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University of Michigan
Guidelines for
Health System
Clinical Care
Acute Low Back Pain

Low Back Pain
Guideline Team
Patient population: Adults (>18 years) with pain <6 weeks.
Team leaders
Objectives: (1) Identify persons at risk for chronic disability and intervene early. (2) Detect
dangerous, but uncommon lesions. (3) Utilize diagnostic tests efficiently. (4) Initiate treatment and Team members
Key points:
Natural history. Low back pain occurs in about 80% of people [evidence C*]. Within 6 weeks 90%
of episodes will resolve satisfactorily regardless of treatment [C*]. Of all persons disabled for more than 1 year, 90% will never work again without intense intervention [C*]. Initial visit.
Assess for “red flags” of serious disease, as well as psychological and social risks for chronic Physical Medicine & Rehabilitation disability. Diagnostic tests are usually unnecessary [C*] Educate about good prognosis [B*]. Treatment options include: ice [D*], NSAIDs [A*], and return to usual activities - bed rest is not recommended [A*]. (COX-2 inhibitors are no more effective than traditional NSAID agents and should be reserved for carefully selected patients. [A]) Close clinical follow up until return to work or key life activities [D*]. General Internal Medicine Amy Tremper, MD By 2 weeks (acute). If work disability persists, consider physiatric consultation [A*] especially is
psychosocial risks to return to work exist. For radicular pain, by 2-4 weeks: If no improvement obtain MRI [B*]. If not diagnostic, obtain
EMG. If pathology proven, consider acute physiatrist or anesthesiology pain specialist evaluation (for injection therapy) or surgical evaluation [A*]. If pathology not proven, consider physiatrist or anesthesiology pain specialist referral [D*]. By 6 weeks (subacute). If activities are still limited, consider anesthesiology pain specialist or
physiatric consultation regarding a complex rehabilitation program [A*].
UMHS Guidelines
Oversight Team
By 12 weeks (chronic). If still disabled from major life activities or work, strongly consider referral
to an anesthesiology pain specialist or physiatrist for a complex rehabilitation team [A*]. Special Circumstances (see discussion):
Literature Search Service
* Levels of evidence for the most significant recommendations:
A=randomized controlled trials; B=controlled trials, no randomization; C=observational trials; D=opinion of expert panel. Clinical Background
Clinical Background
Definitions
• Recurrent LBP: Acute LBP in a patient who
has had previous episodes of LBP from a similar Regents of the
Low back pain (LBP) is posterior trunk pain University of Michigan
between the ribcage and the gluteal folds. It also includes lower extremity pain that results from low back disorder (sciatica/radiating low Epidemiology
back pain), whether there is trunk pain or not. Sciatica is radiating, lower extremity pain and The one-year point prevalence of low back problems may not be associated with back pain. Sciatica specific clinical procedure or treatment in the U.S. population is 15-20%. Eighty percent of must be made by the physician in light of should be clearly distinguished from axial low the population will experience at least one episode of disabling low back pain during their lifetime. • Acute LBP: Back pain <6 weeks duration
Approximately 40% of persons initially seek help • Subacute LBP: Back pain >6 weeks but from a primary care physician, 40% from a
chiropractor, and 20% from a subspecialist. Chronic LBP: Back pain disabling the
patient from some life activity >3 months
(Continued on page 7)
Figure 1. Diagnosis and Treatment
of Acute Low Back Pain
Focused medical history and physical exam • Serious disease (Table 1) [C*] • Risk for chronicity (Table 2) [D*] • Strength and reflexes (Table 4) [D*] scan [C*] or referral [D*] * Levels of Evidence:
Table 1. "Red Flags" for Serious Disease
Table 2. Risks for Chronic Disability
Clinical Factors
• Multiple previous musculoskeletal complaints Pain Experience
Traumatic injury/onset, cumulative trauma X Premorbid Factors
• Believe they will not be working in 6 months X • Don’t get along with supervisors or coworkers No relief at bedtime or worsens when supine Constitutional symptoms (e.g. fever, weight loss) X • Are unmarried or have been married multiple times suppression X • Troubled childhood (abuse, parental death, alcohol, UMHS Low Back Pain Guideline Update, April, 2003 Table 3. Differential Diagnosis of Back Pain
Systemic Causes
Axial Back Pain
Radiating Low Back Pain
Dangerous local causes
Local pathology that mimics
Other causes
radiating low back pain
Myopathy Inflammatory radiculopathy AIDP/CIDP Table 4. Assessing Muscle Strength and Reflexes
Spinal Cord
Location
Reflex Tests
Strength Test
Cord Level
a Ankle plantar flexion--rise up on the toes of one leg 5 times while standing. b Internal rotation--while seated patient keeps knees together and ankles apart, examiner attempts to push ankles together. c While the patient is seated the examiner palpates the medial hamstring tendon and sharply percusses his/her hand. Contraction UMHS Low Back Pain Guideline Update, April, 2003 Table 5. Non-Radiating (Axial) Low Back Pain: Treatment and Follow-Up
(Pain Not Below the Knee)
Initial Visit
If at Risk: Chronic Disability Prevention [A*] (Table 2)
• Address barriers. Discuss with patient any barriers to
Diagnostic Tests: Usually none.
