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Description : This medical presentation titled "Evidence-based Evaluation and Management Of Low Back Pain" describe the epidemiology and natural history of low back pain, trends in evaluation and management of low back pain, outcomes, practice variations, and implications for practice, and makes us understand an evidence-based approach to evaluation and management of low back pain. It also provides a case in this field.

Tags : Evidence-based Evaluation, Management, Low Back Pain, epidemiology, history

Published on : Apr 27, 2021 | Views : 1427 | Downloads : 3

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Evidence-based Evaluation and Management Of Low Back Pain Roger Chou, MD, FACP Professor, Department of Medical Informatics & Clinical Epidemiology, and Department of Medicine Oregon Health & Science University Director, the Pacific Northwest Evidence-based Practice Center John D. Loeser, MD Professor, emeritus, Departments of Neurological Surgery and Anesthesia and Pain Medicine, University of Washington
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2 Disclosures/Conflict of Interest Dr. Chou has received research funding from the Agency for Healthcare Research and Quality and the American College of Physicians, and is a consultant with Palladian Health. Dr. Loeser has received research funding from the National Institutes of Health.
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Session Objectives Describe the epidemiology and natural history of low back pain Describe trends in evaluation and management of low back pain, outcomes, practice variations, and implications for practice Understand an evidence-based approach to evaluation and management of low back pain
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THE PATIENT: 57 yo male with LBP x 2 years, no specific inciting event No associated leg pain or other neurological symptoms Pain slowly worsening, to the point of not being able to walk more than 2 to 3 blocks, rated 7/10 most days Continues to golf most weekends, but riding cart now Works as an engineer, not physically demanding X-rays show lumbar disc degeneration and facet joint arthropathy Tried acetaminophen and NSAIDs and has undergone PT
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LBP Burden 1 LBP is the 5th most common reason for U.S. office visits, and the 2nd most common symptomatic reason >16 million LBP office visits/year 5% of PCP visits are for LBP Most common reason to see a neurosurgeon or orthopedist Up to 84 percent of adults have LBP at some time in their lives, and over one-quarter in the previous 3 months Only 2-5% seek health care or claim disability
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LBP Burden 2 Peaks at 55 to 64 years of age; affects all ages The most common cause of activity limitations in persons <45 years of age More disability than cancer + heart disease + stroke + AIDS In 2013, nearly $90 billion dollars in spending for back and neck pain Increase of $64 billion from 1996
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TRENDS IN LBP Increased utilization of imaging studies Increased incidence of surgery Increased use of injections Increased prescription of opioids Increased costs for LBP No decrease in disability October 24, 2008
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“7 Back Pain Breakthroughs Are you hurting? Here's help.” Reader’s Digest, July, 2007 “End Back Pain Agony” Michael J. Weiss http://www.rd.com/content/chronic-back-pain-breakthroughs-/
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Reader’s Digest “Cures” for LBP Infrared belt - $2,335 “Magic Spinal Wand” Percutaneous automatic discectomy Flexible fusion Stem cells Site-directed bone growth New bed
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“Experts” on causes of low back pain “80% of back pain is caused by weak or tense muscles.” “The majority of LBP actually originates in the sacral ligaments.” “In 50% or more…the facet joint is the site of dysfunction.” “90-95% of back pain is due to disks.” “An extremely high percentage…have fascial problems.” “50-70% of chronic symptoms are psychological in origin.” Deyo RA, Spine 1993;18:2153-2162
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“Experts” on effectiveness of treatments for low back pain “Mobilization and manipulation studies claim an 80% success rate.” “80% of low back pain patients get immediate relief with epidural blocks.” “In the YMCA’s exercise program, 80% improve.” “With microcurrent therapy…82% were pain free with 10 treatments.” “70-80% of those carefully screened for radicular symptoms benefit from surgery.” Deyo RA, Spine 1993;18:2153-2162
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What makes treatments appear effective? Natural history Regression to the mean Hawthorne and other non-specific effects Fraud Placebo effects Selection of patients more likely to improve Specific or “true” effects of treatment
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RISK FACTORS FOR LBP Congenital spine abnormalities Smoking Occupation Prior episode of LBP Physical unfitness Increasing age
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THE PATIENT: 57 yo male with LBP x 2 years, no specific inciting event No associated leg pain or other neurological symptoms Pain slowly worsening, to the point of not being able to walk more than 2 to 3 blocks, rated 7/10 most days Continues to golf most weekends, but riding cart now Works as an engineer, not physically demanding X-rays show lumbar disc degeneration and facet joint arthropathy Tried acetaminophen and NSAIDs and has undergone PT
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2007 American College of Physicians/American Pain Society guidelines
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2017 American College of Physicians guideline Emphasis on nonpharmacologic therapies, particularly for chronic LBP Stronger cautions regarding opioids Acetaminophen no longer recommended for acute LBP More evidence on mind-body interventions (yoga, Tai Chi, mindfulness-based stress reduction)
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STEPS FOR EVIDENCE-BASED DIAGNOSIS AND TREATMENT OF LOW BACK PAIN IN PRIMARY CARE
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STEP 1 IN THE CARE OF THE LBP PATIENT Listen to the patient’s story, obtain adequate medical history and social history. Look for psychological and environmental factors that might impair recovery.
