CE/CME

Low Back Pain: Evidence-based Diagnosis and Treatment

Clinician Reviews. 2016 May;26(5):38-45

References

1. CDC. National Ambulatory Medical Care Survey: 2010 Summary Tables. Table 9. www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf. Accessed March 29, 2016.
2. Davies C, Nitz AJ, Mattacola CG, et al. Practice patterns when treating patients with low back pain: a survey of physical therapists. Physiother Theor Pract. 2014;30(6):399-408.
3. American College of Radiology. ACR Appropriateness Criteria. Low back pain. 2015. www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/LowBackPain.pdf. Accessed March 10, 2016.
4. Henschke N, Maher CG, Ostelo RW, et al. Red flags to screen for malignancy in patients with low back pain. Cochrane Database Syst Rev. 2013;2:CD008686.
5. Koes BW, Tulder M, Lin CW, et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-2094.
6. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760-765.
7. Jarvik JG. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137:586-597.
8. Diagnostic testing for low back pain. In: Post TW (ed), UpToDate, Waltham, MA. www.uptodate.com. Accessed March 16, 2016.
9. Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. 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.
10. Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988;3(3):230-238.
11. Deyo RA, Diehl AK. Patient satisfaction with medical care for low-back pain. Spine. 1986;11(1):28-30.
12. Pradeep S, Rainville J, Katz JN, et al. The accuracy of the physical examination for the diagnosis of midlumbar and low lumbar nerve root impingement. Spine. 2011;36(1):63-73.
13. Leclaire R, Blier F, Fortin L, Proulx R. A cross-sectional study comparing the Oswestry and Roland-Morris Functional Disability Scales in two populations of patients with low back pain of different levels of severity. Spine. 1997;22(1):68-71
14. FDA. Radiation emitting products. www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm115317.htm. Accessed March 29, 2016.
15. Simpson AK, Whang PG, Jonisch A, et al. The radiation exposure associated with cervical and lumbar spine radiographs. J Spinal Disord Tech. 2008;21(6):409-412.
16. Srinivas S, Deyo R, Berger Z. Application of “less is more” to lower back pain. Arch Intern Med. 2012;172(13):1016-1020.
17. Webster BS, Bauer AZ, Choi Y, et al. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling back pain. Spine. 2013;38(22):1939-1946.
18. Webster BS, Bauer AZ, Choi Y, et al. The cascade of medical services and associated longitudinal costs due to nonadherent magnetic resonance imaging for low back pain. Spine. 2014;39(17):1433-1440.
19. Liang M, Komaroff AL. Roentgenograms in primary care patients with acute low back pain: a cost-effectiveness analysis. Arch Intern Med. 1982;142(6):1108-1112.
20. Ash LM, Modic MT, Obuchowski NA, et al. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008;29(6):1098-1103.
21. Kendrick D, Fielding K, Bentley E, et al. Radiography of the lumbar spine in primary care patients with low back pain: randomized controlled trial. BMJ. 2001;322(7283):400-405.
22. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain. JAMA. 2003;289(21):2810-2818.
23. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463-472.
24. Carey TS, Evans AT, Hadler NM, et al. Acute severe low back pain: a population-based study of prevalence and care-seeking. Spine. 1996;21(3):339-344.
25. Roelofs PD, Deyo RA, Koes BW, et al. Nonsteroidal anti-inflammatory drugs for low back pain. Spine. 2008;33(16):1766-1774.
26. Hancock MJ, Maher CG, Latimer J, et al. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomized controlled trial. Lancet. 2007;370(10):1638-1643.
27. Van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low-back pain. Cochrane Database Syst Rev. 2003;(4):CD004252.
28. Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572-1580.
29. Zarghooni K, Rashidi A, Siewe, J, et al. Single-shot epidural injections in the management of radicular pain. Orthop Rev (Pavia). 2015;7(4):5985.
30. Smidt N, deVet HC, Bouter LM, et al. Effectiveness of exercise therapy: A best-evidence summary of systematic reviews. Aust J Physiother. 2005;51(2):71-85.
31. Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012;85(4):343-350.
32. Machado LA, Maher CG, Herbert RD, et al. The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Med. 2010;8(10):1-10.
33. Cho I, Jeon C, Lee S, et al. Effects of lumbar stabilization exercise on functional disability and lumbar lordosis angle in patients with chronic low back pain. J Phys Ther Sci. 2015;27(6):1983-1985.
34. Choi BK, Verbeek JH, Tam WW, Jiang JY. Exercises for prevention of recurrences of low-back pain (review). Cochrane Database Syst Rev. 2010;(1):CD006555.
35. Wegner I, Widyahening IS, van Tulder MW, et al. Traction for low-back pain with or without sciatica (review). Cochrane Database Syst Rev. 2013;(8):CD003010.
36. Hoiriis KT, Pfleger B, McDuffie FC, et al. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. J Manipulative Physiol Ther. 2004;27(6):388-398.
37. Lin CC, Haas M, Maher CG, et al. Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review. Eur Spine J. 2011;20:1024-1038.
38. Walker BF, French SD, Grant W, Green S. A Cochrane Review of combined chiropractic interventions for low-back pain. Spine. 2011;36(3): 230-242.
39. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010;(6):CD007612.
40. Staiger T, Paauw D, Deyo A, Jarvik JG. Imaging studies for acute low back pain. When and when not to order them. Postgrad Med. 1999;105(4):161-162,165-166,171-172.

