Welcome to Welcome and Overview Bill McCarberg Founder Chronic Pain Management Program Kaiser Permanente San Diego California Adjunct Assistant Clinical Professor University of California ID: 568252
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Slide1
Low Back Pain: Evaluation, Management, and Prognosis
Welcome toSlide2
Welcome
and Overview
Bill McCarbergFounderChronic Pain Management Program
Kaiser Permanente
San Diego, California
Adjunct Assistant Clinical Professor
University of California
School of Medicine
San Diego, CaliforniaSlide3
Evidence-Based Evaluation of Patients With
Low Back Pain
Slide4
Learning Objective
Discuss the differential diagnosis for low back pain (LBP) and the importance of clinical red and yellow flags in evaluation of LBPSlide5
Low Back Pain Guidelines
In 2007, the American College of Physicians (ACP) and American Pain Society (APS) issued comprehensive joint clinical practice guidelines for diagnosis and treatment of LBP
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491.Slide6
Guideline #1
Clinicians should conduct a focused history and physical examination to help place patients with LBP into 1 of 3 broad categories
Nonspecific LBPBack pain potentially associated with radiculopathy or spinal stenosis Back pain potentially associated with another specific spinal cause
The history should include assessment of psychosocial risk factors, which predict risk
for chronic disabling back pain
Strong recommendation
Moderate-quality evidence
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491.Slide7
Focused History and
Physical Examination Determine presence and level of
neurological involvement1,2Classify patients into 3 broad categories
Nonspecific LBP potentially associated with radiculopathy
Spinal stenosis
Back pain potentially associated with another specific spinal cause
Patients with serious or progressive neurologic deficits
or underlying conditions requiring prompt evaluation
Tumor
Infection
Cauda equina syndrome
Patients with other conditions that may respond to
specific treatments
Ankylosing spondylitis
Vertebral compression fracture
1.
Deyo
RA, et al.
JAMA.
1992;268(6):760-765.
2.
Bigos
SJ, et al.
Acute Low Back Problems in Adults. Clinical Practice Guideline, No. 14
; 1994.Slide8
Evaluation of Back Pain
SiteLength of illness
SpreadQualityIntensity
Frequency
Duration
Time of onset
Mode of onset
Precipitating factors
Aggravating factors
Relieving factors
Associated features
McGuirk
BE, et al. In:
Ballantyne
J, Fishman S and
Bonica
JJ, eds.
Bonica's
Management of Pain
. 2010:1094-1105.Slide9
Epidemiology of Low Back Pain
90% of American adults experience an episode of back pain during their lifetime
Of patients who have acute back pain 90% to 95% have a non–life-threatening conditionAlthough up to 85% cannot be given an exact diagnosis, nearly all recover within 4 to 6 weeks
For 5% to 10% of patients, acute back pain
is a manifestation of more serious pathology
Vascular catastrophes, malignancy, spinal
cord compressive syndromes, and infectious
disease processes
Winters ME, et al.
Med Clin North Am.
2006;90(3):505-523.Slide10
What Is Seen in Primary
Care Practice?In minority of patients presenting for initial evaluation
in primary care setting, LBP is caused by1Cancer (approximately 0.7% of cases)
Compression fracture (4%)
Spinal infection (0.01%)
Estimates for prevalence of ankylosing spondylitis
in primary care patients range from 0.3%1 to 5%
2
Spinal stenosis and symptomatic herniated disc are present in about 3% and 4% of patients, respectively
Cauda equina syndrome most commonly associated with massive midline disc herniation, but rare
Estimated prevalence of 0.04%
3
1.
Jarvik
JG, et al.
Ann Intern Med.
2002;137(7):586-597.
2. Underwood MR, et al.
Br J
Rheumatol
.
1995;34(11):1074-1077.
3.
Deyo
RA, et al.
JAMA.
1992;268(6):760-765.Slide11
Cost of Low Back Pain
LBP is one of top 10 reasons patients seek care from family physicians1
Prevalence of LBP has varied from 7.6% to 37%Peak prevalence between 45 and 60 years of age
2
Also reported by adolescents and by adults of all ages
80% of adults seek care at some time for acute LBP
3
One-third of US disability costs are due to low
back disorders
3
Direct costs of diagnosing and treating LBP in United States estimated in 1991 to be $25
*
billion annually
4
Indirect costs, including lost earnings, are even higher
4
Proper diagnosis and appropriate treatment of LBP saves healthcare resources, relieves suffering
*40 billon in 2008 using Consumer Price Index to compute the relative value of money.
1. AAFP.
Facts About Family Practice
; 1996.
2. Borenstein DG.
Curr Opin Rheumatol.
1997;9(2):144-150.
3. Kuritzky L, et al.
Prim Care Rep
1995;1:29-38.
4. Frymoyer JW, et al.
Orthop Clin North Am.
1991;22(2):263-271.Slide12
Etiology of Low Back Pain
Nonspecific LBPBack pain potentially associated
with radiculopathy or spinal stenosis Back pain potentially associated with another specific spinal cause
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491.Slide13
Structural Sources of Low Back Pain
Muscles of the back1,2
Interspinous ligaments2-4Zygapophyseal joints
5-7
Sacroiliac joint(s)
8
Intervertebral discs
9-12
Mechanical
12
or chemical irritation
of dura mater
13
1. Kellgren JH.
Clin Sci.
1938;3:175-190.
2. Bogduk N.
Med J Aust.
1980;2(10):537-541.
3. Kellgren JH.
Clin Sci.
1939;4:35-46.
4. Feinstein B, et al.
J Bone Joint Surg Am.
1954;36-A(5):981-997.
5. Mooney V, et al.
Clin Orthop Relat Res.
1976(115):149-156.
6. McCall IW, et al.
Spine (Phila Pa 1976).
1979;4(5):441-446.
7. Fukui S, et al.
Clin J Pain.
1997;13(4):303-307.
8. Fortin JD, et al.
Spine (Phila Pa 1976).
1994;19(13):1475-1482.
9. Wilberg G.
Acta Orthop Scand.
1947;19:211-221.
10. Falconer MA, et al.
J Neurol Neurosurg Psychiatry.
1948;11(1):13-26.
11. Kuslich SD, et al.
Orthop Clin North Am.
1991;22(2):181-187.
12. O'Neill CW, et al.
Spine (Phila Pa 1976).
2002;27(24):2776-2781.
