CE/CME

Low Back Pain: Evidence-based Diagnosis and Treatment

Clinician Reviews. 2016 May;26(5):38-45

References

1. CDC. National Ambulatory Medical Care Survey: 2010 Summary Tables. Table 9. www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf. Accessed March 29, 2016.
2. Davies C, Nitz AJ, Mattacola CG, et al. Practice patterns when treating patients with low back pain: a survey of physical therapists. Physiother Theor Pract. 2014;30(6):399-408.
3. American College of Radiology. ACR Appropriateness Criteria. Low back pain. 2015. www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/LowBackPain.pdf. Accessed March 10, 2016.
4. Henschke N, Maher CG, Ostelo RW, et al. Red flags to screen for malignancy in patients with low back pain. Cochrane Database Syst Rev. 2013;2:CD008686.
5. Koes BW, Tulder M, Lin CW, et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-2094.
6. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760-765.
7. Jarvik JG. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137:586-597.
8. Diagnostic testing for low back pain. In: Post TW (ed), UpToDate, Waltham, MA. www.uptodate.com. Accessed March 16, 2016.
9. Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.
10. Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988;3(3):230-238.
11. Deyo RA, Diehl AK. Patient satisfaction with medical care for low-back pain. Spine. 1986;11(1):28-30.
12. Pradeep S, Rainville J, Katz JN, et al. The accuracy of the physical examination for the diagnosis of midlumbar and low lumbar nerve root impingement. Spine. 2011;36(1):63-73.
13. Leclaire R, Blier F, Fortin L, Proulx R. A cross-sectional study comparing the Oswestry and Roland-Morris Functional Disability Scales in two populations of patients with low back pain of different levels of severity. Spine. 1997;22(1):68-71
14. FDA. Radiation emitting products. www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm115317.htm. Accessed March 29, 2016.
15. Simpson AK, Whang PG, Jonisch A, et al. The radiation exposure associated with cervical and lumbar spine radiographs. J Spinal Disord Tech. 2008;21(6):409-412.
16. Srinivas S, Deyo R, Berger Z. Application of “less is more” to lower back pain. Arch Intern Med. 2012;172(13):1016-1020.
17. Webster BS, Bauer AZ, Choi Y, et al. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling back pain. Spine. 2013;38(22):1939-1946.
18. Webster BS, Bauer AZ, Choi Y, et al. The cascade of medical services and associated longitudinal costs due to nonadherent magnetic resonance imaging for low back pain. Spine. 2014;39(17):1433-1440.
19. Liang M, Komaroff AL. Roentgenograms in primary care patients with acute low back pain: a cost-effectiveness analysis. Arch Intern Med. 1982;142(6):1108-1112.
20. Ash LM, Modic MT, Obuchowski NA, et al. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008;29(6):1098-1103.
21. Kendrick D, Fielding K, Bentley E, et al. Radiography of the lumbar spine in primary care patients with low back pain: randomized controlled trial. BMJ. 2001;322(7283):400-405.
22. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain. JAMA. 2003;289(21):2810-2818.
23. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463-472.
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25. Roelofs PD, Deyo RA, Koes BW, et al. Nonsteroidal anti-inflammatory drugs for low back pain. Spine. 2008;33(16):1766-1774.
26. Hancock MJ, Maher CG, Latimer J, et al. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomized controlled trial. Lancet. 2007;370(10):1638-1643.
27. Van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low-back pain. Cochrane Database Syst Rev. 2003;(4):CD004252.
28. Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572-1580.
29. Zarghooni K, Rashidi A, Siewe, J, et al. Single-shot epidural injections in the management of radicular pain. Orthop Rev (Pavia). 2015;7(4):5985.
30. Smidt N, deVet HC, Bouter LM, et al. Effectiveness of exercise therapy: A best-evidence summary of systematic reviews. Aust J Physiother. 2005;51(2):71-85.
31. Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012;85(4):343-350.
32. Machado LA, Maher CG, Herbert RD, et al. The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Med. 2010;8(10):1-10.
33. Cho I, Jeon C, Lee S, et al. Effects of lumbar stabilization exercise on functional disability and lumbar lordosis angle in patients with chronic low back pain. J Phys Ther Sci. 2015;27(6):1983-1985.
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35. Wegner I, Widyahening IS, van Tulder MW, et al. Traction for low-back pain with or without sciatica (review). Cochrane Database Syst Rev. 2013;(8):CD003010.
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TREATMENT
The prognosis of simple acute mechanical LBP is excellent. Although back pain is a leading reason for visiting health care providers, many affected individuals never seek medical care and apparently improve on their own. In a random telephone survey of North Carolina residents, only 39% of persons with LBP sought medical care.²⁴ Therefore, patients who do seek treatment should be given reassurance, and therapies should be tailored to the individual in the least invasive and most cost-effective manner. Many treatment options are available for LBP, but often strong evidence of benefit is lacking.

