New Treatment Guidelines For Low Back Pain

October 03, 2007

New recommendations from American Pain Society, American College of Physicians are based on research conducted at Oregon Health & Science University

PORTLAND, Ore. - A summary of evidence on the diagnosis and treatment of low-back pain has prompted the American Pain Society (ASP) and the American College of Physicians (ACP) to issue a new treatment guideline. The guideline is based on a thorough analysis of published research conducted by investigators at the Oregon Evidence-Based Practice Center at Oregon Health & Science University.

Among the recommendations issued by a panel of experts convened by the ACP and ASP are: Clinicians should rely less on X-rays and expensive diagnostic imaging and reports and more on therapies support by the evidence, including some medications and some alternative therapies. The guideline and two background papers are published in the October issue of the Annals of Internal Medicine.

"There is good evidence that clinicians should not order X-rays or other imaging tests for patients with nonspecific low-back pain. They are not helpful and could result in excessive radiation exposure or unnecessary procedures," said Roger Chou, M.D., co-author of the new guidelines, senior author of both background papers, and associate professor of medicine (general internal medicine and geriatrics) and medical informatics and clinical epidemiology in the OHSU School of Medicine, Oregon Evidence-Based Practice Center at OHSU.

That said, clinicians should order diagnostic imaging tests for patients known or believed to have underlying neurological or spinal disorders, Chou explained. Chou also is head of the American Pain Society's Clinical Practice Guideline Program.

About one if four Americans experiences low-back pain at least once a day, resulting in more than $26 billion in direct health care costs, studies have shown. And low-back pain is the fifth most common reason patients make a doctor's appointment.

The new guideline recommends clinicians weigh carefully potential benefits and risks of any drug and explain that they be used based on the severity of baseline pain and functional impairment.

"Some medications offer some benefits for low-back pain but they have risks," said Chou. "For example, acetaminophen is safe but not that effective, NSAIDs [nonsteroidal anti-inflammatory drugs) like ibuprofen provide more relief but have gastrointestinal and cardiovascular side effects, and opioids can treat severe pain but pose risks for sedation and dependence over time. Physicians and patients should discuss proven options and select the ones that best suit their specific needs."

There are a number of treatments for low-back pain that don't include medication, such as supervised exercise therapy, chiropractic care and massage therapy. The guideline suggests these options for patients who do not improve with self-care or pain medication.

The Annals article covers low-back-pain treatment in primary care settings only, and does not make recommendations regarding specialized, invasive procedures to treat the condition. Chou said APS will release the complete guideline in 2008 covering both the primary care recommendations as well as invasive treatments for low-back pain.

Members of the panel who issued the guideline represent more than 15 different areas of expertise There seven recommendations are:

*Clinicians should conduct a focused history and physical examination to help place patients with low-back pain into one of three broad categories: nonspecific low-back pain, back pain potentially associated with radiculopathy (nerve disorders) or spinal stenosis (narrowing), or back pain associated with another specific cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain.

*Clinicians should not routinely obtain imaging or other diagnostic tests in patients with non-specific low-back pain.

*Clinicians should perform diagnostic imaging and testing for patients with low-back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.

*Clinicians should evaluate patients with persistent low-back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they potential candidates for surgery or epidural steroid injection (for suspected radiculopathy).

*Clinicians should provide patients with low-back pain evidence-based information about their expected course, advise patients to remain active, and provide information about effective self-care options.

*For patients with low-back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self care. Clinicians should assess the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy.

*For patients who do not improve with self-care options, clinicians should consider the addition of non-pharmacologic therapy with proven benefits for low-back pain. They are spinal manipulation for acute low-back pain; and for chronic or sub-acute low-back pain options include: intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation.

For more information about the Oregon Evidenced-Based Practice Center at OHSU, visit: http://www.ohsu.edu/epc/

