research terms included: barriers, acute low back

pain, evidence-based, and treatment.

What treatment options are available for acute low back pain? Research terms: acute low

back pain, treatment, options.

What are the treatment recommendations/guidelines for the treatment of acute low back

pain in the United States? Research terms: treatment guidelines, treatment pathways,

decision assistance, acute low back pain, evidence-based, and United States.




Once these questions and terms were selected, PubMed and other sites were utilized as

the search engine of choice. Once appropriate literature was found, references were evaluated

and additional supportive literature was identified.

Literature Review

Acute low back pain is a leading cause of pain and healthcare expenditures. A survey of

back pain prevalence and visit rates by Deyo, Mirza, and Brook (2002) revealed that nearly half

of all adults have low back pain during any given year. They go on to explain that

approximately two-thirds of all adults have low back pain at some point in their lives. About one

fourth of these adults had at least a day of back pain during any three-months. Approximately

15% of adults report frequent or regular back pain lasting more than two weeks a year.

The following figure by Waterman et al., (2012) illustrates the incidence rates of low back pain

in the United States seen in the emergency setting (Figure 1). It is noted that the greatest

occurrence of back pain in adults ranges from 20 to 50 years of age. The large majority of adults

seek care for their low back pain through their primary care provider or chiropractor. Smaller

percentages of patients seek care through the emergency setting.

Figure 1. Incidence Rate of Low Back Pain by Age




Source: Waterman, Belmont and Schoenfeld, (2012) Low back pain in the United States:Incidence and risk factors for presentation in the emergency setting. The Spine Journal , 12, 66.

Barriers to Obtaining Adequate Care

Despite the incidence of acute low back pain among Americans, there are many barriers

to obtaining adequate care. Much of the diagnostic workup and subsequent treatment is

inappropriate and unnecessary according to recent literature (Ivanova et al., 2011).

Unfortunately, there are significant barriers that prevent patients from obtaining timely,

evidence-based and appropriate care for conditions related to the spine. One of the barriers is

patient confusion. Many patients simply don't know where to turn for treatment for acute low

back pain. Options for care may include primary care providers, chiropractors, massage

therapists, physical therapists, acupuncturists or surgical clinics (Harstall et al. 2011).

Confusion is not confined to the patient alone. Clinicians also seem confused regarding

what they should do when it comes to the treatment of acute low back pain. According to Scott

et al. (2010) there is a definite inconsistency among clinicians regarding appropriate treatment




recommendations for acute low back pain. Scott et al. (2010) also noted that there were

significant knowledge gaps reported among the various primary care providers “in the

assessment of red flags, use of diagnostic imaging, provisions of advice regarding sick leave and

continuing activity, administration of some medications including muscle relaxers, oral steroids

and opioids” (p. 392).

Scott et al. (2010) goes on to explain that even if primary care physicians are well

educated and well versed in current literature and practices regarding treatment of the acute low

back pain, many of them will divert from recommended treatments and utilize personal

experience and philosophy. “Health care providers often rely on shared beliefs and personalopinion rather than research evidence to make treatment decisions” (p. 394).

There may be good reason for this confusion and misunderstanding. Research shows that

treatment guidelines vary widely between venues. There are a number of conflicting

recommendations regarding the treatment of spine related issues. Williams et al. (2010)

surveyed 3533 patient visits to Australian general practitioners for 3 years before and 3 years

after the publication of a clinical practice guideline for the treatment of acute low back pain and

discovered that “t he usual care provided by GPs for low back pain does not match the care

endorsed international evidence-based guidelines and may not provide the best outcomes for

patients” (p. 271).

Another barrier to adequate healthcare regarding acute low back pain is lack of insurance.

It is a well-known fact that there are millions of Americans that lack health insurance. According

to the US Department of Commerce (2005) “In 2005 46.6 million people were without health

insurance coverage, up from 45.3 million people in 2004. The percentage of people without

health insurance coverage increased from 15.6 percent in 2004 to 15.9 percent in 2005” (p. 20).




A more recent study by the Kaiser Commission of Medicaid and the Uninsured (The HS

Kaiser Family Foundation, 2011) claims that the “number of nonelderly uninsured reached 49.1

million in 2010” (p. 3). The Kaiser Commission of Medicaid and the Uninsured (2011) points

out that health insurance has a considerable impact on utilization. The type of healthcare

insurance determines where people receive care, when they receive care, and generally how

healthy they are. The Kaiser commission also noted that people who are not insured will often

forgo health care altogether.

Treatment Options for Care of Acute Low Back Pain

There are many options for care of acute low back pain. Each of these options comeswith their own historical roots and philosophical underpinnings. Scott et al. (2010) points out

that up to 25% of patients with back pain seek help from health care providers, with nearly three-

quarters of these patients presenting to either a physician or a chiropractor. Most patients tend to

visit more than one provider and between 10% and 50% of patients receive physiotherapy.

Scott et al. (2010) later explains that besides the medical management of acute low back

pain by primary care providers and chiropractors, other modalities such as physical therapy,

psychotherapy, massage therapy and acupuncture are utilized on a less frequent basis. The

assertion of this scholarly project was that there are general best practices that should be

consulted when treating acute low back pain. Best practice should be evidence-based and well

documented.

Recommended Treatment for Acute Low Back Pain: Recommendations

There are a number of recommendations which have been published in the past for the

care of acute low back pain. There has also been significant work done recently regarding the

proper diagnosis, management, and treatment for patients with low back pain. Research




performed by North American Spine Society (2012), Chou et al. (2007) and others provide the

following treatment recommendations.

1. Clinicians should conduct a focused history and physical exam and divide patients into

three broad categories: nonspecific low back pain, back pain potentially associated with

radiculopathy or those not with spinal stenosis or some other specific causative factor. We are

screening for patients without radiculopathy or leg related symptoms to be included in this

particular pathway.

2. Clinicians should not obtain imaging studies of patients with nonspecific low back

pain. This guideline is supported by the National Physicians Alliance’s (2011) “Top 5” list ofhealth care activities in primary care for which “changes in practice could lead to higher-quality

care and better use of finite clinical resources ” (pg . 1386). The National Physicians Alliance’s

first recommendation “Don't do imaging for low back pain within the first 6 weeks unless red

flags are present ” (National Physicians Alliance 2011).