• Maintain work. Avoid time off work if at all possible.
Non-Medication Treatment:
• Minimize restrictions. Minimize any activity
• Ice. Ice (20 minutes at a time) to the painful area as
restrictions by consulting with the patient and possibly the employer about physical demands of the patient’s job • Stretching. Gradual stretching may relieve a cramping
and the availability of alternative work. If restrictions are given, make them time limited (e.g., “no lifting over 30 lb. for 2 weeks, then unrestricted duty”). Specify an Medication: (See Table 7 for specific medications.)
expiration date and the date of physician follow-up • Make time contingent. Except for very minor pain,
prescribe medications on a time contingent basis (e.g., Follow-Up Visits (chronic disability risk patient) [D*]:
q.i.d.), not on a pain contingent basis [A*]. • Schedule
• Medication strategy. Medication treatment depends on
─ If kept out of work: See in 2–3 days, then weekly.
pain severity, with more potent medications used in the ─ If moderate pain/restrictions: See patient weekly.
─ If pain resolved and no restrictions: See patient prn.
1. Acetaminophen. No studies in acute LBP, Analgesic • Early aggressive intervention. At 6 weeks of disability,
effect is known in other musculoskeletal disorders, in a patient at risk for chronic disability, strongly consider referral to a spine rehabilitation team. 2. NSAIDs. Proven to be effective in treating LBP [A*]. • Future prevention. After episode resolves discuss
COX-2 inhibitors are no more effective than traditional NSAID agents. They may offer a short- term, but probably no long-term advantage in GI tolerance for most patients Subsequent Visits
3. Muscle relaxants. While probably more effective than History and Physical: Update history and physical. If
placebo, muscle relaxants have not been shown to be diagnostic impression changed, go to appropriate steps in Activity Limitations:
General Treatment:
• Bed rest. Avoid bed rest [A*].
• If pain better: Reduce medications, increase activity.
• Work restrictions. Patients should not commonly be
• If pain worse: Consider changing/adding medications,
restricted from work [D*].
• General activity. Resume usual activities. Sometimes it
• Physical therapy. If no improvement, at 1-2 weeks [A*]
is reasonable to restrict a person from long distance consider manual physical therapy (spinal manipulation). driving, heavy lifting, sitting for prolonged periods, or repetitive twisting and reaching [D*]. If at Risk: Chronic Disability Prevention (Table 2)
• Patient education [A*]
Patient Education [C*]: (review the following)
• Minimize restrictions
• Epidemiology. Most people have an episode of back
• At 6 weeks consider referral to spine rehab program
pain. Though bothersome, it’s rarely disabling. • Diagnosis. No evidence of nerve damage or other
Follow-Up: Same as at initial visit plus
dangerous disease. Diagnostic tests are rarely helpful for • At 2 weeks: If positive dural tension sign (positive straight
leg raising, or reverse straight leg raising) and no clinical • Prognosis. Prognosis is excellent regardless of treatment.
improvement, consider physiatrist or pain specialist referral for intervention therapy (epidural injection, etc) [D*]. • Activity. Staying active keeps muscles from cramping.
• At 6 weeks and disabled: Consider referral to non-
• Non-medication treatments. Reinforce.
• Medications. Review risks and side effects.
• At 12 weeks and disabled: Consult spine rehabilitation
• Warnings. Seek immediate medical care if true
weakness, sensory loss, bowel or bladder incontinence occur. (All are quite uncommon.) * Levels of evidence for the most significant recommendations:
A=randomized controlled trials; B=controlled trials, no randomization; C=observational trials; D=opinion of expert panel. UMHS Low Back Pain Guideline Update, April, 2003 Table 6. Radiating Low Back Pain: Treatment and Follow-Up
(Sciatica – Pain Below the Knee)
Initial Visit
If at Risk: Chronic Disability Prevention [D*] (Table 2)
• Address barriers. Discuss with patient any barriers to
Diagnostic Tests: Usually none.
Non-Medication Treatment:
• Maintain work. Avoid time off work if at all possible.
• Ice. 20 minutes at a time to the painful area as frequently
• Minimize work restrictions. Consider contacting
employer (with patient permission) to discuss how to • Stretching. Gradual stretching may relieve a cramping
minimize work restrictions. Any restriction should be time limited (e.g., “no lifting over 30 lb. for 2 weeks, then Medication: (See Table 7 for specific medications.)
• Make time contingent. Except for very minor pain, Follow-Up Visits (for patients at risk for chronic disability)
prescribe medications on a time contingent basis (e.g., [D*]: q.i.d.) not on a pain contingent basis [A*]. • Schedule
• Medication strategy. Medication treatment depends on
- If kept out of work: See in 2–3 days, then weekly.
- If moderate pain/restrictions: See patient weekly.
