DATE: September 2018 - OHSU · 2018-12-10 · ACUTE LOW BACK PAIN GUIDELINE . Background: Low back...

DATE: September 2018

© Office of Clinical Integration and EBP, 2018 Oregon Health and Science University

1

OHSU HEALTH SYSTEM OFFICE OF CLINICAL INTEGRATION AND EVIDENCE-BASED PRACTICE

ACUTE LOW BACK PAIN GUIDELINE

Background: Low back pain (LBP) is one of the most common reasons for physician visits in the United States. 1 A majority of low back pain is defined as acute, lasting a few days to a few weeks, and resolves on its own with self-care. 2 However about 20% of people affected by low back pain develop chronic low back pain and have persistent symptoms at one year. 2 Preventive intervention during the acute and subacute stages may be easier to perform and may be more cost-effective than rehabilitation of chronic LBP. 3 Historically there has been little consensus, either within or between specialties, on appropriate clinical evaluation and management of low back pain. 4 Recently, experts recommend focusing efforts to reduce unnecessary health care for low back pain, encouraging patients to be active and stay at work, and reforming clinical pathways and reimbursements to improve patient outcomes.5 Prevalence: The U.S. National Surveys in 2002 estimated lifetime prevalence of LBP at 70%, with 25% of adults report LBP lasting at least 1 day in the past 3 months. 6, 7 Health care costs for LBP in the United States were approximately $86 billion in 2005, 8 and have been increasing faster than overall healthcare spending. 8, 9 Despite increasing resource use, rates of poor outcomes for LBP are increasing. 10, 11

Risks: Most patients with acute back pain have self-limited episodes that resolve on their own and many do not seek medical care. 12 For patients who do seek medical care, pain, disability, and the ability to return to work typically improve rapidly in the first month. 13 However, up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode, and 1 in 5 report substantial limitations in activity. 14 Guideline Eligibility Criteria:

- Patients >/= 18 years with subacute or acute low back pain, or with chronic back pain experiencing a new, discrete flare

Guideline Exclusion Criteria: - Pregnant women - Pediatric patients </= 18 years - Patients with cervical or thoracic back pain - Patients with non-spinal pain Definitions:

Acute Back Pain: Pain lasting less than 4 weeks Subacute Back Pain: Pain lasting 4 – 12 weeks Chronic Back Pain: Pain lasting more than 12 weeks



2

Clinical Practice Recommendation Diagnostic Evaluation Clinicians should not routinely obtain imaging or other diagnostic tests in patients with non-specific low back pain. 4

Strong Recommendation; Moderate-Quality Evidence Clinicians should document the presence or absence of red flags (see table 1 below), and consider performing diagnostic imaging and testing for patients with low back pain meeting criteria, such as when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination. Modality and urgency of initial imaging should be based on possible cause, and key features on history or examination (see table 1 below).15,21-23

Strong Recommendation; Low-Quality Evidence

Table 1. Red Flag Protocol 15,21

Possible Cause Key features on history or examination Urgency for imaging

Suggestions for initial imaging

High risk of cancer • New onset of low back pain with history of cancer

• Multiple risk factors for cancer • Strong clinical suspicion of cancer

Immediate Magnetic Resonance Imaging (MRI) lumbar spine with and without (w/wo) contrast

Spinal infection • New onset of low back pain with fever and history of intravenous drug use

Immediate MRI lumbar spine w/wo contrast

Cauda equina syndrome • New urine retention • Fecal incontinence • Saddle anesthesia

Immediate MRI lumbar spine wo contrast

Neurologic deficits • Progressive motor weakness or

• Motor deficits at multiple neurologic levels

Immediate MRI lumbar spine wo contrast (add contrast if concern for infectious, inflammatory or neoplastic etiologies)

Low risk of cancer • Unexplained weight loss • Age >50y

Defer Imaging after a trial of therapy

MRI lumbar spine w/wo contrast

Ankylosing spondylitis • Morning stiffness that improves with exercise, alternating buttock pain

• Awakening because of back pain during the second part of the night

• Younger age (20 to 40 y)


Radiography with or without erythrocyte sedimentation rate

Vertebral compression fracture

• History of osteoporosis • Use of corticosteroids • Significant trauma • Older age (>65y for men or >75y

for women)