3. Clinicians should obtain diagnostic studies only when there is progressive neurological

deficit or underlying conditions are considered such as cancer, kidney, or gastrointestinal

disorders. (North American Spine Society, 2012). Chou et al (2007) also notes this is a strong

recommendation with moderate-quality evidence.

4. Clinicians should only get MRI or CT scans on patients that are being considered for

surgery or epidural steroid injection.

5. Clinicians should provide patients information that is evidence based regarding

treatment options and self-care measures.

6. Clinicians considering the use of medications and other treatments should do so only

after consideration has been given to risks, benefits, and potential side effects. This should only




be done, after a baseline of physical status and risk for long-term/serious disease has been

performed.

7. Clinicians should consider the use of medications with proven benefits in conjunction

with back care information and self-care. Generally, first-line medication options are

acetaminophen or nonsteroidal anti-inflammatory drugs. Non-pharmacologic interventions

being considered for patients who fail to improve after first-line therapy would include spinal

manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage

and cognitive behavioral therapy

In a subsequent study in 2009, Chou et al. (2009) added additional recommendations tothe 2007 recommendations. These recommendations added additional evidenced based advice on

the treatment of low back pain.

1. Provocative discography is not recommended in patients with chronic low back pain.

Diagnostic selective nerve root block, intra-articular facet joint injections and medial branch

blocks or sacroiliac joint blocks are also discouraged as diagnostic procedures with regard to low

back pain without radiculopathy.

2. For patients with chronic back pain that do not respond to usual therapies, it is

recommended that clinicians consider intensive interdisciplinary interventions that include

cognitive, behavioral, and occupational components. In patients with persistent low back pain

without radiculopathy, the use of facet joint injections, steroid injections, and prolotherapy, and

intradiscal corticosteroid injections are not recommended . There is not enough evidence to

recommend botulinum injections, epidural steroid injections, intradiscal electrothermal,

therapeutic medial branch block, radiofrequency denervation of the medial nerve branch,




sacroiliac joint injection, or intrathecal therapy with opioids or other medications for

nonradicular symptoms.

4. A shared decision-making model should be used when approaching the question of

spinal surgery for nonspecific, nonradicular low back pain. A detailed conversation about risks

versus benefits as compared to interdisciplinary rehabilitation should be performed.

5. There is insufficient evidence that vertebral disc replacement is beneficial for

nonspecific nonradicular low back pain .

6. A shared decision-making approach should be taken when discussing epidural steroid

injections for the treatment of low back pain with radiculopathy secondary to herniated disc.Information regarding efficacy both for long and short-term symptom reduction should be

discussed. The same is true regarding spinal stenosis. Shared decision-making regarding surgery

for persistent back and leg pain secondary to herniated disc and spinal stenosis are also

recommended. There is strong quality evidence supporting this recommendation .

7. It is recommended that a discussion regarding the efficacy and complication rates of spinal

cord stimulation should be conducted with patients who are considering spinal cord stimulation

implant after discectomy for herniated disc with persistent and continued leg pain

postoperatively. Given this information, Figure 2 is an example of a treatment diagram that has

been developed for the treatment of low back pain.

Costs Associated With Acute Low Back Pain

Estimates of the direct cost burden in the United States range considerably. Ivanova et al.

(2011) estimate that spine related costs range to nearly $70 billion in incremental health-care

costs and has a significant impact on the economic structure. The cost of treating spine related

issues are exorbitantly high as related to other health care concerns. Ivanova et al. (2011) goes




on to explain that “patients with low back pain had about three times higher average direct costs

compared with other diagnoses” (p. 629). One major cost associated with treatment of the low

back in unnecessary imaging. Srinivas, et al. (2012) noted “ For acute low back pain patients

who underwent MRI imaging within the first month had more than an 8-fold increased risk for

surgery and more than a 5-fold increase in subsequent total medical costs ” (pg. 1017).

Ivanova et al. (2011) also indicates that not only are the costs to treat low back pain

higher than average, patients with low back pain need to take more days off of work than those

with other illnesses, creating further financial burdens for the patient.

Role of Advanced Practice CliniciansThe paradigm of healthcare is changing and advanced practice clinicians find themselves

in the front lines of healthcare. Physicians are pushing towards specialty areas; advanced practice

clinicians will be directing the care of patients with complaints of acute low back pain. Nurse

practitioners are uniquely positioned to assist in the treatment of patients with spine related

issues. There is much that can be done previous to, or in place of, surgical intervention. It is a

well-accepted fact that spinal surgery is often expensive and shoulders a rather extensive burden

of risk. Chou et al. (2009) suggest that surgery should be carefully considered and only

recommended for those patients who fit a profile that will ensure best outcomes. Everything

should be done to assist patients in avoiding unnecessary surgery.

With proper training and experience, an advanced practice clinician can adequately assess

patients and direct the care they need. The majority of patients with acute low back pain can be

supported with minimal intervention and resolution of symptoms will occur in less than four

weeks. If symptoms do not resolve or if there are "red flags", advanced practice clinicians can

evaluate and treat as clinically indicated or provide appropriate referrals. Advanced practice




clinicians can review additional diagnostic studies, interventional management, physical therapy,

surgery, or other appropriate action. Following a treatment or diagnostic study, patients will

need continuing education and management of their care. Once resolution of symptoms has been

achieved, re-assimilation back into society and the workforce can be facilitated by the advanced

practice clinician.

Guidelines and Pathways

Since there are multiple well researched clinical guidelines regarding the treatment of




Figure 2. Initial Evaluation of Low Back Pain.




Source: Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K.(2007) Diagnosis and treatment of low back pain: A joint clinical practice guideline from theAmerican College of Physicians and the American Pain Society, Annals of Internal Medicine ,147 , 482-482.




acute low back pain, it was determined that the development of a clinical pathway was the next

step to assist the provider in appropriate treatment of the spine.

