Low Back Pain August 2014 Update

Care Process Model August 2014

PRIMARY CARE MANAGEMENT OF

Low Back Pain August 2014 update

This care process model (CPM) was created by the Functional Restoration/Chronic Pain Development Team of Intermountain Healthcare’s Pain Management Service. Based on national guidelines AIR, ICSI, KOE, NICE, emerging evidence, and expert opinion, this CPM provides guidance for primary care providers on diagnosis and treatment of acute and chronic low back pain. This document presents an evidence-based approach that is appropriate for most patients; it should be adapted to meet the needs of individual patients and situations, and should not replace clinical judgment.

Why Focus ON low back pain? What’s inside • Prevalence and cost. Low back pain (LBP) is a common disorder estimated to Algorithm and notes...... 2 affect up to 84% of adults at some time in their lives. In the U.S., low back pain Acute mechanical LBP ...... 4 FOU causes direct and indirect economic losses of nearly $90 billion each year. Core treatment...... 4 • Natural history of low back pain. LBP is often a self-limiting problem; few TABLE 1: Medications for acute LBP . . . . 4 patients with acute LBP have a serious underlying condition, and therefore they Additional treatment, based on risk . . . . 5 can be managed with self-care or conservative treatment. However, for some patients acute LBP can lead to chronic pain — a year after an acute episode, 20% Nonsurgical back specialist referral. . . . . 6 of patients report persistent back pain that limits activity. FOU One critical challenge is Chronic LBP ...... 7 predicting which patients are at risk for chronic LBP, and intervening appropriately. Pain assessment...... 7 • Treatment variation and best clinical outcome. Although there is an abundance Psychosocial evaluation...... 7 of research-based evidence to guide best practice for managing both acute and Patient education & SCO chronic LBP, the treatment of LBP varies widely , often resulting in increased cost management plan...... 7 and failure to meet treatment goals. Medication management ...... 7 Key Points in this CPM Considering other treatment options. . . 8 • In most cases, imaging tests are NOT needed to diagnose acute LBP. Imaging NONSURGICAL back SPECIALIST tests can lead to expensive, unnecessary interventions, especially in the first 6 weeks. TREATMENT...... 10 If there are no “red flags” (signs of serious pathology or injury), avoid imaging tests. References ...... 11 • For most LBP, conservative treatment and self-care is adequate and effective. Resources...... 12 The core treatment for acute LBP includes education and reassurance, avoidance of bed rest, a short course of medications, and — depending on the risk of Goals developing persistent LBP — a course of physical therapy. • Improve the patient’s pain management, • Certain psychosocial factors can complicate the course of LBP; a patient’s risk function, and satisfaction with care. for developing chronic LBP can be used to customize treatment. This CPM • Improve the efficiency of LBP care, using recommends a tool that helps you assess a patient’s risk of developing chronic a team approach where appropriate. LBP, and assign patients to an appropriate treatment pathway. • Reduce the use of ineffective imaging and • A nonsurgical back specialist is the best resource for patients with LBP therapeutic procedures. persisting beyond 6 weeks. A nonsurgical back specialist can obtain appropriate • Increase the patient’s understanding of imaging studies, identify the pain generator, perform or recommend appropriate effective LBP management. nonsurgical interventions, and expedite care to a surgeon if necessary. • Chronic LBP that persists despite ongoing conservative treatment and Measures nonsurgical back specialist treatment is best managed using a team approach. • Patients with an LBP diagnosis referred for This includes physical therapy, physiatry (PM&R), anesthesia or neurology with radiology and physical therapy pain subspecialty, and mental health support if indicated. • Severity of patient pain over time • Medication management of LBP What’s new in this update? • Indications for ankylosing spondylitis. Five key indicators for ankylosing spondylitis and direction to refer to a rheumatologist if it is suspected. (See page 3.) • Goals and measures. Intermountain has data capture and reporting to measure prescriptions, imaging, and other information for our LBP patients. (See sidebar and page 2.) Management of low back pain August 2014

ALGORITHM: LBP diagnosis and core treatment Definitions Types of leg pain: Patients with low back pain often experience leg pain. Leg pain falls Patient presents with acute low back pain into 3 general categories:

