VA/DoD CLINICAL PRACTICE GUIDELINE FOR DIAGNOSIS AND TREATMENT OF LOW BACK PAIN Department of Veterans Affairs Department of Defense QUALIFYING STATEMENTS The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent Department of Veterans Affairs or TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. Version 2.0 – 2017 VA/DoD Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain Prepared by: The Diagnosis and Treatment of Low Back Pain Work Group With support from: The Office of Quality, Safety and Value, VA, Washington, DC & Office of Evidence Based Practice, U.S. Army Medical Command Version 2.0 – 2017 Based on evidence reviewed through October 21, 2016 September 2017 Page 2 of 110 VA/DoD Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain Table of Contents I. Introduction ..................................................................................................................................... 5 II. Recommendations ........................................................................................................................... 6 III. Background...................................................................................................................................... 9 A. Description of Low Back Pain .............................................................................................................. 9 B. Epidemiology and Impact .................................................................................................................. 10 a. General Population ................................................................................................................................... 10 b. Veterans Affairs Population ..................................................................................................................... 11 c. Department of Defense Population ......................................................................................................... 11 IV. About this Clinical Practice Guideline ............................................................................................. 12 A. Scope of this Clinical Practice Guideline ........................................................................................... 12 B. Methods ............................................................................................................................................. 13 a. Grading Recommendations ...................................................................................................................... 14 b. Reconciling 2007 Clinical Practice Guideline Recommendations ............................................................ 15 c. Peer Review Process ................................................................................................................................. 16 C. Summary of Patient Focus Group Methods and Findings ................................................................ 16 D. Conflict of Interest ............................................................................................................................. 17 E. Highlighted Features of this Clinical Practice Guideline ................................................................... 18 F. Patient-centered Care ....................................................................................................................... 18 G. Shared Decision Making .................................................................................................................... 18 H. Implementation ................................................................................................................................. 19 V. Guideline Work Group ................................................................................................................... 20 VI. Algorithm ...................................................................................................................................... 21 Module A: Initial Evaluation of Low Back Pain .......................................................................................... 22 Module B: Management of Low Back Pain ............................................................................................... 24 VII. Discussion of Recommendations .................................................................................................... 26 A. Diagnostic Approach .......................................................................................................................... 26 B. Education and Self-care ..................................................................................................................... 31 C. Non-pharmacologic and Non-invasive Therapy ............................................................................... 33 D. Pharmacologic Therapy ..................................................................................................................... 39 E. Dietary Supplements ......................................................................................................................... 46 F. Non-surgical Invasive Therapy .......................................................................................................... 48 G. Team Approach to Treatment of Chronic Low Back Pain ................................................................ 50 September 2017 Page 3 of 110 VA/DoD Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain VIII. Knowledge Gaps and Recommended Research .............................................................................. 51 Appendix A: Evidence Review Methodology ....................................................................................... 53 A. Developing the Scope and Key Questions ........................................................................................ 53 a. Population(s) ............................................................................................................................................. 53 b. Intervention(s) .......................................................................................................................................... 54 c. Comparator(s) .......................................................................................................................................... 56 d. Outcomes .................................................................................................................................................. 56 e. Timing ....................................................................................................................................................... 57 f. Setting ....................................................................................................................................................... 57 B. Conducting the Systematic Review ................................................................................................... 57 a. Criteria for Study Inclusion/Exclusion....................................................................................................... 59 b. Literature Search Strategy........................................................................................................................ 60 C. Convening the Face-to-face Meeting ................................................................................................ 61 D. Grading Recommendations ............................................................................................................... 62 E. Recommendation Categorization ..................................................................................................... 65 a. Categorizing Recommendations with an Updated Review of the Evidence ........................................... 65 b. Categorizing Recommendations without an Updated Review of the Evidence ..................................... 66 c. Recommendation Categories and Definitions ......................................................................................... 66 F. Drafting and Submitting the Final Clinical Practice