Transcript Evidence-Based Evaluation of Patients with Low Back Pain

Welcome to
Low Back Pain:
Evaluation, Management,
and Prognosis
Welcome
and Overview
Bill McCarberg
Founder
Chronic Pain Management Program
Kaiser Permanente
San Diego, California
Adjunct Assistant Clinical Professor
University of California
School of Medicine
San Diego, California
Evidence-Based
Evaluation of
Patients With
Low Back Pain
Learning Objective
 Discuss
the differential diagnosis
for low back pain (LBP) and the
importance of clinical red and yellow
flags in evaluation of LBP
Low Back Pain Guidelines
 In
2007, the American College of
Physicians (ACP) and American Pain
Society (APS) issued comprehensive
joint clinical practice guidelines for
diagnosis and treatment of LBP
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Guideline #1

Clinicians should conduct a focused history
and physical examination to help place
patients with LBP into 1 of 3 broad categories






Nonspecific LBP
Back pain potentially associated with radiculopathy
or spinal stenosis
Back pain potentially associated with another
specific spinal cause
The history should include assessment of
psychosocial risk factors, which predict risk
for chronic disabling back pain
Strong recommendation
Moderate-quality evidence
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Focused History and
Physical Examination


Determine presence and level of
neurological involvement1,2
Classify patients into 3 broad categories



Nonspecific LBP potentially associated with radiculopathy
Spinal stenosis
Back pain potentially associated with another specific
spinal cause

Patients with serious or progressive neurologic deficits
or underlying conditions requiring prompt evaluation




Tumor
Infection
Cauda equina syndrome
Patients with other conditions that may respond to
specific treatments


Ankylosing spondylitis
Vertebral compression fracture
1. Deyo RA, et al. JAMA. 1992;268(6):760-765.
2. Bigos SJ, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, No. 14; 1994.
Evaluation of Back Pain

Site

Duration

Length of illness

Time of onset

Spread

Mode of onset

Quality

Precipitating factors

Intensity

Aggravating factors

Frequency

Relieving factors

Associated features
McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1094-1105.
Epidemiology of Low Back Pain

90% of American adults experience an
episode of back pain during their lifetime

Of patients who have acute back pain

90% to 95% have a non–life-threatening condition


Although up to 85% cannot be given an exact diagnosis,
nearly all recover within 4 to 6 weeks
For 5% to 10% of patients, acute back pain
is a manifestation of more serious pathology

Vascular catastrophes, malignancy, spinal
cord compressive syndromes, and infectious
disease processes
Winters ME, et al. Med Clin North Am. 2006;90(3):505-523.
What Is Seen in Primary
Care Practice?

In minority of patients presenting for initial evaluation
in primary care setting, LBP is caused by1



Cancer (approximately 0.7% of cases)
Compression fracture (4%)
Spinal infection (0.01%)

Estimates for prevalence of ankylosing spondylitis
in primary care patients range from 0.3%1 to 5%2

Spinal stenosis and symptomatic herniated disc are
present in about 3% and 4% of patients, respectively

Cauda equina syndrome most commonly associated
with massive midline disc herniation, but rare

Estimated prevalence of 0.04%3
1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.
2. Underwood MR, et al. Br J Rheumatol. 1995;34(11):1074-1077.
3. Deyo RA, et al. JAMA. 1992;268(6):760-765.
Cost of Low Back Pain

LBP is one of top 10 reasons patients seek care from
family physicians1
 Prevalence of LBP has varied from 7.6% to 37%

Peak prevalence between 45 and 60 years of age2

Also reported by adolescents and by adults of all ages
80% of adults seek care at some time for acute LBP3
 One-third of US disability costs are due to low
back disorders3
 Direct costs of diagnosing and treating LBP in United
States estimated in 1991 to be $25* billion annually4



Indirect costs, including lost earnings, are even higher4
Proper diagnosis and appropriate treatment of LBP
saves healthcare resources, relieves suffering
*40 billon in 2008 using Consumer Price Index to compute the relative value of money.
1. AAFP. Facts About Family Practice; 1996.
2. Borenstein DG. Curr Opin Rheumatol. 1997;9(2):144-150.
3. Kuritzky L, et al. Prim Care Rep 1995;1:29-38.
4. Frymoyer JW, et al. Orthop Clin North Am. 1991;22(2):263-271.
Etiology of Low Back Pain
 Nonspecific
LBP
 Back
pain potentially associated
with radiculopathy or spinal stenosis
 Back
pain potentially associated
with another specific spinal cause
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Structural Sources of Low Back Pain
 Muscles
of the back1,2
 Interspinous
ligaments2-4
 Zygapophyseal
 Sacroiliac
joints5-7
joint(s)8
 Intervertebral
discs9-12
 Mechanical12
or chemical irritation
of dura mater13
1. Kellgren JH. Clin Sci. 1938;3:175-190.
2. Bogduk N. Med J Aust. 1980;2(10):537-541.
3. Kellgren JH. Clin Sci. 1939;4:35-46.
4. Feinstein B, et al. J Bone Joint Surg Am. 1954;36-A(5):981-997.
5. Mooney V, et al. Clin Orthop Relat Res. 1976(115):149-156.
6. McCall IW, et al. Spine (Phila Pa 1976). 1979;4(5):441-446.
7. Fukui S, et al. Clin J Pain. 1997;13(4):303-307.
8. Fortin JD, et al. Spine (Phila Pa 1976). 1994;19(13):1475-1482.
9. Wilberg G. Acta Orthop Scand. 1947;19:211-221.
10. Falconer MA, et al. J Neurol Neurosurg Psychiatry. 1948;11(1):13-26.
11. Kuslich SD, et al. Orthop Clin North Am. 1991;22(2):181-187.
12. O'Neill CW, et al. Spine (Phila Pa 1976). 2002;27(24):2776-2781.
13. El-Mahdi MA, et al. Neurochirurgia (Stuttg). 1981;24(4):137-141.
Causes of Low Back Pain

Possible sources of back pain have
been demonstrated; causes have been
more elusive

Refuted: conditions traditionally considered
to be possible causes are actually not causes

Eg, spondylolysis, spondylolisthesis, degenerative
changes (spondylosis)