The difference between national clinical guidelines and pathways are that guidelines are

designed to include all available options that are within reason for the presentation of

disease being discussed. Pathways are designed to add additional layers of scrutiny to the

available treatment options for a specific presentation of disease to further standardize

treatment patterns (Rodgers, 2012).

Rogers (2012) suggests that guidelines usually show all treatment options whereas

pathways may be developed around the treatment that they deem superior in terms of efficacy,

side effect profile, or cost-benefit when efficacy and side effects are equal.

Development of a Treatment Pathway

Treatment pathways are gaining acceptance and support in all areas of healthcare. They

are increasingly being recognized as tools that can be used to decrease cost, streamline care, and

improve outcomes. Jackson and Feder (1998) indicate that clinicians need simple, patient

specific, user-friendly guidelines. They highlight three basic components that are needed in a

clinical pathway:

identification of the key decisions and their consequences, review of the relevant, valid

evidence on the benefits, risks, and costs of alternative decisions, and presentation of the

evidence required to inform key decisions in a simple, accessible format that is flexible to

stakeholder preferences (p. 428).

There are a number of small and crucial decisions involved in each patient encounter. If

all of these decisions were addressed in a patient care algorithm or clinical pathway it would

become far too cumbersome to be useful. Jackson and Feder (1998) indicate that only the basic




and most important decisions should be addressed initially and recommended that a diagram or

algorithm be developed that identifies the key decisions and important outcomes relevant to

patients care.

Valid evidence is a requisite for best practice outcomes. An increasing interest in

evidence-based practice and guidelines has highlighted the gaps in the evidence. Jackson and

Feder (1998) also state that a systematic review of the prevailing evidence is necessary. Special

attention should be paid to appropriateness of the underlying data.

Treatment pathways should be guided by the absolute risk and benefit of the treatment

proposed (Chou et al., 2007). These measures can be presented in units such as the number ofevents occurring in 100 patients treated per year or the number of patients who would need to be

treated to prevent an event. Explicit statements about the benefits and risks of a treatment can

then be weighed by patient preference and the available resources. This is currently difficult to

achieve for most clinical problems, making it difficult to write some evidence-based accurate

pathways. Pathway developers are encouraged to follow the process outlined above by Jackson

and Feder (1998) and acknowledge where recommendations are based on inadequate evidence.

Another component of a successful pathway is the presentation of evidence and

recommendations in a concise accessible format. Decision makers must be able to retrieve and

assimilate information quickly. Moreover, information must be presented in a flexible format

that is applicable to the specific patients or circumstances.

Implementation and Evaluation

As the purpose of this project was to develop a clinical pathway with an algorithm for the

treatment of acute uncomplicated low back pain, an extensive literature review was done to

procure the latest, evidence based information dealing with acute low back pain diagnosis and




treatment. This information was then organized into a clinical pathway and an algorithm which

outlines the basics of the pathway for providers.

A publishable article was written. The article includes the clinical pathway along with the

algorithm. The article was submitted with the accompanying algorithm and the pathway to the

Journal of the American Academy of Nurse Practitioners according to the journal's publication

rules.

Evaluation of the pathway and the algorithm was coordinated with content experts and

the chairperson related to this scholarly project. Their input was solicited to ensure accurate

representation of the literature, content, and face validity of the products. The value of this project was discussed at length with Diana Thurston, PhD., Dr. Kade Huntsman, Dr. Gary

Snook, and Amber Wright, MBA. It was noted through these conversations that there are a

number of phenomenons noted regarding treatment of low back pain, particularly early

treatment, which could be improved upon. As addressed earlier in this project, primary care

providers and patients are quite disjointed regarding proper evidence-based treatment of low

back pain. There is much variability in patient care and patients enter the care system unaware of

the best course of care. Spine surgeons prefer to see patients that are surgical candidates and

many primary care providers would rather have complaints of the spine be treated elsewhere,

especially complicated issues. Through these discussions and observation, it was noted that a

process could be implemented to increase quality in early evaluation and treatment, utilizing

national guidelines that would streamline the entire process. This would enable patients to

receive appropriate evidence-based healthcare early in the treatment cycle while helping spine

surgeons and other providers eliminate patients from their practice that may be more

appropriately treated elsewhere. When and if patients were referred to see a surgeon they would




be well prepared with the appropriate treatment measures completed that are necessary to an

effective surgical consultation. It was noted through these discussions that this would save time,

frustration, and cost for the patient and for the physician as well as expedite and improve patient

care.

Evaluation of the dissemination of the clinical pathway will be done after the project ’s

completion through quarterly performance evaluation for each provider utilizing the treatment

algorithm and is outside the scope of the DNP project. The goal will be that caseloads are

sampled and charts reviewed for adherence to algorithmic data.

Long term plans for this project involve the development of an outpatient nurse practitioner -driven back pain clinic. Following completion of this scholarly project, the

treatment algorithm/protocol will be used to guide the treatment of patients in this outpatient

setting. At some time in the future, the goal will be to introduce the pathway into emergency

departments and clinics that treat for patients for acute uncomplicated low back pain. Evaluation

of efficacy of the pathway is beyond the scope of this scholarly project, but will be done later. As

the use of the protocol is adopted, ongoing utilization review and improvements will be made as

necessary.

Results

As stated earlier, in proceeding with the original objectives for this project, it was soon

discovered that to develop a patient treatment clinical guideline including an algorithm based on

evidenced literature to assist healthcare providers in managing patient care as related to acute

low back pain issues was not a feasible work as much of this work has previously been done and

published by Chou et al. (2007). Therefore a new set of objectives was developed and approved

by the Capstone Chair. The results section now details the work done on the new objective of

developing a patient treatment clinical pathway, including an algorithm for the treatment of acute




low back pain. Given the previous work that has been reported in the literature, this objective

seemed to be the next step in application of the recommendations in the literature.

The goals of this scholarly project were changed to:

1. Develop a patient treatment clinical pathway including an algorithm based on

evidenced literature.

This goal was completed by searching the literature and discovering evidence-based data

that was applicable to this goal. Appendix A shows the treatment clinical pathway. Appendix B

shows the treatment algorithms.