PATIENT PERCEPTION
Patient satisfaction plays a very important role in health care and may correlate with compliance and other outcomes. One study showed that while radiography in patients with LBP was not associated with improved clinical outcomes, it did increase patients’ satisfaction with the care they received.²¹A study that grouped patients requiring imaging for LBP into rapid MRI and plain film radiography cohorts found that patients who received rapid MRI were more assured by their results than were patients in the radiography group (74% vs 58%, P = .002).²² Both groups showed significant clinical improvement in the first three months, but there was no difference between groups at either the three- or 12-month mark. In both groups, reassurance was positively correlated with patient satisfaction (Pearson correlation coefficients, 0.55-0.59, P < .001).

Patients may be reassured by imaging, even when it is unnecessary. Effectively explaining symptomatology during the HPE to patients with LBP should be of high priority to clinicians. A study found that when patients with mechanical LBP did not receive an adequate explanation of the problem, they were less satisfied with their visit and wanted more diagnostic tests.¹¹ Another study found that when low-risk patients were randomly assigned to a control group and received an educational intervention only, they reported equal satisfaction with their care and had clinical outcomes equal to those of the treatment group that received a plain radiograph.¹¹

Given the costs, radiation risks, and other negative aspects of unnecessary imaging, additional diagnostic tests may not be in a patient’s best interest. A careful physical exam should be performed, with the clinician providing ongoing commentary to reassure patients that the clinician is neither dismissing the patient’s symptoms nor inappropriately avoiding further tests.

Often, medical providers order imaging with the intention to reassure patients with the results and thus ultimately increase the patient’s sense of well-being. However, the opposite effect may occur, with patients actually developing a decreased sense of wellness with no alteration of outcomes. A study evaluated general health (GH) scores (based on results from several screening questionnaires that assessed the patient’s current physical and mental health state) in patients receiving MRI results.²⁰ The patients were divided into those who received results (within 48 hours), and those who did not unless it was critical to patient management (blinded group). At six weeks, the blinded group’s GH score was significantly higher than the early-informed group’s GH score. This suggests that receiving MRI results may negatively influence patients’ perception of their general health.²⁰

The same meta-analysis that reviewed patient outcomes also evaluated mental health and quality-of-life scores of LBP patients who received either MRI, CT, or radiography.²³ There was no short-term (< 3 mo) or long-term (6-12 mo) difference between patients who received radiography versus advanced imaging. This indicates that using imaging of any kind in patients with LBP but without indications of serious underlying conditions does not improve clinical outcomes and is negatively correlated with quality-of-life measures at short- and long-term intervals.²³

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Low Back Pain: Evidence-based Diagnosis and Treatment

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