Accepted: tumors and infections

Untested: muscle sprain, ligament sprain,
segmental dysfunction, and trigger points

Known source, unknown cause: sacroiliac joints,
zygapophyseal joints, internal disc disruption
McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1105-1122.
Diagnostic Triage Guides
Subsequent Decision-Making

Inquire about
Location of pain
 Frequency of symptoms
 Duration of pain
 History of previous symptoms, treatment,
and response to treatment


Consider possibility of LBP due to problems
outside the back
Pancreatitis
 Nephrolithiasis
 Aortic aneurysm
 Systemic illnesses (eg, endocarditis or
viral syndromes)

Differential Diagnosis
for Acute Low Back Pain
Disease or
Condition
Patient
Age
(Years)
Back strain
20-40
Acute disc
herniation
30-50
Osteoarthritis or
spinal stenosis
Spondylolisthesis
30-50
Location
of Pain
Quality of Pain
Aggravating or
Relieving Factors
Signs
Low back,
buttock,
posterior thigh
Ache, spasm
Increased with activity
or bending
Local tenderness, limited
spinal motion
Low back to
lower leg
Sharp, shooting,
or burning pain;
paresthesia in leg
Decreased with
standing; increased
with bending or sitting
Positive straight leg
raise test, weakness,
asymmetric reflexes
Increased with walking,
Low back to
Ache, shooting
especially up an
lower leg;
pain, “pins and
incline;
decreased with
often bilateral needles” sensation
sitting
Back,
Any age posterior
thigh
Mild decrease in
extension of spine;
may have weakness
or asymmetric reflexes
Ache
Increased with activity
or bending
Exaggeration of the lumbar
curve, palpable “step off”
(defect between spinous
processes), tight hamstrings
Ache
Morning stiffness
Decreased back
motion, tenderness
over sacroiliac joints
15-40
Sacroiliac
joints,
lumbar spine
Infection
Any age
Lumbar spine,
sacrum
Sharp pain, ache
Varies
Fever, percussive
tenderness; may have
neurologic abnormalities or
decreased motion
Malignancy
>50
Affected
bone(s)
Dull ache,
throbbing pain;
slowly progressive
Increased with
recumbency or cough
May have localized
tenderness, neurologic
signs, or fever
Ankylosing
spondylitis
Adapted from: Patel AT, et al. Am Fam Physician. 2000;61(6):1779-1786.
Guideline #2
 Clinicians
should not routinely obtain
imaging or other diagnostic tests
in patients with nonspecific LBP
 Strong
recommendation
 Moderate-quality
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
evidence
Plain X-Rays for Low Back Pain

There is no evidence that routine plain radiography in
patients with nonspecific LBP is associated with a greater
improvement in patient outcomes than selective imaging1-3

Exposure to unnecessary ionizing radiation should be
avoided, particularly in young women (amount of gonadal
radiation from obtaining a single plain radiograph [2 views]
of the lumbar spine is equivalent to daily chest radiograph
for more than 1 year)4

Routine advanced imaging (computed tomography [CT]
or magnetic resonance imaging [MRI]) is not associated
with improved patient outcomes,5 identifies radiographic
abnormalities poorly correlated with symptoms,6 and could
lead to additional, possibly unnecessary interventions7,8
1. Deyo RA, et al. Arch Intern Med. 1987;147(1):141-145.
2. Kendrick D, et al. BMJ. 2001;322(7283):400-405.
3. Kerry S, et al. Br J Gen Pract. 2002;52(479):469-474.
4. Jarvik JG. Neuroimaging Clin N Am. 2003;13(2):293-305.
5. Gilbert FJ, et al. Radiology. 2004;231(2):343-351.
6. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.
7. Jarvik JG, et al. JAMA. 2003;289(21):2810-2818.
8. Lurie JD, et al. Spine (Phila Pa 1976). 2003;28(6):616-620.
Plain X-Rays for Low Back Pain (cont.)

Plain radiography is recommended for initial
evaluation of possible vertebral compression fracture
in select high-risk patients, such as those with a
history of osteoporosis or steroid use1

Evidence to guide optimal imaging strategies is
not available for LBP that persists for more than
1 to 2 months if there are no symptoms suggesting
radiculopathy or spinal stenosis, although plain
radiography may be a reasonable initial option
(see recommendation 4 for imaging recommendations
in patients with symptoms suggesting radiculopathy
or spinal stenosis)2

Thermography and electrophysiologic testing are
not recommended for evaluation of nonspecific LBP
1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.
2. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Guideline #3
 Clinicians
should perform diagnostic
imaging and testing for patients with
LBP when severe or progressive
neurologic deficits are present or
when serious underlying conditions
are suspected on the basis of history
and physical examination
 Strong
recommendation
 Moderate-quality
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
evidence
CT or MRI Diagnostic Imaging
 Prompt
work-up with MRI or CT is
recommended if severe or progressive
neurologic deficits or suspected serious
underlying condition; delayed diagnosis
and treatment associated with
poorer outcomes1-3
 MRI
is generally preferred over CT if
available; does not use ionizing radiation,
provides better visualization of soft tissue,
vertebral marrow, and the spinal canal4
1. Loblaw DA, et al. J Clin Oncol. 2005;23(9):2028-2037.
2. Todd NV. Br J Neurosurg. 2005;19(4):301-306.
3. Tsiodras S, et al. Clin Orthop Relat Res. 2006;444:38-50.
4. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.
CT or MRI Diagnostic Imaging (cont.)