2. Production of a scholarly article that was submitted for publication consideration.

An article based on the content of this project was developed and submitted to the

Journal of the American Academy of Nurse Practitioners in accordance with their submission

rules and guidelines (see Appendix C). This article was written using the structure of quality

improvements reports suggested by Smith (2007) as the JAANP does not have a specific

structure for reports involving clinical quality improvements.

The Essentials of Doctoral Education for Advanced Practice Nurses

The Essentials of Doctoral Education for Advanced Practice Nurses (American

Association of Colleges of Nursing, 2006) are made up of a number of key elements, many of

which were integrated and used to guide this project. Included were Essentials I. II, III VII, and

VIII. DNP Essential I focus on the scientific underpinnings of nursing practice. This essential

element deals primarily with the scientific basis of the project. Care was taken to ensure that all

suggestions, treatment options, and clinical pathways were based on evidenced literature. This

literature directs the way patients are screened, evaluated, diagnosed and treated throughout the

clinical pathway. An emphasis on patient education and shared decision-making was utilized.




Acute low back pain sufferers negotiate a gauntlet of therapies, treatments, and protocols

that are often misguided and expensive. This patient population is underserved because of the

dysfunctional nature of our current system with regards to appropriate and timely management of

spinal related complaints. This project was chosen to improved access to appropriate care in the

hopes that outcomes could be improved. Advanced practice clinicians are in a unique position to

improve this process and facilitate positive change which satisfies the DNP Essential II.

Drawing upon current evidenced-based research and utilizing well supported clinical

guidelines, a clinical pathway for acute uncomplicated low back pain was developed. The

criterion for DNP Essential III is the process which focuses mainly on the clinical scholarshipand analytical methods of evidence based practice. DNP Essential VII, clinical prevention and

population for improving the nation's health was addressed. One overall goal was to improve

access to appropriate care and treatment for acute uncomplicated low back pain. Another goal

was to improve the general understanding and education of those suffering from spine related

issues. This goal was accomplished in the patient teaching aspects of the pathway. Lastly, DNP

Essential VIII advanced nursing practice, was supported and met by improving education and

experience of the advanced practice clinician in the area of acute uncomplicated low back pain.

As the advanced practice clinician applies the patient care pathway and algorithm, that has been

developed for the treatment of acute uncomplicated low back pain, they will be better able to

accurately evaluate, diagnose, and treat patients.

Recommendations

It is recommended that this project be expanded and extended to complete development

of patient care pathways for the evaluation and treatment of the spine. These patient care

pathways will include clinical direction for the assessment and treatment of patients with acute




and chronic low back pain with and without radiculopathy. Patients with complaints of

intermittent pseudo-claudication or signs and symptoms of lumbar stenosis will also be

addressed. All of these are outside the scope of this DNP project. The support of St. Mark's

hospital, the chief executive officer Steve Bateman, the chief operations officer, Matt Dixon and

other supporting staff including the manager of the spine department will be involved in the

future development of these treatment pathways. It is projected that these pathways will be in

place and completed by July 2013. Once successfully completed, these clinical pathways could

be used in other facilities. Improvement of rates at which patients receive quality, evidence-

based spinal care that is timely and consistent with national guidelines. There is no way giventhe constraints of this scholarly project that this could be effectively evaluated. The literature

does offer some evidence as what could be expected with adherence to national guidelines, but as

for the purposes of this project as it is pertaining to a particular clinic it would take a significant

amount of time and data collection to be able to show improved rates at which patients receive

quality evidence-based care. Key barriers include lack of time and constraints of the scholarly

project.

Facilitate training of new providers regarding treatment of acute low back pain. Again,

this training has yet to be implemented. This is also outside of the constraints of the DNP

scholarly project. Plans are being made to implement this project and its content into the training

of new advanced practice clinicians with regards to the spine clinic. Barriers include lack of time

and constraints of the scholarly project.

Conclusion

Initially this scholarly project undertook the daunting task of developing clinical

guidelines for the treatment of low back related issues. With research and continued




understanding this was found to be far outside the scope of this scholarly project. Therefore, one

aspect of this endeavor was identified as an appropriate starting point and became the emphasis

of this scholarly project. The focus was development of a clinical pathway and algorithm for the

treatment of acute uncomplicated low back pain. This clinical pathway will be utilized in the

future by St. Mark's hospital as a template for the development of additional pathways related to

spine disease. Utilizing evidenced-based research, the pathway and algorithm was developed to

streamline and to improve accuracy of the patient course through the care process. This pathway

and algorithm was completed and plans for additional pathways and algorithms have been made.

To assist the advanced practice clinician, at the point of care, a treatment algorithm wasdeveloped. To disseminate this information to the body of advanced practice clinicians a

scholarly article containing this information was submitted to the Journal of the American

Academy of Nurse Practitioners for publication.




References

American Association of Colleges of Nursing. (2006, October). The Essentials of Doctoral

Education . Washington, DC: American Association of Colleges of Nursing

Chou, R., Loeser, J. D., Owens, D. K., Rosenquist, R. W., Atlas, S. J., Baisden, J., Carragee, E.

J., ... American Pain Society Low Back Pain Guideline Panel. (2009). Interventional

therapies, surgery, and interdisciplinary rehabilitation for low back pain: An evidence-

based clinical practice guideline from the American pain society. Spine, 34 (10), 1066-

1077.

Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007).

Diagnosis and treatment of low back pain: A joint clinical practice guideline from the

American College of Physicians and the American Pain Society. Annals of Internal

Medicine, 147 , 481-491.

Deyo, R. A., Mirza, S. K., & Martin, B. I. (2006). Back pain prevalence and visit rates estimates

from U.S. national surveys. Spine, 31 (23), 2724-2727.

Harstall, C., Taenzer, P., Angus, D. K., Moga, C., Schuller, T., & Scott, N. A. (2011). Creating a

multidisciplinary low back pain guideline: Anatomy of a guideline adaptation process.

Journal of Evaluation in Clinical Practice, 17 , 693-704.