• Referred leg pain radiates into the groin, EVALUATION buttock, and upper thigh, but without •• Obtain Patient History (a) objective neuropathic findings (listed • Perform a Physical Exam (b) below). Referred leg pain is not caused • by the spinal nerve root, but the result of sensory nerves that supply the low back, Any RED FLAGS Evaluate for serious pathology pelvis, and thigh. (Note: legs that are tender yes for serious illness and refer if necessary (c) to palpation are usually a primary issue of or injury? (c) the leg, not radicular pain.) CONSIDER • Radicular pain is sharp, shooting pain early referral LEG pain? Signs of that radiates along the course of a nerve Radicular to nonsurgical See definitions yes yes radiculopathy yes back specialist root (often extending below the knee) — at left . pain? but without neurologic changes such as (d)? (see page 6) sensory disturbances, muscle weakness, or no no no hypoactive muscle stretch reflexes. • Radiculopathy is caused by dysfunction ASSESS RISK of chronic LBP using the of the spinal nerve root. Signs and Keele STarT Back Screening Tool (e) symptoms include pain in the distribution of the nerve root (often extending below the Low risk Moderate or high risk knee), dermatomal sensory disturbances, weakness of muscles innervated by that INITIATE core treatment for mechanical LBP nerve root, and hypoactive muscle stretch reflexes of the same muscle. Low risk of developing chronic LBP Moderate/high risk Stages of low back pain: While some •• Education and reassurance. Cover these Education/reassurance and guidelines define the stages of LBP solely points (see page 4 for more details): medication (see left) PLUS: based on time since symptoms began, this –– A history and physical did not show anything •• Physical therapy (PT). Early PT can CPM recommends also considering function dangerous. You’re likely to recover in a few weeks. decrease the likelihood of subsequent and response to treatment in staging LBP: –– Staying active will help you recover. back surgery, injections, or frequent LBP–related physician visits. GEL • Acute LBP: Pain <6 weeks –– Imaging tests are not needed at this stage. Determine PT approach based on risk: • Subacute LBP: Continued pain after 6 •• Medication (see page 4), based on pain severity: –– Moderate risk: Treatment with –– 1st line: Acetaminophen or NSAIDs weeks, but patient continues to function standard PT approach well and core treatment provides some relief; –– 2nd line: Muscle relaxants, 7 days max –– High risk: PT with practitioner trained patient may also be receiving nonsurgical (not in elderly) in psychologically informed approach back specialist treatment at this stage. –– 3rd line: Consider short-acting opioids, 3 weeks max (opioids have no better outcomes •• Mental health screening and • Chronic LBP: Core LBP treatment than NSAIDs in LBP) treatment if needed (see page 5). has failed, nonsurgical back specialist treatment has not helped, the patient is not a surgery candidate — and FOLLOW UP RISK in 3–6 weeks persistent pain interferes with function and alters the patient’s life. yes — continue core treatment Improving? no

REFER to nonsurgical back AND FURTHER EVALUATE specialist (see page 6) psychosocial factors (see page 6)

If disabling pain persists despite Intermountain measures nonsurgical interventions and other treatment LBP treatments, referrals to PT, medications, and referrals for radiology . INITIATE chronic LBP management (see page 7)

Algorithm notes (a) Patient history. The patient history for acute low (b) Patient exam. The physical exam should include the back pain should include the components below. components below. Intermountain’s Patient Exam: Lumbar Intermountain‘s Patient Self History: Back Pain form can Spine Evaluation form can help in the exam, and HELP2 Hot help in obtaining this information. Text (“LBPexam”) is available for import from Wayne Cannon, • Description of current pain, including time of onset Primary Care Program Medical Director. (Auto Text will be and how pain responds to positioning available in iCentra.) • Previous back history, including tests and treatments • Motor weakness and • Upper motor neuron findings • Systemic disease (osteoporosis, cancer, arthritis, infection, etc.) reflex changes • Localized spinal tenderness • • Neurological symptoms Sensory deficit (perineal • Hip examination or lower extremity) • Bowel/bladder symptoms • Dural tension (straight leg raise, • Biological and psychosocial risk factors prone femoral nerve test) (c) RED Flag evaluation and response Suspected condition and signs Labs Imaging (see page 6) Referral Suspected cauda equina syndrome: ••For suspected cauda equina: spinal MRI* URGENT referral to ortho/neuro •• New bowel or bladder dysfunction ••For myelopathy/upper motor neuron spine surgeon •• Perineal numbness/saddle anesthesia changes: MRI* or CT, spine or brain •• Persistent/increasing lower motor neuron weakness Myelopathy/upper motor neuron changes: •• New-onset Babinski or sustained clonus •• New-onset gait or balance abnormalities •• Upper motor neuron weakness Recent trauma with suspected spinal fracture ••X-ray: anteroposterior (AP) and cone URGENT referral to ortho/neuro down, consider CT or MRI* if x-ray spine surgeon if imaging is nondiagnostic reveals fracture Suspected compression fracture: Osteoporosis or osteoporosis risk ••X-ray: AP and cone down; repeat in 2 weeks Referral to nonsurgical back if suspicion high specialist if imaging reveals ••Consider MRI* if suspicion high compression fracture Suspected cancer: CHO1 History of cancer, multiple cancer risk factors, CBC, ESR, ••X-ray (evaluate in context with ESR) URGENT referral to oncologist or strong clinical suspicion CRP ••If negative x-ray but strong suspicion remains: consider T1 weighted, noncontrasted spinal MRI* (full study w/contrast for abnormal areas) Suspected infection: immunocompromised patient, UTI, IV drug use, recent CBC, ESR, ••Consider MRI* with gadolinium or URGENT referral may be needed, spinal procedure, or fever/chills in addition to pain with rest or at night CRP bone scan depending on type of infection Suspected spinal deformity or spondylolysis: Age <20, pain with standing, ••Standing x-rays, 3 view, flexion, Referral to sports medicine walking, and extension (occurs more often in athletes and dancers) extension, plus cone down specialist, nonsurgical back ••Consider MRI* to identify spondylolysis specialist, or ortho/neuro spine represented by pedicle edema surgeon if x-ray or MRI positive Suspected spondyloarthropathies: CBC, ESR, ••X-ray: lumbar spine and sacroiliac joint Referral to rheumatologist •• Ankylosing spondylitis (AS): at least 4 of the following: age of pain onset <40 CRP, RF, ••Note: If clinical features lasting longer years; insidious onset; improvement with exercise; no improvement with rest; anti-CCP, than 3 months strongly suggest AS pain at night (with improvement upon rising) UTD; also consider morning stiffness. HLA B27 despite negative radiographs of SI joint, •• Reactive arthritis/Reiter’s Syndrome: recent history of genitourinary consider close follow up and/or referral to or gastrointestinal tract infection; acute onset; usually affecting lower joints; rheumatologist. asymmetrically painful and swollen joints; weight loss; high temperatures. •• Spondyloarthropathy associated with inflammatory bowel disease (IBD): abrupt onset; asymmetric, affecting lower limbs; generally subsides in 6–8 weeks; 10% develop chronic arthritis; other symptoms: uveitis, chronic skin lesions, AAFP Spinal MRI Order Guidelines AUGUST 2014