1. Acetaminophen. No studies in acute LBP, Analgesic - If pain resolved and no restrictions: See patient prn
effect is known in other musculoskeletal disorders, and • Early aggressive intervention. At 2-3 weeks of disability
strongly consider referral to a spine rehabilitation team. 2. NSAIDs and COX-2 inhibitors. Not yet been shown to • Future prevention. After episode resolves discuss
be more effective than placebo in acute sciatica [D*]. 3. Acetaminophen with codeine or other narcotic Subsequent Visits
Muscle relaxants. No studies in sciatica [D*]. Activity Limitations:
History and Physical: Update history and physical. If
• Bed rest. Up to 3-5 days of bed rest may provide comfort
diagnostic impression is changed, go to appropriate steps in . Longer duration of bed rest may lead to debilitation. Figure 1. Resume usual activities as soon as possible [D*]. If pain better: Reduce medications, increase activity [D*].
• Work restrictions. Restrict from work depending on
neurologic findings, pain, and work demands [D*]. If no improvement:
• General activity restrictions. Sometimes it is
• At 1-2 weeks [D*] consider physical therapy McKenzie
reasonable to restrict a person from long distance driving, heavy lifting, sitting for prolonged periods, or repetitive • At 2-4 weeks obtain MRI [B*]. If MRI is not diagnostic,
obtain EMG [B*’]. (Plain X-rays are usually not helpful.) • Minimize restrictions. Minimize any activity restrictions
If pathology proven by MRI/EMG: consider acute
by consulting with the patient and possibly the employer physiatric or pain specialist evaluation (for injection about physical demands of the patient’s job and the - If pathology not proven by MRI/EMG: consider
• Timetable. For all activity limits specify an expiration
date and the date of physician follow-up [D*]. If at Risk: Chronic Disability Prevention (Table 2)
Patient Education:
• Patient education: See relevant information under “initial
• Diagnosis. Most likely diagnosis is disk herniation.
Diagnostic tests will not change the initial treatment. Tests • Minimize restrictions
will be ordered if the pain does not change or symptoms • At 6 weeks consider referral to spine rehab program.
Follow-Up (in patient at risk for chronic disability)
• Prognosis. Chances of spontaneous recovery are good. • If kept out of work: See in 2–3 days, then weekly.
About half of people are better within 6 weeks. • If moderate pain/some restrictions: See patient weekly.
• Activity. A few days of bed rest may help with discomfort,
• At 6 weeks and disabled [A*]: Consider referral to spine
but staying active will speed recovery. Avoid highly specialist -- leg pain to surgeon, back pain or psychosocial • Non-medication treatments. Reinforce.
• At 12 weeks and disabled [B*]: Consult spine
• Medications. Review risks and side effects.
rehabilitation program. Consider surgical consultation. • Warnings. Seek medical care if pain or weakness worsens
and seek immediate medical care if bowel or bladder incontinence occurs. * Levels of evidence for the most significant recommendations:
A=randomized controlled trials; B=controlled trials, no randomization; C=observational trials; D=opinion of expert panel. UMHS Low Back Pain Guideline Update, April, 2003 Table 7. Medications for Low Back Pain (Non-Radiating and Radiating) [UMHS Preferred Agents in Bold]
Typical Oral
Cost/Month ($)
Class NSAID
Dose (mg)
Side Effects
Brand Generic
Proprionic Acids
Ibuprofen
Naproxen
Oxaprozin
Carbolic Acids
Diflunisal
Acetic Acids
Diclofenac
Voltaren, Arthrotec
Etodolac
Indomethacin
Risk of headaches Avoid in renal disease Sulindac
Ketorolac
Enolic Acids
Piroxicam
Fenamic Acids
Naphthylkanones
Nabumetone
“Muscle
Cyclobenzaprine Flexeril
Relaxants”
Carisprodol
Baclofen
Diazepam
COX-2 Inhibitor
Celecoxib
Celebrex
For brand drugs, Average Wholesale Price minus 10%. AWP from Amerisource Bergen Wholesale Catalog 10/02. For generic drugs, Maximum Allowable Cost plus $3 from BCBS of Michigan MAC List, 1/15/03. Those generic drugs where MAC is not established, cost is based upon double the Wholesale Acquisition Cost (WAC) from the Amerisource Bergen Wholesale Catalog 10/02 plus $3. Table 8. COX-2 Criteria and Precautions
Patient: 1) has a history of upper GI bleeding 2) is receiving chronic, high dose systemic corticosteroids 5) has a documented intolerance to traditional NSAIDs 6) elderly patients with multiple comorbidities Note: Do not prescribe COX-2s to patients with known coronary heart disease. Exercise extreme caution in prescribing to patients with multiple risk factors for coronary heart disease. UMHS Low Back Pain Guideline Update, April, 2003 Clinical Background (continued)
asymptomatic. In these cases diagnostic tests must be interpreted in conjunction with the clinical history and Acute LBP is the second most common symptomatic reason for office visits to primary care physicians, and the most common reason for office visits to orthopedic surgeons, Finally, a small number of patients will have dangerous neurosurgeons, and occupational medicine physicians. cases of LBP. Cauda equina syndrome – progressive loss Recurrence of LBP is common, 60-80% of patients of nerve function including bowel and bladder continence – is a surgical emergency. Fractures can occur with high velocity impacts or in persons with osteoporosis. A high Financial Impact
index of suspicion is needed to diagnose uncommon problems such as tumors (metastatic more often than
The personal, social, and financial effects of back pain are
primary) and infections such as epidural abscesses or disk substantial. In America the direct annual cost is 40 billion space infections. Systemic disorders including dollars, with indirect costs--lost wages and productivity, polyarthritis, renal stones or infections, aortic aneurysms, legal and insurance overhead, and impact on family--at over nerve diseases, muscle diseases, and various metabolic 100 billion dollars. Important acute care costs result from disorders may present with back pain. Psychiatric diseases over utilization of diagnostic and treatment modalities, and such as hysteria, malingering, or somatization disorders are inappropriate activity restrictions. The small number of persons who become chronically disabled consume 80% of History. The history should answer the following