Consider immediate imaging

Radiography with or without erythrocyte sedimentation rate

Radiculopathy • Back pain with leg pain and positive result on straight leg raise†


MRI lumbar spine wo contrast



3

• positive result on straight leg raise or crossed straight leg raise test

Spinal Stenosis • Radiating leg pain • Older age • Pseudo claudication

Defer Imaging after a trial of therapy in patients who are candidates for surgery

MRI lumbar spine wo contrast

No Red Flags • No criteria for immediate imaging and back pain improved or resolved after 1-mo trial of therapy

• Previous spinal imaging with no change in clinical status

No Imaging No Imaging

† “If the patient experiences sciatic nerve distribution pain distal to the knee when the straight leg is at an angle of between 30 and 70 degrees, then the test is positive and a herniated disk a possible cause of the pain.” Speed C (2004). "Low back pain". BMJ. 328 (7448): 1119–21.and Capra, Francesco et al. (2011) “Validity of the Straight-Leg Raise Test for Patients With Sciatic Pain With or Without Lumbar Pain Using Magnetic Resonance Imaging Results as a Reference Standard.” Journal of Manipulative & Physiological Therapeutics. 34(4): 231 - 238

*bold indicates that the flag is a strong predictor

Risk Assessment Tool In the absence of red flag symptoms, patients with a new episode of low back pain should be assessed using the STarT Back tool (Appendix B) to inform shared-decision making about stratified management. 18 Strong Recommendation; Moderate-Quality Evidence Education and self-care Education All patients should receive appropriate education on the treatment and recovery expectations for acute and subacute low back pain. 16 Strong Recommendation; Moderate-Quality Evidence Educational strategies should emphasize (1) the promotion of the understanding of the anatomical/structural strength inherent in the human spine, (2) the neuroscience that explains pain perception, (3) the overall favorable prognosis of low back pain, (4) the use of active pain coping strategies that decrease fear and catastrophizing, (5) the early resumption of normal or vocational activities, even when still experiencing pain, and (6) the importance of improvement in activity levels, not just pain relief. 17 Strong Recommendation; Moderate-Quality Evidence Education strategies should not increase the perceived threat or fear associated with low back pain. Educational strategies should not (1) promote extended bed-rest or (2) provide in-depth, pathoanatomical explanations for the specific cause of the patient’s low back pain. 17 Strong Recommendation; Moderate-Quality Evidence Self-care Advise patients with acute and subacute low back pain to remain active as a first-line treatment. 4, 16, 18 Strong Recommendation; Moderate-Quality Evidence Advise patients to use heat as a second-line treatment. 4, 16, 18 Strong Recommendation; Moderate-Quality Evidence



4

Non-Pharmacologic Interventions Low Risk Patients For patients who are determined to be low risk on the STarT Back assessment tool (Appendix B), clinicians and patients should establish treatment goals using shared decision-making. 16, 19 Strong Recommendation; Moderate-Quality Evidence

- Appropriate treatments for low risk patients include: o Acupuncture; 1, 16 (Conditional Recommendation; Low-Quality Evidence) o Physical Therapy; 19 (Conditional Recommendation; Low-Quality Evidence) o Spinal Manipulation; 1, 16, 19 (Conditional Recommendation; Low-Quality Evidence) o Massage Therapy; 1 (Conditional Recommendation; Low-Quality Evidence)

PRACTICE IMPLICATIONS FOR OHSU Health System: -Recommend up to 4 treatment visits for low-risk patients. Although number of visits required should be determined on a patient-by-patient circumstance.

Medium to High Risk Patients For patients who are determined to be medium to high risk on the STarT Back assessment tool (Appendix B), clinicians and patients should establish treatment goals using shared decision-making. 16, 19 Strong Recommendation; Moderate-Quality Evidence

