CARE PATH GUIDE Low Back Pain · II. LBP CLASSIFICATION AND EVALUATION: CLASSIFYING II. LOW BACK...

CARE PATH GUIDE

Low Back Pain

CONTENTS

I. Introduction 3

II. Low Back Pain Classification and Evaluation 5

Imaging 7

III. Treatment Recommendations 9

Overview 9

Physical Therapy 10

Treatment Table 11

Medication Table 13

Acute Low Back Pain Specifics 20

Subacute Low Back Pain Specifics 21

Chronic Low Back Pain Specifics 23

Opioid Avoidance and Precautions 25

I V. Algorithms 27

V. Patient Education and Resources 32

VI. References 35

VII. Appendix: Keele STarT Back Screening Tool 38

Vanderbilt Health Affiliated Network | Low Back Pain 3

I. INTRODUCTION

I. INTRODUCTIONCLINICAL JUDGMENTThis care path guide is intended to be broadly applicable, but it is not meant to substitute for clinical judgment. Clinicians and specialists should tailor processes and approaches to align with patient needs, abilities and goals for care.

LOW BACK PAIN: A HEAVY BURDEN ON PUBLIC HEALTHOne of the most common conditions medical providers treat,1 low back pain affects an estimated 80% of people at least once over a lifetime.2 During a given three-month period, approximately 25% of adults in the United States will experience at least one day-long episode of low back pain.3 The prevalence of this condition and its effects on public health have led some experts to label it an epidemic.4

In the U.S. and globally, disability and healthcare costs associated with spinal pain, including low back pain, are on the rise,5,6 and that trajectory is projected to continue.7 Americans lead more sedentary lifestyles today than at any other time in history, spending more time sitting, which can lead to poor posture—a contributor to low back pain.

Worldwide, low back pain is linked with more disability than any other condition.8 From 1996 to 2013, spending on low back and neck pain increased by an estimated $57.2 billion, second only to the spending increase on diabetes ($64.4 billion) during that time span.7

THE CASE FOR A CARE PATH GUIDE Recent studies have demonstrated that inadequate, unnecessary, uncoordinated and inefficient care are responsible for waste in the healthcare system that may account for 35–50%9 of the nearly $3 trillion the U.S. spends annually on healthcare.7 Care path guides, with reduction of unnecessary variability as the primary goal, become tools for education, reporting, measurement and continuous improvement. Care paths are designed to standardize care to reduce variability and assure a consistent level of quality for patients across time, venue and provider, combining workflow-friendly, evidence-based practice principles.

HEALTH STATUS MEASURES AND PATIENT-REPORTED OUTCOME MEASURESHealth status measures (HSMs) in general and patient-reported outcome measures (PROMs) in particular (see Sidebar 1, page 4) are becoming important standard components of patient care. These measures are validated tools that furnish insight into patient relevant issues, improve patient/clinician communication and guide individual management. They provide a method to objectify outcomes and quality in a manner that can be shared with patients. These measures require patient participation and have been shown to improve patient engagement in their own healthcare. The outcome measures are an important component of value-based care and are beginning to be important in health policy and reimbursement.


I. INTRODUCTION

Sidebar 1 PATIENT REPORTED OUTCOME MEASURES (PROM) TOOLS

GENERAL AND BEHAVIORAL

Comorbid depression can slow response to low back pain treatment. The following PROMs help clinicians evaluate general and behavioral health status that could affect outcomes and guide treatment:

z Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10: A 10-question screening tool designed to assess physical, mental and social health, including pain, fatigue and quality of life.

z Patient Health Questionnaire-2 (PHQ-2): A two-question depression screening tool that can provide information about the patient’s mental health status.10 The PHQ-2 consists of the first two questions from the PHQ-9. If the patient has a positive PHQ-2 score of 3 or higher, they could be further screened with the PHQ-9 screening tool.

z PHQ-9: A nine-question screening tool to evaluate the severity of depression symptoms.11

DISEASE-SPECIFIC

z Keele STarT Back Screening (SBT) Tool: A nine-question agree-disagree screening tool developed in the U.K. to identify biomedical, psychological and social risk factors for ongoing back pain disability.12,42 Through an overall score and a psychological distress score, the SBT can be used to stratify patients into low-, medium- and high-chronicity risk groups and guide referrals and/or therapy plans based on this risk stratification. Explore the Keele online SBT calculator, SBT printout or other SBT resources. Please note: STarT Back screening is not appropriate for patients presenting with acute low back pain in the ER setting but could be used by ER clinicians for patients presenting with a secondary diagnosis of subacute or chronic low back pain (existing for > 6–12 weeks).

z Oswestry Disability Index (ODI): A 10-question screening tool for use in spine specialty and physical therapy settings, ODI is an extensively validated PROM that has been used in clinical practice and numerous research studies over the past 20 years13,14 to measure the effectiveness of low back pain treatment. The ODI score ranges from 0–100 with higher numbers indicating greater disability (81–100 is generally consistent with a patient being bed-bound). Changes of 10 points or greater are considered clinically significant.

ABOUT THIS CARE PATH GUIDEThis care path was developed by an interdisciplinary team within the Vanderbilt Health Affiliated Network to guide nursing, advanced practice providers, and rehabilitation, primary care and spine specialists in an evidence-based approach to diagnosis and treatment of acute, subacute and chronic low back pain. An evidence-based resource, the care path guide is based on national and international guidelines, as well as the expert opinions of members of our network.

The objective of care paths is to provide a workflow-friendly summary of evidence-based guidelines in an effort to reduce unnecessary variability in the overall management of disease conditions by standardizing assessment, treatment and referral behavior. In so doing, overall quality is maintained or improved and costs invariably decrease.

http://www.healthmeasures.net/index.php?Itemid=992


https://www.phqscreeners.com/select-screener/31

https://www.phqscreeners.com/sites/g/files/g10049256/f/201412/PHQ-9_English.pdf


https://startback.hfac.keele.ac.uk/training/resources/startback-online/

https://startback.hfac.keele.ac.uk/training/resources/

https://eprovide.mapi-trust.org/instruments/oswestry-disability-index




II. LBP CLASSIFICATION AND EVALUATION: CLASSIFYING

II. LOW BACK PAIN CLASSIFICATION AND EVALUATION

ClassifyingPatients may present with one of three categories of low back pain, based largely on the origin of pain, and may experience more than one type concurrently. Types include:

z Radicular—nerve-related pain felt most prominently in the legs15

z Low back pain without radiation—muscle or bone pain with no identifiable cause felt in the low back16 (e.g., no red flags or radicular pain/paresthesias)

z Other—pain caused by a disease or medical condition that is not radicular or musculoskeletal in nature, such as cancer, spinal infection or pain related to internal organs (abdominal aneurysm, nephrolithiasis, etc.)

Low back pain is recognized as acute, subacute or chronic, based on pain duration.

z Acute—symptoms lasting four to six weeks. Most cases of acute low back pain will resolve without intervention.

z Subacute—symptoms lasting six to 12 weeks

z Chronic—symptoms present for more than 12 weeks17

Sidebar 2 LOW BACK PAIN CAUSES

SPINAL

These spinal causes of low back pain may or may not require more aggressive evaluation, treatment or specialty referrals, depending on the presence of red flags or duration of symptoms:

z Ankylosing spondylitis

z Nerve compression or related disorders (radiculopathy)

z Spinal stenosis, spondylosis, spondylolisthesis

z Cancer

z Infection

z Fracture

NON-SPINAL

It is important to keep internal organ and adjacent joints in mind as other causes of back pain during the patient history and physical examination because not all low back pain is of spinal origin. The following list of conditions may cause a patient to present with back pain. A thorough review of systems can help to screen for these non-spinal causes of back pain.

z Abdominal aortic aneurysm (AAA)

z Degenerative and inflammatory changes of adjacent musculoskeletal structures (e.g., hip joint pathology)

z Nephrolithiasis

z Peptic ulcer disease

z Pyelonephritis


II. LBP CLASSIFICATION AND EVALUATION: EVALUATING

EvaluatingRED FLAGSRed flags that may warrant departure from the care path guide and initiation of disease specific work-up and/or referral are typically identified from a patient medical history and physical exam (see Red Flags Algorithm, page 30).

Patient History Red Flags

z Bowel or bladder incontinence

z Saddle anesthesia

z History of cancer

z Unexplained weight loss

z Unexplained fever, chills, night sweats

z Immunocompromised status

z Intravenous (IV) drug use

z Recent spinal procedure

z Significant trauma

z History of osteoporosis

z Medications that can cause bone loss (glucocorticoids, phenytoin, phenobarbital)

z Gait difficulties (drop foot, spastic gait)

z Incoordination, loss of fine motor skills

z Increasing weakness

Physical Exam Red Flags

z Gait abnormality

z Atrophy

z Point tenderness over spinal column or step-off deformity

z Weakness

z Abnormal reflexes

z Hyperreflexia, clonus, +Babinski—Upper motor neuron signs that can indicate a cord or brain lesion (myelopathy, tumor, demyelinating disease)

z Hyporeflexia—A lower motor neuron sign that can indicate nerve root impingement, radiculopathy or peripheral neuropathy. This may improve with conservative care, but red flag signs of severe nerve dysfunction include weakness, gait abnormality and atrophy.