Oregon Health & Science University

---

---

	Low Back Disorders, Second Edition by Stuart McGill (Author) Access the latest research and applications to build effective prevention and rehabilitation programs for your patients or clients with Low Back Disorders: Evidence-Based Prevention and Rehabilitation, Second Edition. Internationally recognized low back specialist Stuart McGill presents original research to quantify the forces that specific movements and exercises impose on the low back, dispels myths regarding spine stabilization exercises, and suggests prevention approaches and strategies to offset injuries and restore function. Low Back Disorders: Evidence-Based Prevention and Rehabilitation, Second Edition, presents a clear exposition of back anatomy and biomechanics and demonstrates how to interpret the latest research on low back involvement for clinical applications. The...
	Low Back Pain: Mechanism, Diagnosis and Treatment by James M Cox (Author) The Seventh Edition of this textbook is built upon the peer-reviewed literature and research studies in the diagnosis and treatment of low back and radicular pain, focusing on the nonsurgical chiropractic adjusting methods. This text is the culmination of twelve years of updated research and development of spinal manipulation. From spinal stenosis to rehabilitation of low back pain patients to the latest treatise on fibromyalgia, you’ll find it all in Low Back Pain, Seventh Edition.You’ll find detailed discussion of: Biomechanics of the spine involved in low back pain The neurophysiology and pathology of the intervertebral disc and neural tissues in pain production, emphasizing compressive and chemical etiology of nerve pain Both federally and non federally funded spine...
	8 Steps to a Pain-Free Back: Natural Posture Solutions for Pain in the Back, Neck, Shoulder, Hip, Knee, and Foot by Esther Gokhale (Author), Susan Adams (Editor) Nearly 90% of American adults suffer from back pain, and the number continues to climb. Why does this condition affect so many people in the industrialized world, while in some countries only 5% of adults report back pain? In a quest to find the root cause of back pain, Esther Gokhale studied at the Aplomb Institute in Paris and traveled to parts of the world where back pain is virtually unknown. Her research took her to remote Burkina Faso, rural Portugal, and fishing villages in Brazil. What she learned in each of these places has changed the lives of thousands of people. Preserved in the movements of weavers, millers, and farmers in more traditional societies is ancient body wisdom that prevents pain and enhances health. For the first time, these insights have been brought...
	Lower Back Pain Relief: The Amazing Story Of How I Cured My Chronic Lower Back Pain In Only Ten Days And How You Too Can Get Rid Of Your Lower Back Pain Fast And Be Free Of Back Pain Once And For All! Hello, my name is Kent Ellis and I am a fifty-seven year old man who not so long ago suffered from severe, chronic lower back pain. In this ebook you will get the complete lowdown on what I did to create a rapid healing of my own lower back pain. If you think this was a difficult or time-consuming task, you're wrong! To accomplish the healing of my lower back pain, it involved using a dead simple method for only thirty seconds per day to start, then gradually increasing to several minutes per day over the next ten or eleven days. That was it. And to my astonishment, my pain was gone, never to return. My discovery is so simple, so natural and so basic, that it has been completely overlooked. My technique requires no medication, no surgery, no equipment, no special environment,...
	Back RX: A 15-Minute-a-Day Yoga- and Pilates-Based Program to End Low Back Pain by Vijay Vad (Author), Hilary Hinzmann (Author) As a physician specializing in treating athletes, Dr. Vijay Vad has spent years researching how to cure back pain using medical yoga and Pilates. Profiled in The Wall Street Journal, his program requires just fifteen minutes a day for eight weeks to restore flexibility and prevent future injuries. Offering a proven alternative to invasive surgery, Dr. Vad’s Back Rx provides the best of mind/body medicine by giving readers three step-by-step exercise series, demonstrated in 130 precise photographs, for implementing his popular program at home. Even readers with severely limited mobility will rejoice in Dr. Vad’s gentle introductory workout. Progressing through his self-paced program, they will discover a new range of exercises, breathing techniques, and tips for self-massage. For...
	Trigger Point Therapy for Low Back Pain: A Self-Treatment Workbook (New Harbinger Self-Help Workbook) by Mary Biancalana MS CMTPT LMT (Author), Sharon Sauer CMTPT LMT (Author), Bernard Filner MD (Foreword) Learn the secrets to lasting pain relief: finding and deactivating trigger points, the underlying cause of most low back pain. Trigger points are sensitive tight spots in taut bands of muscle tissue. Treating trigger points that refer pain to the low back and buttock areas, rather than addressing only the specific sites of your pain, is the best way to comprehensively treat occasional or chronic discomfort and prevent it from coming back.Packed with illustrated treatment techniques, Trigger Point Therapy for Low Back Pain offers effective strategies beginners can practice at home and detailed hands-on protocols health care practitioners can use while working with patients. Find out which of eleven muscles could be causing back pain, then learn specific trigger point treatments and correct...
	Evidence-Based Management of Low Back Pain, 1e by Simon Dagenais CD PhD (Author), Scott Haldeman DC MD PhD (Author) Covering all commonly used interventions for acute and chronic low back pain conditions, Evidence-Based Management of Low Back Pain consolidates current scientific studies and research evidence into a single, practical resource. Its multidisciplinary approach covers a wide scope of treatments from manual therapies to medical interventions to surgery, organizing interventions from least to most invasive. Editors Simon Dagenais and Scott Haldeman, along with expert contributors from a variety of clinical and academic institutions throughout the world, focus on the best available scientific evidence, summarizing the results from the strongest to the weakest types of studies. No other book makes it so easy to compare the different interventions and treatment approaches, giving you the tools...
	Low Back Syndromes: Integrated Clinical Management by Craig Morris (Author) Written by an interdisciplinary team, Low Back Syndromes is the first truly comprehensive multidisciplinary text for low back conditions. Because today’s patients expect their clinicians to possess an in-depth understanding of available treatments, this text covers the broad spectrum of clinical options currently available. From chiropractic to osteopathy, from medicine to physical therapy, from occupational medicine to evidence based health care, from psychology to surgery, from pain medicine to manipulation, from post-surgical rehabilitation to end-stage training of elite athletes, this is the first textbook to bring all the specialists together to allow clinicians direct access to state-of –the art standards of practice from a single source. Featuring internationally acclaimed...
	Low Back Pain: Mechanism, Diagnosis and Treatment by James Cox (Author) Here's your complete guide to managing low back pain. This Sixth Edition features eight years of completely updated research by Dr. Cox...all resulting in this comprehensive source for diagnosis and treatment. Extensive algorithms of decision making are featured representing the standard of care in distraction adjusting. New chapters include: / History, development and acceptance of distraction adjusting procedures / Complete treatment protocol with distraction adjusting for radicular and non-radicular low back pain patient / Research of distraction adjusting written by Ram Gudavalli, PhD, principal investigator of the combined research study "Biomechanics of Flexion Distraction Manipulation of the Lumbar Spine" between the National College of Chiropractic and Loyola University Stretch...
	Harvard Medical School Low Back Pain: Healing your aching back by Harvard Health Publications Back pain is one of the most common, non-life-threatening, painful conditions, affecting four in five Americans at some point in their lives. And many have to be wary of return bouts. But low back pain treatment has undergone a sea change since the 1990s. Experts now appreciate the central role of exercise in treating back problems and maintaining a healthy back. They also better understand which conditions surgery will help and which patients are good surgical candidates. This report describes the different types of back problems and the tailored treatments that are more likely to help specific conditions. A special section is dedicated to the self-care steps you can take to mend your back, and features information on different types of exercise and complementary therapies...