New guidelines on back pain seen as collaborative effort

The recommendations are intended to help primary care physicians sort through the options available to diagnose and treat this common condition.

By Susan J. Landers — Posted Nov. 5, 2007

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Two physician organizations have produced what are considered by many to be the first comprehensive national guidelines since 1994 on the diagnosis and treatment of acute low back pain, when a federal directive on the same topic caused a furor that resulted in congressional hearings and the government's stepping out of the guidelines business.

So far, the blueprint published in the Oct. 2 Annals of Internal Medicine has not generated the same controversy as the earlier venture, which came under fire by those who favored a surgical approach to alleviate back pain. The new document, available online (link), was spearheaded by the American College of Physicians and the American Pain Society and is intended to aid primary care physicians in handling this common condition.

The two organizations enlisted the help of numerous specialty physician groups, including spine surgeons, and weighed evidence offered in hundreds of published studies. The process took more than two years.

This time around, the guidelines -- which ironically make many of the same recommendations as did those put forward 13 years ago -- are enjoying the support of groups that condemned the earlier effort made by the Agency for Health Care Policy and Research, the predecessor of the Agency for Healthcare Research and Quality.

What changed in the intervening years is the mounting evidence in support of the recommendations.

What has not changed is the prevalence of back pain. The condition is second only to headaches as the most common neurological ailment in the United States. It is also the most common cause of job-related disability and is a leading cause of missed work, according to the National Center for Health Statistics, which asks about back pain in its National Health Interview Survey.

The guidelines include an algorithm to guide doctors in obtaining and interpreting data during the first patient visit to place those with back pain in groups ranging from nonspecific low back pain -- 85% fall into this group -- to pain associated with conditions such as spinal stenosis and sciatica or to pain thought to be caused by cancer or infections.

Why new guidelines?

"We wanted to review all the evidence and develop guidance for clinicians and give our patients a realistic sense of what they can expect when they visit a clinician for low back pain," said Amir Qaseem, MD, PhD, senior medical associate in the ACP Dept. of Clinical Programs and Quality of Care and an author of the guidelines.

The groups were not dissuaded from their task by the 1994 ruckus, said Roger Chou, MD, the director of the pain society's clinical guidelines program. He was also an author of the latest document. "We really felt it was time to update the guidelines, because there has been a ton of new evidence since 1994."

Plus, the lead groups worked hard to assemble the many stakeholders who diagnose and treat acute low back pain, he noted. "They range from surgeons to anesthesiologists to primary care physicians to chiropractors to physical therapists and psychologists," he said. "We had 14 or 15 disciplines represented."

Consensus was achieved for all seven recommendations, Dr. Chou said. "We tried to ground things as much as we could in the evidence. So it is pretty bulletproof from that perspective."

The guidelines probably include the most comprehensive review of the evidence on diagnosing and treating low back pain since the 1994 effort, said Jeffrey Susman, MD, a professor and chair of family medicine at the University of Cincinnati College of Medicine. He served on the panel that developed the earlier guidelines.

Both documents arrived at the same basic take-home message, he noted: "Treating low back pain is a case of more is less, and we should be parsimonious in our diagnosis and management."

The new set is "first rate" and valuable for primary care physicians, said Richard Deyo, MD, MPH, professor of family medicine at the Oregon Health and Science University in Portland. Dr. Deyo also served on the 1994 guidelines panel. "Primary care doctors can't do the kind of extensive literature searching and appraisal of those articles that this group has done," he said.

Surgeons also found the new directive of value. "This is a very good attempt at gathering the plethora of information we have out there guiding us on what we should do with a patient with acute back pain," said Arya Nick Shamie, MD, assistant professor of orthopedic surgery and neurosurgery at the University of California, Los Angeles and a spokesman for the American Academy of Orthopaedic Surgeons.

Good for primary care

This set of principles is "extraordinarily educational to primary care physicians," agreed William Watters, MD, chair of the evidence-based guidelines committee at the North American Spine Society. The spine society was one group that had campaigned hard against the earlier guidelines and the agency that developed them.

Today's situation is entirely different from that of 1994, Dr. Watters said. "Guidelines are being created now in a very different fashion than they were even that short time ago," he said. "Any reasonable guidelines today will be evidence-based in order to even get published."

The next ACP/APS back pain guidelines, due to be published next year, will cover surgical procedures, a more challenging area because the evidence isn't as strong, Dr. Chou said.

Dr. Deyo wondered whether the release of this next set could cause an uproar and said, "I think the controversy has to do with the parts that haven't been published yet."

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Pain, pain, go away

The American College of Physicians and the American Pain Society developed clinical guidelines intended to help primary care physicians diagnose and treat low back pain. The recommendations include:

  • Conduct a physical examination and focused history, including assessment of psychosocial risk factors, to help place patients with low back pain into one of three broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific cause such as cancer or infection.
  • Do not routinely obtain imaging or other diagnostic tests, but do so when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination.
  • Evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with MRI or CT only if they are potential candidates for surgery or epidural steroid injection.
  • Provide patients with evidence-based information on low back pain and on their expected course, advise them to remain active and provide information on self-care options.
  • Consider the use of medications in conjunction with back care. For most patients, first-line medications are acetaminophen or nonsteroidal anti-inflammatory drugs.
  • For those who don't improve with self-care options, consider adding nonpharmacologic therapy with proven benefit, including spinal manipulation, exercise therapy, acupuncture, yoga, massage therapy or cognitive-behavioral therapy.

Source: "Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society," Annals of Internal Medicine, Oct. 2

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Oh, my aching back ...

Low back pain proved to be the most common type of chronic pain -- 27% -- cited in a recent national health survey. Adults with this affliction are often in worse physical and mental health than those without. For instance, 28% of adults with low back pain report limited activity due to a chronic condition, compared with 10% of adults without low back pain. Also, adults reporting low back pain were three times as likely to be in fair or poor health and more than four times as likely to experience serious psychological distress.

Consider the following responses from people reporting low back pain in the three months before the interview or no low back pain in the same three months:

Age Low back pain No low back pain
Activity limited by chronic conditions
All 28.1% 9.6%
18-44 14.8% 4.1%
45-64 32.4% 10.5%
65 or older 52.9% 27.1%
Fair or poor health
All 23.5% 8.1%
18-44 12.6% 3.7%
45-64 28.8% 10.1%
65 or older 39.8% 19.3%
Serious psychological distress
All 7.2% 1.5%
18-44 6.4% 1.7%
45-64 9.3% 1.4%
65 or older 5.0% 1.1%

Source: Centers for Disease Control and Prevention National Center for Health Statistics, Health, United States, 2006

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