- Appropriate treatments for medium to high risk patients include: o Cognitive Behavioral Therapy; 4, 16, 18, 19 (Conditional Recommendation; Moderate-Quality Evidence) o Physical Therapy 18-20 (Conditional Recommendation; Low-Quality Evidence) o Yoga; 4, 16 (Conditional Recommendation; Moderate-Quality Evidence) o Massage Therapy; 1, 4 (Conditional Recommendation; Low-Quality Evidence) o Exercise Therapy; 4, 16, 18 (Conditional Recommendation; Low-Quality Evidence) o Intensive Interdisciplinary Rehabilitation; 4,18,19 (Conditional Recommendation; Low-Quality Evidence) o Acupuncture; 1,4,16,18,19 (Conditional Recommendation; Low-Quality Evidence) o Spinal Manipulation; 1,16, 18-20 (Conditional Recommendation; Low-Quality Evidence) o Progressive Relaxation; 4,18 (Conditional Recommendation; Moderate-Quality Evidence)

PRACTICE IMPLICATIONS FOR OHSU Health System: - Recommend up to 30 treatment visits of any combination for medium- to high-risk patients. Number of visits required should be determined on a patient-by-patient circumstance. - Measureable clinically significant progress toward the therapy plan of care goals and objectives should be documented using evidence-based objective tools such as Oswestry, SF-MPQ, MSPQ, and Patient-Specific Functional Scale (Appendix C, D, E, and F).

Pharmacologic Interventions Recommendations for Patients with Radiculopathy If pharmacologic treatment for acute or subacute low back pain with radiculopathy is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs, acetaminophen, SNRI's and/ or muscle relaxants as first-line, or antisiezure medications and/or opioids (limited use in select patients) as second-line therapy. 16,24 Strong recommendation; low-quality evidence Epidural steroid injections are recommended as second-line therapy for the treatment of acute low back pain with radiculopathy (for select patients) 16. Conditional recommendation; low-quality evidence



5

Systemic steroids and benzodiazepines are not recommended for the treatment of acute low back pain with radiculopathy5, 24. Strong recommendation; low-quality evidence Recommendations for Patients without Radiculopathy If pharmacologic treatment is desired for acute or subacute low back pain without radiculopathy, clinicians and patients should select nonsteroidal anti-inflammatory drugs, acetaminophen, SNRI's and/ or muscle relaxants as first-line, or opioids (limited use in select patients) as second-line therapy 16, 24. Strong recommendation; low-quality evidence Epidural steroid injections, antisiezure medications, systemic steroids and benzodiazepines are not recommended for the treatment of acute low back pain without radiculopathy 5,24. Strong recommendation; low-quality evidence

Medication Back Pain with Radiculopathy Back Pain without Radiculopathy

NSAIDs for first line therapy Recommended Recommended

Acetaminophen for first line therapy

Recommended Recommended

Muscle Relaxants for first line therapy

Recommended Recommended

Opioids for second line therapy Limited use in select patients, use caution

Limited use in select patients, use caution

Epidural Injections for second line therapy

Limited use in select patients Not recommended

Benzodiazepines for second line therapy

Not Recommended Not Recommended

Antiseizure medications for second line therapy

Recommended Not recommended

Systemic corticosteroids Not recommended Not recommended

SNRIs for first line therapy Recommended Recommended



6

Quality Measures: Process-

- # Red Flag Protocols Completed - # Red Flag vs. # Non-Red Flag Patients - # Patients with complete Start Back Assessment: % low, med-high risk - # Patient Referrals - Treatment Adherence - # Patients Referred to Surgical Intervention

Outcome-

– # of patients with acute LBP – Total cost of care for acute low back pain – Opioid use for acute LBP – Advanced imaging use for acute LBP – Patient functional assessment: before/after 4-week – # missed pathologies – Patient satisfaction with acute LBP treatment



7



8



9

References

1. Qaseem, A., et al. (2017). "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians." Annals of Internal Medicine 166(7): 514-530.

2. National Institute of Neurological Disorders and Stroke (2015). “Low Back Pain Fact Sheet.” Available at https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet, acccessed March 26, 2018.

3. Linton, S. J., et al. (1993). "A controlled study of the effects of an early intervention on acute musculoskeletal pain problems." Pain 54(3): 353-359.

4. Chou, R., et al. (2007). "Diagnosis and treatment of low back pain: A joint clinical practice guideline from the american college of physicians and the american pain society." Annals of Internal Medicine 147(7): 478-491.

5. Foster, N. E., et al. (2018). "Prevention and treatment of low back pain: evidence, challenges, and promising directions." The Lancet.

6. Deyo, R. A., et al. (2006). "Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002." Spine (Phila Pa 1976) 31(23): 2724-2727.