13. El-Mahdi MA, et al.
Neurochirurgia (Stuttg).
1981;24(4):137-141.Slide14
Causes of Low Back Pain
Possible sources of back pain have been demonstrated; causes have been
more elusiveRefuted: conditions traditionally considered to be possible causes are actually not causes
Eg, spondylolysis, spondylolisthesis, degenerative changes (spondylosis)
Accepted: tumors and infections
Untested: muscle sprain, ligament sprain, segmental dysfunction, and trigger points
Known source, unknown cause: sacroiliac joints, zygapophyseal joints, internal disc disruption
McGuirk
BE, et al. In:
Ballantyne
J, Fishman S and
Bonica
JJ, eds.
Bonica's
Management of Pain
. 2010:1105-1122.Slide15
Diagnostic Triage Guides Subsequent Decision-Making
Inquire about Location of pain
Frequency of symptomsDuration of painHistory of previous symptoms, treatment,
and response to treatment
Consider possibility of LBP due to problems outside the back
Pancreatitis
Nephrolithiasis
Aortic aneurysm
Systemic illnesses (eg, endocarditis or
viral syndromes)Slide16
Differential Diagnosis
for Acute Low Back Pain
Disease or Condition
Patient Age (Years)
Location
of Pain
Quality of Pain
Aggravating or
Relieving Factors
Signs
Back strain
20-40
Low back, buttock, posterior thigh
Ache, spasm
Increased with activity or bending
Local tenderness, limited spinal motion
Acute disc herniation
30-50
Low back to lower leg
Sharp, shooting,
or burning pain; paresthesia in leg
Decreased with standing; increased with bending or sitting
Positive straight leg
raise test, weakness, asymmetric reflexes
Osteoarthritis or spinal stenosis
30-50
Low back to lower leg; often bilateral
Ache, shooting
pain, “pins and needles” sensation
Increased with walking, especially up an incline; decreased with sitting
Mild decrease in
extension of spine;
may have weakness
or asymmetric reflexes
Spondylolisthesis
Any age
Back, posterior thigh
Ache
Increased with activity or bending
Exaggeration of the lumbar curve, palpable “step off” (defect between spinous processes), tight hamstrings
Ankylosing spondylitis
15-40
Sacroiliac joints,
lumbar spine
Ache
Morning stiffnessDecreased back motion, tenderness over sacroiliac jointsInfectionAny ageLumbar spine, sacrumSharp pain, acheVariesFever, percussive tenderness; may have neurologic abnormalities or decreased motionMalignancy>50Affected bone(s)Dull ache, throbbing pain; slowly progressiveIncreased with recumbency or coughMay have localized tenderness, neurologic signs, or fever
Adapted from: Patel AT, et al.
Am
Fam
Physician.
2000;61(6):1779-1786.Slide17
Guideline #2
Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific LBP
Strong recommendationModerate-quality evidence
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491.Slide18
Plain X-Rays for Low Back Pain
There is no evidence that routine plain radiography in patients with nonspecific LBP is associated with a greater improvement in patient outcomes than selective imaging
1-3 Exposure to unnecessary ionizing radiation should be avoided, particularly in young women (amount of gonadal radiation from obtaining a single plain radiograph [2 views] of the lumbar spine is equivalent to daily chest radiograph for more than 1 year)
4
Routine advanced imaging (computed tomography [CT]
or magnetic resonance imaging [MRI]) is not associated with improved patient outcomes,
5
identifies radiographic abnormalities poorly correlated with symptoms,
6
and could lead to additional, possibly unnecessary interventions
7,8
1.
Deyo
RA, et al.
Arch Intern Med.
1987;147(1):141-145.
2. Kendrick D, et al.
BMJ.
2001;322(7283):400-405.
3. Kerry S, et al.
Br J Gen
Pract
.
2002;52(479):469-474
.
4.
Jarvik
JG.
Neuroimaging
Clin
N Am.
2003;13(2):293-305.
5. Gilbert FJ, et al.
Radiology.
2004;231(2):343-351.
6.
Jarvik
JG, et al.
Ann Intern Med.
2002;137(7):586-597.
7.
Jarvik
JG, et al.
JAMA. 2003;289(21):2810-2818. 8. Lurie JD, et al. Spine (Phila Pa 1976). 2003;28(6):616-620. Slide19
Plain X-Rays for Low Back Pain
(cont.)Plain radiography is recommended for initial evaluation of possible vertebral compression fracture in select high-risk patients, such as those with a history of osteoporosis or steroid use
1 Evidence to guide optimal imaging strategies is
not available for LBP that persists for more than
1 to 2 months if there are no symptoms suggesting radiculopathy or spinal stenosis, although plain radiography may be a reasonable initial option
(see recommendation 4 for imaging recommendations in patients with symptoms suggesting radiculopathy
or spinal stenosis)
2
Thermography and electrophysiologic testing are
not recommended for evaluation of nonspecific LBP
Jarvik
JG, et al.
Ann Intern Med.
2002;137(7):586-597.
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491. Slide20
Guideline #3
Clinicians should perform diagnostic imaging and testing for patients with LBP when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination
Strong recommendationModerate-quality evidence
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491. Slide21
CT or MRI Diagnostic Imaging
Prompt work-up with MRI or CT is recommended if severe or progressive neurologic deficits or suspected serious underlying condition; delayed diagnosis
and treatment associated with poorer outcomes1-3
MRI is generally preferred over CT if available; does not use ionizing radiation, provides better visualization of soft tissue, vertebral marrow, and the spinal canal
4
1. Loblaw DA, et al.
J
Clin
Oncol
.
2005;23(9):2028-2037.
2. Todd NV.
Br J
Neurosurg
.
2005;19(4):301-306.
3.
Tsiodras
S, et al.
Clin
Orthop
Relat
Res.
2006;444:38-50.
4.
Jarvik
JG, et al.
Ann Intern Med.
2002;137(7):586-597. Slide22
CT or MRI Diagnostic Imaging
(cont.)There is insufficient evidence to guide diagnostic strategies in patients who have risk factors for cancer
but no signs of spinal cord compressionProposed strategies generally recommend plain radiography or measurement of erythrocyte sedimentation rate3
, with MRI reserved for patients
with abnormalities on initial testing
1,2
Alternative strategy is to directly perform MRI
in patients with a history of cancer, the strongest predictor of vertebral cancer;
2
for patients older than
50 without other risk factors for cancer, delaying imaging while offering standard treatments and reevaluating within 1 month may also be a reasonable option
4
1.
