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Low Back Pain August 2014 Update

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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) 2 ©2013–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. AUGUST 2014 MANAGEMENT OF LOW BACK PAIN 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
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