Acute vs. Chronic Pain Prognosis
• Is it likely that the patient has a serious illness or injury? • Is the patient likely to become chronically disabled? A great majority of persons with non-radiating low back • Is there a disorder, which would benefit from specific pain will have resolution of symptoms within 6 weeks. Half of all persons with radiating low back pain recover • Are there contraindications to certain treatments? spontaneously in the same time period. As time passes, the prognosis worsens to the point where the small group of • Are there social factors such as work or avocation, persons who remain disabled with LBP at three months has less than a 50% chance of recovery, and those out of work at one year have a 10% chance of ever returning to gainful Most serious illnesses or injuries can be detected by asking appropriate questions during the history used to identify "red flags" in the AHCPR guidelines for acute low back pain. Table 1 lists many of these and the underlying conditions that they suggest. Clinical judgment is needed in Rationale for Recommendations
interpreting whether a red flag requires further diagnostic Diagnosis
The history should also assess risk for chronic disability. Diagnostic difficulties. The medical model of "diagnose,
At initial presentation, trained physicians can predict with treat, cure" does not easily fit low back pain, given the state high sensitivity which persons will become chronically of our knowledge. An anatomical diagnosis cannot be disabled by obtaining an adequate social history, as outlined made in most persons. A differential diagnosis of back pain in Table 2. Aggressive interventions to prevent chronic is presented in Table 3 as background. Currently no disability should be focused on this population. diagnostic test can verify the presence of muscle strains, ligament sprains, or small tears of the annulus fibrosis of Physical examination. The physical examination should
the disk, which seem intuitively plausible as causes of pain. Other possible diagnoses such as facet joint arthritis (degenerative joint "disease"), sacroiliac joint asymmetry, Is the pain reproduced in a specific anatomic structure? or disk "bulges" do not correlate statistically with the presence of pain in large populations or with • Are there any clues to a dangerous systemic disorder? reproduction/alleviation of pain on examination or • What is the extent and appropriateness of the patient's General assessment should include areas of back tenderness Other patients fit into well documented syndromes such as and back mobility, including degree of flexion, extension, disk herniation, spondylolisthesis, or spinal stenosis. Even and lateral rotation (see Table 4). The focused examination in these cases the diagnosis is often not simple. For includes the testing of muscle strength, reflexes, and range example one-third of asymptomatic volunteers have disk of motion. The strength examination should overcome the changes on MRI. The correlation of spinal canal diameter strength of each muscle in order to assess its full and symptoms is highly variable in stenosis patients. Low- innervation. Especially in subtle cases, determination of a grade spondylolisthesis noted on x-ray are most often UMHS Low Back Pain Guideline Update, April, 2003 true radiculopathy is more certain when two muscles from acute LBP. In the absence of red flags and high index of different nerves, but the same root, and the corresponding suspicion, or of increasing pain and weakness, imaging reflex are all abnormal. Neurologic deficits in multiple studies are usually not helpful during the first 3-4 weeks of roots suggest more serious spinal or neurologic disorders. back symptoms. If low back symptoms persist for more than 4-6 weeks, further evaluation may be indicated. If The L-5 innervated medial hamstring reflex is not radicular symptoms (leg pain and weakness) persist commonly taught. With the patient prone or sitting with undiminished for more than 4 weeks, further evaluation is knees bent to 90 degrees, one hand palpates to locate the strongly indicated. Reevaluation begins with a review and medial hamstring tendon (posterior knee). A reflex update of the history and physical exam to assess again for hammer in the other hand briskly percusses the first hand. red flags or evidence of nonspinal conditions causing back Hamstring contraction is palpated and knee flexion may be observed. The reflex is facilitated by having the patient activate the hamstring (flex the knee) slightly. MRI, CT, CT-myelography. The use of these imaging tests for patients with acute low back problems is to define Reproduction of pain in a specific anatomical structure medically or surgically remediable pathological conditions. provides some assurance that the lesion is "mechanical" as Imaging studies must be interpreted in conjunction with the opposed to a systemic disorder. It may hint at a specific clinical history and physical examination. In one study, spinal disorder. Palpation of the spine and flexion and MRI showed significant degenerative change and extension of the spine are common maneuvers to encroachment into the spinal canal in more than 50% of differentiate between mechanical and systemic disorders. asymptomatic older persons; the incidence of asymptomatic herniated discs was approximately 20% in persons in their A positive straight leg test requires pain radiation below the 30’s. The imaging findings may not be significant unless knee. The straight leg raise test detects over 90% of they correlate with the findings on physical examination. clinically significant radiculopathies due to disk herniation, and the femoral stretch test is about 50% sensitive for less These tests should in general be used only for patients who present with one of these three clinical situations: (CT scans are to be avoided during pregnancy. Consultation The examination also includes Gordon Waddel's five "non- with a radiologist is strongly advised when considering organic pain" signs. If 3 or more of these 5 "Waddel" signs are present, then it is likely that there is a psychogenic component to the patient’s pain behavior. 