Jarvik
JG, et al.
Ann Intern Med.
2002;137(7):586-597.
2.
Joines
JD, et al.
J Gen Intern Med.
2001;16(1):14-23
.
3. van den
Hoogen
HM, et al.
Spine (
Phila
Pa 1976).
1995;20(3):318-327.
4. Suarez-
Almazor
ME, et al.
JAMA.
1997;277(22):1782-1786. Slide23
Guideline #4
Clinicians should evaluate patients with persistent LBP and signs or symptoms or radiculopathy or spinal stenosis with MRI (preferred) or CT only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy)
Strong recommendationModerate-quality evidence
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491. Slide24
Imaging for Low Back Pain
The natural history of lumbar disc herniation with radiculopathy in most patients is for improvement within the first 4 weeks with noninvasive management1,2
There is no compelling evidence that routine imaging effects treatment decisions or improves outcomes3
For prolapsed lumbar disc with persistent radicular symptoms despite noninvasive therapy, discectomy
or epidural steroids are potential treatment options
4-8
Surgery is also a treatment option for persistent symptoms associated with spinal stenosis
9-12
1.
Vroomen
PC, et al.
Br J Gen
Pract
.
2002;52(475):119-123.
2. Weber H.
Spine (
Phila
Pa 1976).
1983;8(2):131-140.
3.
Modic
MT, et al.
Radiology.
2005;237(2):597-604.
4. Gibson JN, et al.
Cochrane Database
Syst
Rev.
2000(3):CD001350.
5. Gibson JN, et al.
Cochrane Database
Syst
Rev.
2005(4):CD001352.
6.
Nelemans
PJ, et al.
Spine (
Phila
Pa 1976).
2001;26(5):501-515.
7.
Peul
WC, et al. N Engl J Med. 2007;356(22):2245-2256. 8. Weinstein JN, et al. JAMA. 2006;296(20):2451-2459. 9. Amundsen T, et al. Spine (Phila Pa 1976). 2000;25(11):1424-1435. 10. Atlas SJ, et al. Spine (Phila Pa 1976). 2005;30(8):936-943. 11. Weinstein JN, et al. N Engl J Med. 2007;356(22):2257-2270. 12. Malmivaara A, et al. Spine (Phila Pa 1976). 2007;32(1):1-8. Slide25
MRI for Low Back Pain
MRI (preferred if available) or CT is recommended for evaluating patients with persistent back and leg pain who are potential candidates for invasive interventions
Plain radiography cannot visualize discs or accurately evaluate the degree of spinal stenosis1 However, clinicians should be aware that findings on MRI or CT (such as bulging disc without nerve root impingement) are often nonspecific
Recommendations for specific invasive interventions, interpretation of radiographic findings, and additional work-up beyond scope of guideline, but decisions should be based on clinical correlation between symptoms and radiographic findings, severity of symptoms, patient preferences, surgical risks,
and costs and will generally require specialist input
2
1. Jarvik JG, et al.
Ann Intern Med.
2002;137(7):586-597.
2. Chou R, et al.
Ann Intern Med.
2007;147(7):478-491.Slide26
Critical Clinical Indicators
of PathologyIn patients with back and leg pain, a typical history for sciatica (back and leg pain in
a typical lumbar nerve root distribution) has a fairly high sensitivity, but uncertain specificity for herniated disc
1,2
>90% of symptomatic lumbar disc herniations (back and leg pain due to a prolapsed lumbar disc compressing a nerve root) occur at L4/L5 and L5/S1 levels
3
1. van den
Hoogen
HM, et al.
Spine (
Phila
Pa 1976).
1995;20(3):318-327.
2.
Vroomen
PC, et al.
J Neurol.
1999;246(10):899-906.
3. Chou R, et al.
Ann Intern Med.
2007;147(7):478-491. Slide27
Critical Clinical Indicators
of Pathology (cont.)
A focused examination that includes straight-leg-raise testing and a neurologic examination that includes evaluation of knee strength and reflexes (L4 nerve root), great toe and foot dorsiflexion strength (L5 nerve root), foot plantarflexion and ankle reflexes
(S1 nerve root), and distribution of sensory symptoms should be done to assess the presence and severity of nerve root dysfunction
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491.Slide28
Critical Clinical Indicators
of Pathology (cont.)
A positive result on straight-leg-raise test (defined as reproduction of the patient’s sciatica between 30 and 70 degrees of leg elevation) has a relatively high sensitivity (91% [95% CI, 82% to 94%]), but modest specificity (26%
[CI, 16% to 38%])
for diagnosing herniated disc
Crossed straight-leg-raise test is more specific (88%
[CI, 86% to 90%])
, but
less sensitive (29%
[CI, 24% to 34%])
Deville WL, et al.
Spine (
Phila
Pa 1976).
2000;25(9):1140-1147.Slide29
Critical Clinical Indicators
of Pathology (cont.)
All patients should be evaluated forPresence of rapidly progressive or severe neurologic deficits
Motor deficits at more than 1 level, fecal incontinence, and bladder dysfunction
Most frequent finding in cauda
equina syndrome is urinary retention (90% sensitivity)
Without urinary retention, probability
is approximately 1 in 10,000
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491.
Deyo
RA, et al.
JAMA.
1992;268(6):760-765.Slide30
Yellow Flags
Identify psychosocial problems in acute phase
Slow progress to recovery may be due to undetected, or unrevealed
psychosocial factors
Pertain to patient's beliefs and behaviors
concerning physical activity and domestic,
social, and vocational responsibilities
Example: patient believes physical activity might harm back, make pain worse, so avoids activities
Most destructive is aversion to work
Belief that work caused pain, work aggravates pain, work is too heavy, and work should not be done
McGuirk
BE, et al. In:
Ballantyne
J, Fishman S and
Bonica
JJ, eds.
Bonica's
Management of Pain
. 2010:1094-1105.Slide31
Psychosocial Factors
of Low Back PainStronger predictors of LBP outcomes than either physical findings or severity/duration of pain
1-3Assessment of psychosocial factors identifies patients who
may have delayed recovery and could help target interventions
1 trial in referral setting found intensive multidisciplinary rehabilitation more effective than usual care in patients with acute or subacute LBP identified
as having risk factors for chronic back pain disability
4
Direct evidence on effective primary care interventions for identifying and treating such factors in patients with acute LBP
is lacking
5,6
Evidence is currently insufficient to recommend optimal methods for assessing psychosocial factors and emotional distress
7
However, psychosocial factors that may predict poorer LBP outcomes include presence of depression, passive coping strategies, job dissatisfaction, higher disability levels, disputed compensation claims, or somatization
8-10
1.