The Henry J. Kaiser Family Foundation. (2011, October). The uninsured a primer key facts

about Americans without health insurance . Washington, DC: The Henry J. Kaiser Family

Foundation

Ivanova, J. I., Birnbaum, H. G., Schiller, B. A., Kantor, E., Johnstone, B. M., & Swindle, R. W.

(2011). Real-world practice patterns, health-care utilization, and costs in patients. The

Spine Journal, 11 , 622-632.

Jackson, R., & Feder, G. (1998). Guidelines for clinical guidelines. BMJ, 317 , 427-428.




Lippi, G., Plebani, M., Di Somma, S., Mozani, V., Tubaro, M., Volpe, M., Moscatelli, P....

Peracino, A. (2012). Considerations for early acute myocardial infarction rule-out for

emergency department chest pain patients: The case of copeptin. Clinical Chemistry and

Laboratory Medicine, 50 (2), 243-253.

National Physicians Alliance, The Good Stewardship Working Group. (2011). The "Top 5" lists

in primary care. Archives of Internal Medicine, 171 (15), 1385-1390.

North American Spine Society. (2012, October 15). Acute Low Back Pain . Retrieved October 15,

2012, from North American Spine Society http://www.knowyourback.org/Pages/

SpinalConditions/LowBackPain/Acute.aspxRogers, E. (2012, October 27). Difference between clinical guidelines and clinical pathways .

Retrieved October 27, 2012, from http://www.healthinformaticsforum.com/forum/topics/

difference-between-clinical-guidelines-and-clinical-pathways

Scott, N. A., Moga, C., & Harstall, C. (2010). Managing low back pain in the primary care

setting: The know-do gap. Pain Research & Management, 15 (6), 392-400.

Smith, R. (2000). Quality improvement reports: A new kind of article. BMJ, 321 , 1428.

Srinivas, S. V., Deyo, R. A., & Berger, Z. D. (2012). Application of "less is more" to low back

pain. Archives of Internal Medicine, 172 (13), 1016-1020.

Stevens, K. R. (2004). ACE Star Model of EBP: Knowledge Transformation. Academic Center

for Evidence-based Practice. The University of Texas Health Science Center at San

Antonio.

Taylor, J. A., & Bussieres, A. (2012). Diagnostic imaging for spinal disorders in the elderly: A

narrative review. Chiropractic & Manual Therapies, 20 (16), 1-36.




U.S. Department of Commerce. (2005). In C. DeNavas-Walt (Ed.), Income, poverty, and health

insurance coverage in the United States: 2005 (Current population reports). Washington,

DC: U.S. Government Printing Office.

Waterman, B. R., Belmont, P. J., & Schoenfeld, A. J. (2012). Low back pain in the United

States: Incidence and risk factors for presentation in the emergency setting. The Spine

Journal, 12 , 63-70.

Williams, C. M., Maher, C. G., Hancock, M. J., McAuley, J. H., McLachlan, A. J., Britt, H.,

Fhridin, S., ... Latimer, J. (2010). Low back pain and best practice care. Archives of

Internal Medicine, 170 (3), 271-277.




Appendix A

Patient Care Pathway for Acute Uncomplicated Low Back Pain




Patient Care Pathway for Acute Uncomplicated Low Back Pain

It is expected that there will be a variety of patients introduced to the clinic. Some

patients will have been referred and others with no referral. Referral sources will include

primary care clinics, chiropractors, pain management, internal medicine and others. Scott et al.

(2010) report that the majority of patients with back pain seek assistance from primary care

providers and chiropractors first then move to others as needed. These patients will have a

variety of experiences and in many cases treatment will have been initiated; some patients will

have had no treatment at all (Harstall et al. 2011). Issues addressed in this clinic will include

both acute and chronic neck and back pain with and without radiculopathy as well as complaints

of pseudo-claudication. The purpose of this clinical pathway is to guide the treatment of acute

uncomplicated low back pain only. There are additional sections to this document dedicated to

the treatment of other spine related issues.

Initial Patient Contact (the call-in/referral/walk-in)

This phase of the patient-provider relationship will be overseen by the provider and

therefore is of interest to the provider. Detailed instruction regarding patient triage and referral

must be managed and monitored by the advanced practice clinician. This will facilitate

appropriate patient appointment to the clinic and increase speed at which patients see the

appropriate provider. For example, if a patient calls the clinic with acute back pain and a high

fever or recent chest pain it may be more appropriate for the patient to see the primary care

provider prior to a visit to the spine clinic. The primary goal of the initial patient contact will be

to screen patients for emergent concerns. These concerns include: high fever, untreated accident

victims, patients with possible cauda equina syndrome, or any other possible life or limb




threatening condition. This will also enable the receptionist to schedule more emergent patients

sooner than later.

The receptionist has an algorithm that enables her to ask the appropriate questions to

ensure that disposition of the patient is appropriate to their concern. Once patients have been

screened for life-threatening or emergent conditions they will be sent to the nearest emergency

department. Others are given an appointment on the clinic schedule as quickly as possible with

careful attention to patient concerns such as complicating factors including leg symptoms, fever,

or other serious complaints. The goal is to see each new patient within 72 hours of initial contact

and those of higher acuity even sooner.To expedite care and facilitate early integration into the system the receptionist will

collect a detailed history as outlined by the patient care pathway. Registration to the clinic may

also be initiated at this time by the receptionist to expedite care.

Initial Clinical Visit

In the clinical visit patients will be evaluated for their specific concern. The advanced

practice clinician will collect a detailed history and perform a focused physical exam. Even if a

history was taken over the phone prior to the visit, it will be reviewed with the patient during the

initial clinic visit and appropriate corrections and additions made. The history will include:

Onset and duration of symptoms

Precipitating event or injury

Character of symptoms

Numerical pain score

Location and radiation of pain

Other associated symptoms




Treatments already initiated or attempted

Pertinent medical history

Current films and studies

Following a detailed history and allowing the patients to express their concern, a focused

physical exam will be performed to include:

Neuromuscular exam as well as exams of the ankle, knee, hip, and greater

trochanteric bursa

Other items determined while reviewing history and physical exam that may need to

be assessed.