There is insufficient evidence to guide diagnostic
strategies in patients who have risk factors for cancer
but no signs of spinal cord compression

Proposed strategies generally recommend plain
radiography or measurement of erythrocyte
sedimentation rate3, with MRI reserved for patients
with abnormalities on initial testing1,2

Alternative strategy is to directly perform MRI
in patients with a history of cancer, the strongest
predictor of vertebral cancer;2 for patients older than
50 without other risk factors for cancer, delaying imaging
while offering standard treatments and reevaluating
within 1 month may also be a reasonable option4
1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.
2. Joines JD, et al. J Gen Intern Med. 2001;16(1):14-23.
3. van den Hoogen HM, et al. Spine (Phila Pa 1976). 1995;20(3):318-327.
4. Suarez-Almazor ME, et al. JAMA. 1997;277(22):1782-1786.
Guideline #4
 Clinicians
should evaluate patients
with persistent LBP and signs or
symptoms or radiculopathy or spinal
stenosis with MRI (preferred) or CT
only if they are potential candidates
for surgery or epidural steroid injection
(for suspected radiculopathy)
 Strong
recommendation
 Moderate-quality
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
evidence
Imaging for Low Back Pain

The natural history of lumbar disc herniation with
radiculopathy in most patients is for improvement within
the first 4 weeks with noninvasive management1,2

There is no compelling evidence that routine imaging
effects treatment decisions or improves outcomes3

For prolapsed lumbar disc with persistent radicular
symptoms despite noninvasive therapy, discectomy
or epidural steroids are potential treatment options4-8

Surgery is also a treatment option for persistent
symptoms associated with spinal stenosis9-12
1. Vroomen PC, et al. Br J Gen Pract. 2002;52(475):119-123.
2. Weber H. Spine (Phila Pa 1976). 1983;8(2):131-140.
3. Modic MT, et al. Radiology. 2005;237(2):597-604.
4. Gibson JN, et al. Cochrane Database Syst Rev. 2000(3):CD001350.
5. Gibson JN, et al. Cochrane Database Syst Rev. 2005(4):CD001352.
6. Nelemans PJ, et al. Spine (Phila Pa 1976). 2001;26(5):501-515.
7. Peul WC, et al. N Engl J Med. 2007;356(22):2245-2256.
8. Weinstein JN, et al. JAMA. 2006;296(20):2451-2459.
9. Amundsen T, et al. Spine (Phila Pa 1976). 2000;25(11):1424-1435.
10. Atlas SJ, et al. Spine (Phila Pa 1976). 2005;30(8):936-943.
11. Weinstein JN, et al. N Engl J Med. 2007;356(22):2257-2270.
12. Malmivaara A, et al. Spine (Phila Pa 1976). 2007;32(1):1-8.
MRI for Low Back Pain

MRI (preferred if available) or CT is recommended for
evaluating patients with persistent back and leg pain
who are potential candidates for invasive interventions

Plain radiography cannot visualize discs or accurately evaluate
the degree of spinal stenosis1

However, clinicians should be aware that findings on
MRI or CT (such as bulging disc without nerve root
impingement) are often nonspecific

Recommendations for specific invasive interventions,
interpretation of radiographic findings, and additional
work-up beyond scope of guideline, but decisions
should be based on clinical correlation between
symptoms and radiographic findings, severity of
symptoms, patient preferences, surgical risks,
and costs and will generally require specialist input 2
1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.
2. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Critical Clinical Indicators
of Pathology

In patients with back and leg pain, a typical
history for sciatica (back and leg pain in
a typical lumbar nerve root distribution)
has a fairly high sensitivity, but uncertain
specificity for herniated disc1,2

>90% of symptomatic lumbar disc
herniations (back and leg pain due to a
prolapsed lumbar disc compressing a nerve
root) occur at L4/L5 and L5/S1 levels3
1. van den Hoogen HM, et al. Spine (Phila Pa 1976). 1995;20(3):318-327.
2. Vroomen PC, et al. J Neurol. 1999;246(10):899-906.
3. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Critical Clinical Indicators
of Pathology (cont.)
 A focused
examination that includes
straight-leg-raise testing and a
neurologic examination that includes
evaluation of knee strength and reflexes
(L4 nerve root), great toe and foot
dorsiflexion strength (L5 nerve root),
foot plantarflexion and ankle reflexes
(S1 nerve root), and distribution of
sensory symptoms should be done to
assess the presence and severity of
nerve root dysfunction
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Critical Clinical Indicators
of Pathology (cont.)
 A positive
result on straight-leg-raise test
(defined as reproduction of the patient’s
sciatica between 30 and 70 degrees
of leg elevation) has a relatively high
sensitivity (91% [95% CI, 82% to 94%]), but
modest specificity (26% [CI, 16% to 38%])
for diagnosing herniated disc
 Crossed
straight-leg-raise test is more
specific (88% [CI, 86% to 90%]), but
less sensitive (29% [CI, 24% to 34%])
Deville WL, et al. Spine (Phila Pa 1976). 2000;25(9):1140-1147.
Critical Clinical Indicators
of Pathology (cont.)
 All
patients should be evaluated for
 Presence
of rapidly progressive
or severe neurologic deficits
 Motor
deficits at more than 1 level, fecal
incontinence, and bladder dysfunction
 Most
frequent finding in cauda
equina syndrome is urinary retention
(90% sensitivity)
 Without
urinary retention, probability
is approximately 1 in 10,000
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Deyo RA, et al. JAMA. 1992;268(6):760-765.
Yellow Flags

Identify psychosocial problems in
acute phase
 Slow progress to recovery may be
due to undetected, or unrevealed
psychosocial factors

Pertain to patient's beliefs and behaviors
concerning physical activity and domestic,
social, and vocational responsibilities


Example: patient believes physical activity might harm
back, make pain worse, so avoids activities
Most destructive is aversion to work

Belief that work caused pain, work aggravates pain,
work is too heavy, and work should not be done
McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1094-1105.
Psychosocial Factors
of Low Back Pain

Stronger predictors of LBP outcomes than either physical
findings or severity/duration of pain1-3
 Assessment of psychosocial factors identifies patients who
may have delayed recovery and could help target interventions

1 trial in referral setting found intensive multidisciplinary rehabilitation more
effective than usual care in patients with acute or subacute LBP identified
as having risk factors for chronic back pain disability4

