Low Back Pain Studies 2010

The Spine Journal 2010 (514–529)
Haldeman S, DC, MD, PhD.
Dagenais S, DC, PhD,
Tricco AC, PhD,

Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines.

Key Points:

The volume of literature related to Low Back Pain precludes clinicians reading all studies in their fields.

This is a major review of all recent guidelines in English from the United States & the United Kingdom.

There is a great deal of consistency in the various guidelines concerning both assessment and management.

These Clinical practice guidelines included data from 2001-2009 published in:
1. Australia
2. Belgium
3. Europe (Acute Low Back Pain)
4. Europe (Chronic Low Back Pain), Italy, New Zealand, Norway, United Kingdom, & 2 from the United States.

6 of the 16 of the Clinical practice guidelines had Doctors of Chiropractic as participating panelists.

Of 16 total guidelines recommendations on Acute Low Back Pain, Chronic Low Back Pain, & LBP with neurologic involvement all but 2 (14 of 16) recommended spinal manipulation.

Of 6 total guidelines on management of Acute Low Back Pain none recommended exercise, but 5 of 6 recommended Spinal Manipulation.

All 6 guidelines on management of Chronic Low Back Pain recommended exercise.

Only 1 of 16 guidelines recommended traction & that is auto-traction for neurologic involvement from the USA.

Bed rest is only recommended in 1 of 16 guidelines (from Italy for LBP with neurologic involvement).

Background:

Clinical practice guidelines locate, evaluate, & summarize the scientific evidence & are important tools in the implementation of evidence-based medicine.

Adherence to recommendations from Clinical practice guidelines on the management of Low Back Pain is associated with improved clinical outcomes & decreased costs.

However, compliance with recommendations from Clinical practice guidelines is consistently low in studies of MDs, DCs, PTs, & others.

Objective: Synthesize recommendations from recent clinical practice guidelines  (based on data from 2000 – 2009) in English to provide guidance to clinicians on evidence-based assessment and management of

1) Acute LBP (<3 mo),
2) Chronic LBP (>3mo),
3) Low Back Pain with substantial neurologic involvement.

Ideally, all providers involved in managing Low Back Pain should be guided by the best available scientific evidence to minimize the use of ineffective, excessively costly, or even harmful procedures.

10 Clinical practice guidelines  were included in the review.

6 Clinical practice guidelines discussed acute Low Back Pain, 6 chronic Low Back Pain, and 6 Low Back Pain with neurologic involvement.

The Clinical practice guidelines reviewed had high levels of methodological quality.

Clinical practice guidelines were not included if they were not endorsed by a national government agency or professional health provider group.

6 Clinical practice guidelines appeared to be endorsed by a national association of primary care physicians (PCPs), four by PTs, 4 by nonsurgical spine specialists, 3 by Doctors of Ciropractic & 2 by surgical spine specialists.

All Clinical practice guidelines appeared to have been sponsored or funded by their respective national governments, with the exception of those from the United States.

Recommendations for assessment of Low Back Pain:

1.  Rule out potentially serious spinal pathology
2.  Identify specific causes of Low Back Pain and neurologic involvement
3.  Identify risk factors for delayed recovery & chronicity: Of 10 risk factors identified, 7  were psychosocial including emotional issues (anxiety and depression) & fear avoidance behavior
4.  Measure the severity of symptoms
5.  Measure functional limitations

A synthesis of recommendations regarding the assessment of acute Low Back Pain suggests that a history, physical exam, & neurologic exam should be sufficient in the vast majority of patients.

Recommendations for management of Acute Low Back Pain:

1.  Patient education
2.  Advice to stay active
3.  Short-term use of acetaminophen, NSAIDs, or Spinal Manipulation.
4.  No Clinical Practice Guidlines recommended bed rest, back exercises, lumbar supports, acupuncture, biofeedback, TENS, traction, or ultrasound.

Recommendations for management of Chronic Low Back Pain:

Recommendations for Chronic are similar to Acute Low Back Pain but with the major addition of:
1. Back exercises
2. Behavioral therapy
3. Short-term opioid analgesics
4. Brief education about Low Back Pain, advice to stay active, back schools
5. NSAIDs and weak opioid analgesics
6. Spinal Manipulation

Secondary interventions:

1..Multidisciplinary rehabilitation
2.  Adjunctive analgesics
3.  Behavioral therapy
4.  Strong opioid analgesics

No guidelines recommended: bed rest, biofeedback, lumbar supports, heat/ cold, traction, or ultrasound for chronic Low Back Pain.

Management of Low Back Pain with neurologic involvement: Recommendations are similar, but with additional consideration given to MRI, CT, or to identify appropriate candidates willing to undergo epidural steroid injections or  surgical decompression if more conservative approaches are not successful.

Conclusions: Recommendations from several recent Clinical practice guidelines regarding the assessment and management of Low Back Pain were quite similar.

Clinicians who care for patients with Low Back Pain should endeavor to adopt these recommendations to improve patient care.