A full body physical exam may need to be performed if conditions such as long tract signs

(neurologic signs such as clonus, muscle spasticity, or bladder involvement that usually indicate

a lesion in the middle or upper parts of the spinal cord or in the brain), poor balance, instability

or other issues are noted. Once the physical exam is completed the consideration for additional

diagnostic studies are made. If the diagnosis is determined to be uncomplicated acute low back

pain then recommendations by Chou et al. (2007), North American Spine Society (2012), and

others are initiated and would include:

Continued activity and avoid bed rest

Anti-inflammatory medications (over-the-counter preparations)

Non-narcotic pain medications such as acetaminophen

Physical Therapy

Massage Therapy

Spinal manipulation






The clinic is open most business hours to address any needs patients may have. This

clinic is not an emergent care clinic and patients will be directed to the emergency department

should needs occur during off business hours. Our goal is excellent patient care that is evidenced

based, timely, and patient oriented.




Appendix B

Treatment Algorithms for Acute Uncomplicated Low Back Pain













Appendix C

Acute Uncomplicated Low Back Pain Article for

The Journal of the American Academy of Nurse Practitioners




Pathway and Decision Support for


Ryan D. Church FNP-C

[email protected]

University of Utah

College of Nursing




Clinical Treatment Pathway and Decision Support for


The author meets the criteria for authorship as stated by the ICMJE in the Uniform

Requirements for Manuscripts Submitted to Biomedical Journals

I attest that the manuscript is submitted in accordance with the JAANP Guidelines for

Authors (version 111020)




Abstract:

Problem

Many patients receive a variety of diagnostic studies and treatments when

complaining of acute uncomplicated low back pain lasting fewer than 6 weeks.

A need to improve the process by which patients are evaluated and treated was

identified to ensure appropriate evidenced-based care while managing costs and

speeding recovery.

Design

Clinical staff observed that patients being referred to a surgical spine clinic had a

broad variety of diagnostic tests and treatments prior to referral. Many such

actions lacked basis in current literature. Recommended time off work for back

injury seemed arbitrary and treatment course lacked homogenization. The

Academic Center for Excellence (ACE) Star Model of Knowledge

Transformation (2004) was utilized as the theoretical framework to devise a

clinical pathway to improve the care of patients with acute uncomplicated low

back pain. This was a done to improve rates at which patients received evidenced

care, reduced cost, and improved outcomes.

Background and setting

A small nurse practitioner owned spine care clinic working closely with two

orthopedic spine surgeons serving a population of 100,000 predominantly retired-age patients.

Key measures for improvement




The purpose of this project was to improve rates at which patients receive

evidence-based spinal care, appropriate diagnostic studies, and return to normal

activity. Another purpose was to decrease cost by eliminating unnecessary

diagnostic tests, treatment, and procedures that lack an evidence base.

Strategies for change

Utilizing the ACE Star Model of Knowledge Transformation (2004) as the

theoretical framework, the development of an evidenced-based clinical pathway

was developed to include decision support algorithm. This process was designed

to improve patient flow through a clinic from initial phone call to discharge

regarding the treatment of acute uncomplicated low back pain.

Effects of change

It is expected that utilizing this clinical pathway and algorithm for decision

support will increase rates at which patients are able to return to normal activity or

seek other appropriate care. It will also decrease inappropriate diagnostic studies

and treatments that lack evidence.

Lessons learned

More work is needed and plans to do this work have been made. Additional

clinical pathways for the treatment of acute and chronic neck pain with and

without radiculopathy, chronic low back pain with and without radiculopathy,

acute low back pain with radiculopathy, and low back pain with and without

intermittent pseudo-claudication need to be developed.

This article was written after clinical observations were made regarding the primary care

of acute uncomplicated low back pain. Many patients had a significantly different clinical course




prior to referral. Overuse of imaging studies that include CT scan, MRI scan, and x-rays was

noted. The lack of an evidenced-based approach to treatment was also noted. Many patients with

significant neurological deficit did not receive evidence-based treatment in the appropriate time

frames. The purpose of this article, evidence-based clinical pathway and decision support

algorithm, is to assist the user (clinician) to better understand evidence-based data regarding the

diagnosis and treatment of patients with acute uncomplicated low back pain. Understanding the

data and how to apply it is integral to proper management of diagnosis, treatment, and referral.

Outline the problem

Acute low back pain is a common complaint in primary care settings across the country.Acute low back pain is one of the leading reasons why people seek healthcare. Scott, Moga, and

Harstall (2010) noted that Between 49% and 90% of people in developed countries will experience at least oneepisode of low back pain during their lifetime. Pain will resolve within two weeks for themajority of these individuals. However, 20% to 44% of patients, especially those with ahistory of low back pain, will experience further episodes within a year, and more thanthree-quarters will experience a recurrence at some point in their lives. A small minorityof patients (2% to 7%) will develop chronic low back pain (p. 396).

Unfortunately, many who experience back pain undergo inappropriate and/or

unnecessary diagnostic studies and treatments. According to Taylor and Bussieres (2012), this is

due to provider lack of knowledge and experience. Diagnostic studies and treatment options

carry significant risk and cost; these risks and cost may be avoided by reducing unnecessary

diagnostic procedures and treatment. Srinivas, Deyo, and Berger (2012) document harm

associated with early imaging for low back pain, including patient “labeling,” unneeded follow -

up tests for incidental findings, irradiation exposure, unnecessary surgery, and significant cost.

“Routine imaging should not be pursued in acute uncomplicated low back pain. Not imaging




patients with acute low back pain will reduce harms and costs, without affecting clinical

outcomes ” (Srinivas, et al., 2012 , p. 1016).

Estimates of the direct cost burden in the United States range considerably. Ivanova et al.

(2011) estimate that spine related costs range to nearly $70 billion in incremental health-care

costs and has a significant impact on the economic structure. The cost of treating spine related

issues are exorbitantly high as related to other health care concerns. Ivanova et al. (2011) goes

on to explain that “patients with low back pain had about three times higher average direct costs

compared with other diagnoses” (p. 629). One major cost associated with treatment of the low

back in unnecessary imaging. Srinivas, et al. (2012) noted “ For acute low back pain patientswho underwent MR imaging within the first month had more than an 8-fold increased risk for

surgery and more than a 5-fold increase in subsequent total medical costs ” (pg. 1017).