1) History and clinical examination findings or other test results suggesting other serious conditions affecting 2. Simulated testing. Positive when pain is reported with the spine such as suggesting cauda equina syndrome, axial loading (pressing on top of the head) or rotation spinal fracture, infection, tumor, or other mass lesions with the pelvis and shoulders in the same plane. 3. Distracted testing. Test straight leg raise while 2) Patients limited by radiating low back pain for more distracted when sitting. (e.g. extend knee in sitting than 4 weeks with physiologic evidence of nerve root position while appearing to be performing a Babinski compromise and symptoms/disability severe enough to consider injection or surgical intervention. 4. Superficial, nonanatomical or variable tenderness. 3) A history of neurogenic claudication and other When skin rolling over the back markedly increases the findings in elderly patients suggesting spinal stenosis pain. Mark areas of tenderness and examine later for with symptoms severe enough to consider injection or 5. Nonanatomical motor or sensory disturbances. Positive when sensory loss does not follow a For patients with acute low back problems who have had dermatome or entire leg is numb or without strength or prior back surgery, MRI with contrast appears to be the when there is a “ratchety” giveway on strength testing. imaging test of choice to distinguish disc herniation from scar tissue associated with prior surgery. Presence of two or more of these findings correlates with poor surgical outcome, but not rehabilitation outcome. It is EMG. EMG testing is not recommended if the incorrect to interpret them as specific for malingering, diagnosis of radiculopathy is obvious on the clinical exam. which is an uncommon disorder. In a primary care setting EMG results may be unreliable in detecting subtle nerve they are best viewed as a warning that the patient's report of damage until a patient has had significant radiculopathy for pain will not be a reliable guide to treatment success, and over 3 weeks. EMG may be used to help delineate that the patient is at risk for becoming chronically disabled. abnormal neurological exams in patients with risk factors for neuropathy (e.g. alcohol or diabetes). Diagnostic tests. A complete blood count (CBC) and
erythrocyte sedimentation rate (ESR) are sufficiently Following imaging studies, EMG of the lower limb and inexpensive and efficacious for use as initial tests when paraspinal muscles may be helpful in the following there is suspicion of cancer or infection as the cause of UMHS Low Back Pain Guideline Update, April, 2003 LBP. Back schools may be more effective in an industrial 1) in patients limited by radiating low back pain for more than 4 weeks without clear evidence on imaging Ice and Heat. Self-applied ice (in a plastic bag wrapped in
2) for patients whose imaging study demonstrates lesions a moist towel, and applied for 20 minutes at a time) that do not correlate with the clinical picture (the false temporarily decreases pain and has an anti-inflammatory effect. Heat (in the form of a warm shower, bath, or hot 3) for persons with radiating pain or neurological deficits pack) and counterirritants (such as “deep” heating in the absence of imaging findings of disc herniation compounds) distract the patient from the pain, and may to assess for neuropathies, radiculitis, and focal nerve injuries which can mimic radiating low back pain. 4) for patients with abnormal MRI at multiple levels Spinal manipulation. Spinal manipulation (by
where clinical examination does not clarify the level of chiropractors, osteopathic physicians, or specially-trained physical therapists) has been shown in randomized controlled trials to provide symptomatic relief for low back x-rays. Plain x-rays are not recommended for pain. Relief is rapid and patient satisfaction high, but routine evaluation of patients with acute low back problems multiple treatments are typically provided. However, in within the first 4-6 weeks of symptoms unless a red flag trials to date, manipulation does not improve function (e.g. and high index of suspicion is noted on clinical evaluation. return to work, decreased disabilities indexes). Plain x-rays are recommended for ruling out fractures in patients with acute low back problems when any of the Exercises. McKenzie exercises—a program of specific
following red flags are present: recent significant trauma conditioning exercises, usually involving trunk extension, (any age), recent mild trauma (patient over age 50), history which strives to “centralize” pain—may be effective in of prolonged steroid use, osteoporosis, patient over age 70). relieving radiating LBP. A program of gradually increased Plain x-rays in combination with CBC and ESR may be aerobic and back-strengthening exercises may help prevent useful for ruling out tumor or infection in patients with debilitation due to inactivity. Aerobic exercise programs, acute low back problems when any of the following red which minimally stress the back (walking, biking, or flags are present: prior prolonged steroid use, low back swimming), can be started during the first 2 weeks for most pain worse at night and with rest, unexplained weight loss. patients with acute LBP. Recommending exercise quotas In the presence of red flags, especially for tumor or that are gradually increased result in better outcomes than infection, the use of other imaging studies such as bone telling patients to stop exercising if pain occurs. scan, CT or MRI may be clinically indicated even if plain x-ray is negative. The use of lumbar x-rays to screen for Other treatments. More complex physical modalities such