PATIENT HISTORYFor acute, subacute and chronic low back pain, obtain a clinical history and review of systems:

z Obtain a patient history.

z Onset - When did the pain start? Was there a precipitating event?

z Location - Where is the pain located? Does the pain radiate?

z Duration - How long has the patient had this pain? Does the patient have a history of pain like this that resolved previously?

z Character - What is the quality of pain (dull ache, sharp, stabbing, throbbing, etc.)?

z Aggravating factors - What makes the pain worse (prolonged standing or sitting, lifting, etc.)?

z Relieving factors - What makes the pain better (position, medications, stretching, ice/heat, etc.)?

z Timing - Is the pain constant or intermittent? What time of day is the pain noticeable?

z Severity - Clinicians should assess pain intensity by asking their patients to rate their pain on the pain scale.

z Review of systems should include abdominal pain, urinary symptoms or other symptoms found with internal organ causes of non-musculoskeletal back pain (AAA, pyelonephritis, nephrolithiasis, peptic ulcer disease, etc.) as this would require disease specific work-up.

z Evaluate for red flags—signs of trauma, cancer, infection, cauda equina syndrome, etc., which may warrant urgent testing and/or spine specialty referral.

z Establish baseline measures of pain, function and mental health. The pain scale and PROM tools (Sidebar 1, page 4) may help gain insight into patient perceptions of pain (SBT) and function (ODI).4

z Identify and address psychosocial issues related to low back pain, as doing so may remove barriers to treatment and prevent pain progression.18 Again, PROMs are useful tools for gathering this information. Inquire about psychosocial factors (using PROMIS-10, PHQ-2 (first two questions from PHQ-9) or PHQ-9, SBT—see Sidebar 1, page 4) to identify patients who may need more aggressive treatment. Ask patients about effects on daily function (ODI), missed days of work due to pain, comorbid mental health issues, etc.








PATIENT PHYSICAL EXAMFor acute, subacute and chronic low back pain, perform a physical exam, which at minimum should include:

z Observation of the patient’s gait and of their seated and standing posture

z Palpation of the lumbar spinous processes, sacroiliac joints and paraspinal muscles to assess for tenderness, step-off deformity or hypertonicity

z Straight leg raise (SLR), which should reproduce radicular pain or paresthesias (not just back pain) between 30–70 degrees in order to be considered positive

z Patellar and Achilles deep tendon reflexes with note of hyporeflexia—which could indicate peripheral pathology, such as nerve root impingement—or hyperreflexia— which could indicate central pathology, such as myelopathy.

z Strength testing of knee extension (L4), ankle dorsiflexion (L4, L5), great toe extension (L5) and ankle plantar flexion (S1) with note of strength less than or equal to 4/5, asymmetric strength loss of at least one grade with contralateral comparison, or progressive strength loss

z Additional physical examination testing, including dermatomal sensory testing, active range of motion of the lumbar spine and hips, dynamic balance testing and flexion, abduction and external rotation (FABER) testing, to be considered if clinical suspicion mandates

IMAGING In the absence of red flags suggestive of serious underlying conditions, imaging does not have measurable value in the evaluation or conservative management of patients with low back pain (with or without radiation). Early imaging, especially in the acute phase of low back pain, does not improve findings or clinical outcomes compared with usual clinical care without imaging. Furthermore, there is significant potential for confounding information, unnecessary therapy and worry. If imaging is indicated in the presence of red flags or for procedural planning, MRI is the exam of choice. In cases of trauma or if a vertebral fracture is suspected, conventional radiographs or CT would be the most appropriate imaging choice.19-22

Whenever imaging is performed, it is important to remember the very high prevalence of morphologic abnormalities in the asymptomatic population when factoring the significance of findings. Research studies of patients who have never had back pain have shown that 25% of these individuals will have a herniated disk and

over 50% have a disk bulge.23,24 MRIs are typically used to evaluate the need for surgical intervention or injections, which, in the absence of dysfunction, is typically deferred until response to conservative care is measured. Exam findings that may warrant imaging include:

z Spinal deformities (significant scoliosis, kyphosis, etc.) may require a scoliosis survey radiograph to evaluate degree of curvature or, in the case of kyphosis, to rule out compression fracture18

z Point tenderness of the spine in patients with known osteoporosis, higher risk of osteoporosis or recent trauma, which may warrant radiography to evaluate for fracture

z Other concerning physical exam findings, such as hyperreflexia, weakness not secondary to pain and gait abnormality, as these findings may suggest a cord or brain lesion

z Atrophy, weakness, gait abnormality (e.g., drop foot) or lower motor neuron signs in patients with radicular pain

PSYCHOSOCIAL IMPEDIMENTS TO CAREPsychosocial factors (see Psychosocial Flags, Sidebar 3, below) can significantly affect a patient’s prognosis by adversely influencing care through catastrophizing, depression and fear avoidance.4,25,26 When psychosocial factors are present, patients benefit from further evaluation and treatment of these conditions. The PROMIS-10, PHQ-2 (first two questions from PHQ-9) and SBT PROMs (Sidebar 1, page 4) are useful in identifying patients with psychosocial impediments to care for low back pain of any duration.

Psychosocial flags should be evaluated more aggressively in patients for whom clinical suspicion is high initially or for those who do not respond appropriately to conservative care. For instance, a clinician may decide to use the PHQ-9 over the PHQ-2 screening tool for patients with a history of mood disorder in order to ensure optimal treatment of comorbid psychiatric issues and determine the need for medication adjustments or referrals to psychiatry or psychology. Patients found to have psychosocial impediments to care may benefit from cognitive behavioral therapy and/or medications to treat an underlying mood disorder if having moderate to severe depression. SSRIs are first-line therapy for depression, but SNRIs (duloxetine, venlafaxine) can also help manage neuropathic pain symptoms.







Sidebar 3 PSYCHOSOCIAL FLAGS

z Mental illness, including depression

z Negativity, belief that pain will not improve

z Restricted activity due to fear of pain or belief that activity and pain are harmful

z History of work absenteeism due to back pain

z Pain disproportionate to the diagnosis

z Drug-seeking behavior (see Sidebar 5, page 26)

z Treatment noncompliance or prolonged bed rest

z Stressful job

z Social isolation

z Marital issues

z Financial concerns related to cost of care, workers’ compensation or lawsuits


III. TREATMENT RECOMMENDATIONS: OVERVIEW

III. TREATMENT RECOMMENDATIONSOVERVIEWRecommendation 1: Because the majority of people with low back pain recover within four to six weeks no matter the treatment, the American College of Physicians strongly recommends choosing non-drug treatments for acute and subacute low back pain, including superficial heat, massage, acupuncture and spinal rehabilitation efforts.

Formalized rehabilitation/PT should be instituted if the patient’s STarT Back Tool (SBT) assessment indicates a high risk of disability [a total score ≥ 4 and a distress subscale score (questions 5–9) ≥ 4] and should be considered if the SBT stratification indicates moderate risk [a total score ≥ 4 or more and a distress subscale score (questions 5–9) ≥ 3]. If patients and clinicians desire the use of medication for low back pain, choose a nonsteroidal anti-inflammatory medicine or muscle relaxers. Patients with low-risk SBT scores [a total score ≤ 3] usually recover within six weeks of low back pain onset without PT and should be encouraged to be active.

Recommendation 2: The American College of Physicians strongly recommends clinicians and their chronic low back pain patients begin care for chronic low back pain with non-drug treatments, such as exercise, rehabilitation, spinal manipulation, acupuncture, stress reduction and relaxation techniques, motor control exercises, tai

chi, yoga, and laser, cognitive behavioral and operant therapies.

Recommendation 3: For chronic low back pain patients who do not respond satisfactorily to non-drug treatments, the American College of Physicians recommends (weak recommendation) considering pharmacologic treatment with NSAIDs as first-line therapy, or duloxetine or tramadol as second-line therapy. Only after more conservative treatments have not provided relief and when benefits outweigh risks should opioids be considered. When prescribing opioids, clinicians must talk with their patients about the risks and benefits.

FOLLOW-UP AND RETURN PRECAUTIONSPatients should be instructed to schedule a follow-up appointment for new or worsening symptoms or for symptoms persisting for longer than four to six weeks. They should also be counseled on alarm signs (red flags) that would warrant emergent evaluation (e.g., bowel or bladder incontinence, saddle anesthesia, gait difficulties or significant weakness).

See the Medication Table (pages 13–17) for additional pharmacologic therapy details.


III. TREATMENT RECOMMENDATIONS: PHYSICAL THERAPY

Sidebar 4 PHYSICAL THERAPY

Refer to a physical therapist who specializes in working with low back pain patients for spinal rehabilitation. Physical therapy may provide additional education about body mechanics and posture, as well as exercises (core strengthening, trunk coordination, endurance, centralization and directional preference exercises),4 assistive devices to correct gait abnormalities and manual therapy (manipulation and mobilization).4,25

DEFINITIONS

z Manual therapy—Passive or hand movement techniques used by physical therapists, osteopathic clinicians and chiropractors to improve range of motion and flexibility, reduce inflammation or swelling, decrease muscle spasms, and regulate pain.27 Examples of manual therapy techniques are manipulation/mobilization, lymphatic drainage, massage, traction and passive range of motion exercises.

z Manipulation—Passive joint movements, typically high-velocity, low-amplitude,28 applied manually to improve joint mobility. Thrust joint manipulation, which sometimes produces an audible popping sound, is an example of joint manipulation. Some states do not allow physical therapists to perform manipulations. Please follow your state’s guidelines.

z Mobilization—Passive joint or soft tissue movements, typically low-velocity, applied manually28 to improve joint mobility and reduce inflammation.

z Myofascial release is an example of a soft tissue mobilization technique used to reduce muscle spasm associated with painful range of motion and improve flexibility and physical functional ability.

z Passive range of motion and traction are examples of low-velocity joint mobilization techniques used to improve range of motion and physical functioning.