Before ordering a spinal MRI for your patient, check for at least 1 of the following indications.

dactylitis, enthesitis. • Radiculopathy (focal neurologic deficit with progressive or • Suspected cauda equina syndrome. ICD-9: 344.61. disabling features): Pain in the distribution of the nerve root • New bowel or bladder dysfunction. ICD-9: unspecified (often extending below the knee or elbow), with motor, reflex, or functional disorder of intestine 564.9. sensory deficit. ICD-9: thoracic and lumbar 724.4; cervical 723.4. • Perineal numbness / saddle anesthesia. ICD-9: numbness 782.0. • Radicular pain (radiating pain): Order an MRI only after failed conservative treatment (see LBP CPM) for 4 to 6 weeks. ICD-9: • Persistent or increasing motor weakness. ICD-9: generalized thoracic and lumbar 724.4; cervical 723.4. muscle weakness 728.87. • Significant loss of coordination in one or both legs. •• Psoriatic arthritis: asymmetric, affecting distal joints; morning stiffness; pain • Myelopathy (Babinski or sustained clonus — cervical or thoracic MRI). ICD-9: other myelopathy 336.8 — needs an • Suspected compression fracture: Osteoporosis or additional E code to identify the cause. osteoporosis risk. ICD-9: pathological fracture 733.13. • Associated lumbar spine symptoms/findings WITH cancer • Suspected spinal fracture: Significant recent trauma or fall. history, cancer symptoms, and/or infection. • Prior surgery or planned surgery or injection.

accentuated by prolonged immobility, alleviated by physical activity; psoriatic lesions. For more information, see Intermountain’s Low Back Pain Care Process Model and Flash Card.

(d) RADICULOPATHY. Fewer than 10% of patients have true radiculopathy, even with leg pain; the majority is mechanical or nonspecific. Consider early referral to nonsurgical back specialist for patients with radiculopathy. Patients with signs of radiculopathy may also need more frequent evaluation and follow-up. Signs of radiculopathy are motor deficit, reflex deficit, sensory deficit, and positive dural tension signs: positive straight leg raise and positive prone femoral stretch. (e) Assessing for risk of developing chronic LBP based on psychosocial factors, using the STarT Back Tool. This 9-item screening tool identifies factors that increase a person’s risk for developing chronic low back pain; it is helpful in stratifying care HIL1,HIL2 and can alert you to factors that can influence prognosis. See page 5 for information on using the form, and page 12 for information on accessing this form. Scoring: On questions 1 to 8, every “Agree” answer is worth 1 point; on question 9, “Very much” or “Extremely” is worth 1 point. • Low risk: Total score is 0 to 3 • Moderate risk: Total score is ≥4, score on • High risk: Total score is ≥4, score on questions 5 through 9 is 0 to 3 questions 5 through 9 is ≥4

ACUTE mechanical LOW BACK PAIN Once “red flags” for serious disease or pathology have been eliminated (see page 3), approximately 85% to 90% of LBP patients have mechanical or “nonspecific” back pain. Core treatment This CPM recommends core treatment elements based on national guidelines ICSI,KOE,NICE and a method for stratifying treatment based on a patient’s risk of developing chronic pain. HIL1,HIL2 Education and reassurance Patient education To correct misconceptions, calm fears, and encourage patients to participate in their fact sheet own recovery, focus on these four messages: Intermountain’s Low Back Pain fact sheet • A detailed history and physical didn’t reveal any serious problem. The spine is helps you educate patients with acute low back pain. This 4-page handout: strong and flexible, and it’s difficult to damage or dislocate anything. • Most people recover in a few weeks. • Dispels myths about Most people with acute mechanical back pain acute low back pain are symptom free within 2 weeks. Among those that don’t recover quite as quickly, many are back to normal work and activities within 3 months. • Explains why imaging is rarely needed • Staying active helps your back recover. Research shows that bed rest for more than • Encourages patients to a day or two can be harmful. If you keep moving, your back will recover more keep moving quickly. Walking, yoga, and pool exercise are particularly helpful — and if you sit • Answers other common questions at your job, try to stand up and move around for 2 to 3 minutes every half hour. • Imaging tests are NOT needed at this stage. An x-ray or MRI isn’t necessary to know what to do, and imaging may lead to expensive, unnecessary treatment. CHO1 For example, most of us have bulging discs that cause no symptoms. Appropriate pain medication, with a conservative approach See the table below; note that opioids do not have better outcomes that NSAIDs. WHI