7. U.S. Department of Health and Human Services. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2002. Vital and Health Statistics Series 10, No. 222 [DHHS Publication No. (PHS) 2004-1550]. Hyattsville, MD, 2004. Available at https://www.cdc.gov/nchs/data/series/sr_10/sr10_222.pdf, accessed March 26, 2018.

8. Martin, B. I., et al. (2008). "Expenditures and health status among adults with back and neck problems." JAMA 299(6): 656-664.

9. Davis, M. A., et al. (2012). "Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions." Spine (Phila Pa 1976) 37(19): 1693-1701.

10. Freburger, J. K., et al. (2009). "The rising prevalence of chronic low back pain." Archives of Internal Medicine 169(3): 251-258.

11. Mafi, J. N., et al. (2013). "Worsening trends in the management and treatment of back pain." JAMA Intern Med 173(17): 1573-1581.

12. Carey, T. S., et al. (1996). "Acute severe low back pain. A population-based study of prevalence and care-seeking." Spine (Phila Pa 1976) 21(3): 339-344.

13. Pengel, L. H., et al. (2003). "Acute low back pain: systematic review of its prognosis." BMJ 327(7410): 323. 14. Von Korff, M. and K. Saunders (1996). "The course of back pain in primary care." Spine (Phila Pa 1976) 21(24):

2833-2837; discussion 2838-2839. 15. Chou R, Qaseem A, Owens DK, Shekelle P,. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health

Care From the American College of Physicians. Ann Intern Med. 2011;154:181–189 16. Institute for Clinical Systems Improvement (2018). “Health Care Guideline: Adult Acute and Subacute Low Back

Pain. “ Available at https://www.icsi.org/_asset/lkvb5o/LBP-PC-11.17.pdf. 17. Delitto, A., George, S. Z., Van Dillen, L., Whitman, J. M., Sowa, G. A., Shekelle, P., … Godges, J. J. (2012). 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. The Journal of Orthopaedic and Sports Physical Therapy, 42(4), A1–57. http://doi.org/10.2519/jospt.2012.42.4.A1

18. Health Evidence Review Commission (HERC). (2014). Coverage Guidance: Lower Back Pain: Non-Pharmacological/Non-invasive Interventions. Available at http://www.oregon.gov/oha/HPA/CSI-HERC/EvidenceBasedReports/Low-Back-Pain-Non-Pharmacologic-Non-Invasive-Interventions-11-13-14.pdf

19. Health Evidence Review Commission (HERC). (2017). Guideline Note 56, Non-Interventinal Treatments for Conditions of the Back and Spine. Available at http://wvchealth.org/images/pdf/OHA%20GL%2056%20&%2060.pdf

20. American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain. (2016). Journal of the American Osteopathic Association, 116(8), 536-549. doi:10.7556/jaoa.2016.107

https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet

https://www.cdc.gov/nchs/data/series/sr_10/sr10_222.pdf

https://www.icsi.org/_asset/lkvb5o/LBP-PC-11.17.pdf

http://www.oregon.gov/oha/HPA/CSI-HERC/EvidenceBasedReports/Low-Back-Pain-Non-Pharmacologic-Non-Invasive-Interventions-11-13-14.pdf

http://www.oregon.gov/oha/HPA/CSI-HERC/EvidenceBasedReports/Low-Back-Pain-Non-Pharmacologic-Non-Invasive-Interventions-11-13-14.pdf

http://wvchealth.org/images/pdf/OHA%20GL%2056%20&%2060.pdf



10

21. Patel, N. D., et al. (2016). "ACR Appropriateness Criteria Low Back Pain." J Am Coll Radiol 13(9): 1069-1078. 22. Goertz M., et al., (2012). Low back pain, adult acute and subacute. Bloomington (MN): Institute for Clinical

Systems Improvement (ICSI). Nov. 91 p. 23. Livingston, C., Little, A., King, V., Pettinari, C., Thielke, A., Vandegriff, S., & Gordon, C. (2012). State of Oregon

Evidence-based Clinical Guidelines Project. Advanced imaging for 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 & Research.

24. Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt E. Noninvasive Treatments for Low Back Pain. Comparative Effectiveness Review No. 169. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.) AHRQ Publication No. 16-EHC004-EF. Rockville, MD: Agency for Healthcare Research and Quality; February 2016. www.effectivehealthcare.ahrq.gov/reports/final.cfm.