spinal degenerative changes, scoliosis, spondylolysis, as ultrasound, diathermy, phonophoresis or iontophoresis of spondylolisthesis, or congenital anomalies very rarely adds medications, transcutaneous electrical nerve stimulators useful clinical information. X-rays are to be avoided in (TENS), and others have not been shown to be of benefit. When applied by a therapist, these increase cost Scan. A bone scan is recommended to evaluate acute low back problems when spinal tumor, infection, or Shock absorbing shoe inserts may be of benefit to persons occult fracture is suspected from positive “red flags”. Bone whose work involves long periods of standing on hard surfaces. Lumbar corsets or belts have no supportive effect, and most literature suggests that they are ineffective. Treatment
Patient education. Exactly what to teach is not proven. In
Activity limitations. Strong evidence shows that bed rest
one study educating patients to resume usual activity was is not an effective treatment option for acute LBP. both safe and therapeutic and led to less work disability, Maintaining usual activities has been shown to improve less pain, and less health care utilization. One randomized recovery. It may be appropriate in some circumstances to controlled trial showed patients receiving educational limit physical activity, upon weighing the nature of a booklets had significantly fewer subsequent follow-up visits patient’s work and the severity of the pain. Since pain is over the next year than control populations. Substantial not objectively quantified, and the physician is typically not literature elsewhere in medicine indicates that physician expert in the patient’s work situation, the patient’s education can have a positive effect on a disease process. knowledge of these factors should be taken into account in Lack of clear physician communication regarding the cause of the patient’s LBP may prolong recovery and is a frequent Length of time off work is directly correlated with the risk of long-term disability. Thus a number of measures should Several randomized controlled trials have shown be taken to minimize activity limitations. Activity contradictory results regarding “back schools” in acute limitations should be for a specific time period. Before UMHS Low Back Pain Guideline Update, April, 2003 taking a patient off of work completely, the physician might Injections. Epidural steroid injections for the radiating
consider communicating with the employer to see if light pain of disk herniations or spinal stenosis may be of some duty or limited hours are available. Workplace benefit in decreasing radiating leg pain, however the effect modification improves return to work rates and decreases on long-term outcome is not clear. Steroid injections into disability time. Consultation with an occupational therapist the facet joints and sacroiliac joints do not appear to have or other allied health professional with expertise in job site significant effect when completed outside the confines of a evaluation should be considered. Patients should be comprehensive rehabilitation program. Trigger point followed frequently through any period of time off work. injections with local anesthetic, “dry needling”, and botulinum toxin injections have been shown to have short- Medications. Commonly used medications are listed in
term effectiveness in the management of low back pain. Table 7. Certain medications have been shown to decrease the discomfort of acute low back pain. None has been Surgery. Since many patients with radiating pain get better
shown to decrease disability or change the natural history of within the first few weeks, surgery is usually not considered until a patient has failed at least 4 weeks of aggressive conservative treatment. Patients with progressive Acetaminophen has not been studied in acute low back neurologic deficits require emergent surgical evaluation. pain, but it should be considered based on its effectiveness Patients with pain radiating below the knee, positive in other disorders and its low side effect and cost profile neurologic findings, and disk herniation on imaging studies have faster relief of symptoms with surgery as opposed to Nonsteroidal anti-inflammatory drugs (NSAIDs) are more conservative treatment. For disk herniation, long-term effective than placebo in patients with uncomplicated acute outcome is not statistically different between surgically and LBP, but not in patients with acute sciatica. The choice of conservatively treated patients. The length of disability can NSAID depends on cost and side effect profile. be considerably shortened by surgical intervention. Patients with symptomatic spondylolisthesis, spinal stenosis, and Traditional NSAIDs should be recommended over COX-2 segmental hypermobility may also respond to surgery. inhibitors in most patients. When patients taking a COX-2 inhibitor were compared to patients taking traditional Counseling. The effect of psychosocial counseling on
NSAIDs, short-term (6 months) gastrointestinal side effects most persons with acute back pain is not known. Reactive were less, but were no different at one year follow up. depression and anxiety may occur and are effectively Differences in the rate of serious GI side effects are most treated with medication and counseling. Patients with pronounced in patients with a history of peptic ulcer and premorbid personality, thought or mood disorders may have gastrointestinal bleeding. Conditions warranting the use of exacerbations. Counseling may be of benefit for these COX-2 inhibitors are summarized in Table 8. COX-2 patients. Biofeedback and self-hypnosis, often taught by inhibitors are significantly more expensive than counselors, have not been shown to have an effect on acute acetaminophen or ibuprofen (see Table 7). Rofecoxib (Vioxx) was withdrawn from the market in 9/2004 and valdecoxib (Bextra) in 4/2005 by the manufacturers due to Multidisciplinary rehabilitation. Two randomized