III. TREATMENT RECOMMENDATIONS: TREATMENT TABLE

TABLE 1. TREATMENT TABLE

TREATMENTSRECOMMENDED FOR

Acute Subacute Chronic

Self-Care Options

Regular exercise (cardiovascular, core strengthening, yoga, tai chi); Stretches Yes Yes Yes

Heat Yes Yes Yes

Ice packs; Cryotherapy Yes Yes Yes

Epsom salt soaks Yes Yes Yes

Non-Pharmacologic Therapy

Massage If having myofascial pain If having myofascial pain Only for myofascial pain

Acupuncture If having myofascial pain If having myofascial pain If having myofascial pain

Physical therapy

Yes, outpatient PT for high-risk SBT score [a total score ≥ 4 and a distress subscale score (questions 5–9) ≥ 4].

Consider outpatient PT for moderate SBT score [a total score ≥ 4 and a distress subscale score (questions 5–9) ≥ 3].

Only refer the patient to be seen by PT in the acute setting if the patient is not independent with mobility. If the patient is independent with mobility, PT does not have anything to offer the patient in acute.

Special considerations are applicable in the acute and emergency room settings, e.g., if the patient is having difficulty with ADLs (bed mobility, transfers, gait or performance, etc.), the patient would benefit from a therapy consultation. Refer to a physical therapist who specializes in working with low back pain patients for spinal rehabilitation for additional education about body mechanics and posture, as well as exercises (core strengthening, trunk coordination, endurance, centralization and directional preference exercises), assistive devices to correct gait abnormalities and manual therapy (manipulation and mobilization).

Yes Yes

Spinal manipulation Yes Yes Yes


III. TREATMENT RECOMMENDATIONS: TREATMENT TABLE

Pharmacologic Therapy

Topical Medications (relatively low risk with directed use, mild evidence) Yes Yes Yes

NSAID (low/mod risk with short 2-4wk course, mod evidence) Yes Yes Yes

APAP Yes Yes Yes

SMRs atypical antiepileptics (if radicicular) (mod risk, mild/mod evidence)

Yes, short course Yes, short course Yes, short course

Steroids (mild/mod risk, no good evidence) No No No

SNRI For comorbid psychosocial issues

For neuropathic pain or comorbid psychosocial issues

For neuropathic pain or comorbid psychosocial issues

Gabapentinoid medications No No For neuropathic pain

Opioid medications No; if used, limit to short-acting, short course

No; if used, limit to short-acting, short course

Yes, if other treatment options are exhausted


III. TREATMENT RECOMMENDATIONS: MEDICATION TABLE

TABLE 2. MEDICATION TABLE

Pain Type Medication Classes & Agents

Typical Initial Dose

Max Dose/ Day

Common Side Effects

Cautions & Contraindications

Additional Information

Approx. Cost/Month

Mild Topical Agents

Capsaicin Cream (Zostrix, Capsaicin HP, etc.)

Apply thin layer and massage gently.

Up to QID Application site reactions, including burning, that usually decrease over time

Hypersensitivity concerns

Counseling: Wash hands after use; not for use on open/broken skin.

$ OTC

Capsaicin Patch (Salonpas-Hot, etc.)

Apply patch up to 8 hours/day.

4 patches/day $ OTC

Diclofenac Epolamine 1.3% (Flector)

1 patch (180mg) BID

1 patch BID

Application site reactions

BBW: GI bleeds and CV events

Avoid use in ESRD.

Comments: Should not be combined with oral NSAIDs.

$$$$ Rx

Diclofenac Sodium 1% (Voltaren Gel)

Apply 2–4g 3–4 times/day.

Upper extremities: 8g/joint/day

Lower extremities: 16g/joint/day

$$-$$$$ Rx

Lidocaine Cream (Aspercreme Lidocaine, etc.)

3–4 applications/day

Up to QID

Nausea, vomiting, application site reactions

Hypersensitivity concerns

Systemic adverse effects with excessive dosing may require supportive care and/or resuscitative equipment.

Counseling: Do not occlude, use for longer than directed or expose to external heat sources; patches may be cut; fold patches together before discarding.

Patch availability: 4% OTC; 5% prescription

$ OTC

Lidocaine Patch (LidoPatch, Lidoderm 5%, etc.)

1 patch Qday

1 patch may be worn up to 12 hours/day

$ OTC;

$$$ Rx

Miscellaneous Counterirritants: Salicylates, Menthol, Camphor, etc (Aspercreme, Bengay, Biofreeze, Salonpas, etc.)

Creams/

Sprays/Sticks: Apply thin layer per product directions.

Patches: Apply patch q 8–12 h per product directions.

Varies per product

Skin irritation, including application site, burns requiring medical treatment

Use caution in patients with ulcers, bleeding problems, hypertension, heart or kidney disease.

Comments: Often multiple ingredient products

$ OTC

Mild-mod Non-Opioid Analgesic

BBW = Black Box Warning

CI = Contraindicated

REMS = Risk Evaluation and Mitigation Strategies





Max Dose/ Day

Common Side Effects



Approx. Cost/Month

Acetaminophen (Tylenol) 325–650mg q 4–6 h

4g (3g in elderly)

Nausea, vomiting, skin rashes

Use caution in patients with liver disease and those that consume 3 or more alcoholic drinks/day.

Counseling: Check other medications for APAP.

$

Mild-mod NSAIDs

Celecoxib (Celebrex)

100–200mg daily to q 12 h

400mg

Dizziness, edema, GI disturbances, headache, LFT increases, nausea, skin rash, postoperative hemorrhage (indomethacin), URIs (celecoxib)

Avoid use in advanced renal disease and moderate to severe hepatic impairment.

BBW: Cardiovascular events, GI events, high risk for bleeding (toradol), prior hypersensitivity reactions to aspirin or NSAIDs (toradol)

Caution: Patients with hypertension, renal insufficiency, cardiovascular disease, heart failure

Consideration: Selective COX2 inhibitors

Counseling: Take with food; avoid use with other NSAIDs; administration with PPIs may be considered when using NSAIDs long term or in high-risk patients.

$$

Diclofenac Sodium (Voltaren)

100mg loading dose then 50mg TID

150mg

Avoid use in advanced renal disease.

$$

Ibuprofen (Motrin)

400–800mg q 6–8 h 3200mg $

Indomethacin (Indocin)

25–50mg q 6–12 h 200mg $

Hyperacute Ketorolac (Toradol)

20mg loading dose then 10mg q 6 h

40mg; LIMIT USE TO 5 DAYS ONLY

Intended as continuation of IM or IV therapy only

CI: advanced renal disease

Use caution in hepatic impairment and elderly patients.

$

Meloxicam (Mobic) 5mg daily 15mg

Avoid in CrCl

< 20mL/min

Use caution in hemodialysis, severe hepatic impairment.

$

Naproxen (Naprosyn)

220–500mg q 8–12 h

1000mg (up to 6 months)

Avoid use in advanced renal disease.

$

Piroxicam (Feldene) 10mg qday 20mg qday $








Max Dose/ Day

Common Side Effects



Approx. Cost/Month

Mild-mod Skeletal Muscle Relaxants

Baclofen (Lioresal) 5mg TID 80mg

Confusion, dizziness, drowsiness, headache, hypotension, asthenia (tizanidine), bradycardia (methocarbamol, tizanidine)

BBW: Do not stop abruptly; CNS depression.

Avoid use in ESRD; start with 2.5mg if renally impaired.

May cause urinary retention

Comments: Beers listed

Counseling: Avoid EtOH

$

Cyclobenzaprine (Flexeril) 5mg TID 30mg

CI: Hyperthyroidism, HF, dysrhythmias, acute recovery phase of MI

May cause significant CNS depression or serotonin syndrome when used with other serotonergic agents

Comments: Wait 14 days after stopping MAOIs.

Counseling: Take at bedtime; Recommended use only 2–3 weeks;

Avoid EtOH

$

Methocarbamol (Robaxin)

1-1.5g TID to QID x 48-72h, then 500–750mg TID to QID

8g

CI: renal impairment

May cause significant CNS depression



Tizanidine (Zanaflex)

2mg up to TID 36mg

CI: concomitant therapy w/ cipro or fluvoxamine

Avoid use in hepatic impairment.

Caution in patients with CrCl < 25ml/min

May cause significant CNS depression

Counseling: Abrupt discontinuation not advised;

Avoid EtOH


$








Max Dose/ Day

Common Side Effects



Approx. Cost/Month

Mod-sev Neuropathic Pain Agents

Gabapentinoids:

Gabapentin (Neurontin)

100mg QHS to TID 3600mg

Cognitive difficulties, dizziness, drowsiness, respiratory depression, sedation, peripheral edema, visual disturbances, weight gain

Use caution in patients with histories of substance abuse.

Renal adjustment necessary

May cause suicidal ideation

Comments: Controlled substances

Counseling: Take with food;

Do not stop abruptly;

May take up to 2 months to determine full effect;

Avoid EtOH

$

Pregabalin (Lyrica, Lyrica CR)

25mg BID to TID 300mg $$$$

SNRIs:

Duloxetine (Cymbalta)

30mg daily x 1 week then 60mg daily

60mg

Dizziness, drowsiness, fatigue, headache, nausea, orthostatic hypotension, weight loss, xerostomia, anxiety, /insomnia (venlafaxine)

BBW: suicidal ideation

CI: concurrent use with MAOIs

Dose adjustments necessary in renal and hepatic impairment

Cautions w/ duloxetine: Glaucoma, chronic liver disease, alcohol abuse

Cautions w/ venlafaxine: Glaucoma, HTN, bleeding risk

Comments: May increase bleeding risk or cause serotonin syndrome when used with other serotonergic agents

Counseling: Take with food; Do not stop abruptly; Minimum 6 week trial is necessary to determine full effect.