Ivanova et al. (2011) also indicates that not only are the costs to treat low back pain

higher than average, patients with low back pain need to take more days off of work than those

with other illnesses, creating further financial burdens for the patient.

Design/gathering information

The following research questions and search terms were utilized in developing research

parameters.

What is the incidence and prevalence of acute low back pain in the United States?

Research terms included: incidence, prevalence, acute low back pain, United States

What are the barriers for Americans to receive adequate appropriate timely evidence-

based care for acute low back pain? Research terms included: barriers, acute low back

pain, evidence-based, and treatment.




What treatment options are available for acute low back pain? Research terms: acute low

back pain, treatment, options.

What are the treatment recommendations/guidelines for the treatment of acute low back

pain in the United States? Research terms: treatment guidelines, decision assistance,

acute low back pain, evidence-based, and United States.

Once these questions and terms were selected, PubMed and other sites were utilized as

the search engine of choice. Once appropriate literature was found, references were evaluated

and additional supportive literature was identified.

Analysis and interpretation

There are a number of recommendations which have been published in the past for the

care of acute low back pain. There has also been significant work done recently regarding the

proper diagnosis, management, and treatment for patients with low back pain. Research

performed by North American Spine Society (2012), Chou et al. (2007) and others provide the

following treatment recommendations.

1. Clinicians should conduct a focused history and physical exam and divide patients into

three broad categories: nonspecific low back pain, back pain potentially associated with

radiculopathy or those not with spinal stenosis or some other specific causative factor. Here we

are looking for patients without radiculopathy or leg related symptoms

2. Clinicians should not obtain imaging studies of patients with nonspecific low back

pain. This guideline is supported by the National Physicians Alliance’s (2011) “Top 5” list ofhealth care activities in primary care for which “changes in practice could lead to higher-quality

care and better use of finite clinical resources ” (pg . 1386). The National Physicians Alliance’s




first recommendation “Don't do imaging for low back pain within the first 6 weeks unless red

flags are present” (National Physicians Allia nce 2011).

3. Clinicians should obtain diagnostic studies only when there is progressive neurological

deficit or underlying conditions are considered (North American Spine Society, 2012). Chou et

al (2007) also notes this is a strong recommendation with moderate-quality evidence.

4. Clinicians should only get MRI or CT scans on patients that are being considered for

surgery or epidural steroid injection.

5. Clinicians should provide patients information that is evidence based regarding

treatment options and self-care measures.6. Clinicians considering the use of medications and other treatments should do so only

after consideration has been given to risks, benefits, and potential side effects. This should only

be done, after a baseline of physical status and risk for long-term/serious disease has been

performed.

7. Clinicians should consider the use of medications with proven benefits in conjunction

with back care information and self-care. Generally, first-line medication options are

acetaminophen or nonsteroidal anti-inflammatory drugs. Non-pharmacologic interventions

being considered for patients who fail to improve after first-line therapy would include spinal

manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage

and cognitive behavioral therapy

In a subsequent study in 2009, Chou et al. (2009) added additional recommendations to

the 2007 recommendations. These recommendations added additional evidenced based advice on

the treatment of low back pain.




1. Provocative discography is not recommended in patients with chronic low back pain.

Diagnostic selective nerve root block, intra-articular facet joint injections and medial branch

blocks or sacroiliac joint blocks are also discouraged as diagnostic procedures with regard to low

back pain without radiculopathy.

2. For patients with chronic back pain that do not respond to usual therapies, it is

recommended that clinicians consider intensive interdisciplinary interventions that include

cognitive, behavioral, and occupational components. In patients with persistent low back pain

without radiculopathy, the use of facet joint injections, steroid injections, and prolotherapy, and

intradiscal corticosteroid injections are not recommended . There is not enough evidence torecommend botulinum injections, epidural steroid injections, intradiscal electrothermal,

therapeutic medial branch block, radiofrequency denervation of the medial nerve branch,

sacroiliac joint injection, or intrathecal therapy with opioids or other medications for

nonradicular symptoms.

4. A shared decision-making model should be used when approaching the question of

spinal surgery for nonspecific, nonradicular low back pain. A detailed conversation about risks

versus benefits as compared to interdisciplinary rehabilitation should be performed.

5. There is insufficient evidence that vertebral disc replacement is beneficial for

nonspecific nonradicular low back pain .

6. A shared decision-making approach should be taken when discussing epidural steroid

injections for the treatment of low back pain with radiculopathy secondary to herniated disc.

Information regarding efficacy both for long and short-term symptom reduction should be

discussed. The same is true regarding spinal stenosis. Shared decision-making regarding surgery




for persistent back and leg pain secondary to herniated disc and spinal stenosis are also

recommended. There is strong quality evidence supporting this recommendation .

7. It is recommended that a discussion regarding the efficacy and complication rates of

spinal cord stimulation should be conducted with patients who are considering spinal cord

stimulation implant after discectomy for herniated disc with persistent and continued leg pain

postoperatively.

Key measures for improvement

Treatment pathways are gaining acceptance and support in all areas of healthcare. They

are increasingly being recognized as tools that can be used to decrease cost, streamline care, andimprove outcomes. Jackson and Feder (1998) indicate that clinicians need simple, patient

specific, user-friendly guidelines. They highlight three basic components that are needed in a

clinical pathway:

Identification of the key decisions and their consequences, review of the relevant, valid

evidence on the benefits, risks, and costs of alternative decisions, and presentation of the

evidence required to inform key decisions in a simple, accessible format that is flexible to

stakeholder preferences (p. 428).

There are a number of small and crucial decisions involved in each patient encounter. If

all of these decisions were addressed in a patient care algorithm or clinical pathway it would

become far too cumbersome to be useful. Jackson and Feder (1998) indicate that only the basic

and most important decisions should be addressed initially and recommended that a diagram or

algorithm be developed that identifies the key decisions and important outcomes relevant to

patients care.




