Physician's Weekly Article - New Guidelines for Treating Low Back Pain

       Two associations have collaborated to release new, evidence-based clinical practice guidelines for the diagnosis and treatment of low back pain.

      Through a unique collaboration, the American Pain Society (APS) and American College of Physicians (ACP) assembled a multidisciplinary panel of experts and subsequently released new, evidence-based clinical practice guidelines for low back pain. The recommendations, published in the October 2007 Annals of Internal Medicine, address the efficacy of conservative treatments with pharmacologic and non-pharmacologic therapies. “This is the first major effort on a national basis to review available evidence in this field since the early 1990s,” says Roger Chou, MD. “It provides recommendations to assist clinicians in the diagnosis and management of low back pain.”

      The scope of low back pain is large, ranking as the fifth most common reason for physician visits in the United States. However, the use of diagnostic tests and treatment options available for low back pain varies. “Across the country, there continues to be significant variations in practice to diagnose and treat low back pain, many of which do not have proven benefits,” says Dr. Chou. “Frequently, more invasive or aggressive therapies are pursued prematurely.”

      Unnecessary Imaging During Diagnosis

      The ACP-APS guidelines strongly recommend that physicians conduct a focused history and physical examination for patients presenting with low back pain (Figure 1). This involves placing patients into one of three categories: 1) nonspecific low back pain, which accounts for 85% of patients, 2) back pain potentially associated with radiculopathy or spinal stenosis, and 3) back pain potentially associated with another specific spinal cause. In addition, patients with nonspecific low back pain should not be routinely imaged or undergo other diagnostic tests. “Routine imaging during diagnosis and evaluation does not benefit the average patient,” Dr. Chou says. “Physicians should recognize specific symptoms that may warrant imaging, such as a history of cancer, weight loss, recent trauma, or progressive weakness. However, the majority of patients won’t have any risk factors. Nonetheless, many of these patients are imaged and exposed to unnecessary radiation.”

      According to Dr. Chou, routine advanced imaging modalities such as CT and MRI are not associated with improved patient outcomes and may even lead to unnecessary interventions. “Evidence has shown that surgeries are more likely to occur when patients undergo MRIs because these images tend to identify abnormalities, such as arthritis and degenerated discs, which may poorly correlate with the patient’s symptoms,” he says. “An MRI of a patient who is completely asymptomatic may reveal similar abnormalities. As a result, long-term consequences may result from unnecessary imaging, especially when surgery can potentially do more harm than good.”

      Analyzing Noninvasive Therapies

      “An important emphasis of the ACP-APS guidelines is that there are a number of effective noninvasive treatment options currently available for low back pain, albeit not the ‘miracle cures’ patients or physicians may hope for,” explains Dr. Chou. “There are many treatments for low back pain, and the purpose of our evidence review was to perform systematic evaluations of existing literature with an open mind and to let the evidence provide answers about which therapies work.” The expert panel noted that physicians should consider the following noninvasive, nonpharmacologic therapies that have been proven effective in evidence-based trials: exercise therapy, spinal manipulation, acupuncture, yoga, intensive interdisciplinary rehabilitation, cognitive-behavioral therapy, and progressive relaxation.

      According to Dr. Chou, some of these recommendations may surprise allopathic doctors who have viewed such interventions with skepticism. However, there are well-conducted trials supporting the efficacy of such therapies, including acupuncture, massage, and yoga. “Remaining active by continuing low-impact activities is critical to the recovery process and will not cause further harm,” says Dr. Chou. “In the past, bed rest was prescribed for low back pain, but research shows that recovery time may actually increase for those who remain inactive because the back becomes deconditioned and more prone to re-injury.”

      When to Pursue a Second Opinion

      Although rapid improvement in low back pain is common over the first month, some patients may require further evaluation, diagnostic imaging, and/or more aggressive interventions. If patients fail to improve or worsen after pursuing three or four standard therapies, a second opinion may be beneficial. “It may be appropriate to consider consultation with a back specialist when patients do not respond to standard, noninvasive therapies,” says Dr. Chou. “It should be noted, however, that such decisions should be individualized, based on patient symptoms and responses to standard therapies.”

      Dr. Chou has indicated to Physician’s Weekly that he has received a one-time honorarium fee from Bayer Pharmaceuticals.