evidence that they increase risk of cardiovascular events. controlled trials have shown that complex rehabilitation programs are effect for persons that are disabled by “Muscle relaxants” used for back pain appear to have no subacute (6-12 week) or chronic (≥ 12 week) back pain. direct effect on skeletal muscle, yet a number of them have Psychosocial evaluation can identify patients likely to have been shown to be more effective than placebo in relieving chronic back pain. These individuals are candidates for LBP. However, muscle relaxants have been proven not to multi-disciplinary rehabilitation programs. These programs be more effective than NSAIDs. Drowsiness is a common, typically involve a team of physical therapists, occupational therapists, psychologists, social workers or vocational counselors, and physiatrists. These programs involve Opiate analgesics have not been shown to be more effective intensive exercise and counseling, which are probably not than NSAIDs in acute LBP. Side effects of drowsiness, cost effective in the acute stage. Less intensive addiction, and constipation need to be considered. rehabilitation efforts including “work hardening” and “work conditioning” may be effective in the subacute 6-12 week Other drugs. The literature does not support the use of oral period. Cognitive-behavioral therapy is also effective in steroids and tricyclic antidepressants in the treatment of patients with subacute low back pain, resulting in a acute LBP. Patients with psychological risk factors for significant reduction of the time of disability. subacute and chronic low back pain have decreased duration of disability with the use of SSRI anti-depressants. Chronic pain is better managed with norepinephrigenic antidepressants when other health issues allow. Gabapentin has resulted in decreased pain intensity and duration in chronic low back pain. UMHS Low Back Pain Guideline Update, April, 2003 Special Circumstances
Possible causes for back pain including radiating low back Primary Prevention
Screening. In a healthy population there is no utility for
screening x-rays and little utility for screening physical
examination. Since employees who are unable to perform • Sciatic nerve or lumbar plexus pressure by the uterus. the basic physical requirements of physically demanding jobs are more likely to be injured than others, it is thought Unproven, but possibly effective non-pharmacologic that physical fitness for the job is an important, but reversible risk factor. Factors such as obesity, mild to moderate scoliosis, and a number of common congenital Prophylactic initiation of low back stretching exercises anomalies are not strongly predictive of back pain. A • Conditioning and exercise, especially exercise in the history of LBP is a predictor of future back ache, but since back ache is so common in the population, this is typically not a useful screen. Previous back surgery also predicts the • Job and activity modification including bed rest Preventive interventions. Prevention interventions that
are probably effective include:
• Judicious use of heat: heating pad, hot packs, shower, • Back extensor muscle strength [C*] • Smoking cessation affects outcome [C*] • Supportive devices such as “prenatal cradles” or • Psychosocial demands should be addressed [C*] • Job satisfaction issues should be addressed [C*] • General aerobic and strengthening exercises Medications are limited and should be appropriate for a pregnant woman. A consultation with a radiologist is strongly advised when considering an MRI scan during Modification of work design (job modification). • Back supports are ineffective in preventing work • Avoid NSAIDs during first and third trimesters Back schools have not shown effectiveness in Narcotic pain medication (acetaminophen/codeine) • Epidural steroids can be considered before surgery. In older women or persons at risk for osteoporosis, trunk extension exercises are preventive, while trunk flexion exercises may increase the risk of osteoporotic fractures. Orthotic devices such as braces or back belts are probably Pregnant women with back pain may want to discuss with their obstetrical care provider different positions, strategies, and methods of pain relief. This may include anesthesia consultation, or referral to hospital or community based Recurrent Low Back Pain
prophylactic back classes specifically designed for pregnancy. For diagnostic testing, MRI and EMG may be Most persons who have an episode of back pain will have performed if necessary. In general, x-rays and CT scans are recurrences within the year. As long as they are similar in nature and not more severe, treatments previously used can be re-instituted. Patients who have recurrent, activity limiting acute episodes over a longer period of time may Controversial Areas
require further diagnostic and treatment efforts, and perhaps consultation with a specialist. Alternative / Complimentary Medicine
(Note: manual or manipulative medicine is discussed under Pregnancy and Low Back Pain
About 50% of pregnant women will have a significant About 40% of Americans with a low back pain first seek complaint of back ache. Pregnant women who have low help from an alternative health care provider. Because of back pain will likely have an increase in complaints through the considerable variation of the techniques applied and the the pregnancy. Risk of back pain increases after delivery. strong placebo effect, it is difficult to measure the effect of such interventions. Many alternative medicine treatments UMHS Low Back Pain Guideline Update, April, 2003 are not thought to be clinically or cost effective following a brief trial. Ineffectiveness was noted for prolotherapy The literature search for the current update was based on a (injecting neutral substance, e.g. dextrose, into connective supplemental Medline search of literature from 1997 tissue structures to decrease pain and increase stability), through the fall of 2002. The population was adults and the magnet therapy, and acupuncture [A*]. results were limited to English language. The major keywords were: low back pain and back pain and low Work Restrictions and Disability Ratings