$

Venlafaxine ER (Effexor XR) 37.5mg daily 225mg $-$$








Max Dose/ Day

Common Side Effects



Approx. Cost/Month

Mod-Sev Short-Acting Opioids

Hydrocodone (Norco) 5mg q 4–6 h < 4g of

APAP

Constipation, nausea, pruritus, sedation, vomiting

BBW: *CYP3A4 inhibitors, hepatotoxicity


$$-$$$

Morphine (MSIR) 10mg q 4 h Differs per

ptBBW: *Concomitant EtOH use

Comments: Controlled substance; REMS program; Should not be first choice in patients w/ renal impairment


$$-$$$

Oxycodone (Roxicodone/Percocet)

5–10mg q 6 h

Differs per pt

BBW: *CYP3A4 inhibitors

Comments: Controlled substance; REMS program


$$

Tapentadol (Nucynta) 50mg q 12 h 500mg

BBW: *Avoid use in renal and hepatic impairment and those with history of seizures.

May cause serotonin syndrome when used with other serotonergic agents

Comments: Controlled substance; REMS program


$$$$

Tramadol (Ultram) 50mg q 6 h

400mg (300mg in elderly)

BBW: *CYP3A4 interactions

Dose adjustments necessary in renal and hepatic insufficiency

Use with extreme caution in patients with history of seizures.

Comments: Controlled substance; May cause serotonin syndrome when used with other serotonergic agents


$$








Max Dose/ Day

Common Side Effects



Approx. Cost/Month

Severe Long-Acting Opioids

Hydrocodone ER

Zohydro ER: 10mg q 12 h

Vantrela ER: 15mg q 12 h

Hysingla ER: 20mg qday

Differs per patient

Constipation, nausea, pruritus, sedation, vomiting


Counseling: Take with food. $$$

Morphine ER

Avinza/Kadian: 30mg qday

MS Contin: 15mg q 8–12 h

Differs per patient

BBW: *Concomitant EtOH use

Comments: REMS program; Should not be first choice in patients with renal impairment

$$$

Oxycodone ER (OxyContin) 10mg q 12 h Differs per

patientBBW: *CYP3A4 inhibitors

Comments: REMS program $$$-$$$$

Tapentadol ER (Nucynta ER) 50mg q 12 h 500mg

Avoid use in renal and hepatic impairment and those with history of seizures.

BBW: *May cause serotonin syndrome when used with other serotonergic agents

Comments: REMS program $$$$

Tramadol ER (Ultram ER) 100mg qday 300mg

Dose adjustments necessary in renal and hepatic insufficiency

Use with extreme caution in patients with history of seizures.

May cause serotonin syndrome when used with other serotonergic agents, CYP3A4 interactions.

Comments: Controlled substance

$$$







*All opioids have a BBW: addiction, abuse, misuse, respiratory depression, accidental overdose potential, neonatal withdrawal syndrome, concomitant use w/ benzodiazepines or other CNS depressants.

Medications for pain (see table starting on page 13) should be used to help facilitate less painful motion patterns. Medication use should be reassessed monthly.

Additional medication information is listed below:

z Non-steroidal anti-inflammatory drugs (NSAIDs) - After two to four weeks of taking NSAIDs, the patient should be evaluated to reassess the need for NSAID and, if still needed, switched to a more selective NSAID, such as celecoxib or meloxicam,40,41 which carry a lower risk of GI bleed. The PRECISION trial of 2016 shows a similar risk of CV events for both COX-2 selective and non-selective NSAIDs.

z Acetaminophen (APAP) may provide short-term relief of symptoms, but its ability to aid recovery is unknown.25 Low-quality evidence has shown it may have little to no effect on pain relief, function or recovery within three weeks.29 Patients should be counseled to check all OTC medications for other APAP-containing products and limit their total daily intake of APAP to 4 grams/day (3 grams in the elderly).

z Skeletal muscle relaxants (SMRs) may be an appropriate secondary option for certain patients, particularly those with associated muscle spasm, but should be used with caution and only for a short time.25 SMRs can be used in conjunction with NSAIDs or APAP. All SMRs have a potential for sedating side effects, but some tend to be more sedating than others. Choose SMRs in consultation with the patient and based on each drug’s risk of side effects.17 Advise patients to avoid performing tasks that could be dangerous if experiencing sedating effects, (e.g., driving or operating heavy machinery). Carisoprodol (Soma) is not recommended because of the potential for abuse and addiction and because it offers no significant benefit over other SMRs. Benzodiazepines are not recommended for low back pain.

z Systemic corticosteroids are not recommended for acute low back pain, including radiculopathy.25

z Opioids are not recommended for acute or subacute low back pain but, if selected, should be prescribed with caution and only in very short courses (two to three days).25 Tramadol can lower the seizure threshold and, therefore, should be avoided in patients with epilepsy. There is a risk of serotonin syndrome when tramadol is combined with SSRIs, SNRIs, trazodone or cyclobenzaprine. Patients should be counseled that opioids may mask their pain but provide no therapeutic effect to aid in recovery.


III. TREATMENT RECOMMENDATIONS: ACUTE LBP

Acute Low Back Pain Specifics(DURATION: 4–6 WEEKS)Acute low back pain is very common and, in most cases, has a favorable natural history, resolving or significantly improving within four to six weeks.25,30,31 It is important to evaluate for serious causes of low back pain, as certain etiologies, although very uncommon, can be life-threatening or can result in impaired function and long-term disability. See Acute Low Back Pain Algorithm, page 27.

ACUTE EVALUATION z Obtain a history and review of systems; perform a

physical exam. See Evaluating, page 6.

z Avoid diagnostic imaging in the absence of suspected serious pathology. See Imaging, page 7.

z Avoid electromyography and nerve conduction studies (EMG/NCV) for localized pain or for radicular pain or paresthesias that have been present for less than three weeks. These tools may be useful if the patient reports radicular pain and neurological involvement is suspected.10,32-34 However, EMG/NCV are helpful only if radicular symptoms have been present for more than three weeks and could result in a false negative test if performed prematurely. Additionally, radicular symptoms can often be secondary to peripheral nerve impingement due to muscle spasm and often respond well to conservative care. This is especially true for leg pain/paresthesia that stops above or at the knee (e.g., piriformis syndrome), intermittent radicular symptoms or in individuals with negative straight leg raise (SLR) testing.

ACUTE-SPECIFIC TREATMENTSee overall treatment recommendations for low back pain starting on page 9. Most people experiencing acute low back pain (including radiculopathy) without red flags respond well to conservative measures. The following may help facilitate a quicker recovery.

z Reassure the patient of the favorable outcome for most cases of acute low back pain.

z Provide patient education and self-care information (see pages 32–34).

z Explore standalone or multimodal non-drug therapies if self-care alone is ineffective or if screening tools show the patient may have moderate to high risk of chronic pain or disability. Referral for outpatient physical therapy (see Sidebar 4, page 10) is appropriate in high-risk patients.

z Additional treatments for those with psychosocial impediments to care (page 7):

z Refer to psychology or psychiatry or prescribe treatment (SNRI) if indicated on STarT Back (SBT) tool or PHQ PROM questionnaires (Sidebar 1, page 4) and psychosocial impediments to care (see page 7).

z Evaluate options for non-pharmacologic and pharmacologic therapy (NSAIDs, APAP, topical treatments). See Treatment Table, page 11 and Medication Table, pages 13–17.



III. TREATMENT RECOMMENDATIONS: SUBACUTE LBP

Subacute Low Back Pain Specifics(DURATION: 6–12 WEEKS)Patients with low back pain (with or without radiating pain) that persists longer than six weeks should undergo re-evaluation of their condition to reassess for red flags, psychosocial barriers, and new or worsening symptoms. See Subacute LBP Algorithm, page 28. Reasons for delayed recovery include previously unrecognized pathology, excessive passive behavior (e.g. prolonged bed rest), and most frequently, unrecognized or unaddressed psychosocial issues.

SUBACUTE EVALUATION z Obtain a detailed history and review of systems;

perform a physical exam. See Evaluating, page 6.

z Ask patients about pain level, radicular symptoms and response to treatment:

z Are symptoms improving, worsening or staying the same?

z If patient had radicular symptoms, are they improving (less frequent episodes of leg pain or paresthesias) or worsening?

z Did they develop new symptoms?

z What treatment and self-care protocols did the patient try, and what was the response?

z Evaluate for red flags (see page 6).

z Evaluate and screen for any psychosocial barriers to treatment. When a patient has back pain that is worsening or not responding to conservative measures after six weeks, it is important to screen again for psychosocial issues (PROMIS-10, SBT—see Sidebar 1, page 4) that could be contributing to a delayed response to care, as these are often missed on initial evaluation. Even if the screening was negative at the first visit, the patient situation may have changed, or his or her pain could be causing new depression, fear avoidance or catastrophic thoughts that the pain will never subside, which can impede recovery. See Sidebar 3, page 8, for a list of psychosocial flags. Identifying and addressing psychosocial issues may remove barriers to treatment and prevent pain progression.18

z Evaluate measures of pain and function. The ODI or other functional tool may be administered to evaluate objective progress or decline in the patient’s functional ability. Patients at higher risk of chronic back pain or disability should be managed with more aggressive treatment and might benefit from cognitive/behavior therapy due to risk of mood disorder with chronic pain and functional impairment.

z Perform a physical exam.

z If red flags are present, pursue appropriate imaging and other testing for suspected condition (see Red Flags Algorithm, page 30). At this stage, hyporeflexia with radicular pain or paresthesias may warrant MRI of the lumbar spine (see Radicular Symptoms Without Red Flags Algorithm, page 31).