TABLE 1. Medications for acute low back pain Class Medication Usual dosing Notes Simple acetaminophen (Tylenol) 500 mg, every 4 to 6 hours •• Before moving to 2nd-line meds, a 2- to 4-week course of analgesics (max 3,000 to 4,000 mg daily) acetaminophen or NSAIDs is suggested. NSAIDs ibuprofen (Advil, Motrin) 800 mg, 3 times daily (max 3,200 mg daily) •• Avoid NSAIDs for patients with chronic kidney disease or history of 1st NSAID-related dyspepsia or bleeding PUD. naproxen (Aleve, Naprosyn) 500 mg, 2 times daily (max 1,250 mg daily) line •• If ibuprofen or naproxen are not effective, consider switching to another NSAID before moving to muscle relaxants, steroids, or opioids. Refer to the Chronic Pain CPM for details on other NSAIDs that can be used in acute or chronic neck pain. Muscle baclofen (Lioresal) 10 mg, 3 times daily (max 80 mg daily) •• Limit muscle relaxants to a 7-day course. relaxants cyclobenzaprine (Flexeril) 10 mg, 3 times daily (max 60 mg daily) •• Muscle relaxants are contraindicated in elderly patients due 2nd to fall risk and sedation. methocarbamol (Robaxin) 1,000 mg, 4 times daily (max 6,000 mg daily line • Note that carisoprodol (Soma) is NOT recommended, for first 48–72 hours, then 4,000 mg daily) • due to risk of addiction and abuse issues. tizanidine (Zanaflex) 4 mg, 3 times daily (max 36 mg daily) Short- tramadol (Ultram) 25 mg to 100 mg every 4 to 6 hours •• In most acute LBP cases, no difference has been found in pain and acting (max 400 mg daily) overall improvement between NSAIDs and opioids. WHI opioids hydrocodone/APAP (Lortab) Hydrocodone 7.5 mg/APAP 325 mg every •• Limit course of opioids to 2–3 weeks; the need for extended 4 to 6 hours (max 12 tablets daily) opioids should prompt a reevaluation of pathophysiology. 3rd •• Avoid abrupt withdrawal of medication. line oxycodone/APAP (Percocet) Oxycodone 5 mg/APAP 325 mg every 4 to 6 hours (max 12 tablets daily) •• Tramadol is contraindicated if history of seizures or serotonin reuptake inhibition. •• Products containing more than 325 mg of APAP per tablet or capsule should not be prescribed. 4th If pain is severe and above therapies have not been effective, consider early referral to nonsurgical low back pain specialist for evaluation. See page 6. line

Additional treatment, based on chronic LBP risk Multiple studies have shown that specific psychosocial factors can increase the risk of developing chronic disabling symptoms CHO2,HIL3 — and that early identification of patients more likely to develop chronic LBP can help guide treatment. A tool to assess risk, based on psychosocial factors The STarT (Subgrouping for Targeted Treatment) Back Screening Tool, Validity of the TOOL developed by Keele University, is a 9-item tool that helps clinicians The STarT Back Screening Tool has been stratify patients into appropriate treatment. HIL1,HIL2 It identifies patients at tested for reliability and validity in an array HIL1,HIL3,HIL4,FRI low, moderate, or high risk for persistent, disabling pain. Its questions of settings. focus on established predictors for persistent disabling LBP: radiating leg A recent, randomized clinical trial showed pain, pain elsewhere, disability, fear of activity, anxiety, catastrophizing, low mood, that using the tool to stratify treatment can improve efficiency in physical therapy and how much the patient is bothered by the pain. Click the image at right to open the referrals, improve clinical outcomes, and form, or for information on ordering, see page 12. reduce costs. HIL2 Scoring the tool and using the results to stratify care The Intermountain form that incorporates theST aRT Back Screening Tool includes a scoring guide. Thetotal score (questions 1–9) identifies low risk versus moderate/high risk, and a distress subscale score (questions 5–9) discriminates between moderate and high risk. See the table below for scoring and recommendations at each risk level.

TABLE 2. Stratified care based on theST arT Back Screening Tool Risk Categories and Recommendations Risk level Treatment recommendations MENTAL HEALTH INTEGRATION Low risk: Education and reassurance, with appropriate pain Mental Health Integration (MHI) is a program •• Total score = 0 to 3 medications as needed — see the previous page. that coordinates mental health services within (See sidebar note about considering PT for some low-risk patients.) the primary care clinic. For more information on the MHI process and tools (including Moderate risk: Education and reassurance, appropriate pain meds, plus: baseline packets to screen for mental health •• Total score = 4 or above •• Physical therapy (begin as soon as possible). disorders), see page 12. If your clinic does •• Distress subscale (q. 5–9) •• Brief depression screen using the PHQ-9; refer to mental not have the MHI program, you can use the score = 3 or less health specialist if depression present (see the MHI Care Process MHI screening packets and refer to a mental Model and Adult Scoring Guide for more information). health specialist if necessary. High risk: Education and reassurance, appropriate pain meds, plus: Physical therapy for •• Total score = 4 or above •• Physical therapy with a practitioner trained in addressing psychosocial issues (begin as soon as possible). some low-risk patients •• Distress subscale (q. 5–9) score = 4 or above •• Mental health screening using the MHI Adult Baseline This CPM suggests that the STarT Back Packet . This packet screens for depression, anxiety/stress Screening Tool can be used to identify disorders, mood disorders, sleep problems, personal and family history of abuse or trauma, substance abuse, life stressors, and low‑risk patients who will often recover overall impairment. (See the Mental Health Integration Care without physical therapy. However, Process Model for details.) current physical therapy guidelines DEL also •• Referral to mental health specialist if needed (see MHI CPM). recommend that some low-risk patients can benefit from early evaluation and treatment Setting patient expectations for physical therapy by a physical therapist. Help patients referred to physical therapy understand the following points: • Physical therapy includes guided exercise and exercise plans — exercise is a long‑term therapy for low back pain. (See page 8 for exercise advice to give patients who are not referred to PT.) • Patients may not get better after just one or two sessions; it takes time and daily exercise to improve their pain. • Physical therapy may include strategies to change their thinking patterns about pain and activity.