11

Guideline Preparation This guideline was prepared by the Office of Clinical Integration (CI) and Evidence-Based Practice (EBP) in collaboration with content experts at Oregon Health and Science University. Content Expert Team Daniel Albrecht, MD, Physical Medicine and Rehabilitation, Tuality Connie Amos, MS, Rehabilitation Services, OHSU Hans Carlson, MD, Orthopedics and Rehabilitation, OHSU Nels Carlson, MD, Orthopedics and Rehabilitation, OHSU Jason Chang, MD, Neurological Surgery, OHSU Anthony Cheng, MD, Family Medicine, OHSU Roger Chou, MD, Internal Medicine/PNW EPC, OHSU Christa Fiske, PA-C, Emergency Department, OHSU Tannia Flemming, PA-C, Orthopedics and Rehabilitation, OHSU Emily Houston, PT, DPT, Rehabilitation Services, OHSU Adam King, PA-C, Family Medicine, OHSU Kimberly Mauer, MD, Anesthesiology and Perioperative Medicine, OHSU Scott Mist, Ph.D., MAcOM, Anesthesiology and Perioperative Medicine, OHSU Ross Meinhart, Rehabilitation Services, OHSU Long Ong, MSN, ACNP-BC, Anesthesiology and Perioperative Medicine, OHSU Renita Patel, PharmD, OHSU Ryan Petering, MD, Family Medicine, OHSU David Senft, PA-C, Internal Medicine, Tuality David Sibell, MD, Anesthesiology and Perioperative Medicine, OHSU Adam Soll, MD, Physical Medicine and Rehabilitation, Tuality Daniel Stein, PA-C, Family Medicine, OHSU Adam Stone, MS, Clinical Reporting, OHSU Mary Tanski, MD, MBA, Emergency Medicine, OHSU Jill Viggiano, Patient Representative Megan Ward, MS, PA-C, Orthopedics and Rehabilitation, OHSU Cherri Warren, MS, Nursing Informatics, OHSU Johanna Warren, MD, Center for Women’s Health Primary Care Practice, OHSU Lisa Whitmore, RN, BC-FNP, Anesthesiology and Perioperative Medicine, OHSU Payer Representatives

Joe Badolato, MD, Regence James Rickards, MD, Moda Amit Shah, MD, Care Oregon Clinical Integration and EBP Team Elizabeth Crabtree, PhD, MPH Director of Clinical Integration and EBP Marcy Hager, MA, EBP Program Manager Andrew Hamilton, MS/MLS, Liaison Librarian Tovah Kohl, MA, EBP Program Manager Development Process This guideline was developed using the process outlined in the CI and EBP Manual (2016). The review summary documents the following steps: 1. Review Preparation

- PICO questions established - Evidence search confirmed with content experts

2. Review of Existing Internal and External Guidelines - Literature Review of Relevant Evidence

3. Critically Analyze the Evidence 4. Summarize the Evidence by preparing the guideline,

and order sets - Materials used in the development of the guidelines, review summaries and content expert team meeting minutes are maintained in an Acute Low Back Pain EB review manual with the Office of CI and EBP.

Evaluating the Quality of the Evidence

Published clinical guidelines were evaluated for this review using the University of Pennsylvania’s Trustworthy Guideline Rating Scale. The summary of these guidelines are included in the evidence summary. The rating scale is based on the Institute of Medicine’s “Standards for Developing Trustworthy Clinical Practice Guidelines” (IOM), as well as a review of the AGREE Enterprise and Guidelines International Network domains. This scale evaluates a guideline’s transparency, conflict of interest, development group, systematic review, supporting evidence, recommendations, external review and currency and updates. The purpose of this scale is to focus on the weaknesses of a guideline that may reduce the trust a clinical user can have in the guideline, and distinguish weaknesses in documentation (e.g. guideline does not have a documented updating process) from weaknesses in the guidance itself (e.g. recommendations are outdated). The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) criteria were utilized to



12

evaluate the body of evidence used to make clinical recommendations. The table below defines how the quality of the evidence is rated and how a strong versus conditional recommendation is established. The evidence summary reflects the critical points of evidence.