Pengel
LH, et al.
BMJ.
2003;327(7410):323.
2.
Fayad
F, et al.
Ann Readapt Med Phys.
2004;47(4):179-189.
3.
Pincus
T, et al.
Spine (
Phila
Pa 1976).
2002;27(5):E109-120
.
4.
Gatchel
RJ, et al.
J
Occup
Rehabil
.
2003;13(1):1-9.
5.
Hay EM, et al.
Lancet.
2005;365(9476):2024-2030. 6. Jellema P, et al. BMJ. 2005;331(7508):84.7. Chou R, et al. Ann Intern Med. 2007;147(7):478-491. 8. Steenstra IA, et al. Occup Environ Med. 2005;62(12):851-860. 9. Deyo RA, et al. Spine (Phila Pa 1976). 2006;31(23):2724-2727. 10. Carey TS, et al. Spine (Phila Pa 1976). 1996;21(3):339-344. Slide32
Red Flags of Lower Back Pain
History
Gradual onset of back painAge <20 years or >50 years
Thoracic back pain
Pain lasting longer than 6 weeks
History of trauma
Fever/chills/night sweats
Unintentional weight loss
Pain worse with recumbency
Pain worse at night
Unrelenting pain despite supratherapeutic doses of analgesics
History of malignancy
History of immunosuppression
Recent procedure causing bacteremia
History of intravenous drug use
Physical Examination
Fever
Hypotension
Extreme hypertension
Pale, ashen appearance
Pulsatile abdominal mass
Pulse amplitude differentials
Spinous process tenderness
Focal neurologic signs
Acute urinary retention
Winters ME, et al.
Med
Clin
North Am.
2006;90(3):505-523.Slide33
Risk for Chronicity
Vertebral infectionIntravenous drug use, recent infection
Vertebral compression fracture Older age, history of osteoporosis, and steroid use
Musculoskeletal
Inactivity
In general
Emotional distressSlide34
Cancer-Related Risk Factors
Large, prospective study from a primary
care settingHistory of cancer (positive likelihood ratio, 14.7)Unexplained weight loss (positive likelihood ratio, 2.7)
Failure to improve after 1 month (positive likelihood ratio, 3.0)
Age >50 years (positive likelihood ratio, 2.7)
Posttest probability of cancer increases from approximately 0.7% to 9% in patients with a history
of cancer (not including nonmelanoma skin cancer)
In patients with any 1 of the other 3 risk factors,
the likelihood of cancer only increases to approximately 1.2%
Deyo
RA, et al.
J Gen Intern Med.
1988;3(3):230-238.Slide35
Non-Cancer-Related Risk Factors
Features predicting vertebral infection not well studied, but may include fever, intravenous drug use, or
recent infection1 Consider risk factors for vertebral compression fracture, such as older age, history of osteoporosis, and steroid use; and for ankylosing spondylitis, such as younger age, morning stiffness, improvement with exercise, alternating buttock pain, and awakening due to back pain during the second part of the night only
2
Clinicians should be aware that criteria for diagnosing early ankylosing spondylitis (before the development
of radiographic abnormalities) are evolving
3
1.
Jarvik
JG, et al.
Ann Intern Med.
2002;137(7):586-597.
2.
Rudwaleit
M, et al.
Arthritis Rheum.
2006;54(2):569-578.
3.
Rudwaleit
M, et al.
Arthritis Rheum.
2005;52(4):1000-1008. Slide36
Racial/Cultural Aspects
of AssessmentTo communicate effectively with all patients
Always use simple words, not medical jargonDetermine what the patient/caregiver already knows or believes about his/her health situationEncourage questions by asking, “What questions do you have?” (allows for an open-ended response), instead of “Do you have any questions?” (allows for a “no” response, ending the conversation)
Use the “teach-back” method to confirm the level of understanding: Ask patients/family members to restate what was just communicated in the appointment or meeting
Zacharoff
KL.
Cross-Cultural Pain Management: Effective Treatment of Pain in the Hispanic Population;
2009.Slide37
Culturally Competent Care
Ensure that patients/consumers receive effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and
preferred languageImplement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area
Ensure that staff, at all levels and across all disciplines, receives ongoing education and training in CLAS delivery
USDHHS OMH.
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care
; 2001.Slide38
Avoiding Racial and Cultural Bias per Knox H. Todd, MD, MPH
Make pain assessment mandatoryGive a nonopioid analgesic at triage
Track reasons for unscheduled returnsAudit for ethnic biasConsider which pain scales should
be used
Use multilingual laminated cards
Todd KH.
Medical Ethics Advisor.
1999.Slide39
Pearls for Practice
Categorize patients into 1 of 3 broad groups: nonspecific low back pain, back pain potentially associated with radiculopathy
or spinal stenosis, or back pain potentially associated with another specific spinal cause Evaluate psychosocial risk factors to predict the risk for chronic, disabling low back pain Provide patients with evidence-based information on expected course of low back pain, effective self-care options, and recommend that they be physically active
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491. Slide40
Please pass your question card
to a staff member.
?
Questions?Slide41
Treatment of
Low Back Pain: Pharmacologic and Nonpharmacologic Options
Roger Chou, MD, FACPAssociate Professor of Medicine,Department of Medicine
Department of Medical Informatics
and Clinical Epidemiology
Oregon Health & Science UniversitySlide42
Disclosure: Roger Chou, MD, FACP
Dr. Chou has disclosed that he has no actual or potential conflict
of interest in regard to this activityHis presentation will include off-label discussion of anticonvulsants, benzodiazepines, and tricyclic antidepressants for the treatment
of low back pain (LBP)Slide43
Learning Objective
Integrate evidence-based pharmacologic and nonpharmacologic therapies into a comprehensive treatment plan for chronic LBPSlide44
Low Back Pain Burden
LBP is the fifth most common reason for US office visits, and the second most common symptomatic reason1-2
$90.7 billion dollars in total healthcare expenditures in 19983LBP is the most common cause for activity limitations in persons under the age of 45
4
1. Hart LG, et al.
Spine (Phila Pa 1976).