Nonsurgical back specialist referral after 6 weeks A nonsurgical back specialist is the best treatment resource for patients with LBP that persists beyond 6 weeks. These providers include physiatrists, anesthesia/pain management specialists, and sports medicine specialists. They may work independently, in spine programs, or in pain clinics. Referral considerations A multidisciplinary spine care program is the best option. These programs integrate nonsurgical treatment, physical therapy, surgical treatment, and other modalities. Spinal MRI Order Guidelines AUGUST 2014

Before ordering a spinal MRI for your patient, check for at least 1 of the following indications. (For spine procedures, an effective procedure suite has state-of-the-art equipment, • Radiculopathy (focal neurologic deficit with progressive or • Suspected cauda equina syndrome. ICD-9: 344.61. disabling features): Pain in the distribution of the nerve root • New bowel or bladder dysfunction. ICD-9: unspecified (often extending below the knee or elbow), with motor, reflex, or functional disorder of intestine 564.9. sensory deficit. ICD-9: thoracic and lumbar 724.4; cervical 723.4. • Perineal numbness / saddle anesthesia. ICD-9: numbness 782.0. uses fluoroscopy, has experienced staff, and can give IV sedation and antibiotics.) • Radicular pain (radiating pain): Order an MRI only after failed conservative treatment (see LBP CPM) for 4 to 6 weeks. ICD-9: • Persistent or increasing motor weakness. ICD-9: generalized thoracic and lumbar 724.4; cervical 723.4. muscle weakness 728.87. • • Myelopathy (Babinski or sustained clonus — cervical or Significant loss of coordination in one or both legs. thoracic MRI). ICD-9: other myelopathy 336.8 — needs an • Suspected compression fracture: Osteoporosis or additional E code to identify the cause. osteoporosis risk. ICD-9: pathological fracture 733.13. • Associated lumbar spine symptoms/findings WITH cancer • Suspected spinal fracture: Significant recent trauma or fall. history, cancer symptoms, and/or infection. • Prior surgery or planned surgery or injection. Imaging considerations For more information, see Intermountain’s Low Back Pain Care Process Model and Flash Card.

©2014 INTERMOUNTAIN HEALTHCARE. All rights reserved. These guidelines apply to common clinical circumstances, and may not be appropriate for certain patients and situations. The treating clinician must use judgment in applying guidelines to the care of individual patients. Primary Care Clinical Program approval 07/17/2014. CPM009e - 08/14 (Patient and Provider Publications 801-442-2963) Keep in mind that routine imaging at the acute stage does not improve outcomes in mechanical low back pain — and may lead to unnecessary or ineffective treatment. ICSI,KOE,NICE,CHO1 Avoid imaging for patients who do not have Spinal MRI order Guidelines signs of serious pathology (see red flags on page 3), unless pain has persisted Intermountain has developed guidelines for longer than 6 weeks. ordering spinal MRI exams at Intermountain facilities. This list of appropriate indications Common questions about imaging tests as part of a referral: for spinal MRI imaging enables you to Should I order imaging tests as part of a nonsurgical back specialist referral? identify medical necessity and can assist with • preauthorization. These guidelines are not In most cases, no — unless there are obvious signs of radiculopathy or red flags designed to limit your ability to order spinal for serious pathology. MRI exams; they facilitate appropriate use of spinal imaging. • Who should recommend interventions based on imaging tests? A nonsurgical back Click the image above to open the specialist can evaluate imaging to identify which interventions (if any) may be guidelines, or see page 12 for information helpful. It is not generally recommended for primary care providers to order on accessing this document. interventions directly. However, it may be appropriate for a PCP to order an intervention for established patients who have been helped by a specific procedure in the past, if the same symptoms recur. Goals of nonsurgical back specialist care A nonsurgical back specialist aims to do the following (see page 10 for further details): • Identify the pain generator through physical exam, history, and imaging • Perform or recommend appropriate nonsurgical interventions (e.g., manipulation or manual therapy, local injections, or spinal injections) • Initiate and encourage a regular aerobic exercise and conditioning program • Expedite care to a surgeon if necessary Setting patient expectations for nonsurgical specialist treatment Patients should understand that the specialist evaluation may or may not reveal the cause of their pain and that it does not always result in procedures or a surgery referral. Remind patients that while the nonsurgical back specialist is evaluating or treating them, they should continue to remain as active as possible.

Further psychosocial evaluation after 6 weeks, if needed If a patient’s pain and/or function have not improved after 6 weeks, and the patient has not yet been evaluated using the MHI Adult Baseline Packet, consider administering the packet. See the MHI Care Process Model for more information.