Direct evidence on effective primary care interventions for
identifying and treating such factors in patients with acute LBP
is lacking5,6
 Evidence is currently insufficient to recommend optimal methods
for assessing psychosocial factors and emotional distress7
 However, psychosocial factors that may predict poorer LBP
outcomes include presence of depression, passive coping
strategies, job dissatisfaction, higher disability levels, disputed
compensation claims, or somatization8-10
1. Pengel LH, et al. BMJ. 2003;327(7410):323.
2. Fayad F, et al. Ann Readapt Med Phys. 2004;47(4):179-189.
3. Pincus T, et al. Spine (Phila Pa 1976). 2002;27(5):E109-120.
4. Gatchel RJ, et al. J Occup Rehabil. 2003;13(1):1-9.
5. Hay EM, et al. Lancet. 2005;365(9476):2024-2030.
6. Jellema P, et al. BMJ. 2005;331(7508):84.
7. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
8. Steenstra IA, et al. Occup Environ Med. 2005;62(12):851-860.
9. Deyo RA, et al. Spine (Phila Pa 1976). 2006;31(23):2724-2727.
10. Carey TS, et al. Spine (Phila Pa 1976). 1996;21(3):339-344.
Red Flags of Lower Back Pain
History

Physical Examination
Gradual onset of back pain

 Age <20 years or >50 years

 Thoracic back pain

 Pain lasting longer than 6 weeks

 History of trauma

 Fever/chills/night sweats

 Unintentional weight loss

 Pain worse with recumbency

 Pain worse at night

 Unrelenting pain despite
supratherapeutic doses of analgesics
 History of malignancy
 History of immunosuppression
 Recent procedure causing bacteremia
 History of intravenous drug use
Winters ME, et al. Med Clin North Am. 2006;90(3):505-523.
Fever
Hypotension
Extreme hypertension
Pale, ashen appearance
Pulsatile abdominal mass
Pulse amplitude differentials
Spinous process tenderness
Focal neurologic signs
Acute urinary retention
Risk for Chronicity
 Vertebral
infection
 Intravenous
 Vertebral
drug use, recent infection
compression fracture
 Older
age, history of osteoporosis,
and steroid use
 Musculoskeletal
 Inactivity
 In
general
 Emotional
distress
Cancer-Related Risk Factors

Large, prospective study from a primary
care setting






History of cancer (positive likelihood ratio, 14.7)
Unexplained weight loss (positive likelihood ratio, 2.7)
Failure to improve after 1 month (positive likelihood
ratio, 3.0)
Age >50 years (positive likelihood ratio, 2.7)
Posttest probability of cancer increases from
approximately 0.7% to 9% in patients with a history
of cancer (not including nonmelanoma skin cancer)
In patients with any 1 of the other 3 risk factors,
the likelihood of cancer only increases to
approximately 1.2%
Deyo RA, et al. J Gen Intern Med. 1988;3(3):230-238.
Non-Cancer-Related Risk Factors

Features predicting vertebral infection not well studied,
but may include fever, intravenous drug use, or
recent infection1

Consider risk factors for vertebral compression fracture,
such as older age, history of osteoporosis, and steroid
use; and for ankylosing spondylitis, such as younger
age, morning stiffness, improvement with exercise,
alternating buttock pain, and awakening due to back
pain during the second part of the night only2

Clinicians should be aware that criteria for diagnosing
early ankylosing spondylitis (before the development
of radiographic abnormalities) are evolving3
1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.
2. Rudwaleit M, et al. Arthritis Rheum. 2006;54(2):569-578.
3. Rudwaleit M, et al. Arthritis Rheum. 2005;52(4):1000-1008.
Racial/Cultural Aspects
of Assessment

To communicate effectively with all patients

Always use simple words, not medical jargon

Determine what the patient/caregiver already
knows or believes about his/her health situation

Encourage questions by asking, “What
questions do you have?” (allows for an openended response), instead of “Do you have any
questions?” (allows for a “no” response, ending
the conversation)

Use the “teach-back” method to confirm the
level of understanding: Ask patients/family
members to restate what was just
communicated in the appointment or meeting
Zacharoff KL. Cross-Cultural Pain Management: Effective Treatment of Pain in the Hispanic Population; 2009.
Culturally Competent Care

Ensure that patients/consumers receive effective,
understandable, and respectful care that is
provided in a manner compatible with their
cultural health beliefs and practices and
preferred language

Implement strategies to recruit, retain, and
promote at all levels of the organization a diverse
staff and leadership that are representative of the
demographic characteristics of the service area

Ensure that staff, at all levels and across all
disciplines, receives ongoing education and
training in CLAS delivery
USDHHS OMH. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care; 2001.
Avoiding Racial and Cultural
Bias per Knox H. Todd, MD, MPH
 Make
 Give
pain assessment mandatory
a nonopioid analgesic at triage
 Track
reasons for unscheduled returns
 Audit
for ethnic bias
 Consider
which pain scales should
be used
 Use
multilingual laminated cards
Todd KH. Medical Ethics Advisor. 1999.
Pearls for Practice

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

Evaluate psychosocial risk factors to predict
the risk for chronic, disabling low back pain