back. Additional search terms were: chronic disease, chronic back pain, risk, diagnosis, diagnostic use, therapy, Clinical judgment or the advice of an expert may be helpful therapeutic use, clinical trials, and guidelines. The search when the physician is asked to provide permanent was a single cycle. Also included were guidelines on low back pain listed at the National Guideline Clearinghouse and reviews on low back pain in the Cochrane Database of There is little or no correlation between legal disability Systematic Reviews. When possible, conclusions were rating systems (such as the AMA Guidelines to Physical based on prospective randomized clinical trials. In the Impairment or a number of other state compensation absence of randomized controlled trials, observational systems) and actual future risk of injury or disability. studies were considered. If none were available, expert There is little literature to support specific work restrictions for any specific spinal disorder. The literature supports better outcomes with early return to work. It is clear, Disclosures
however, that heavy lifting, twisting, and seated vibration (as in a car or truck) are risk factors for back pain. Clinical The University of Michigan Health System endorses the judgment is needed in determining work restrictions. Guidelines of the Association of American Medical Permanent work restrictions should be given based on Colleges and the Standards of the Accreditation Council for objective findings on physical examination and diagnostic Continuing Medical Education that the individuals who tests. Multidisciplinary evaluations may document physical present educational activities disclose significant abilities, but reversible causes for limited performance, relationships with commercial companies whose products including deconditioning or psychosocial factors must be or services are discussed. Disclosure of a relationship is not intended to suggest bias in the information presented, but is made to provide readers with information that might be of potential importance to their evaluation of the information What the Patient Should Know
The important educational points for patients with non- radiating and with radiating pain are listed in Tables 5 and 6 Providing good educational handouts is also important. One study demonstrated that providing a more detailed booklet produced a better result than providing a simple Strategy for Literature Search
Annotated References
The literature search for the 1997 guideline was based on major reviews and a supplemental search. Three prominent Van Tulder, MW Koes, BW Bouter, LM. Conservative consensus panels funded by the Canadian Province of treatment of acute and chronic nonspecific low back pain: Quebec, The British Royal College of General A systematic review of randomized controlled trails of the Practitioners, and the United States Agency for Health Care most common interventions. In: Spine (1997) 22(18): Policy and Research (AHCPR) have performed exhaustive reviews of the back pain literature for their practice guidelines for acute back pain. A critique of the AHCPR Excellent evaluation of LBP treatment studies. The guidelines (Gonzalez, I. The Nonsurgical Management of quality of the studies is rated and findings summarized in Acute Low Back Pain. Demos Vermande. New York, 1997) was also reviewed. To supplement these references a Medline literature search was performed for the five years Spitzer WO, LeBlanc FE, Dupuis M, et al. Scientific 1992 through 1996, which including the terms: low back approach to the assessment and management of activity pain, diagnosis, treatment, chronic low back pain, related spinal disorders: A monogram for clinicians. guidelines, and controlled trials. 12 UMHS Low Back Pain Guideline Update, April, 2003 Report of the Quebec task force on spinal disorders. Spine Linton SJ and Andersson T. Can chronic disability be prevented: A randomized trial of a cognitive-behavior "The Quebec Study" is the first major governmental intervention and two forms of information for patients with attempt to provide an evidence-based consensus on spinal pain. Spine 2000; 25(21):2825-31. treatment of low back pain. It did not systematically This study demonstrated that early intervention that assesses and changes patients’ behaviors and beliefs to improve coping can lower risk of long-term disability. AHCPR management guidelines for acute low back pain. 1994, The Agency for Health Care Policy and Research, U.S. Department of Health and Human Services. The AHCPR guidelines used the Quebec study conclusions and added more recent data. HTTP://www.AHCPR.gov Waddell G, et al. Clinical Guidelines for the Management of Acute Low Back Pain: Low Back Pain Evidence Review. 1996 London Royal College of General Practitioners The RCGP guidelines reviewed and sometimes disagreed with the AHCPR guidelines, updated the literature search, and performed separate analyses of some parts of the literature, added emphasis on detection and prevention of chronic disability. HTTP://www.rcgp.org.uk/backpain/index.htm Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine 1995;20:473-7. This randomized controlled trial of Norwegians who were disabled due to subacute low back pain involved an individual discussion and educational visit in which an expert physician who showed the patient why the use of body mechanics and activity restrictions could be harmful, and how resuming usual activity was both safe and therapeutic. Controls and treated patients continued usual treatment aside from this visit. Three-year follow-up showed 50% less work disability, less pain, and less health care utilization in the treated group. Hazzard RG, Haugh LD, Reid S, Preble JB, MacDonald L. Early prediction of chronic disability after occupational low back injury. Spine 1996, 21(8);945-951. Hazard et al. showed that an 8-item questionnaire was 94% sensitive and 84% specific in predicting whether persons presenting for their first visit for backache would be working 3 months later. Others, listed in the RCGP review, have demonstrated other risk factors. Haldorsen EM, Gradsal AL, Skouen JS, Risa Ae, Kronholm K, Ursin H. Is there a right treatment for a particular patient group: Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. Pain 2002; 95(1-2):49-63. This randomized controlled trial in Norway demonstrated that patients with a poorer prognosis for return to work are more likely to benefit from intensive treatment. UMHS Low Back Pain Guideline Update, April, 2003

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