Pharmacologic therapy
Anti-inflammatories. It can be assumed that when a patient comes to the practitioner for evaluation of LBP, there is an expectation that some type of medication will be recommended or prescribed for pain relief. Unless there is a contraindication, NSAIDs are often first-line therapy, and they are effective for short-term symptom relief when compared with placebo.²⁵ A mild pain medication, such as acetaminophen, is also a common treatment. The 2007 joint practice guideline from the American Pain Society (APS) and the American College of Physicians (ACP) recommends acetaminophen or NSAIDs as first-line therapy for acute LBP.³ Neither agent—NSAIDs or acetaminophen—has shown superiority, and combining the two has shown no additional benefits.²⁶ Caution must be used, however, as NSAIDs have a risk for gastrointestinal toxicity and nephrotoxicity, and acetaminophen has a dose- and patient-dependent risk for hepatotoxicity.

Muscle relaxants. Muscle relaxants are another pharmacologic treatment option for LBP. Most pain reduction from this class of medication occurs in the first one to two weeks of therapy, although benefit may continue for up to four weeks.²⁷ There is also evidence that a combination of an NSAID and a muscle relaxer has added benefits.²⁷ These medications are centrally acting, so sedation and dizziness are common; all medications in this class have these adverse effects to some degree. Carisoprodol has as its first metabolite meprobamate, which is a tranquilizer used to treat anxiety disorders; it has a potential for abuse and should be used with caution in certain populations.

Opioids. Opioids are commonly prescribed to patients with LBP, though there are limited data regarding efficacy. One trial compared an NSAID alone versus an NSAID plus oxycodone/acetaminophen and found no significant difference in pain or disability after seven days.²⁸ In addition, the adverse effects of opioids, which include sedation, constipation, nausea, and confusion, may be amplified in the elderly population; therefore, opioids should be prescribed with caution in these patients. If prescribed to treat acute LBP, opioids should be used in short, scheduled dosing regimens since NSAIDs or acetaminophen suffice for most patients.

Corticosteroids. Oral glucocorticoids are sometimes given to patients with acute LBP, and they likely are used more frequently in patients with radicular symptoms. However, the APS/ACP 2007 joint guidelines recommend against use of systemic glucocorticoids for acute LBP due to lack of proven benefit.³ Epidural steroid injections are not generally beneficial for isolated acute LBP, but there is evidence that they are helpful with persistent radicular pain.²⁹ Zarghooni and colleagues found significant reductions in pain and use of pain medication after single-shot epidural injections.²⁹

Other pharmacologic therapies, acupuncture, sclerotherapy, and other methods are used to treat back pain, but these are typically reserved for chronic, not acute, LBP.

Nonpharmacologic therapy
Physical therapy. Physical therapy is a commonly prescribed treatment for LBP. Systematic literature reviews indicate that for patients with acute LBP (< 6 wk), there is no difference in the effectiveness of exercise therapy compared to no treatment and care provided by a general practitioner or to manipulations.³⁰ For patients with subacute (6-12 wk) and chronic (≥ 12 wk) LBP, exercise therapy is effective compared to no treatment.³⁰ There is debate, however, over which exercise activities should be used. Research supports strength/resistance and coordination/stabilization exercises.

Most therapists recommend the McKenzie method or spine stabilization exercises.³¹ The McKenzie method is used for LBP with sciatica; the patient moves through exercises within the prone position and focuses on extension of the spine. Spine stabilization is an active form of exercise based on a “neutral spine” position and helps strengthen muscles to maintain this position (core stabilization). The McKenzie method, when added to first-line care for LBP, does not produce significant improvements in pain or other clinical outcomes, although it may reduce health care utilization.³² Spine stabilization exercises have been shown to decrease pain, disability, and risk for recurrence after a first episode of back pain.³³ The apparent success of physical therapy is attributed to compliance with directed home exercise programs, which have been shown to reduce the rate of recurrence, decrease episodes of acute LBP, and decrease the need for health services.³⁴

Spinal traction. Traction or nonsurgical spinal decompression has emerged as a treatment for LBP. Unfortunately, there are little data to support its use as a treatment for acute LBP. Only a few randomized trials showed benefit, and these were small studies with a high risk for bias. A Cochrane review published in 2013 looked at 32 studies involving 2,762 patients with acute, subacute, and chronic LBP.³⁵ The review did not find any evidence that traction alone or in combination with other therapy was any better than placebo treatment.³⁵

Spinal manipulation. Spinal manipulation may be more effective than placebo treatment in reducing pain when the pain has been present for less than six weeks, but it is not more effective in reducing disability.³⁶ There is little or no high-level evidence about spinal manipulation for acute LBP. However, there is some evidence of cost-effectiveness when using spinal manipulation in subacute to chronic pain.³⁷ Chiropractic techniques are considered safe (when performed by a trained provider), but a systematic review found that these techniques provide no clinically relevant improvement in pain or disability when compared to other treatments.³⁸

Bed rest. Bed rest has not been shown to improve outcomes, and in fact patients who had bed rest had less favorable outcomes than those who stayed active.³⁹ Bed rest is less effective at reducing pain and improving function when compared to staying active.³⁹

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References

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Low Back Pain: Evidence-based Diagnosis and Treatment

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