SUBACUTE-SPECIFIC TREATMENTSee overall treatment recommendations for low back pain starting on page 9. Treatment recommendations specific to the subacute phase of low back pain include:

z If red flags are found in history or during physical exam (see Evaluating, page 6), obtain imaging and other testing as outlined in Red Flags Algorithm, page 30, for suspected condition.

z For patients who are responding well to care and have no progression of symptoms, continue self-care (see page 32) and follow up as needed in four to six weeks.

z Consider referral to a physical therapist who specializes in spine rehabilitation if symptoms are not significantly improved.

z Consider acupuncture, therapeutic dry needling or massage if myofascial pain is not significantly improved.

z For patients who are worsening, not improving or have developed new symptoms, consider obtaining imaging. Advanced neuroimaging such as MRI may be needed if red flags are present or radicular pain has been present more than four to six weeks.

z Pharmacotherapy (see Medication Table, pages 13–17):

z Consider switching to a selective NSAID if this medication has been beneficial to the patient during a previous episode of low back pain.

z Consider SNRIs for those with psychosocial impediments to care and for neuropathic pain.

For subacute low back pain without radiation or red flags:

z Continue treatment and delay imaging. Without red flags, imaging is not necessary and may be harmful or lead to unnecessary procedures.

For patients with severe or worsening pain without red flags:

z Consider imaging and non-surgical spine specialist (physical medicine and rehabilitation, pain management, or interventional radiology) referral for




III. TREATMENT RECOMMENDATIONS: SUBACUTE LBP

spinal injections or other non-surgical interventions (see Sidebar 4, page 10).

For stable subacute low back pain:

z Consider AP and lateral lumbar spine radiographs to evaluate for ankylosing spondylitis, and refer to rheumatology if positive (see Subacute Low Back Pain Algorithm, page 28).

For subacute radiating pain that is improving with conservative care:

z Recommend continuing conservative treatment and follow up in six weeks if pain persists or sooner if pain worsens. Use same treatments as subacute low back pain without radiation listed above, if necessary.

For subacute radiating pain that is not improving with conservative care:

z Obtain imaging at the appropriate level of the spine to match the history and physical exam findings, typically MRI of the lumbar spine without contrast, and refer to appropriate specialty if positive (see Red Flags Algorithm, page 30). Take the patient’s symptoms into consideration when reading MRI results to ensure they match with any positive findings (see Imaging, page 7).

z EMG/NCV may be helpful in determining treatment if MRI is not diagnostic. If EMG/NCV show evidence of active axon loss, consultation with a spine surgeon is recommended. If EMG/NCV are negative, refer to a non-surgical spine specialist (physical medicine and rehabilitation, pain management, or interventional radiology) for spinal injections or other non-surgical interventions (see Table 1, page 11) and continue conservative care plan.

z Facet block can be used for pain related to degenerative changes.

z Epidural can be used for radicular pain related to bulging or herniated disks.

z Radiofrequency ablation/rhizotomy can be used for axial pain from spondylosis that has responded to diagnostic and subsequent confirmatory medical branch blockade.

z Trigger point injection(s) with local anesthetic can be used for radiating symptoms related to myofascial spasm that are reliably reproducible with palpation.

z Sacroiliac joint injection can be used for sacroiliitis and pain related to sacroiliac dysfunction.

z Kyphoplasty can be used by appropriately trained spine specialists for treatment of compression fracture.


III. TREATMENT RECOMMENDATIONS: CHRONIC LBP

Chronic Low Back Pain Specifics(DURATION >12 WEEKS)Low back pain lasting longer than 12 weeks is a risk factor for long-term disability35 and functional impairment. Patients with low back pain lasting more than 12 weeks should be evaluated for previously unrecognized structural physiologic causes (see Chronic Low Back Pain Algorithm, page 29). Psychosocial issues (Sidebar 3, page 8) should also be evaluated using PROMs (Sidebar 1, page 4). Psychosocial flags are commonly seen in patients with chronic low back pain and can impede treatment. If psychosocial issues are identified, the patient may benefit from cognitive/behavioral health therapies.

CHRONIC EVALUATION z Obtain a detailed history and review of systems;

perform a physical exam (see Evaluating, page 6).

z Evaluate pain character, location, severity and timing, and ask about the development of new symptoms.

z Review other associated symptoms that could indicate a non-spinal cause of low back pain.

z Ask about development of red flag symptoms.

z Evaluate response to treatments

z Screen for psychosocial barriers to care. (Recommended tools: PROMIS-10, PHQ-2, PHQ-9, SBT—see Sidebar 1, page 4)

z Obtain measures of pain and function. (Recommended tools: SBT, ODI)

z Evaluate for new objective findings or red flag examination findings. If red flags are present on the history and physical, refer to Red Flags Algorithm, page 30, for the appropriate response based on clinical suspicion.

z Evaluate with imaging or other diagnostics if needed.

z If psychosocial issues are present with no red flags, it is reasonable to ensure these are adequately addressed and treated prior to obtaining imaging.

z In the absence of red flags and psychosocial issues, imaging (MRI of the lumbar spine) may be warranted in patients with non-radiating low back pain that is worsening or does not respond appropriately to 12 weeks of conservative care treatments to assess for any issues that may benefit from non-surgical spine

consult or to evaluate for otherwise asymptomatic spinal tumors.

z Evaluate which imaging tests have been performed, if any. If MRI has already been performed and there are no new neurologic deficits, hold off on further imaging.

z Low back pain with radicular symptoms should be evaluated with imaging and possibly nerve studies if not previously performed:

■ Obtain MRI of the lumbar spine to look for signs of nerve root impingement at the level of concern based on history (dermatomal distribution) and physical (reflexes, weakness, atrophy, sensory exam, etc.). Nerve root impingement can be associated with significant neuroforaminal stenosis, degenerative disk disease, bulging disk, herniated disk, osteophytes, spondylolisthesis, spinal tumor, etc.

If the MRI is positive, refer to a spine specialist.

If the MRI is negative (no abnormality identified) or inconclusive (e.g., only mild or moderate degree of foraminal stenosis), refer to neurology or physical medicine and rehabilitation (PM&R) for an EMG/NCV of the lower extremities to evaluate for radiculopathy or other peripheral neuropathies and assess the need for surgical referral.

If the NCV/EMG is positive, refer to a spine specialist.

If NCV/EMG is also negative, use conservative management:

� Physical therapy

� PM&R, pain management or interventional radiology consult to evaluate the need for possible spinal injections, radiofrequency ablation and other treatments

NCV/EMG may identify other causes of leg pain, such as peripheral neuropathies not related to the spine, including peripheral polyneuropathy, lateral femoral cutaneous syndrome, sural mononeuropathy or other compressive neuropathies.







CHRONIC-SPECIFIC TREATMENTSee overall treatment recommendations for low back pain starting on page 9. Treatment recommendations specific to the chronic phase of low back pain include:

z Refer to appropriate specialty if imaging is positive. Non-surgical spine specialist referral, such as physical medicine and rehabilitation, pain management, or interventional radiology, may be beneficial for patients who have:

z Radicular pain without progressive neurologic deficit

z Bulging or herniated disk that is not causing significant spinal canal or neuroforaminal stenosis, or those with significant spinal or neuroforaminal stenosis with no red flags or progressive neurologic symptoms

z Low-grade spondylolisthesis that is not causing nerve impingement, or those with no red flags or progressive neurologic symptoms

z Persistent axial low back pain with negative or equivocal imaging, as this rarely does well with surgery

z Painful or recalcitrant compression fracture, as interventional procedures such as kyphoplasty may prove beneficial

z Positive EMG/NCV with equivocal or negative imaging but no progressive neurologic symptoms

z Surgical consult may be warranted for:

z Progressive weakness, cauda equina syndrome or other progressive neurologic deficits

z Progressive radiculopathy with significant foraminal stenosis or other signs of nerve root impingement on MRI, or with inconclusive MRI but positive NCV/EMG and progressive neurologic deficits

z Highly symptomatic lumbar stenosis that has not responded to conservative measures or interventional procedures

z Major deformity, such as significant, symptomatic scoliosis or high-grade or unstable spondylolisthesis causing nerve compression, or for lower-grade spondylolisthesis that has not responded to conservative measures or interventional procedures or with red flags or progressive neurologic symptoms.

z Refer for a formal psychosocial evaluation if imaging is negative. Unrecognized psychosocial issues are often a contributing factor in chronic pain without identifiable pathology. If no clear cause of pain is found on imaging, it may be helpful to obtain a formal psychosocial evaluation to assess for other issues that may be contributing to somatization and impeding care. Psychosocial factors should be addressed through behavioral health or pharmacologic therapies, or a combination of the two.

z Behavioral health therapies may include mindfulness-based relaxation, cognitive behavioral therapy, progressive relaxation and biofeedback.25

z Pharmacologic therapy for those with chronic pain and comorbid psychosocial factors include:

■ Serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine or venlafaxine

z Continue conservative treatments, including non-pharmacologic therapies (see Table 1, page 11), patient education and self-care (See Patient Education and Resources, page 32). Physical therapy referral should be considered if not previously explored or if beneficial in the past (see Sidebar 4, page 10). TENS unit may also provide temporary relief for chronic pain symptoms but does not aid in functionality.36,37

z Prescribe pharmacologic therapies if pain does not improve with non-pharmacologic interventions,25 or use a combination of pharmacologic and non-pharmacologic treatments.25

z NSAIDs are first-line options.25 Consider switching to a selective NSAID (see Medication Table, pages 13–17).