Chronic LOW BACK PAIN Patients with LBP that does not improve with core treatment or nonsurgical back specialist treatment — and that interferes with work and/or life activities — will need chronic management. Pain assessment Chronic pain Care process model (CPM) • For patients who have received core LBP treatment and nonsurgical specialist Intermountain’s Management treatment without success: Follow the advice in Intermountain’s Management of Chronic Non-Cancer of Chronic Non-Cancer Pain Care Process Model (CPM) (see sidebar) to assess Pain CPM provides guidance psychosocial factors, medication-related risks, and other factors that can impact on assessing chronic pain, chronic pain management. managing treatment, and • For patients who present to you with LBP of 12 weeks or more: Screen for red monitoring safety. flags that may indicate serious pathology (see page 3); refer if needed. If the The CPM is accompanied by patient has not yet been assessed by a nonsurgical back specialist, refer the patient a suite of tools, including: for evaluation. If nonsurgical back specialist treatment is not helpful, follow the • A pain history and coping style assessment assessment advice in the Chronic Non-Cancer Pain CPM (see sidebar). • A pain management plan • Assessments to screen for risk of pain Psychosocial evaluation medication addiction or abuse, with If a patient has not yet been evaluated using the MHI Adult Baseline Packet, administer monitoring advice based on risk level the packet and create a treatment plan for any mental health conditions that are • An opioid therapy agreement (which can be identified, based on their complexity and severity. See theM HI CPM for more scanned into the electronic medical record) information about the MHI process and supporting tools. and a medication side effects form Click the image to open the document, or see Patient education and pain management plan page 12 for ordering information. Intermountain’s booklet Managing Chronic Pain: Reclaiming Your Life helps patients take an active approach to pain management. Self-care education books are an efficient way to supplement provider advice, and self care has been shown to be as effective as modalities such as spinal manipulation or acupuncture. CHO3 The booklet educates patients on proven strategies for low back pain such as mindfulness meditation, ROS along with medication safety and other topics. The Pain Management Plan that accompanies the Chronic Non-Cancer Pain CPM is a shared decision-making tool that documents the patient’s pain management goals, treatments, exercise, and other self-care approaches, and it can help engage patients in self-management. Click the images to open these tools or see page 12 for ordering information. Medication management Intermountain’s Chronic Non-Cancer Pain CPM contains a table listing chronic pain medications and links to tools for medication management. Key points on medication for chronic LBP are as follows: • Consider NSAIDs as first-line treatment. While NSAIDs and opioids are both effective for chronic LBP, NSAIDs should be considered as first-line treatment. Avoid opioids if possible, based on the significant rate of opioid side effects and lack of convincing superiority of opioids over NSAIDs. FOU,WHI • Monitor carefully. Effective pain medication management includes regular monitoring of analgesia, adverse effects, aberrant behavior, activity, and affect. GOU • Consider sleep. Assess for sleep disturbance due to pain, and consider treating sleep problems with low-dose tricyclic antidepressants, unless contraindicated. NICE

Considering other treatment options Patients with back pain that persists long term — pain that is not helped by nonsurgical back specialist treatment — should consider treatment beyond pain medication. In discussing treatment options with patients, keep these points in mind: • Continue to encourage movement. Exercise and everyday activity help to preserve function, delay or prevent further disability, and ease pain. Common exercise strategies for low back pain include: –– Walking and aerobic exercises, which increase baseline physical activity levels, improve blood flow, and may increase endurance of postural muscles. –– Core strengthening exercises, which focus on abdominal, paraspinal, gluteal, diaphragm, and pelvic floor muscles to foster lumbar stability. –– End-range flexion/extension stretches with repeated movements (such as the McKenzie method), which are likely to be most effective when customized by a physical therapist or physician for each patient. –– Yoga, which has been proven effective for pain management (see the table at right). –– Aquatic exercise, which may be preferred by some patients, as warm water can enhance flexibility and support movement. • Consider a team-based approach. Functional restoration programs, which provide Keys to enhancing multidisciplinary team care with a biopsychosocial approach, have been shown communication to improve function and reduce pain (see the table at right). If a full functional Conversational techniques that foster restoration program is not available in your region, consider a team-based approach effective communication with patients that incorporates some of the elements of functional restoration (such as using and families ICSI include the following: MHI providers and creating plans for consistent communication with physical • Open-ended questions that don’t require therapists and other specialists to whom the patient is referred). a yes/no answer. Ex: “What concerns or • Take a shared decision-making approach when discussing other treatment options. questions do you have about this plan?” This approach helps patients and families weigh the information about a treatment –– Reflecting back the speaker’s ICSI feelings and perspectives. Ex: “It option, clarify their goals and values, and make the decision that’s right for them. sounds like you’re worried about your Key elements of shared decision-making include: back pain keeping you from getting back –– to work full-time.” Using conversational techniques that enhance communication (see sidebar). –– Paraphrasing key statements and –– Helping patients and families weigh the risk and cost of an option against its giving a general summary based potential benefits. See the table at right for evidence-based outcomes research on those statements. Condensing key on a range of common treatment options patients may consider. (Intermountain statements and giving a summary of the situation can clarify content, show you’ve Healthcare is piloting several online shared decision-making tools for low back understood the patient’s perspective, and pain; this CPM will include links to recommended tools as the pilot concludes.) help the patient and family focus on the • broader perspective rather than being If patients want to try a benign, low-cost therapy, supporting this decision may mired in the details. Ex: “From what be helpful — even if the research is not conclusive about outcomes. The sense of you’ve said, it sounds like you’d like to…” self-efficacy that may come from pursuing an option can bring its own benefits in –– Asking for teach-back. Ask patients terms of pain and function. to repeat key points (information about benefits and risks, etc.) in their own –– If the patient asks about surgery, stress the guidance that a nonsurgical back words. Ex: “Can you explain back to me specialist can provide. An evaluation (or repeated evaluation) by a nonsurgical the pros and cons of this plan?” back specialist may be more helpful than a direct referral to a surgeon. If the specialist feels the patient needs a surgical evaluation, then a referral can be made.