Provide patients with evidence-based
information on expected course of low back
pain, effective self-care options, and
recommend that they be physically active
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Questions?
Please pass your question card
to a staff member.
Treatment of
Low Back Pain:
Pharmacologic and
Nonpharmacologic
Options
Roger Chou, MD, FACP
Associate Professor of Medicine,
Department of Medicine
Department of Medical Informatics
and Clinical Epidemiology
Oregon Health & Science University
Disclosure: Roger Chou, MD, FACP
 Dr.
Chou has disclosed that he
has no actual or potential conflict
of interest in regard to this activity
 His
presentation will include off-label
discussion of anticonvulsants,
benzodiazepines, and tricyclic
antidepressants for the treatment
of low back pain (LBP)
Learning Objective
 Integrate
evidence-based pharmacologic
and nonpharmacologic therapies into
a comprehensive treatment plan for
chronic LBP
Low Back Pain Burden
 LBP
is the fifth most common reason
for US office visits, and the second
most common symptomatic reason1-2
 $90.7
billion dollars in total healthcare
expenditures in 19983
 LBP
is the most common cause for
activity limitations in persons under
the age of 454
1. Hart LG, et al. Spine (Phila Pa 1976). 1995;20(1):11-19.
2. Deyo RA, et al. Spine (Phila Pa 1976). 2006;31(23):2724-2727.
3. Luo X, et al. Spine (Phila Pa 1976). 2004;29(1):79-86.
4. Von Korff M, et al. Spine (Phila Pa 1976). 1996;21(24):2833-2837.
Increasing Rates of Back Surgery
US Average Rate of Discharges
per 1000 Medicare Enrollees
Trends in Rates of Discectomy/Laminectomy and Fusion in 1992-2003
Weinstein JN, et al. Spine (Phila Pa 1976). 2006;31(23):2707-2714.
Increasing Rates of Back Injections
Lumbosacral Injection Rates by Year: Age- and Sex-Adjusted per 100,000
2055.2
553.4
79.7
SI=sacroiliac.
Friedly J, et al. Spine (Phila Pa 1976). 2007;32(16):1754-1760.
263.9
212.3
Mean ($)
Increasing Costs
Year
Martin BI, et al. JAMA. 2008;299(6):656-664.
Rising Prevalence of Chronic LBP
Prevalence of Chronic Low Back Pain in North Carolina, 1992 and 2006
% Prevalence (95% CI)
1992: 3.9%
Characteristic
Total
Sex
Male
Female
Age (Years)
21-34
35-44
45-54
55-64
65
Race/Ethnicity
Non-Hispanic White
Non-Hispanic Black
Hispanic
Other
2006: 10.2%
1992
(n=8067)
3.9 (3.4-4.4)
2006
(n=9924)
10.2 (9.3-11.0)
% Increase
162
PRR
(2.5-97.5% CI)*
2.62 (2.21-3.13)
2.9 (2.2-3.6)
4.8 (4.0-5.6)
8.0 (6.8-9.2)
12.2 (10.9-13.5)
176
154
2.76 (2.11-3.75)
2.54 (2.13-3.08)
1.4 (0.8-2.0)
4.8 (3.3-6.3)
4.2 (3.0-5.5)
6.3 (4.2-8.3)
5.9 (4.5-7.3)
4.3 (3.0-5.6)
9.2 (7.2-11.2)
13.5 (11.4-15.7)
15.4 (12.8-17.9)
12.3 (10.2-14.4)
201
92
219
146
109
3.01 (1.95-5.17)
1.92 (1.35-2.86)
3.19 (2.29-4.59)
2.46 (1.73-3.50)
2.09 (1.62-2.84)
4.1 (3.5-4.7)
3.0 (2.0-4.0)
**
4.1 (1.4-6.8)
10.5 (9.4-11.5)
9.8 (8.2-11.4)
6.3 (3.8-8.9)
9.1 (6.0-12.0)
155
226
2.55 (2.13-3.05)
3.26 (2.32-4.96)
120
2.20 (1.16-6.99)
CI=confidence interval. PRR=prevalence rate ratio.
*The PRRs and CI were estimated via bootstrapping; 97.5% CIs were reported rather than to assume normality.
**Unable to estimate owing to scall cell count (n<5).
Freburger JK, et al. Arch Intern Med. 2009;169(3):251-258.
Practice Patterns

Spine surgery rates in the US are the
highest in the world
Rates in the US 5 times higher than in the UK
 20-fold variation in fusion: 4.6 per 1000 in
Idaho Falls to 0.2 per 1000 in Bangor, Maine


Interventional therapies are also
widely used
Intradiscal electrothermal therapy estimated
at 7000-10,000 annually
 20-fold variation in epidural steroid injections:
104 per 1000 in Palm Springs to 5.6 per 1000
in Honolulu

Deyo RA, et al. Clin Orthop Relat Res. 2006;443:139-146.
Weinstein JN, et al. Spine (Phila Pa 1976). 2006;31(23):2707-2714.
“7 Back Pain Breakthroughs:
Are you hurting? Here’s help.”

Reader’s Digest
July 2007

End Back
Pain Agony
(Michael J. Weiss)
Weiss MJ. Reader's Digest. July, 2007.
Reader’s Digest “Cures”
for Low Back Pain

“Cures” based on anecdotal evidence, not
yet approved, and/or only in animal studies

Infrared belt: $2335

“Magic Spinal Wand”

Percutaneous automatic discectomy

Flexible fusion

Stem cells

Site-directed bone growth

New bed

Based on an unpublished observational study funded
by a sleep products trade group
Weiss MJ. Reader's Digest. July, 2007.
Low Back Pain Guidelines Project
Overview and Timeline

Began 2004; primary care guidelines published
October 2007






Address both acute and chronic LBP, and nonspecific
LBP and LBP with radiculopathy or spinal stenosis
Guideline for interventional therapies/surgery
published May 2009
Partnership between the American Pain Society
and the American College of Physicians (ACP)
Funded by the American Pain Society
Multidisciplinary panel with 25 members;
over 15 specialties/organizations represented
Series of 3 face-to-face meetings to
develop guidelines

Consensus achieved for all recommendations
Recommendation Grid
ACP Methods
Strength of Recommendation
Quality of
Evidence
Benefits Do or Do Not
Clearly Outweigh Risks
Benefits and Risks and
Burdens Finely Balanced
High
Strong
Weak
Moderate
Strong
Weak
Low
Strong
Weak
Insufficient
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
I
Basic Principles of Selecting
Therapy for Low Back Pain

For most LBP, labeling with a specific etiology
doesn’t help inform therapy choices

Most patients with acute LBP will improve
regardless of which therapy is chosen

For chronic LBP, therapies are moderately
effective at best

Use interventions with proven efficacy

Noninvasive approaches to most LBP

Consider psychosocial factors
Recommendation
Treatment of Low Back Pain
 Provide
patients with evidence-based
information about their expected
course, advise patients to remain
active, and provide information
about effective self-care options
 Strong
recommendation
 Moderate-quality evidence
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Advice and Self-Care
for Low Back Pain

Inform patients of generally favorable
prognosis of acute LBP with or without sciatica