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STEP 2 IN THE CARE OF THE LBP PATIENT Perform a directed physical examination
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History and physical for diagnosing specific conditions Cancer: History of cancer, elevated ESR Weaker predictors: unexplained weight loss, failure to improve after 1 month, age >50 Herniated disc: Leg pain in radicular distribution and positive straight leg raise test Spinal stenosis: Wide-based gait, lack of pain when seated Weaker predictors: neurogenic claudication, age >65 Cauda equina syndrome: Urinary retention
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Epidemiology of low back pain >85% of patients who present to primary care have LBP that cannot be attributed to a specific disease or spinal pathology; therefore “non-specific lbp” Labeling most patients with specific diagnosis is misleading and doesn’t improve outcomes Conditions to rule out: (all are rare) Cancer 0.7%, compression fracture 4%, ankylosing spondylitis 0.3% to 5%, spinal infection 0.01% Spinal stenosis 3%, symptomatic herniated disc 4% Cauda equina syndrome 0.04% (usually due to massive midline disc herniation)
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STEP 3 IN THE CARE OF THE LBP PATIENT Review any laboratory or imaging data and any prior medical records.
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STEP 4 ESTABLISH A PRELIMINARY DIAGNOSIS Non-specific low back pain (most likely) Radiculopathy and/or spinal stenosis Another specific diagnosis
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“For each ailment that doctors cure with medications (as I am told they do occasionally succeed in doing) they produce ten others in healthy individuals by inoculating them with the pathological agent a thousand times more virulent than all the microbes—the idea that they are ill.” PROUST The Remembrance of Things Past
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NOT A STEP No imaging or other diagnostic tests needed initially in a patient with nonspecific low back pain.
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When to obtain imaging and other diagnostic tests Use history and physical to guide approach High risk for vertebral compression fracture Suspected infection, cauda equina syndrome, progressive/severe neurologic deficits Advanced imaging usually necessary Risk factors for cancer If age only risk factor, consider time-limited (e.g. 1 month) trial of therapy If previous cancer or cancer more strongly suspected, consider x-ray plus ESR initially Suspected radiculopathy or spinal stenosis In absence of severe/progressive neurologic symptoms with no improvement after >1 month, consider MRI or CT after >1 month in candidates for surgery or epidural steroid injections
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Why isn’t routine imaging helpful? Favorable natural history of acute LBP Low prevalence of serious underlying conditions Almost all have identifiable risk factors Poor correlation between common imaging findings and symptoms Labeling patients with a specific diagnosis may cause harm Fear avoidance behaviors, anxiety Minimal impact on clinical decision-making Increase likelihood of unnecessary and potentially harmful interventions
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STEP 5 IMPLEMENT CONSERVATIVE CARE Physical activity Medications Education Follow-up
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STEP 5a PHYSICAL ACTIVITY The role of the therapist is to educate and monitor the patient’s progress. Most of the planned activities do not require medical supervision or high technology: a gym will do. Group activities are often helpful.
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RAPID RETURN TO NORMAL ACTIVITIES Bed rest is bad for your health.
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Recommend a gradual and progressive increase in physical activities on a quota system. Never “…let pain be your guide”.
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Educate the patient: HURT AND HARM ARE NOT SYNONYMS.
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PASSIVE THERAPIES ARE OF LITTLE VALUE.
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34 Recommendation: Self-care and education Provide patients with evidence-based information about their expected course, advise patients to remain active, and provide information about effective self-care options.
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STEP 5b MEDICATIONS Adjuncts to comprehensive therapies Antidepressants are most useful class No role for anxiolytics (benzos) in most pts Opioids for short-term use only NSAIDs may be helpful; watch for side-effects
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STEP 5d FOLLOW-UP Planned follow-up reduces health care consumption. Re-assess if unsatisfactory progress or any yellow flags for adverse outcomes. Physician as teacher and leader and reinforcer
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STEP 6: REASSESSMENT AT 4-6 WEEKS If symptoms persist unabated, look for impediments to recovery. Consider imaging studies if clinical signs and symptoms are suspicious. Know the consultant to whom you refer the patient.
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PREVENTION OF DISABILITY SHOULD BE THE PRIMARY OUTCOME GOAL FOR ALL PATIENTS WITH LOW BACK AND LEG PAIN.
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THE NATURAL HISTORIES OF ACUTE, RECURRENT AND CHRONIC LOW BACK PAIN AND SCIATICA ARE RELATIVELY BENIGN. Why didn’t they tell me that in my residency?