1995;20(1):11-19.
2. Deyo RA, et al.
Spine (Phila Pa 1976).
2006;31(23):2724-2727.
3. Luo X, et al.
Spine (Phila Pa 1976).
2004;29(1):79-86.
4. Von Korff M, et al.
Spine (Phila Pa 1976).
1996;21(24):2833-2837
.Slide45
Weinstein JN, et al.
Spine (
Phila Pa 1976). 2006;31(23):2707-2714.
Increasing Rates of Back Surgery
Trends in Rates of
Discectomy
/
Laminectomy
and Fusion in 1992-2003
US Average Rate of Discharges
per 1000 Medicare EnrolleesSlide46
Increasing Rates of Back Injections
SI=sacroiliac.
Friedly
J, et al.
Spine (
Phila
Pa 1976).
2007;32(16):1754-1760.
Lumbosacral
Injection Rates by Year: Age- and Sex-Adjusted per 100,000
553.4
79.7
2055.2
263.9
212.3Slide47
Increasing Costs
Martin BI, et al.
JAMA. 2008;299(6):656-664.
Year
Mean ($)Slide48
Rising Prevalence of Chronic LBP
CI=confidence interval. PRR=prevalence rate ratio.
*The PRRs and CI were estimated via bootstrapping; 97.5% CIs were reported rather than to assume normality.
**Unable to estimate owing to
scall
cell count (n<5).
Freburger
JK, et al.
Arch Intern Med.
2009;169(3):251-258.
Characteristic
1992
(n=8067)
2006
(n=9924)
% Increase
PRR
(2.5-97.5% CI)*
Total
3.9 (3.4-4.4)
10.2 (9.3-11.0)
162
2.62 (2.21-3.13)
Sex
Male
2.9 (2.2-3.6)
8.0 (6.8-9.2)
176
2.76 (2.11-3.75)
Female
4.8 (4.0-5.6)
12.2 (10.9-13.5)
154
2.54 (2.13-3.08)
Age (Years)
21-34
1.4 (0.8-2.0)
4.3 (3.0-5.6)
201
3.01 (1.95-5.17)
35-44
4.8 (3.3-6.3)
9.2 (7.2-11.2)
92
1.92 (1.35-2.86)
45-544.2 (3.0-5.5)13.5 (11.4-15.7)2193.19 (2.29-4.59) 55-646.3 (4.2-8.3)15.4 (12.8-17.9)1462.46 (1.73-3.50) 655.9 (4.5-7.3)12.3 (10.2-14.4)1092.09 (1.62-2.84)Race/Ethnicity
Non-Hispanic White
4.1 (3.5-4.7)
10.5 (9.4-11.5)
155
2.55 (2.13-3.05)
Non-Hispanic Black
3.0 (2.0-4.0)
9.8 (8.2-11.4)
226
3.26 (2.32-4.96)
Hispanic
**
6.3 (3.8-8.9)
Other
4.1 (1.4-6.8)
9.1 (6.0-12.0)
120
2.20 (1.16-6.99)
Prevalence of Chronic Low Back Pain in North Carolina, 1992 and 2006
% Prevalence (95% CI)
1992: 3.9%
2006: 10.2%Slide49
Practice Patterns
Spine surgery rates in the US are the highest in the worldRates in the US 5 times higher than in the UK
20-fold variation in fusion: 4.6 per 1000 in Idaho Falls to 0.2 per 1000 in Bangor, MaineInterventional therapies are also
widely used
Intradiscal electrothermal therapy estimated
at 7000-10,000 annually
20-fold variation in epidural steroid injections: 104 per 1000 in Palm Springs to 5.6 per 1000
in Honolulu
Deyo
RA, et al.
Clin
Orthop
Relat
Res.
2006;443:139-146.
Weinstein JN, et al.
Spine (
Phila
Pa 1976).
2006;31(23):2707-2714.Slide50
“7 Back Pain Breakthroughs:
Are you hurting? Here’s help.”
Reader’s Digest
July 2007
End Back
Pain Agony
(Michael J. Weiss)
Weiss MJ.
Reader's Digest.
July, 2007.Slide51
Reader’s Digest
“Cures” for Low Back Pain
“Cures” based on anecdotal evidence, not yet approved, and/or only in animal studiesInfrared belt: $2335“Magic Spinal Wand”
Percutaneous automatic discectomy
Flexible fusion
Stem cells
Site-directed bone growth
New bed
Based on an unpublished observational study funded by a sleep products trade group
Weiss MJ.
Reader's Digest.
July, 2007.Slide52
Low Back Pain Guidelines Project
Overview and Timeline
Began 2004; primary care guidelines published October 2007Address both acute and chronic LBP, and nonspecific LBP and LBP with radiculopathy or spinal stenosis
Guideline for interventional therapies/surgery published May 2009
Partnership between the American Pain Society
and the American College of Physicians (ACP)
Funded by the American Pain Society
Multidisciplinary panel with 25 members;
over 15 specialties/organizations represented
Series of 3 face-to-face meetings to
develop guidelines
Consensus achieved for all recommendationsSlide53
Recommendation Grid
ACP Methods
Quality of Evidence
Benefits Do or Do Not Clearly Outweigh Risks
Benefits and Risks and Burdens Finely Balanced
High
Strong
Weak
Moderate
Strong
Weak
Low
Strong
Weak
Insufficient
I
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491.
Strength of RecommendationSlide54
Basic Principles of Selecting Therapy for Low Back Pain
For most LBP, labeling with a specific etiology doesn’t help inform therapy choices
Most patients with acute LBP will improve regardless of which therapy is chosenFor chronic LBP, therapies are moderately effective at bestUse interventions with proven efficacy
Noninvasive approaches to most LBP
Consider psychosocial factorsSlide55
Recommendation
Treatment of Low Back Pain
Provide patients with evidence-based information about their expected course, advise patients to remain active, and provide information about effective self-care optionsStrong recommendation
Moderate-quality evidence
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491.Slide56
Advice and Self-Care
for Low Back PainInform patients of generally favorable prognosis of acute LBP with or without sciatica
Discuss need for re-evaluation if not improvedAdvise to remain activeConsider self-care education books
Superficial heat moderately effective for
acute LBP
No evidence to support use of lumbar supports
Firm mattresses inferior to medium-firm mattresses (1 RCT)
RCT=randomized controlled trial.Slide57
Recommendation
Treatment of Low Back Pain
Consider the use of medications with proven benefits in conjunction with back care information and self-care … for most patients, first-line medication options are acetaminophen or NSAIDsStrong recommendationModerate-quality evidence
NSAIDs=
nonsteroidal
anti-inflammatory drugs.
