Oh my aching back

Back pain is one of the most difficult and frequent complaints in primary care offices. It is difficult partly because many patients who use this complaint for non-legitimate reasons in an effort to obtain drugs or malinger for other financial benefits. It creates a skeptical view from many physicians.

Just recently, the American College of Physicians (ACP) and the American Pain Society (APS) have issued a comprehensive joint clinical practice guideline for the diagnosis and treatment of low back pain and published them in the October 2 issue of the Annals of Internal Medicine.

These new guidelines offer recommendations concerning how to categorize patients, when to perform imaging studies, educational information for patients, self-care, when to prescribe medications and what types, and nonpharmacologic therapy.

The most important recommendation is that clinicians should not routinely order imaging and other diagnostic tests. This will not set well with most patients, because the majority immediately wants an MRI or something else to determine the cause.

The impetus for the creation of these guidelines was a meeting of a multidisciplinary panel of experts convened in 2006 by ACP and APS. Their mission was to develop questions and the scope of an evidence report on low back pain, to review the available evidence in this field, and to generate recommendations assisting primary care clinicians in diagnosing and treating low back pain.

The joint ACP-APS guidelines target primary care physicians and these guidelines do not address invasive therapies performed by specialists.

The current joint ACP-APS recommendations provide an algorithm for physicians that would categorize patients into 1 of 3 general subgroups: (1) nonspecific low back pain (accounts for 85% of patients); (2) back pain potentially associated with spinal conditions, such as spinal stenosis, sciatica, and vertebral compression fracture; and (3) back pain potentially associated with another specific cause, such as cancer.

Of the first group (85%) the guidelines recommend not routinely ordering imaging studies like X-rays, computerized tomography (CT) scans, magnetic resonance imaging (MRI), or other diagnostic tests.

The guidelines recommend these tests being reserved to evaluate only those patients who have severe or progressive neurologic deficits or who are suspected to have cancer, infection, or other underlying condition.

The specific recommendations in the guidelines are as follows:

• Focused history and physical examination should help 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. Evaluation of psychosocial risk factors is essential during history taking because these predict the risk for chronic disabling low back pain (strong recommendation; moderate-quality evidence).
• For patients with nonspecific low back pain, clinicians should not routinely perform imaging studies, including radiographs, CT scans, and MRI, or other diagnostic tests (strong recommendation; moderate-quality evidence).
• Patients with severe or progressive neurologic deficits, or in whom history and physical examination suggest cancer, infection, or other underlying condition as the cause of their low back pain, should undergo imaging studies and other appropriate diagnostic tests (strong recommendation; moderate-quality evidence).
• Patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis should undergo MRI or CT only if positive results would potentially lead to surgery or epidural steroid injection for suspected radiculopathy. In choosing an imaging procedure, MRI is preferred to CT (strong recommendation; moderate-quality evidence).
• Patient education by clinicians should include provision of evidence-based information on low back pain. Topics that should be covered include expected course and effective self-care options. Clinicians should also counsel their patients to stay physically active (strong recommendation; moderate-quality evidence).
• When pharmacotherapy is considered, drugs of choice should be those with proven benefits, and they should be used together with self-care and back care education. Before starting a patient on pharmacotherapy, clinicians should evaluate pain and functional deficits at baseline. They should also review the risk-benefit ratio of specific medications before prescribing them and should consider the relative lack of long-term efficacy and safety data (strong recommendation; moderate-quality evidence). Acetaminophen or NSAIDs are preferred first-line drugs for most patients.
• When self-care options do not result in improvement, clinicians should consider adding nonpharmacologic modalities shown to be of benefit. For acute low back pain, the only modality in this category is spinal manipulation. For chronic or subacute low back pain, modalities shown to be of benefit are intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation; moderate-quality evidence).