z Second-line options include SNRIs (duloxetine) for neuropathic pain.25

z For non-surgical radicular pain, gabapentin or pregabalin may provide relief for neuropathic pain. Both medications should be titrated up to improve tolerability of side effects, such as sedation and memory impairment, and should be used with caution in the elderly, who may be at higher risk of falling. SNRIs can also be helpful in reducing nerve pain.

z Opioid treatment requires serious assessment of the potential risks and benefits and should be used as a last resort after other treatments have proved ineffective.17



OPIOID AVOIDANCE AND PRECAUTIONSOpioid treatment requires serious assessment of the potential risks and benefits, and should be used as a last resort after other treatments have proved ineffective.17 Opioid overdose was recently declared an epidemic by the CDC, with a six-fold increase in opioid-related deaths in 2017 compared with 1999.38 In 2017, opioid overdose was responsible for an average of 130 deaths per day in the U.S.38

z Before prescribing opioids, review psychological history for any type of substance abuse, assess Prescription Drug Monitoring Program and/or Controlled Substance Monitoring Database, and perform baseline urine drug screen.

z Review patient responsibilities, risk of therapy, treatment goals, and shared decision making. Implement a pain contract when prescribing opioids long term.

z Limit use to when function is compromised, quality of life is affected and after appropriate trials of previously suggested medications. Benefits should outweigh the risks of therapy.

z Extended-release/long-acting formulations should not be used in opioid-naïve patients.

z Common side effects include constipation (consider recommending use of a stool softener while taking opioids), nausea (patients should take with food), sedation and cognitive ability.

z Use with caution in elderly patients and those with renal, hepatic or respiratory disease.

z Tramadol may be helpful in patients with fibromyalgia but carries the same risks as other opioids.

z Avoid prescribing opioids and benzodiazepines together. Coordinate care with other providers when necessary.

z Assess chronic opioid use a minimum of every three months.

z If tolerance develops, consider an opioid rotation instead of a higher dose.

z Gradually taper opioids when possible.

z Check the Prescription Drug Monitoring Program/Controlled Substance Monitoring Database at every visit and when writing an opioid prescription.

z Prescribe naloxone for patients at high risk for respiratory depression and those on extended release/long-acting formulations.

z The risk for overdose increases for patients on morphine equivalent doses (MED) > 40mg.

z Random urine drug screening should be performed at least twice a year during chronic opioid use.

z Consider referral to pain specialist when doses exceed MED doses > 40mg.

Buprenorphine, fentanyl and methadone should be reserved for prescribing by pain specialists.



Sidebar 5 SIGNS OF DRUG-SEEKING BEHAVIOR

z History of substance abuse

z Prescription-monitoring database shows controlled substance prescriptions from multiple providers

z Previous provider discharged the patient from the practice for breaking contract or for unclear reasons

z Patient may request an opioid saying they are allergic to all conservative medications

z Failed drug testing (other substances or negative)

z Noncompliance with other aspects of care, such as completion of diagnostic studies or specialist referrals

z Patient reporting lost or stolen opioid prescription without a viable police report to corroborate

z Multiple pain-related visits to urgent care or emergency room


IV. ALGORITHMS

Acute LBP Algorithm (4-6 weeks)

Non-Spinal Causes

Treatment or Appropriate

Consult

Patient Presents With LBP or Radicular

Symptoms

Evaluate and Assess for Red Flags in History, Review of Systems and

Physical Exam

Non-Spinal Causes (AAA, Renal, etc.) Present?

Screen for Psychosocial Factors (Tool: SBT, PHQ-2);

Establish Measures of Function

Educate Patient on Return Precautions; Follow-Up in

4–6 Weeks.

Determine Appropriate

Work-Up

Low Risk of Chronicity

Conservative Treatment

• Reassurance• Education • Ice/Heat • Exercises/Stretches • Weight Loss (if

applicable)• Medications: NSAID,

APAP, SMR, topicals

No need for PT or diagnostic studies at this time.


AND Consider Early Referral to PT

AND Consider Depression

Screening (PHQ-9)


AND Screen for

Depression (PHQ-9) AND

Consider Antidepressant:

SSRI, SNRI

Moderate Risk; Mainly Physical

Obstacles to Recovery

High Risk; Additional Psychosocial Barriers

2

1

YES NO

Red Flags Present?

YESNO

(page 30)


IV. ALGORITHMS

Subacute LBP Algorithm (6-12 weeks)

ID Consult Based on Findings

Continue Treatment;

Give Return Precautions

+ Rheumatology

Referral for Ankylosing Spondylitis

Patient Presents With Low Back Pain or

Radicular Symptoms

Response-to-Care Evaluation; Patient

History; Physical Exam Screening Tools: PHQ-2

or PHQ-9, SBT, ODI

New or Worsening Low Back Pain or Unacceptable

Improvement

Radicular Sx Without Red Flags

New or Worsening Pain: MRI of the Lumbar

Spine

Stable Pain: Consider AP and lateral

lumbar x-ray if pain is stable to evaluate for ankylosing

spondylitis

Screen for Psychosocial Factors (Tool: SBT, PHQ);

Establish Measures of Function (Tool: ODI)

Educate patient on return precautions;

Follow-up in 6–12 weeks

Psychosocial Factors Present Make medication adjustments: Discontinue ineffective

medications, consider switching to a selective NSAID if beneficial, +/- SNRI for comorbid mood disorder.

Refer to Behavioral Health. Refer to PT (if not previously done). Continue conservative therapies if effective.

Psychosocial Factors Absent Make medication adjustments:

Discontinue ineffective medications, consider switching to a selective NSAID.

Refer to PT (if not previously done), continue conservative therapies if

effective.

Determine appropriate work-up

LBP Without

Radicular Sx or Red

Flags

Radicular Pain > 4 Weeks (Leg pain > LBP) Not

Improving or Resolved With Conservative Care;

Increasing Leg Weakness Drop Foot or Other Gait Abnormalities; Atrophy; Hyporeflexia; Increasing

Sensory Disturbance

Improved LBP Without Radiation or

New Symptoms

2

13 Red Flags Present?

YES

YES

+ - +-

(page 30)(page 31)


IV. ALGORITHMS

Refer to Ortho or

Neuro-Spine Specialist

Refer to PM&R,

Interventional Medicine

Give Return Precautions

Patient Presents With Low Back Pain or

LBP With Leg Pain

Medical History, Physical Exam, Tools: ODI, PHQ-9

If red flags are present, refer to Red Flag Algorithm for clinical response; otherwise proceed.

2

3

YES

+ -

New or Worsening

Radicular Pain: Pain or Radicular

Symptoms for 4 Weeks or

Longer Without Improvement and No Prior Imaging; Signs of Atrophy

or Hyporeflexia on Exam

Symptoms Improved?

LBP w/ No Radicular Pain

MRI if Not Previously Performed

Consider Formal Psychosocial Evaluation +/- Medical Spine Specialist Referral (PM&R, Pain Management) if

LBP Is Severe or Worsening

CONSERVATIVE TREATMENT FOR 3 MONTHS

Medications: NSAIDs (good evidence) (3 months), Acetaminophen (fair evidence), Topicals, SMRs (moderate evidence), SNRI antidepressants (good evidence), Gabapentinoids (fair evidence), Opioids (fair evidence)

Time-Contingent Physical Therapy: Core Strengthening (good), Conditioning (good), Exercises (good)

Patient Education: Stay Active (fair), Discourage Bed Rest (fair)

Cognitive-Behavioral Therapy

Complementary Therapies: Massage (fair), Acupuncture (fair), Yoga (fair)

Radicular Pain (Leg Pain >

LBP)

Stable

Unacceptable Improvement

Chronic LBP Algorithm (>12 weeks)

(page 31)


IV. ALGORITHMS

Possible Cauda Equina• Fecal incontinence or urgency• Urinary incontinence or retention• Saddle anesthesia• Gait difficulties• Reduced sphincter tone or

impaired anal wink on exam

MRI of the lumbar spine

MRI of the spine with contrast at the level of concernLabs: CBC, ESR, CRP

MRI of the spine at the level of concernLabs: CBC, ESR, CRP

AP and lateral lumbar spine x-rays vs. CT scan for neuro deficits or if high clinical suspicion after negative x-ray

MRI of the cervical

spine

MRI of the thoracic

spine

Possible Cancer• History of cancer• Unexplained weight loss • New onset pain in patients over 50

Possible Infection• Unexplained fever• Chills• Night sweats• Immunocompromised status

(HIV, immunodeficiency, chronic steroid use, chemo, phenytoin, phenobarbitol)

• IV drug use• Recent spinal procedure

Possible Fracture• Trauma• History of osteoporosis• Medications that can cause

bone loss (steroids, phenytoin, phenobarbitol)

• Point tenderness or step-off deformity on exam

+

+

+

+

-

-

-

-

Urgent Spine

Surgery Consult

Oncology Consult

Infectious Disease Consult

Spine Surgery Consult

Urgent Spine

Surgery Consult

Neurology Consult

2

1

1

1

1

1

2

2

2

2

Possible Myelopathy• Declining fine motor

skills• Legs feel “heavy”• Gait difficulties• Imbalance• Urinary retention• Weakness• Hyperreflexia on exam

Possible Cervical Myelopathy• Neck or shoulder pain with leg

sensory disturbance or gait difficulties

• Hyperreflexia in upper and lower extremities on exam

Possible Thoracic Myelopathy• Mid-low back pain or

paresthesias• Hyperreflexia in the lower

extremities, but not the upper extremities on exam

-

+Myelopathy

Demyelinating

Disorder

Red Flags Algorithm

(back to referring page)