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491.Slide58
Pharmacologic Interventions
Chou R, et al.
Ann Intern Med. 2007;147(7):478-491.
Chou R, et al.
Ann Intern Med.
2007;147(7):505-514.
This information includes a use that has not been approved by the US FDA.
Drug
Net Benefit
Level of Evidence
Acetaminophen
Small to moderate
Fair
Skeletal muscle relaxants
Moderate
(for acute LBP only)
Good
NSAIDs
Moderate
Good
Tricyclic
antidepressants
Small to moderate
(for chronic LBP only)
GoodSlide59
Pharmacologic Interventions
(cont.)
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Chou R, et al.
Ann Intern Med.
2007;147(7):505-514.
This information includes a use that has not been approved by the US FDA.
Drug
Net Benefit
Level of Evidence
Opioids
and
tramadol
Moderate
Fair
Benzodiazepines
Moderate
Fair
Antiepileptic medications
Small
(for
radiculopathy
only)
Fair
Systemic steroids
No benefit
GoodSlide60
Recommendation
Treatment of Low Back PainFor patients who do not improve with
self-care options, consider the addition of nonpharmacologic therapy with proven benefitsFor chronic or subacute LBP, options includeIntensive interdisciplinary
rehabilitation
Exercise therapy
Acupuncture
Massage therapy
Chou R, et al.
Ann Intern Med.
2007;147(7):478-491.
Spinal manipulation
Yoga
Cognitive-behavioral
therapy
Progressive relaxation
Weak recommendation
Moderate-quality evidenceSlide61
Noninvasive Interventions for Chronic or Subacute LBP
Intervention
Net Benefit
Level of Evidence
Behavioral therapy
Moderate
Good
Exercise therapy
Moderate
Good
Spinal manipulation
Moderate
Good
Acupuncture
Moderate
Fair
Chou R, et al.
Ann Intern Med.
2007;147(7):492-504.Slide62
Noninvasive Interventions for Chronic or Subacute LBP (cont.)
Intervention
Net Benefit
Level of Evidence
Massage
Moderate
Fair
Yoga
Moderate
Fair
(for
Viniyoga
)
Back schools
Small
Fair
Traction
No benefit
Fair
Interferential therapy,
lumbar supports, short-wave diathermy, TENS, ultrasound
Unclear
Poor
TENS=
transcutaneous
electrical nerve stimulation.
Chou R, et al.
Ann Intern Med.
2007;147(7):492-504.Slide63
Recommendation
Interventional Therapies for
Nonradicular
Low Back Pain
In patients with persistent nonradicular LBP, facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injection are not recommended
Strong recommendation
Moderate-quality evidence
There is insufficient evidence to adequately evaluate benefits of other interventional therapies for nonradicular LBP
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1066-1077.Slide64
Interventional Therapies for
Nonradicular Low Back PainInterventional therapies not proven to be effective in placebo-controlled, randomized trials
No trials (SI joint injection), trials showing no benefit (facet joint injection), inconsistent results (IDET, RFDN), or poor-quality evidence (trigger point injections)Promising results from nonrandomized studies not replicated in randomized trials
IDET
Facet joint steroid injection
Not clear if interventions are ineffective,
or if patients were not accurately selected
IDET=
intradiscal
electrothermal
therapy.
RFDN=radiofrequency
denervation
.
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1066-1077.Slide65
Placebo-Controlled Trials of RFDN
for Presumed Facet Joint Pain
Study
Sample Size
Selection
Quality
Benefits
Gallagher, 1994
41
Uncontrolled block
Poor quality
Can’t tell
Leclaire, 2001
70
Uncontrolled block
No major issues
No
Nath, 2008
40
Controlled block
Baseline differences
(1.6 points
for pain)
1.5 points for leg pain,
NS for back pain
Tekin, 2007
60
Clinical criteria
Poor quality
<1 point for pain,
0.5 points for function
van Kleef, 1999
30
Uncontrolled block
No major issues
1-2 point for pain
and function
van Wijk, 2005
81
Uncontrolled block
Technical issues?
No
NS=not significant.Slide66
Placebo-Controlled Trials of RFDN
for Presumed Facet Joint Pain
Study
Sample Size
Selection
Quality
Benefits
Gallagher, 1994
41
Uncontrolled block
Poor quality
Can’t tell
Leclaire, 2001
70
Uncontrolled block
No major issues
No
Nath, 2008
40
Controlled block
Baseline differences
(1.6 points
for pain)
1.5 points for leg pain,
NS for back pain
Tekin, 2007
60
Clinical criteria
Poor quality
<1 point for pain,
0.5 points for function
van Kleef, 1999
30
Uncontrolled block
No major issues
1-2 point for pain
and function
van Wijk, 2005
81
Uncontrolled block
Technical issues?
NoSlide67
Placebo-Controlled Trials of RFDN
for Presumed Facet Joint Pain (cont.)
Study
Sample Size
Selection
Quality
Benefits
Leclaire
, 2001
70
Uncontrolled block
No major issues
No
Nath
, 2008
40
Controlled block
Baseline differences
(1.6 points
for pain)
1.5 points for leg pain,
NS for back pain
van
Kleef
, 1999
30
Uncontrolled block
No major issues
1-2 point for pain
and functionSlide68
Recommendation
Surgery for
Nonradicular
Low Back Pain
In patients with nonradicular LBP, common degenerative spinal changes, and persistent and disabling symptoms … discuss risks and benefits of surgery as an option
Weak recommendation
High-quality evidence
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1066-1077.Slide69
Surgery for Nonradicular Low Back Pain With Degenerative Changes
Benefits vary depending on comparatorBenefits of fusion vs standard nonsurgical therapy
less than 15 points on a 100-point pain or function scale (1 RCT)No difference vs intensive interdisciplinary rehabilitation (3 RCTs)All enrollees failed >1 year of nonsurgical management and are not at higher risk for poor surgical outcomes
Fewer than half experience optimal outcomes
(relief of pain, return to work, decreased analgesic use)
No evidence that instrumentation improves outcomes
Shared decision-making approach recommended
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1066-1077.