Valid evidence is a requisite for best practice outcomes. An increasing interest in

evidence-based practice and guidelines and pathways has highlighted the gaps in the evidence.

Jackson and Feder (1998) also state that a systematic review of the prevailing evidence is

necessary. Special attention should be paid to appropriateness of the underlying data.

Treatment pathways should be guided by the absolute risk and benefit of the treatment

proposed. These measures can be presented in units such as the number of events occurring in

100 patients treated per year or the number of patients who would need to be treated to prevent

an event or (numbers needed to treat). Explicit statements about the benefits and risks of a

treatment can then be weighed by patient preference and the available resources. This iscurrently difficult to achieve for most clinical problems, making it difficult to write some

evidence-based accurate pathways. Pathway developers are encouraged to follow the process

outlined above and acknowledge where recommendations are based on inadequate evidence.

Another component of a successful pathway is the presentation of evidence and

recommendations in a concise accessible format. Decision makers must be able to retrieve and

assimilate information quickly. Moreover, information must be presented in a flexible format

that is applicable to the specific patients or circumstances.

Strategies for change

Change strategies include the presentation of the clinical pathway with its supporting

literature and the decision support algorithm to clinicians in a healthcare system. Clinicians will

be required to address spine related issues as recommended by the evidence-based literature and

the clinical care pathway which is based on well-documented guidelines. Additionally, the

presentation of this article to the body of advanced practice clinicians for consideration and

integration into individual practices where appropriate.




The paradigm of healthcare is changing and advanced practice clinicians find themselves

in the front lines of healthcare. Physicians are pushing towards specialty areas; advanced

practice clinicians will be directing the care of patients with complaints of acute low back pain.

Nurse practitioners are uniquely positioned to assist in the treatment of patients with spine

related issues. There is much that can be done previous to, or in place of, surgical intervention. It

is a well-accepted fact that spinal surgery is often expensive and shoulders a rather extensive

burden of risk. Chou et al. (2009) suggest that surgery should be carefully considered and only

recommended for those patients who fit a profile that will ensure best outcomes. Everything

should be done to assist patients in avoiding unnecessary surgery.With proper training and experience, an advanced practice clinician can adequately assess

patients and direct the care they need. The majority of patients with acute low back pain can be

supported with minimal intervention and resolution of symptoms will occur in less than four

weeks. If symptoms do not resolve or if there are "red flags", advanced practice clinicians can

evaluate and treat as clinically indicated or provide appropriate referrals. Advanced practice

clinicians can review additional diagnostic studies, interventional management, physical therapy,

surgery, or other appropriate action. Following a treatment or diagnostic study, patients will

need continuing education and management of their care. Once resolution of symptoms has been

achieved, re-assimilation back into society and the workforce can be facilitated by the advanced

practice clinician.

Effects of change

Implementation of a patient care pathway regarding diagnosis and treatment of acute

uncomplicated low back pain as well as other ailments of the spine are expected to have a

number of clinical implications. Of these, the most important will be homogenization of care.








evidence-based care without wasting resources or exposing patients to unnecessary diagnostic

studies, treatments or surgery.




Figure 1.




Figure 2.




Figure 3.




Acknowledgements

It is with the deepest gratitude and thanks that I acknowledge the tremendous assistance renderedto me in this effort. Indeed, I may say this was a group project. First, I would like to thankDiana Thurston, PhD, APRN for her vast experience, tireless assistance, and patient mentoring.

Next, my content experts Kade Huntsman, MD, Gary Snook, MD, and Amber Wright MBA fortheir ideas, suggestions, and direction. Without them, new roads could never be forged. Lastly,to my very talented wife and editor, Becky, she did so much more than proof my work; she was acheerleader, motivator, and never lost sight of my abilities, even when I did.




References

Chou, R., Loeser, J. D., Owens, D. K., Rosenquist, R. W., Atlas, S. J., Baisden, J., Carragee, E.

J., ... American Pain Society Low Back Pain Guideline Panel. (2009). Interventional

therapies, surgery, and interdisciplinary rehabilitation for low back pain: An evidence-

based clinical practice guideline from the American pain society. Spine, 34 (10), 1066-

1077.

Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007).

Diagnosis and treatment of low back pain: A joint clinical practice guideline from the

American College of Physicians and the American Pain Society. Annals of Internal

Medicine, 147 , 481-491.

Ivanova, J. I., Birnbaum, H. G., Schiller, B. A., Kantor, E., Johnstone, B. M., & Swindle, R. W.

(2011). Real-world practice patterns, health-care utilization, and costs in patients. The

Spine Journal, 11 , 622-632.

Jackson, R., & Feder, G. (1998). Guidelines for clinical guidelines. BMJ, 317 , 427-428.

Lippi, G., Plebani, M., Di Somma, S., Mozani, V., Tubaro, M., Volpe, M., Moscatelli, P....

Peracino, A. (2012). Considerations for early acute myocardial infarction rule-out for

emergency department chest pain patients: The case of copeptin. Clinical Chemistry and

Laboratory Medicine, 50 (2), 243-253.

National Physicians Alliance, The Good Stewardship Working Group. (2011). The "Top 5" lists

in primary care. Archives of Internal Medicine, 171 (15), 1385-1390.

North American Spine Society. (2012, October 15). Acute Low Back Pain . Retrieved October 15,

2012, from North American Spine Society http://www.knowyourback.org/Pages/

SpinalConditions/LowBackPain/Acute.aspx




Scott, N. A., Moga, C., & Harstall, C. (2010). Managing low back pain in the primary care

setting: The know-do gap. Pain Research & Management, 15 (6), 392-400.

Srinivas, S. V., Deyo, R. A., & Berger, Z. D. (2012). Application of "less is more" to low back

pain. Archives of Internal Medicine, 172 (13), 1016-1020.

Stevens, K. R. (2004). ACE Star Model of EBP: Knowledge Transformation. Academic Center

for Evidence-based Practice. The University of Texas Health Science Center at San

Antonio.

Taylor, J. A., & Bussieres, A. (2012). Diagnostic imaging for spinal disorders in the elderly: A

narrative review. Chiropractic & Manual Therapies, 20 (16), 1-36.

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