IV. ALGORITHMS

Spine Surgery Consult

Neurology Consult (Versus Surgical Consult for Compressive

Neuropathy)

Refer to PM&R or PM for

Interventional Therapies

Neurology Consult (Versus Surgical Consult for Compressive

Neuropathy)

2

3

+ Imaging:

Nerve Root Impingement; High-Grade

Spondylolisthesis+ Confirms Radicular

Origin

NCV/EMG of the Lower Extremities

Equivocal Imaging: Bulging/Herniated Disc

Without Nerve Root Impingement, Spinal

Stenosis, Spondylosis, Spondylolisthesis

Without Nerve Root or Cord Impingement

Non-Radicular Origin

Peripheral Nerve Cause of Leg Pain

Present

MRI of Spine Without Contrast

- Imaging:

Normal MRI

NCV/EMG of the Lower Extremities to Evaluate for

Peripheral Neuropathy

Peripheral Nerve Cause of Leg Pain Present

Normal Study

Normal Study

Radicular Symptoms Without Red Flags Algorithm



V. PATIENT EDUCATION AND RESOURCES

IV. PATIENT EDUCATION AND RESOURCESEducating patients about the typical course of low back pain and what they can do at home to reduce symptoms and maintain function is an essential element of treatment.25 Key components include sharing this information with the patient:

z Low back pain is likely to improve in a few weeks. For most patients, the first four to six weeks bring major improvement. The cause of pain is often benign.25

z Learning how to do things differently can help relieve pain and prevent future pain. The patient should be educated about proper body mechanics, posture, sleep position and protecting the spine during everyday activities (e.g., lifting) to avoid pain flare-ups.

z Bed rest is not helpful. Bed rest does not improve low back pain or boost function.33 The patient should remain as active as possible to maintain function.17 Graduated activity as tolerated with the intent to keep the patient active is recommended.

z Patient engagement in care is important. Patients and clinicians should work cooperatively to identify the treatment that best aligns with patient preferences while taking potential harms and costs into account.17

z Psychosocial impediments to care (Sidebar 3, page 8) should be addressed.4 Fear avoidance and catastrophizing can cause symptoms to linger.25 Educating patients about and addressing psychosocial issues therapeutically may improve outcomes.

z Several non-pharmacologic forms of self-care (see Table 1, page 11) may yield improvement in pain and/or function. Advise the patient to remain active to help maintain function. Encourage cardiovascular exercise, stretches, yoga, tai chi and core-strengthening exercises (See resources below and to the right). Inform the patient about self-care options to relieve pain, such as the use of heat, ice packs or Epsom salt soaks.17,25 Massage may be beneficial for patients with associated muscle spasm.17 Acupuncture or therapeutic dry needling may also be beneficial for some patients with myofascial pain.

VANDERBILT HEALTH AFFILIATED NETWORK PATIENT RESOURCESClick to link to digital sources: Exercises for a Healthy Back [Video]

Self-Care for Low Back Pain [Article]

Reduce Your Risk for Low Back Pain [Article]

Low Back Strengthening Exercises [Instructional PDF]

Low Back Flexibility Exercises [Instructional PDF]

OTHER ONLINE RESOURCESNational organizations, including The American College of Physicians and the National Institutes of Health, publish useful patient education materials. Among recommended resources are:

Noninvasive Treatments for Acute, Subacute and Chronic Low Back Pain An informative article from the American College of Physicians, designed to help patients understand low back pain and to suggest options for self-care.

Back Pain This National Institutes of Health micro-website is dedicated to providing back pain information to the public, covering topics ranging from who is at risk for back pain to non-pharmacologic and pharmacologic treatments, when to see a clinician, and how to prevent back pain. Available in online format and also as a downloadable, printable PDF or epub in multiple languages, including Spanish, Chinese, Korean and Vietnamese.

Tobacco Cessation Reduced blood flow caused by smoking may contribute to spinal disk degeneration, a common source of back pain. Smoking, which slows the healing process, is also a risk factor for osteoporosis. Additionally, a smoker’s cough can irritate back pain.39 Advise patients who smoke to quit and provide support if needed. Nicotine replacement therapy and other smoking cessation aids may be beneficial, especially in conjunction with counseling. Patients can call the Tennessee Tobacco QuitLine at 1-800-784-8669 (1-800-QUIT-NOW) or find support at SmokeFree.gov.

SilverSneakers A health and fitness program for adults 65 and older, SilverSneakers may be covered by Medicare Advantage. The website allows people to check their eligibility, locate classes or participate in exercise sessions via online instruction; however, the online instruction is paywalled.

Tennessee Disability Pathfinder A statewide database of social services, low-income medical clinics, recreational programs and other resources for disabled persons. This resource may be useful to patients with cost barriers to care: Applying for TennCare Healthcare.gov 1-800-318-2596 Any Department of Health and Human Services office in Tennessee can help people apply and pick a plan.

http://healthlibrary.vanderbilthealth.com/MultimediaRoom/VideoLibrary/?e=0#player:138,v1117

http://healthlibrary.vanderbilthealth.com/Search/3,84645

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https://www.vumc.org/sports-medicine/sites/vumc.org.sports-medicine/files/public_files/documents/Lower_Back_Strengthening.pdf

https://www.vumc.org/sports-medicine/sites/vumc.org.sports-medicine/files/public_files/documents/Low_Back_Flexibility_Program.pdf

https://annals.org/aim/fullarticle/2603231/noninvasive-treatments-acute-subacute-chronic-low-back-pain

https://annals.org/aim/fullarticle/2603231/noninvasive-treatments-acute-subacute-chronic-low-back-pain

https://www.niams.nih.gov/health-topics/back-pain

https://www.tnquitline.org/

https://www.tnquitline.org/

https://smokefree.gov/

https://www.silversneakers.com/

https://vkc.mc.vanderbilt.edu/pathsearch/

https://www.tn.gov/tenncare

https://www.healthcare.gov/

A Patient’s Guide to

LOW BACK PAIN? EXPECT THIS, NOT THAT

LOW BACK PAIN CARE

DIAGNOSISA patient medical history and a physical exam typically provide all the information your clinician needs to evaluate low back pain.

Scientific evidence does not support the use of diagnostic imaging for low back pain unless it is needed to investigate a potential underlying condition or lingering pain. In some instances of prolonged low back pain, imaging may be necessary to plan for a procedure.

TREATMENTCare usually begins with non-drug treatments, such as a heating pad and/or ice pack, massage, acupuncture, acupressure, exercise, rehabilitation therapy, tai chi, and yoga. If non-drug treatments do not provide relief, pain-relieving creams, nonsteroidal anti-inflammatory drugs (such as ibuprofen, aspirin and naproxen) or acetaminophen may be recommended.

Prescription medications like muscle relaxers and opioids are never first-line treatments for low back pain. In some instances of prolonged pain, clinicians may prescribe a short course of muscle relaxers. For chronic pain, a limited course of carefully monitored opioid medication may be considered.

Low back pain rarely requires surgery, but your clinician may discuss it with you if the pain becomes chronic and life-limiting and other treatments have not helped, or if certain underlying conditions are present.

PARTICIPATION IN YOUR CAREYou are the key to successful low back pain treatment. Follow your clinician’s recommendations and keep your follow-up appointments so that you and your clinician can determine if treatment needs to be adjusted.

Many people think imaging, prescription drugs and surgery are standards of care for low back pain, but that’s not the case.

Clinicians proceed cautiously with low back pain treatment because there is a good chance the pain will improve in a short time frame. In fact, most patients with low back pain recover within a few weeks, whether or not they seek treatment.

To minimize discomfort and prevent low back pain flare-ups, follow your clinician’s advice about exercising, practicing proper posture, lifting techniques and sleeping positions.

EXPECT: To provide your medical history and have a physical exam

DON’T EXPECT: X-rays, CT scans or other imaging to diagnose most cases of low back pain

EXPECT: Conservative treatments, like applying heat or ice, exercising and using over-the-counter pain relievers DON’T EXPECT: Muscle relaxer or opioid prescriptions or surgery

EXPECT: To keep moving and remain active to promote recovery

DON’T EXPECT: To spend excessive time resting in bed

LOW BACK

PAIN USUALLY

IMPROVES WITHIN

4 TO 6 WEEKS, NO

MATTER THE

TREATMENT.

Notes:


VI. REFERENCES

VI. REFERENCES1. Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001;16(2):120–131. doi:10.1111/j.1525-1497.2001.91141.

2. Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin. 2007;25(2):353-371. doi: 10.1016/j.ncl.2007.01.004.

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8. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356–2367. doi.org/10.1016/S0140-6736(18)30480-X.

9. James B, Poulsen G. The Case for Capitation. Harvard Business Review. July–August 2016. https://hbr.org/2016/07/the-case-for-capitation. Accessed April 24, 2019.

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11. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613. doi:10.1046/j.1525-1497.2001.016009606.x.

12. Livingston C, King V, Little A, et al. State of Oregon Evidence-based Clinical Guidelines Project. Evaluation and management of low back pain: A clinical practice guideline based on the joint practice guideline of the American College of Physicians and the American Pain Society (diagnosis and treatment of low back pain). Salem: Office for Oregon Health Policy and Research; 2011. Cited by: Nordin M, Randhawa K, Torres P, et al. Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities. Eur Spine J. 2018 Sep;27(Suppl 6):816-827.

13. Bach SM, Holten KB. Guideline update: what’s the best approach to acute low back pain? J Fam Pract. 2009; 58(12):E1. Cited by: Nordin M, Randhawa K, The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations. Eur Spine J. 2018 Sep;27(Suppl 6):816-827.

14. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147(7):478–491. Cited by: Nordin M, Randhawa K, The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations. Eur Spine J. 2018 Sep;27(Suppl 6):816-827.

15. Mwale F. Molecular therapy for disk degeneration and pain. Global Spine J. 2013;3(3):185–192. doi:10.1055/s-0033-1349400.

16. O’Sullivan P, Beales D, Jensen L, et al. Characteristics of chronic non-specific musculoskeltal pain in children and adolescents attending a rheumatology outpatients clinic: a cross-sectional study. Pediatr Rheumatol Online J. 2011; 9:3. Published online Jan. 19, 2011. Accessed April 24, 2019. doi:10.1186/1546-0096-9-3.

17. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514–530.

18. Nordin M, Randhawa K, Torres P, et al. The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities. Eur Spine J. 2018 Sep;27(Suppl 6):816-827.

19. Carragee E, Alamin T, Cheng I, Franklin T, Van den Haak E, Hurwitz E. Are first-time episodes of serious low back pain associated with new MRI findings? Spine J. 2006;6:624-635. doi: 10.1016/j.spinee.2006.03.005.

20. Chou R, Qaseem A, Owens DK, Shekelle P. Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181–189. doi: 10.7326/0003-4819-154-3-201102010-00008.

21. Gilbert FJ, Grant AM, Gillan, MG, et al. Low back pain: Influence of Early MR Imaging or CT on Treatment and Outcome—Multicenter Randomized Trial. Radiology. 2004 May;231(2):343-51. Epub 2004 Mar 18. https://doi.org/10.1148/radiol.2312030886.

22. Modic M, Obuchowski N, Ross J, Bant-Zawadzki M, Grooff P, Mazanec D, et al. Acute low back pain: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005;237(2):597–604. https://doi.org/10.1148/radiol.2372041509.

23. Powell MC, Szypryt P, Wilson M, EM Symonds, Worthington, BS. Prevalence of Lumbar Disc Degeneration Observed by Magnetic Resonance in Symptomless Women. Lancet. 1986 Dec 13;2(8520):1366-7. doi.org/10.1016/S0140-6736(86)92008-8.

24. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994; 331:69-73. doi: 10.1056/NEJM199407143310201.

25. Chou R, Côté P, Randhawa K, et al. The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities. Eur Spine J. 2018 Sep;27(Suppl 6):851–860. doi.org/10.1007/s00586-017-5433-8.

26. Rainville J, Jouve CA, Hartigan C, Martinez E, Hipona M. Comparison of short- and long-term outcomes for aggressive spine rehabilitation delivered two versus three times per week. Spine J. 2002;2(6):402–407. Cited by: Delitto, A & G, et al. Low back pain clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2012:42.A1-A57.


VI. REFERENCES

27. Guide to Physical Therapist Practice. Manual Therapy Techniques. doi: 10.2522/ptguide3.0_38.

28. Sran M, Khan K. Spinal manipulation versus mobilization. CMAJ. 2002;167(1):13–14.

29. Williams C, Maher C, Latimer J, Mclachlan A, Hancock M, et al. Efficacy of paracetamol for acute low-back pain: A double-blind, randomised controlled trial. The Lancet. 384. doi: 10.1016/S0140-6736(14)60805-9. Cited by: Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514–530.

30. Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute LBP: systematic review of its prognosis. BMJ. 2003;327:323. Cited by: Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic LBP: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514–530.

31. Hestbaek L, Leboeuf-Yde C, Manniche C. LBP: what is the long-term course? A review of studies of general patient populations. Eur Spine J. 2003;12:149-65. Cited by: Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic LBP: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514–530.

32. North American Spine Society. Diagnosis and treatment of lumbar disc herniation with radiculopathy. North American Spine Society, Burr Ridge; 2012. Cited by: Nordin M, Randhawa K, Torres P, et al. The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities. Eur Spine J. 2018 Sep;27(Suppl 6):816-827.

33. Choosing Wisely. American Academy of Physical Medicine and Rehabilitation. Five things physicians and patients should question. https://www.choosingwisely.org/societies/american-academy-of-physical-medicine-and-rehabilitation. Accessed February 4, 2019.

34. Choosing Wisely. North American Spine Society. Five things physicians and patients should question. https://www.choosingwisely.org/societies/north-american-spine-society. Published online Oct. 9, 2013. Accessed February 4, 2019.

35. Chou R. In the Clinic: low back pain. Ann Intern Med. 2014;160(11):ITC6–1. doi:10.7326/0003-4819-160-11-201406030-01006.

36. DeSantana JM, Walsh DM, Vance C, Rakel BA, Sluka KA. Effectiveness of transcutaneous electrical nerve stimulation for treatment of hyperalgesia and pain. Curr Rheumatol Rep. 2008;10(6):492–499.

37. Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database of Syst Rev. 2008;(4):CD003008. doi:10.1002/14651858.

38. Centers for Disease Control and Prevention. Understanding the epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html. Published Dec. 19, 2018. Accessed March 8, 2019.

39. National Institute of Neurological Disorders and Stroke. Low Back Pain Fact Sheet. NIH Publication No. 15-5161. Publication December 2014. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet. Accessed June 5, 2019.

40. French L. Is Meloxicam as Safe as Other NSAIDs? Am Fam Physician. 2005 Apr 1;71(7):1399-1400. https://www.aafp.org/afp/2005/0401/p1399.html. Accessed October 3, 2019.

41. Schattenkirchner M. Meloxicam:a selective COX-2 inhibitor non-steroidal anti-inflammatory drug. Expert Opinion on Investigational Drugs. 6:3, 321-334, DOI: 10.1517/13543784.6.3.321.

42. Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011; 378(9802):1560-71. doi: 10.1016/S0140-6736(11)60937-9.


CONTRIBUTORSColin McKnight, MD, Assistant Professor, Vanderbilt University Medical Center Radiology

Daniel Cottrell, MD, Assistant Professor, Internal Medicine

Ross Whitacre, MD, Assistant Professor, Physical Medicine & Rehabilitation

Robert (Bobby) Knight, PT, Clinical Team Leader, Rehabilitation Services Administration

Jennifer Emery, PT, Clinical Coordinator Vanderbilt Orthopaedics Rehab Services

Megan Monroe, PharmD, BCACP, Population Health Clinical Pharmacist, Vanderbilt Health Affiliated Network

Mike Modic, MD, Senior Vice President, Vanderbilt Health Affiliated Network

Esther Smith, Administrative Director, Vanderbilt Health Affiliated Network Strategic Ops

Megan Pacella, Content Manager, Vanderbilt Health Affiliated Network B2B Marketing

Karen Stone, Director, Vanderbilt Health Affiliated Network B2B Marketing

Matthew Resnick, Associate Professor, Vanderbilt University Medical Center Urology

Megan Pruce, Vice President, Strategic Marketing, Vanderbilt Health Affiliated Network

Claude Pirtle, MD, Clinical Fellow, Vanderbilt University Medical Center Biomedical Informatics

Justin Bachmann, MD, MPH, Assistant Professor, Vanderbilt University Medical Center Cardiovascular

Andrew O. Smith, Senior Project Manager, Population Health, Vanderbilt Health Affiliated Network

Russell Brothers, Principal Analytics Consultant, Enterprise Analytics, Vanderbilt Health Affiliated Network

Produced by True North Custom


The Keele STarT Back Screening ToolPatient name: _______________________________ Date: _____________

Thinking about the last 2 weeks tick your response to the following questions:

Disagree Agree

0 1

1. My back pain has spread down my leg(s) at some time in the last 2 weeks □ □

2. I have had pain in the shoulder or neck at some time in the last 2 weeks □ □

3. I have only walked short distances because of my back pain □ □

4. In the last 2 weeks, I have dressed more slowly than usual because of back pain □ □

5. It’s not really safe for a person with a condition like mine to be physically active □ □

6. Worrying thoughts have been going through my mind a lot of the time □ □

7. I feel that my back pain is terrible and it’s never going to get any better □ □

8. In general I have not enjoyed all the things I used to enjoy □ □

9. Overall, how bothersome has your back pain been in the last 2 weeks?

Not at all Slightly Moderately Very much Extremely

□ □ □ □ □

0 0 0 1 1

Total score (all 9): __________________ Sub Score (Q5-9):______________

© Keele University 01/08/07. Reprinted with permission.

Funded by Arthritis Research UK

APPENDIX


APPENDIX

The STarT Back Tool Scoring System

IV. APPENDIX

Total score

3 or less

Low risk Medium risk High risk

4 or more

Sub score Q5-9

4 or more3 or less

COLLEAGUES:

This care path guide is an effort to share a multidisciplinary approach and rationale in the management of patients with low back pain. How this translates into actual practice is key. The following bulleted points, abstracted from the care path guide, are the critical items for documentation that will enable clinical care, follow-up and measurement of outcomes.

z BASELINE PROM

z HISTORY

z Pain Duration

z Character of Pain

z ROS–Focus on non-spinal causes

z Presence/Absence of Red Flags

z Psychosocial Flags

z PHYSICAL EXAM

z Physical Exam Red Flags

z TREATMENT

z Acute (symptoms persisting < 6 weeks)

z Subacute (symptoms persisting 6– 12 weeks)

z Chronic (symptoms persisting > 12 weeks)

Outcome Metrics:

z Utilization of care paths

z Opioid prescriptions and referrals for imaging

z PT and subspecialty consultation

CARE PATH GUIDE Low Back Pain · II. LBP CLASSIFICATION AND EVALUATION: CLASSIFYING II. LOW BACK...

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