Discuss need for re-evaluation if not improved

Advise to remain active

Consider self-care education books

Superficial heat moderately effective for
acute LBP

No evidence to support use of lumbar supports

Firm mattresses inferior to medium-firm
mattresses (1 RCT)
RCT=randomized controlled trial.
Recommendation
Treatment of Low Back Pain
 Consider
the use of medications with
proven benefits in conjunction with
back care information and self-care …
for most patients, first-line medication
options are acetaminophen or NSAIDs
 Strong
recommendation
 Moderate-quality evidence
NSAIDs=nonsteroidal anti-inflammatory drugs.
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Pharmacologic Interventions
Drug
Net Benefit
Level of Evidence
Acetaminophen
Small to moderate
Fair
Skeletal muscle
relaxants
Moderate
(for acute LBP only)
Good
Moderate
Good
Small to moderate
(for chronic LBP only)
Good
NSAIDs
Tricyclic
antidepressants
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Chou R, et al. Ann Intern Med. 2007;147(7):505-514.
This information includes a use that has not been approved by the US FDA.
Pharmacologic Interventions (cont.)
Drug
Net Benefit
Level of Evidence
Opioids and
tramadol
Moderate
Fair
Benzodiazepines
Moderate
Fair
Small
(for radiculopathy only)
Fair
No benefit
Good
Antiepileptic
medications
Systemic steroids
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Chou R, et al. Ann Intern Med. 2007;147(7):505-514.
This information includes a use that has not been approved by the US FDA.
Recommendation
Treatment of Low Back Pain


For patients who do not improve with
self-care options, consider the addition of
nonpharmacologic therapy with proven benefits
For chronic or subacute LBP, options include

Intensive interdisciplinary
rehabilitation

Exercise therapy

Acupuncture

Massage therapy

Spinal manipulation

Yoga

Cognitive-behavioral
therapy

Progressive relaxation
Weak recommendation
Moderate-quality evidence
Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Noninvasive Interventions for
Chronic or Subacute LBP
Intervention
Net Benefit
Level of Evidence
Behavioral therapy
Moderate
Good
Exercise therapy
Moderate
Good
Spinal manipulation
Moderate
Good
Acupuncture
Moderate
Fair
Chou R, et al. Ann Intern Med. 2007;147(7):492-504.
Noninvasive Interventions for
Chronic or Subacute LBP (cont.)
Intervention
Net Benefit
Level of Evidence
Massage
Moderate
Fair
Yoga
Moderate
Fair
(for Viniyoga)
Small
Fair
No benefit
Fair
Unclear
Poor
Back schools
Traction
Interferential therapy,
lumbar supports, short-wave
diathermy, TENS, ultrasound
TENS=transcutaneous electrical nerve stimulation.
Chou R, et al. Ann Intern Med. 2007;147(7):492-504.
Recommendation
Interventional Therapies for
Nonradicular Low Back Pain


In patients with persistent nonradicular LBP,
facet joint corticosteroid injection,
prolotherapy, and intradiscal corticosteroid
injection are not recommended

Strong recommendation

Moderate-quality evidence
There is insufficient evidence to adequately
evaluate benefits of other interventional
therapies for nonradicular LBP
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Interventional Therapies for
Nonradicular Low Back Pain

Interventional therapies not proven to be effective
in placebo-controlled, randomized trials



No trials (SI joint injection), trials showing no benefit
(facet joint injection), inconsistent results (IDET, RFDN),
or poor-quality evidence (trigger point injections)
Promising results from nonrandomized studies
not replicated in randomized trials

IDET

Facet joint steroid injection
Not clear if interventions are ineffective,
or if patients were not accurately selected
IDET=intradiscal electrothermal therapy.
RFDN=radiofrequency denervation.
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Placebo-Controlled Trials of RFDN
for Presumed Facet Joint Pain
Sample
Size
Selection
Quality
Benefits
Gallagher, 1994
41
Uncontrolled
block
Poor quality
Can’t tell
Leclaire, 2001
70
Uncontrolled
block
No major issues
No
Nath, 2008
40
Controlled
block
Baseline
differences
(1.6 points
for pain)
1.5 points for leg pain,
NS for back pain
Tekin, 2007
60
Clinical
criteria
Poor quality
<1 point for pain,
0.5 points for function
van Kleef, 1999
30
Uncontrolled
block
No major issues
1-2 point for pain
and function
van Wijk, 2005
81
Uncontrolled
block
Technical
issues?
No
Study
NS=not significant.
Placebo-Controlled Trials of RFDN
for Presumed Facet Joint Pain
Sample
Size
Selection
Quality
Benefits
Gallagher, 1994
41
Uncontrolled
block
Poor quality
Can’t tell
Leclaire, 2001
70
Uncontrolled
block
No major issues
No
Nath, 2008
40
Controlled
block
Baseline
differences
(1.6 points
for pain)
1.5 points for leg pain,
NS for back pain
Tekin, 2007
60
Clinical
criteria
Poor quality
<1 point for pain,
0.5 points for function
van Kleef, 1999
30
Uncontrolled
block
No major issues
1-2 point for pain
and function
van Wijk, 2005
81
Uncontrolled
block
Technical
issues?
No
Study
Placebo-Controlled Trials of RFDN
for Presumed Facet Joint Pain (cont.)
Study
Leclaire, 2001
Sample
Size
Selection
Quality
Benefits
70
Uncontrolled
block
No major issues
No
1.5 points for leg pain,
NS for back pain
1-2 point for pain
and function
Nath, 2008
40
Controlled
block
Baseline
differences
(1.6 points
for pain)
van Kleef, 1999
30
Uncontrolled
block
No major issues
Recommendation
Surgery for Nonradicular
Low Back Pain
 In
patients with nonradicular LBP,
common degenerative spinal
changes, and persistent and disabling
symptoms … discuss risks and
benefits of surgery as an option
 Weak
recommendation
 High-quality
evidence
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Surgery for Nonradicular Low Back
Pain With Degenerative Changes

Benefits vary depending on comparator

Benefits of fusion vs standard nonsurgical therapy
less than 15 points on a 100-point pain or function
scale (1 RCT)

No difference vs intensive interdisciplinary
rehabilitation (3 RCTs)

All enrollees failed >1 year of nonsurgical management
and are not at higher risk for poor surgical outcomes

Fewer than half experience optimal outcomes
(relief of pain, return to work, decreased analgesic use)