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1094-1109.Slide70
Recommendation
Interventional Therapies
for
Radicular
LBP
In patients with persistent radiculopathy due to herniated lumbar disc … discuss risks and benefits of epidural steroid injection as an option
Weak recommendation
Moderate-quality evidence
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1066-1077.Slide71
Interventional Therapies for Radiculopathy/Prolapsed Disc
Epidural steroid injectionShort-term benefits in some higher-quality trials, but data are inconsistent (could be related to comparator used in trials)
No long-term benefitsNo route clearly superior
Limited evidence of no benefit for
spinal stenosis
Shared decision-making
approach recommended
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1066-1077.Slide72
Recommendation
Surgery for
Radicular
Low Back Pain and Spinal
Stenosis
In patients with persistent radiculopathy due to herniated lumbar disc or persistent and disabling leg pain due
to spinal stenosis … discuss risks
and benefits of surgery as an option
Strong recommendation
High-quality evidence
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1066-1077.Slide73
Surgery for Herniated Disc
With RadiculopathyDiscectomy associated with more
rapid improvement in symptoms than nonsurgical therapyPatients improved either with or without surgery
No progressive neurologic deficits without
immediate surgery
Long-term (after 1-2 years) outcomes similar
in some trials
Most trials evaluated standard open discectomy
or microdiscectomy
Shared decision-making approach recommended
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1066-1077.
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1094-1109.Slide74
Surgery for Spinal Stenosis
Decompressive laminectomy associated with superior outcomes vs nonsurgical therapy
Mild improvement with nonsurgical therapyNo severe neurologic deficits without immediate surgery
Benefits may diminish with long-term
(>2 years) follow-up
Shared decision-making approach recommended
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1066-1077.
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1094-1109.Slide75
Conclusions
The quality of evidence for different LBP therapies variesA number of therapies appear similarly
and moderately effective for LBPGuidelines can provide clinicians with a useful framework for choosing therapiesFactors that influence choices from recommended therapies include patient preferences, availability, and costs
Shared decision-making can help make decisions consistent with patient values
and preferencesSlide76
Please pass your question card
to a staff member.
?
Questions?Slide77
Current Understanding of the Prevention
of Chronicity of Low Back Pain
Bill McCarberg, MD
Founder, Chronic Pain Management Program
Kaiser Permanente San Diego
Adjunct Assistant Clinical Professor,
University of California, San DiegoSlide78
Disclosure: Bill McCarberg, MD
Dr. McCarberg’s presentation will not include discussion of off-label, experimental, and/or investigational uses of drugs or devices
Type
Company
Speakers Bureau
Abbott Laboratories; Cephalon, Inc.; Eli Lilly and Company;
Endo
Pharmaceuticals; Forest Pharmaceuticals; King Pharmaceuticals;
Ligand Pharmaceuticals, Inc.; Merck & Co., Inc.; Mylan Pharmaceuticals, Inc.; Pfizer, Inc.; PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc.; Purdue Pharma LPSlide79
Learning Objective
Evaluate early interventions for acute back pain in patients considered at high risk for transition to chronic low back pain (CLBP)Slide80
Disability from Back Pain
The minority of cases which involve disability account for a disproportionate percentage of overall healthcare costs
The most cost-effective approach is to more aggressively pursue secondary prevention efforts on
subacute patients
before chronic disability is fully established
1
Acute: <3 weeks
Subacute: >3 weeks but <3 months
Chronic: >3 months, or more than 6 episodes
in 12 months
1. Waddell G, et al.
Occup Med (Lond).
2001;51(2):124-135.Slide81
Adverse Prognostic Indicators
Yellow flags are psychosocial indicators suggesting increased risk
of progression to long-term distress, disability, and pain Can be applied more broadly to assess likelihood of development of persistent problems from acute pain presentation
Yellow flags can relate to the patient’s attitudes and beliefs, emotions, behaviors, family, and workplace
Kendall NA.
Baillieres Best Pract Res Clin Rheumatol.
1999;13(3):545-554.Slide82
Risk Factors for Chronic Low Back Pain:
Yellow FlagsBelief that pain and activity are harmful
“Sickness behavior” such as extended restBodily preoccupation and catastrophic thinking
Low or negative mood, anxiety, social withdrawal
Personal problems (eg, marital, financial, etc)
History of substance abuse
Problems/dissatisfaction with work (“blue flags”)
Overprotective family/lack of support
History of disability and other claims
Inappropriate expectations of treatment
Low expectation of active participation
The presence of yellow flags highlights the need to address specific psychosocial factors as part of a multimodal management approachSlide83
Additional Risk Factors
for ChronicityPrevious history of low back pain
AgeNerve root involvementPoor physical fitness
Self-rated health poor
Heavy manual labor, inability for light duty upon return to work (“black flags”)
Ongoing medico-legal actions
Obesity
*
Smoking
*
*
No evidence for efficacy of smoking cessation or nonoperative weight loss as interventions for CLBP.
Wai EK, et al.
Spine J.
2008;8(1):195-202.Slide84
Interventional Therapies
Do Not Prevent ChronicityAdditionally, regardless of the comparator intervention, there is
no convincing evidence that epidural steroids are associated with long-term benefits or reduced rates of subsequent surgery
Chou R, et al.
Spine (
Phila
Pa 1976).
2009;34(10):1066-1077.
Level of Evidence and Summary Grades for Interdisciplinary Rehabilitation, Injections,
Other Interventional Therapies, and Surgery for Patients With Nonradicular LBP
Intervention
Condition
Level of Evidence
Net Benefit
Grade
Interdisciplinary rehabilitation
Nonspecific LBP
Good
Moderate
B
Prolotherapy
Nonspecific LBP
Good
No benefit
D
Intradiscal steroid injection
Presumed discogenic pain
Good
No benefit
D
Fusion surgery
Nonradicular LBP
with common
dengerative changes
Fair
Moderate vs standard nonsurgical therapy, no difference vs
intensive rehabilitation
B
Facet joint steroid injection
Presumed facet joint pain
Fair
No benefit
D
Botulinum toxin injection
Nonspecific LBP
PoorUnable to estimateILocal injectionsNonspecific LBPPoorUnable to estimateIEpidural steroid injectionNonspecific LBPPoorUnable to estimateIMedial branch block (therapeutic)Presumed facet joint pain
Poor
Unable to estimate
I
Sacroiliac joint
steroid injection
Presumed sacroiliac
joint pain
Poor
Unable to estimate
ISlide85
The Fear-Avoidance Model
of Chronic Pain
Leeuw M, et al.