Recommendation

STRONG Desirable effects clearly outweigh undesirable effects or vice versa

CONDITIONAL Desirable effects closely balanced with undesirable effects

Quality Type of Evidence High Consistent evidence from well-

performed RCTs or exceptionally strong evidence from unbiased observational studies

Moderate Evidence from RCTs with important limitations (e.g., inconsistent results, methodological flaws, indirect evidence, or imprecise results) or unusually strong evidence from unbiased observational studies

Low Evidence for at least 1 critical outcome from observational studies, from RCTs with serious flaws or indirect evidence

Very Low Evidence for at least 1 critical outcome from unsystematic clinical observations or very indirect evidence

Recommendations Recommendations for the guidelines were directed by the existing evidence, content experts, patient values and preferences and consensus. When evidence is lacking, options in care are provided in the guideline and the order sets that accompany the guideline.

Approval Process

Guidelines are reviewed and approved by the Content Expert Team, Office of CI and EBP, Clinical Knowledge and Therapeutics Executive Committee, Professional Board, and other hospital committees as deemed appropriate for the guideline’s intended use. Guidelines are reviewed and updated as necessary every 2 to 3 years within the Office of CI and EBP at OHSU. Content

Expert Teams will be involved with every review and update.

Conflict of Interest None of the content expert team members has any affiliations or financial involvement that conflicts with the material presented in this guideline.

Disclaimer

Guideline recommendations are made from the best evidence, clinical expertise and consensus, in addition to thoughtful consideration for the patients and families cared for within the Integrated Delivery System. When evidence was lacking or inconclusive, content experts made recommendations based on consensus. Expert consensus is implied when a reference is not otherwise indicated. The guideline is not intended to impose standards of care preventing selective variation in practice that is necessary to meet the unique needs of individual patients. The physician must consider each patient and family’s circumstance to make the ultimate judgment regarding best care.



13

Appendix A. Suggested pharmacological interventions and dosing strategies Drug Initial Dosing Maximum 24 hour dosing Comments

NSAIDs* • Adverse events for NSAIDs include gastrointestinal and cardiovascular events.

• GI risk may be reduced with PPI’s while on NSAID therapy

• All risks can be reduced by using the lowest dose for the shortest duration needed.

Ibuprofen 400-600mg every 6 hours 3200mg

Naproxen 250-500 mg every 12 hours 1000mg • May be associated with lower cardiovascular risk

Acetaminophen 500mg every 6 hours 3000mg (4000mg with provider oversight)

Muscle Relaxants† • Adverse events may include sedation

Tizanidine 2-4mg every 8 hours 36mg

Cyclobenzaprine 5-10mg every 8 hours 30mg

Anti-seizure medications

Gabapentin 300mg every 8 hours 3600mg

Pregabalin 75mg every 12 hours 600mg

SNRI¥

Duloxetine 30 mg once daily for 1 week, then increase to 60 mg once daily as tolerated

60mg

*Ibuprofen and Naproxen are first line options for NSAIDS. There are other NSAIDs that can be used at the discretion of the prescriber, including Celecoxib (a COX-2 selective NSAID). †Tizanidine is similar in structure to clonidine and approved for spasticity and cyclobenzaprine is similar to a tricyclic antidepressant and approved for musculoskeletal conditions and are the first line options for muscle relaxants. There are other muscle relaxants that can be used at the discretion of the prescriber including: methocarbamol, chlorzoxazone, orphenadrine, and metaxalone. Carisoprodol is not recommended due to its abuse potential. ¥ Duloxetine is considered a first line suggestion. Other SNRI’s include venlafaxine and desvenlafaxine to be prescribed at the discretion of the provider.



14

Appendix B. The Keele STarT Back Screening Tool



15

Appendix C. Oswestry Disability Index



16

Appendix D. Short Form McGill Pain Questionnaire (SF-MPQ)



17

Appendix E. Modified Somatic Perceptions Questionnaire (MSPQ)



18



19

Appendix F. Patient-Specific Functional Scale

DATE: September 2018 - OHSU · 2018-12-10 · ACUTE LOW BACK PAIN GUIDELINE . Background: Low back...

Documents

Transcript of DATE: September 2018 - OHSU · 2018-12-10 · ACUTE LOW BACK PAIN GUIDELINE . Background: Low back...