No evidence that instrumentation improves outcomes

Shared decision-making approach recommended
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1094-1109.
Recommendation
Interventional Therapies
for Radicular LBP
 In
patients with persistent radiculopathy
due to herniated lumbar disc … discuss
risks and benefits of epidural steroid
injection as an option
 Weak
recommendation
 Moderate-quality
evidence
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Interventional Therapies for
Radiculopathy/Prolapsed Disc
 Epidural
steroid injection
 Short-term
benefits in some higher-quality
trials, but data are inconsistent (could be
related to comparator used in trials)
 No
long-term benefits
 No
route clearly superior
 Limited
evidence of no benefit for
spinal stenosis
 Shared
decision-making
approach recommended
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Recommendation
Surgery for Radicular Low Back
Pain and Spinal Stenosis
 In
patients with persistent radiculopathy
due to herniated lumbar disc or
persistent and disabling leg pain due
to spinal stenosis … discuss risks
and benefits of surgery as an option
 Strong
recommendation
 High-quality
evidence
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Surgery for Herniated Disc
With Radiculopathy

Discectomy associated with more
rapid improvement in symptoms than
nonsurgical therapy

Patients improved either with or without surgery

No progressive neurologic deficits without
immediate surgery

Long-term (after 1-2 years) outcomes similar
in some trials

Most trials evaluated standard open discectomy
or microdiscectomy

Shared decision-making approach recommended
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1094-1109.
Surgery for Spinal Stenosis

Decompressive laminectomy associated with
superior outcomes vs nonsurgical therapy

Mild improvement with nonsurgical therapy

No severe neurologic deficits without
immediate surgery

Benefits may diminish with long-term
(>2 years) follow-up

Shared decision-making approach recommended
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1094-1109.
Conclusions

The quality of evidence for different LBP
therapies varies
 A number of therapies appear similarly
and moderately effective for LBP
 Guidelines can provide clinicians with a
useful framework for choosing therapies
 Factors that influence choices from
recommended therapies include patient
preferences, availability, and costs
 Shared decision-making can help make
decisions consistent with patient values
and preferences
Questions?
Please pass your question card
to a staff member.
Current Understanding
of the Prevention
of Chronicity of
Low Back Pain
Bill McCarberg, MD
Founder, Chronic Pain Management Program
Kaiser Permanente San Diego
Adjunct Assistant Clinical Professor,
University of California, San Diego
Disclosure: Bill McCarberg, MD
Type
Company
Speakers Bureau
Abbott Laboratories; Cephalon, Inc.; Eli Lilly and Company;
Endo Pharmaceuticals; Forest Pharmaceuticals; King
Pharmaceuticals; Ligand Pharmaceuticals, Inc.; Merck & Co.,
Inc.; Mylan Pharmaceuticals, Inc.; Pfizer, Inc.; PriCara,
Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc.;
Purdue Pharma LP

Dr. McCarberg’s presentation will not include
discussion of off-label, experimental, and/or
investigational uses of drugs or devices
Learning Objective
 Evaluate
early interventions for acute
back pain in patients considered at
high risk for transition to chronic low
back pain (CLBP)
Disability from Back Pain

The minority of cases which involve disability
account for a disproportionate percentage
of overall healthcare costs

The most cost-effective approach is to more
aggressively pursue secondary prevention
efforts on subacute patients before chronic
disability is fully established1

Acute: <3 weeks

Subacute: >3 weeks but <3 months

Chronic: >3 months, or more than 6 episodes
in 12 months
1. Waddell G, et al. Occup Med (Lond). 2001;51(2):124-135.
Adverse Prognostic Indicators
 Yellow
flags are psychosocial
indicators suggesting increased risk
of progression to long-term distress,
disability, and pain
 Can
be applied more broadly to assess
likelihood of development of persistent
problems from acute pain presentation
 Yellow
flags can relate to the patient’s
attitudes and beliefs, emotions,
behaviors, family, and workplace
Kendall NA. Baillieres Best Pract Res Clin Rheumatol. 1999;13(3):545-554.
Risk Factors for Chronic Low
Back Pain: Yellow Flags










Belief that pain and activity are harmful
“Sickness behavior” such as extended rest
Bodily preoccupation and catastrophic thinking
Low or negative mood, anxiety, social withdrawal
Personal problems (eg, marital, financial, etc)
History of substance abuse
Problems/dissatisfaction with work (“blue flags”)
Overprotective family/lack of support
History of disability and other claims
Inappropriate expectations of treatment

Low expectation of active participation
The presence of yellow flags highlights the need to address
specific psychosocial factors as part of a multimodal
management approach
Additional Risk Factors
for Chronicity

Previous history of low back pain
 Age
 Nerve root involvement
 Poor physical fitness
 Self-rated health poor
 Heavy manual labor, inability for light duty
upon return to work (“black flags”)
 Ongoing medico-legal actions
 Obesity*
 Smoking*
*No evidence for efficacy of smoking cessation or nonoperative weight loss as interventions for CLBP.
Wai EK, et al. Spine J. 2008;8(1):195-202.
Interventional Therapies
Do Not Prevent Chronicity
Level of Evidence and Summary Grades for Interdisciplinary Rehabilitation, Injections,
Other Interventional Therapies, and Surgery for Patients With Nonradicular LBP
Intervention
Condition
Level of
Evidence
Net Benefit
Grade
Interdisciplinary rehabilitation
Nonspecific LBP
Good
Moderate
B
Prolotherapy
Nonspecific LBP
Good
No benefit
D
Intradiscal steroid injection
Presumed discogenic pain
Good
No benefit
D
Fusion surgery
Nonradicular LBP
with common
dengerative changes
Fair
Moderate vs standard nonsurgical
therapy, no difference vs
intensive rehabilitation
B
Facet joint steroid injection
Presumed facet joint pain
Fair
No benefit
D
Botulinum toxin injection
Nonspecific LBP
Poor
Unable to estimate
I
Local injections
Nonspecific LBP
Poor
Unable to estimate
I
Epidural steroid injection
Nonspecific LBP
Poor
Unable to estimate
I
Medial branch block
(therapeutic)
Presumed facet
joint pain
Poor
Unable to estimate
I
Sacroiliac joint
steroid injection
Presumed sacroiliac
joint pain
Poor
Unable to estimate
I