J Behav Med.
2007;30(1):77-94.
Vlaeyen JW, et al.
Pain.
2000;85(3):317-332
.
Pain
Anxiety
Hypervigilance
Preventative
Motivation
Arousal
Fear
of Pain
Threat Perception
Defensive
Motivation
Arousal
Confrontation
Recovery
Injury
Disuse
Disability
Depression
Avoidance
Escape
Catastrophizing
Negative Affectivity
Threatening Illness Information
Low Fear
Pain ExperienceSlide86
Assessment of
Fear-Avoidance BehaviorsPain Catastrophizing Scale (PCS)
113 itemsFear of Pain Questionnaire (FPQ)
2
30 items
Fear-Avoidance Beliefs Questionnaire (FABQ)
3
16 items
Coping Strategies Questionnaire (CSQ)
4
42 items
1.
Sullivan MJL, et al.
Psychological Assessment.
1995;7(4):524-532
.
2.
McNeil DW, et al.
J
Behav
Med.
1998;21(4):389-410
.
3.
Waddell G, et al.
Pain.
1993;52(2):157-168
.
4.
Rosenstiel
AK, et al.
Pain.
1983;17(1):33-44
.Slide87
Reducing Catastrophizing
Numerous interventions appear effectiveCognitive-behavioral therapies
1-4Physiotherapy and other activity-based interventions
5
Intensive patient education and
exposure interventions
6,
7
Limited understanding of the mechanisms by which changes in catastrophizing occur
1.
Linton SJ, et al.
Pain.
2001;90(1-2):83-90
.
2.
Basler
HD, et al.
Patient
Educ
Couns
.
1997;31(2):113-124.
3.
Vlaeyen
JW, et al.
Pain Res
Manag
.
2002;7(3):144-153.
4.
Hoffman BM, et al.
Health Psychol.
2007;26(1):1-9
.
5.
Smeets RJ, et al.
J Pain.
2006;7(4):261-271
.
6. Moseley GL, et al.
Clin J Pain.
2004;20(5):324-330.
7. Leeuw M, et al.
Pain. 2008;138(1):192-207.Slide88
Comprehensive Interventions With High-Risk Patients Show Promise
High-risk patients identified with SCID
Intensive interdisciplinary team intervention4 major components: psychology, physical therapy, occupational therapy, and case managementPhysical therapy sessions: both individual and group exercise classes
Biofeedback/pain management sessions
Group didactic sessions
Case manager/occupational therapy sessions
Interventions spaced over a 3-week period
SCID=Structured Clinical Interview for DSM-IV Disorders.
Gatchel RJ, et al.
J Occup Rehabil.
2003;13(1):1-9.Slide89
Early Intensive
Intervention Effectiveness*Chi-square analysis. **ANOVA.
HR-I=high-risk intervention group. HR-NI=high-risk nonintervention group. LR=low-risk group.Gatchel RJ, et al. J Occup Rehabil.
2003;13(1):1-9.
Long-Term Outcome Results at 12-Month Follow-Up
Outcome Measure
HR-I
(n=22)
HR-NI
(n=48)
LR
(n=54)
p-Value
% return to work at follow-up*
91%
69%
87%
.027
Average number of healthcare visits regardless of reason**
25.6
28.8
12.4
.004
Average number of healthcare visits related to LBP**
17.0
27.3
9.3
.004
Average number of disability days due to back pain**
38.2
102.4
20.8
.001
Average of self-rated most “intense pain” at 12-month follow-up (0-100 scale)**
46.4
67.3
44.8
.001
Average of self-rated pain over last 3 months (0-100 scale)**
26.8
43.1
25.7
.001
% currently taking narcotic analgesics*
27.3%
43.8%18.5%.020% currently taking psychotropic medication4.5%16.7%1.9%.019Slide90
Most Recent Preventing
Chronicity Study (April 2009)First-onset, subacute LBP patients
Behavioral medicine intervention (n=34)Four 1-hour individual treatment sessions includedEducation about back function and pain
Systematic graduated increases in physical exercise
to quota with feedback
Planning and contracting activities of daily living
Self-management and problem-solving training to cope
with pain
Contingent reinforcement of active functioning and nonreinforcement of pain behaviors
Vocational counseling, as needed
Compared to “attention control” group (n=33)
Slater MA, et al.
Arch Phys Med
Rehabil
.
2009;90(4):545-552.Slide91
Most Recent Preventing
Chronicity Study (April 2009) (cont.)
Chi square analysis comparing proportions recovered at 6 months after pain onset for behavioral medicine and attention control participants found rates 54% vs 23% for those completing all 4 sessions and
6-month follow-up
(p=.02)
Conclusions:
early intervention using a behavioral medicine rehabilitation approach may enhance recovery and reduce chronic pain and disability in patients with first-onset, subacute LBP
Slater MA, et al.
Arch Phys Med
Rehabil
.
2009;90(4):545-552.Slide92
Key Impact Factors in Back Disability Prevention
Spread of Rankings for Impact Provided by Key Stakeholders (N=33)
at the End of a Consensus Process (Round 3)
Guzman J, et al.
Spine (
Phila
Pa 1976).
2007;32(7):807-815.
2
12
10
4
6
8
0
1. Provider Reassurance
2. Recovery Expectation
3. Fears
4. Knowledge
5. Appropriate Care
6. Disability Management
7. Self-Management
8. Case Management
9. Temporary Duties
10. Alternative Care
11. Back Supports
Rankings by Panel
} p=.055
} p=.045
} p<.001
} p<.001Slide93
Provider Reassurance
Tell patients your plan and
your expectationsSet reasonable expectations with patient buy-in
Reassure severity of acute pain does not correlate with outcome or duration
Follow up regularly to check response to treatment
Reassess for further diagnostic
of therapeutic optionsSlide94
Summary
Psychosocial aspects of pain and pain perception significantly influence
patient outcomesAssessing for yellow flags and identifying patients at high risk of chronicity early in
pain process (subacute) yields best chance for intervention and possible prevention
Multiple psychosocial and physical interventions appear promising; aggressive/
intensive intervention seems most important
Nurture the therapeutic relationship with
shared expectations and goals of treatmentSlide95
?
Questions?Slide96
Question and
Answer SessionSlide97
Low Back Pain: Evaluation, Management, and Prognosis
Thank You for Attending