TABLE 3. Treatment options for chronic low back pain: outcomes research Treatments Treatment* Research on outcomes  Exercise therapy Exercise therapy reduces pain and improves function in patients with chronic nonspecific LBP, as shown by several studies. VAN Exercise therapy can be guided by a physical therapist or nonsurgical back specialist. Independent exercise can also be recommended by the primary care provider — see the general suggestions on the previous page.  Physical therapy Spinal manipulation and mobilization, patient education/counseling, and exercise plans — guided by a physical therapist — can improve mobility and reduce pain/disability in some patients with subacute and chronic LBP. DEL  Yoga Several studies showed that yoga brought significantly better pain reduction than usual care, education, or conventional exercises. POS  Team-based programs Functional restoration programs that integrate medical and psychosocial treatment improve function and reduce pain in patients with chronic LBP. GUZ,MAY,GAT If a functional restoration program is not available, consider incorporating as many features of team-based care within your clinic as possible — such as incorporating MHI and planning for consistent communication with physical therapists and other specialists.  Cognitive behavioral Cognitive behavior therapy or psychoeducation are recommended to treat chronic LBP in multiple therapy (CBT) evidence‑based guidelines. AIR,NICE Multiple trials have shown that CBT is more effective for pain, functional status, and behavioral outcomes than placebo or no treatment. AIR  Surgery for lumbar •• Lumbar spinal stenosis: In highly symptomatic patients (with or without degenerative spondylolisthesis), spinal stenosis, the best proven intervention is surgery. WAT radiculopathy, •• Radiculopathy or radicular pain: In general, surgery brings moderate benefits, according to American or deformity Pain Society Guidelines. CHO4 (Note that radiculopathy with progressive neurologic deficit or cauda equina syndrome is an absolute indication for surgery.) •• Deformity: Surgery is an effective treatment for scoliosis or spondylolisthesis. Massage therapy Massage may benefit some patients with chronic nonspecific low back pain if combined with exercise ? and education. FUR Acupuncture Two recent systematic reviews YUA,RUB indicated that acupuncture was more effective than no treatment and ? could be a useful supplement to conventional therapies, but patient beliefs may play an important role in the effectiveness of this treatment. Surgery for chronic According to American Pain Society Guidelines, surgery has small to moderate benefits, but the majority ? mechanical back pain of patients do not have an optimal outcome (defined as minimum or no pain, no pain medications or only occasional use, and return of high-level function).CHO4  TENS A 2008 systematic review KHA reported conflicting evidence about whether TENS reduced back pain intensity, and two trials showed TENS did not improve back-specific functional status.  Traction Traction is not recommended to treat low back pain; this advice is consistent across a number of major guidelines. AIR,ICSI  Surgery for •• A 2011 evidence review in Spine FOU concluded that surgery is not recommended if it is based on degenerative changes degenerative changes on MRI. shown on MRI •• Surgical strategies: A 2008 systematic review DON concluded that lumbar spinal fusion is beneficial for treating fractures, infections, or spondylolisthesis, but offers no or limited benefits over nonoperative management for common degenerative changes. Disc arthroplasty offers similar outcomes to fusion. There is no convincing evidence to support dynamic stabilization surgery for chronic LBP.

*Key to symbols:

 = Research shows good outcomes and/or treatment is recommended in major guidelines. ? = Research is uncertain on outcomes.  = Research shows limited benefits and/or treatment is not recommended in major guidelines.

Nonsurgical back specialist treatment The table below describes problems that can generate low back pain, how a nonsurgical back specialist evaluates for each problem, and treatments that the specialist may consider.

TABLE 4. Nonsurgical back specialist approach Nonsurgical Back Specialist Evaluation and Treatment of Low Back Pain Pain generator Evaluation Treatments the specialist may consider

Lumbar spinal stenosis: Bony and •• Symptoms: Buttock, leg, and back pain when •• Epidural steroid injection trial ligamentous narrowing of the spinal standing and walking, relieved when sitting •• Physical therapy trial canal that compresses nerves; typically •• Exam: Kyphotic gait, variable weakness, numbness, • Surgical referral: In highly symptomatic patients, the degenerative, most common in patients • and loss of DTR; negative straight leg raise test (SLR) best proven intervention is surgical decompression, >50 years old •• Imaging: MRI imaging of choice with or without fusion WAT

Degenerative spondylolisthesis: •• Symptoms: Back pain when standing and walking, •• Physical therapy with lumbar-based stabilization Often associated with spinal stenosis in relieved when sitting (core strength) and leg stretching/strengthening patients >50 years old, especially women •• Physical exam: Kyphotic gait; pain with •• Facet cortisone injections and/or lumbar extension radiofrequency ablation •• Imaging: Standing x-ray and flexion and extension •• Surgical referral for lumbar fusion