Additionally, regardless of the comparator intervention, there is
no convincing evidence that epidural steroids are associated with
long-term benefits or reduced rates of subsequent surgery
Chou R, et al. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
The Fear-Avoidance Model
of Chronic Pain
Injury
Disuse
Disability
Depression
Recovery
Avoidance
Escape
Pain
Anxiety
Hypervigilance
Confrontation
Pain Experience
Fear
of Pain
Threat Perception
Catastrophizing
Negative Affectivity
Threatening Illness Information
Leeuw M, et al. J Behav Med. 2007;30(1):77-94.
Vlaeyen JW, et al. Pain. 2000;85(3):317-332.
Low Fear
Assessment of
Fear-Avoidance Behaviors

Pain Catastrophizing Scale (PCS)1


Fear of Pain Questionnaire (FPQ)2


30 items
Fear-Avoidance Beliefs Questionnaire (FABQ)3


13 items
16 items
Coping Strategies Questionnaire (CSQ)4

42 items
1. Sullivan MJL, et al. Psychological Assessment. 1995;7(4):524-532.
2. McNeil DW, et al. J Behav Med. 1998;21(4):389-410.
3. Waddell G, et al. Pain. 1993;52(2):157-168.
4. Rosenstiel AK, et al. Pain. 1983;17(1):33-44.
Reducing Catastrophizing
 Numerous
interventions appear effective

Cognitive-behavioral therapies1-4

Physiotherapy and other activitybased interventions5

Intensive patient education and
exposure interventions6, 7
 Limited
understanding of the mechanisms
by which changes in catastrophizing occur
1. Linton SJ, et al. Pain. 2001;90(1-2):83-90.
2. Basler HD, et al. Patient Educ Couns. 1997;31(2):113-124.
3. Vlaeyen JW, et al. Pain Res Manag. 2002;7(3):144-153.
4. Hoffman BM, et al. Health Psychol. 2007;26(1):1-9.
5. Smeets RJ, et al. J Pain. 2006;7(4):261-271.
6. Moseley GL, et al. Clin J Pain. 2004;20(5):324-330.
7. Leeuw M, et al. Pain. 2008;138(1):192-207.
Comprehensive Interventions With
High-Risk Patients Show Promise

High-risk patients identified with SCID

Intensive interdisciplinary team intervention

4 major components: psychology, physical therapy,
occupational therapy, and case management





Physical therapy sessions: both individual and group
exercise classes
Biofeedback/pain management sessions
Group didactic sessions
Case manager/occupational therapy sessions
Interventions spaced over a 3-week period
SCID=Structured Clinical Interview for DSM-IV Disorders.
Gatchel RJ, et al. J Occup Rehabil. 2003;13(1):1-9.
Early Intensive
Intervention Effectiveness
Long-Term Outcome Results at 12-Month Follow-Up
HR-I
(n=22)
HR-NI
(n=48)
LR
(n=54)
p-Value
% return to work at follow-up*
91%
69%
87%
.027
Average number of healthcare visits regardless of reason**
25.6
28.8
12.4
.004
Average number of healthcare visits related to LBP**
17.0
27.3
9.3
.004
Average number of disability days due to back pain**
38.2
102.4
20.8
.001
Average of self-rated most “intense pain” at 12-month follow-up
(0-100 scale)**
46.4
67.3
44.8
.001
Average of self-rated pain over last 3 months (0-100 scale)**
26.8
43.1
25.7
.001
% currently taking narcotic analgesics*
27.3%
43.8%
18.5%
.020
% currently taking psychotropic medication
4.5%
16.7%
1.9%
.019
Outcome Measure
*Chi-square analysis. **ANOVA.
HR-I=high-risk intervention group. HR-NI=high-risk nonintervention group. LR=low-risk group.
Gatchel RJ, et al. J Occup Rehabil. 2003;13(1):1-9.
Most Recent Preventing
Chronicity Study (April 2009)

First-onset, subacute LBP patients
 Behavioral medicine intervention (n=34)


Four 1-hour individual treatment sessions included

Education about back function and pain

Systematic graduated increases in physical exercise
to quota with feedback

Planning and contracting activities of daily living

Self-management and problem-solving training to cope
with pain

Contingent reinforcement of active functioning and
nonreinforcement of pain behaviors

Vocational counseling, as needed
Compared to “attention control” group (n=33)
Slater MA, et al. Arch Phys Med Rehabil. 2009;90(4):545-552.
Most Recent Preventing
Chronicity Study (April 2009) (cont.)

Chi square analysis comparing proportions
recovered at 6 months after pain onset
for behavioral medicine and attention
control participants found rates 54% vs 23%
for those completing all 4 sessions and
6-month follow-up (p=.02)

Conclusions: early intervention using a
behavioral medicine rehabilitation approach
may enhance recovery and reduce chronic
pain and disability in patients with first-onset,
subacute LBP
Slater MA, et al. Arch Phys Med Rehabil. 2009;90(4):545-552.
Key Impact Factors in Back
Disability Prevention
Spread of Rankings for Impact Provided by Key Stakeholders (N=33)
at the End of a Consensus Process (Round 3)
1. Provider Reassurance
} p=.055
2. Recovery Expectation
} p=.045
3. Fears
4. Knowledge
5. Appropriate Care
6. Disability Management
7. Self-Management
8. Case Management
9. Temporary Duties
} p<.001
10. Alternative Care
} p<.001
11. Back Supports
0
2
4
6
Rankings by Panel
Guzman J, et al. Spine (Phila Pa 1976). 2007;32(7):807-815.
8
10
12
Provider Reassurance
 Tell
patients your plan and
your expectations
 Set
reasonable expectations
with patient buy-in
 Reassure
severity of acute pain does
not correlate with outcome or duration
 Follow
up regularly to check response
to treatment
 Reassess
for further diagnostic
of therapeutic options
Summary

Psychosocial aspects of pain and
pain perception significantly influence
patient outcomes

Assessing for yellow flags and identifying
patients at high risk of chronicity early in
pain process (subacute) yields best chance
for intervention and possible prevention

Multiple psychosocial and physical
interventions appear promising; aggressive/
intensive intervention seems most important

Nurture the therapeutic relationship with
shared expectations and goals of treatment
Questions?
Question and
Answer Session
Thank You for Attending
Low Back Pain:
Evaluation, Management,
and Prognosis