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Identify and address risk factors for chronicity Small proportion of patients with acute LBP go on to develop persistent LBP, but account for the majority of costs Psychosocial factors the strongest predictor for chronicity, environmental factors also play a role STarT Back Trial 1573 UK patients with LBP (+/- radiculopathy), any duration Randomized to stratified care based on prognosis (low, medium, or high-risk) or usual care Low-risk intervention: educational video and booklet Medium and high-risk interventions: referred for psychologically informed physiotherapy (3 vs. 9 days of additional training) Stratified care more effective than usual care for function (1.8 points at 4 months and 1.1 pts at 12 months); also cost effective STarT Back approach being tested in the U.S. Hill JC et al. Lancet 2011;378:1560
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Advice and self-care for low back pain Inform patients of generally favorable prognosis of acute LBP with or without sciatica Discuss need for re-evaluation if not improved Advise to remain active Counsel that hurt and harm are not synonymous Consider self-care education books Superficial heat moderately effective for acute low back pain No evidence to support use of lumbar supports No evidence to support use of traction
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Recommendation: Nonpharmacological therapies For patients who do not improve with self-care options, consider the use of non-pharmacologic therapy with proven benefits. For chronic low-back pain, options include: intensive interdisciplinary rehabilitation, exercise therapy, cognitive-behavioral therapy, yoga, mindfulness-based stress reduction, acupuncture, massage therapy, or spinal manipulation. For acute low-back pain, options include: exercise, acupuncture, manipulation.
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Approach to use of non-pharmacologic therapies for LBP A number of therapies appear similarly effective Emphasis on active rather than passive therapies Exercise therapies, cognitive-behavioral therapy as first-line treatments Focus on function, not just pain Address maladaptive coping behaviors such as fear-avoidance, catastrophizing Yoga, mindfulness-based stress reduction, Tai Chi options Interdisciplinary rehabilitation for patients with severe functional impairment or strong psychosocial component Manipulation, acupuncture, massage as adjunctive therapy Physical modalities passive and not well supported by evidence
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44 Recommendation: Medications Use as adjunctive therapies in persons receiving non-pharmacological therapies Consider medications in conjunction with back care information and self care For most patients, NSAIDs are the first line medication option
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45 Pharmacological interventions First-line: NSAIDs Small benefits, but low cost and generally good safety profile ?Effectiveness of acetaminophen for acute LBP Second-line Skeletal muscle relaxants (acute) Antidepressants (chronic) ?Antiseizure medications Avoid in most patients: Benzodiazepines (acute), opioids (use with caution!) Not recommended: Systemic corticosteroids
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Case 57 yo male with LBP x 2 years, no specific inciting event No associated leg pain or other neurological symptoms Pain slowly worsening, to the point of not being able to walk more than 2 to 3 blocks, rated 7/10 most days Continues to golf most weekends, but riding cart now Working as engineer X-rays show lumbar disc degeneration and facet joint arthropathy Tried acetaminophen and NSAIDs and has undergone PT
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Case—Risk Assessment Mr. S. has no personal or family history of substance abuse No history of depression or other psychological disorders No serious comorbid conditions that are contraindications to opioid therapy STarT Back Score: 1 (only able to walk short distances) Opioid Risk Tool score: 0 Urine drug test negative Assessed risk for misuse/abuse: Low
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Case—Management Plan and Initial Follow-up Set goal of walking 30 minutes 4 times a week Longer term goal walking 9 holes of golf Low-dose opioid therapy (oxycodone 5 mg twice daily) initiated At 4 week follow-up, pain decreased from 7/10 to 4/10 Able to walk 20-30 minutes 4 times a week No signs of aberrant behaviors Plan: Continue opioid therapy at the same, low dose, follow-up in 2 months
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Case—Follow-up 2 Months Walking 20 minutes once or twice a week. “I can’t walk more because it makes things worse.” Still not able to walk 9 holes of golf Has taken an “extra” oxycodone on several days with increased pain and has run out of prescription one or two days early “I feel like I’m never going to improve” No signs of aberrant behaviors UDS: No oxycodone or other opioids, no illicit drugs PDMP: No controlled substances from other providers
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Case—Management Plan Counsel on need to stick with prescribed doses Counsel on importance of activity and exercise Increase oxycodone to 10 mg twice daily Add duloxetine 10 mg po qD Refer back to physical therapy Follow-up in 1 month
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Case—Follow-up 3 Months Still having pain and not walking Started PT but stopped attending because it hurt too much States taking oxycodone as directed, UDS shows hydrocodone but no oxycodone Duloxetine made him “feel funny” and he stopped it PDMP: OK Requesting more opioids
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Case—Management Plan Refer for cognitive-behavioral therapy Taper opioids Trial of pregabalin instead of duloxetine 1 month follow-up
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Case—Follow-up 5 Months No improvement in pain or function Has attended some CBT and PT sessions, says they are not helping Taking pregabalin but doesn’t think it’s helping Off oxycodone
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Case—Management Plan Continue off oxycodone Referred for intensive interdisciplinary rehabilitation Titrated up pregabalin
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The main concepts from this session are: Rates of LBP and associated costs are increasing despite more aggressive testing and treatment Use evidence-based principles to inform more effective and efficient care Shift away from routine imaging and diagnostic testing Early identification and management of psychosocial contributors to pain Focus on function, not just pain Set achievable functional goals Self-care and education in all patients Focus on use of active nonpharmacological therapies Passive therapies in adjunctive role Cautious use of opioids Non-invasive approaches to most LBP
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THANK YOU October 24, 2008