Facet pain •• Symptoms: Mechanical back pain with or without •• Physical therapy proximal lower limb pain •• Facet cortisone injection and/or •• Physical exam: Exam does not predict the source of radiofrequency rhizotomy pain; degeneration of facets is a normal finding •• Imaging: Not helpful; facet degeneration is a normal finding

Herniated disc •• Symptoms: Acute and often severe buttock, leg, •• Education to explain the natural history of this and back pain, usually worse when sitting, bending, problem (favorable to improvement) lifting, or sneezing •• Epidural cortisone injections • • Physical exam: Positive SLR; variable numbness, •• Surgery referral indicated with progressive weakness, and loss of DTR neurologic deficit, profound weakness, or lack of •• Imaging: MRI improvement in 3 months

Degenerative disc: This is a normal •• Physical exam: Pain with lumbar flexion; negative •• Physical therapy finding that may also cause mechanical straight leg test •• Education to continue activity/exercise, vary back pain; more commonly symptomatic •• Imaging: Not helpful; disc degeneration is a activities, and avoid prolonged sitting or driving in younger people normal finding •• Manipulation (may be considered) •• Long-term home exercise program for stabilization, core endurance and leg flexibility; McKenzie-style extension exercises •• Rarely indicated: Discography, intradiscal procedures, and surgery

Sacroiliac (SI) joint: SI joint pain is •• Symptoms: Buttock and proximal leg pain, which •• Manual therapy with mobilization and more common in pregnant women, may be worse when sitting, bending, or lifting stabilization, provided by a physician or inflammatory spondyloarthropathy, or •• Physical exam: Exam often nonspecific but points physical therapist after a fall on the buttocks to upper buttock or mid-buttock as most painful •• Image-guided SI joint cortisone injection Often overdiagnosed location; positive FABER (flexion, abduction, and •• Surgery almost never indicated external rotation) test •• Imaging: Imaging tests often not helpful; diagnosis often made by image-guided injection

References

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Summary of intermountain resources W EB resources for PROVIDERS For providers: • American Pain Society: www .ampainsoc .org To find the tools listed below, go to intermountainphysician o. rg/ • American Academy of Pain Management: clinicalprograms, choose Clinical www .aapainmanage .org Topics A–Z, and then choose “Pain • American Academy of Pain Medicine: Management” from the A to Z menu. www .painmed .org A Clinical Topic Page (see the example at right) provides access to CPMs and • Back Pain CME Learning Center: www medscape. o. rg/resource/back-pain/cme supporting tools. Resources include:

W EB resources AND BOOKS for patients Websites: • Back pain overview on MedLinePlus: www n. lm ni. h gov/medlineplus. /backpain html. L ow Back Pain CPM S upporting forms: C hronic Pain Care A ssessment tools and •• P atient Self-History: Process Model care plans to support • Back Pain Health Center on WebMD: Back Pain the Chronic Pain CPM www we. bmd c. om/back-pain/guide/ •• P atient Exam: Lumbar default .htm Spine Evaluation • STr a T Back Screening Tool • American Chronic Pain Association: • • Spinal MRI Order Guidelines www t. heacpa or. g • The Pain Action Back Pain Library: www .painaction c. om/members/Home . For patients: aspx?paintypeid=1 • Clinicians can access Intermountain patient education materials using the Books: Clinical Topic Pages described above, and order copies via i-printstore c. om . Call • Do You Really Need Back Surgery?: A Surgeon’s 801-442-3186 for more information. Guide to Back and Neck Pain and How to Managing Chronic Pain: Choose Your Treatment, Aaron G. Filler, MD. • Clinicians can access additional patient Fact sheets: Reclaiming Your Life Oxford University Press, 2007. education from Krames from the PEL page. •• L ow Back Pain This 44-page handbook helps Type PEL in the browser window (from within patients take an active role in self • Harvard Medical School Low Back Pain: •• L eftover Medications: the firewall) and click Krames On-Demand. care, continue physical activity, Healing Your Aching Back, Jeffrey Katz, MD, How to Dispose of and manage treatments (including et al. Harvard Medical School, 2012. Type “low back pain” to search for available Them Safely medication) effectively. materials. Appropriate materials will also • The Pain Survival Guide: How to Reclaim Your appear in iCentra based on diagnosis code or Life (APA Lifetools), American Psychological can be found through the Education Module. Association, 2005. • Patients can also be referred to • Younger Next Year, Chris Crowley and Henry Intermountain’s public website at S. Lodge, MD. Workman, 2007. intermountainhealthcare o. rg for resources. • Younger Next Year for Women, Chris Crowley To find resources, patients should open the and Henry S. Lodge, MD. Workman, 2007. Health Topic Library and search for “low back pain.”

Functional Restoration/Chronic Pain Development Team: Core members for development of this CPM were Timothy Houden, MD; Bridget Shears, RN, MA; Gerard Brennan, PT, PhD; Kurt Dudley, PT; Paula Haberman, MD; Michael Jaffe, MD; and Stephen Warner, MD. Additional review and assistance was provided by Wayne Cannon, MD; Liz Joy, MD; Jack Ruckdeschel, MD; Tom Sanders, MD, and Roy Gandolfi, MD.