Core Treatment Plan Recommendations: This is what the most up to date research tells us.
•Clinicians should educate patients as an adjunct to other treatment. No standardized form of education is suggested [Strong Recommendation, Moderate Quality Evidence].
•Non-steroidal anti-inflammatory drugs (NSAIDs) may be used for short-term pain relief in patients with acute and subacute low back pain [Weak Recommendation, Moderate Quality Evidence].
•Muscle relaxants may be used as an option in treating acute low back pain. However, possible side effects should be considered [Weak Recommendation, Moderate Quality Evidence].
•Cautious and responsible use of opioids may be considered for those carefully selected patients with severe acute pain not controlled with acetaminophen and NSAIDs, at a minimum effective dose, for a limited period of time, usually less than one to two weeks [Strong Recommendation, Low Quality Evidence].
•Heat should be used for pain relief [Strong Recommendation, Moderate Quality Evidence]. •Cold therapy is not recommended for low back pain [Weak Recommendation, Low Quality Evidence].
•Clinicians should advise patients with acute and subacute low back pain to stay active and continue activities of daily living within the limits permitted by their symptoms [Strong Recommendation, Moderate Quality Evidence].
•Exercise should be recommended to reduce the recurrence of low back pain. However, no specific exercise is preferred [Strong Recommendation, Moderate Quality Evidence].
•Clinicians should not recommend bed rest for patients with low back pain [Strong Recommendation, Moderate Quality Evidence].
•Clinicians should not prescribe or recommend traction for the treatment of acute low back pain [Weak Recommendation, Low Quality Evidence].
•Clinicians should not recommend imaging (including computed tomography [CT], magnetic resonance imaging [MRI], and x-ray) for patients with non-specific low back pain [Strong Recommendation, Moderate Quality Evidence].
The core treatment plan addresses the need for patient education, reassurance and expectations. Patient satisfaction is dependent on a clear diagnosis with information and instructions on how to handle their low back pain. A care plan should include the following: •Answers to questions addressed by the patient. In general, this should include discussion of causation and the natural history of low back pain. It may need to include reasons for not ordering tests such as laboratory or imaging. •Instructions on pain and activity management. Include positional and exercise components as well as work recommendations or limitations. •Instructions on treatment recommendations including medications and/or therapy recommendations. •Follow-up and contact information in response to desire for further reassurance or education, and descriptions of specific warning signs, which may require earlier evaluation.
Provide patients with brochures and information that place a greater emphasis on reducing fear and anxiety, promote active self-management and incorporate the following components of care. See Appendix C, “Patient Brochure Example,” in the original guideline document.
There is a good prognosis for low back pain. The majority of patients experience significant improvements in two to four weeks. Most patients who seek attention for their back pain will improve within two weeks and most experience significant improvement within four weeks.
Approximately two-thirds of the people who recover from a first episode of acute low back symptoms will have another episode within 12 months. Unless the back symptoms are very different from the first episode or the patient has a new medical condition, expect improvement to be similar for each episode.
All patients recovering from back pain should understand that episodes of back pain may recur but can be handled similarly to the one from which they are recovering.
Clinicians in clinic systems are encouraged to provide primary education through other community education institutions/businesses to develop and make available patient education materials concerning back pain prevention and care of the healthy back. Emphasis should be on patient responsibility, workplace ergonomics, and home self-care treatment of acute low back pain. Employer groups should also make available reasonable accommodations for modified duties or activities to allow early return to work and minimize the risk of prolonged disability. Education is recommended for frontline supervisors in occupational strategies to facilitate an early return to work and to prevent prolonged disabilities. Identify and manage stressors.
Acetaminophen and Non-steroidal Anti-inflammatory Medication
All medications have potential benefits and risks that patients should be aware of. Short-term use of medications (less than two weeks) may reduce some of the risks.
Use over-the-counter short-term acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) to help ease the pain and/or inflammation in the lower back. Patients need to be aware that all NSAIDs have a risk of gastritis and gastrointestinal bleed, and possible cardiovascular implications. Acetaminophen has the risk of serious liver disease.
Muscle relaxants may be useful for short-term relief of acute low back pain. The use of muscle relaxants is an option that needs to be weighed against the possible side effects and contraindications.
Cautious and Responsible Use of Opioids
The consensus opinion of the work group is that the cautious and responsible use of opioids for severe acute and subacute low back pain in carefully selected patients, for limited periods of time (usually less than one to two weeks) may be considered. Clinicians may consider using low potency opioids, using the lowest daily dose possible. Extended release opioids should be avoided if possible in acute back pain patients, especially in opioid naïve patients. Clinicians should always assess risk before ordering opioids. Risk to the patient, but also to the community, should be considered. Opioids should be used only as one part of a comprehensive care plan for the patient with acute and subacute low back pain.
Apply heat as preferred on the sore area for a short duration in a position of comfort to assist with pain management. Cold therapy is not recommended.
Encourage Activity; Bed Rest Is Not Recommended
Carefully introduce activities as the patient begins to recover from the worst of the back pain episode. Light-duty activities and regular walking are good ways to get back into action. Participate in activity that does not worsen symptoms. Advise to stay active and to continue ordinary activity as normally as tolerated to give faster return to work, less chronic disability and fewer recurrent problems. Patients should also be provided information about effective self-care options. Exercise over no intervention is useful for reducing the rate of low back pain recurrence. Bed rest is not recommended. A gradual return to normal activities is more effective and leads to more rapid improvement with less chronic disability.
Refer to the original guideline document for more information on the above topics and for information about addressing fear-avoidance beliefs (fear of activity) and return-to-work assessment.
The use of imaging including CT, MRI and x-ray is not recommended for non-specific low back pain.
Reassess as Needed
Instruct the patient to return for the following reasons: •Pain that doesn’t seem to be getting better after two to three weeks •Pain and weakness traveling down the leg below the knee •Leg, foot, groin or rectal area feeling numb •Unexplained fever, nausea/vomiting, stomachaches, weakness or sweating •Loss of control of urine or stool •Pain is so intense you can’t move around or get comfortable •Redness or swelling on the back or spine •Desire for further reassurance or education
Early Acute Phase Treatment Considerations
Recommendations in this phase include those found in Annotation #11, “Core Treatment Plan,” in addition to the following: •Spinal manipulative therapy should be considered in the early intervention of low back pain [Strong Recommendation, Moderate Quality Evidence]. •At this point evidence is not sufficient to strongly recommend the clinical prediction rule. However, studies are currently underway which may add further support. Therefore, the work group suggests consideration of the clinical prediction rule in the category of early low back pain patients [Weak Recommendation, Low Quality Evidence].
For those patients who are seen within the first two weeks from onset of symptoms and have severe pain or physical impairment, the following approaches are recommended:
Consider Spinal Manipulative Therapy: Use Clinical Prediction Rule
The clinical prediction rule is used to identify a subgroup of patients by several criteria (see Table 2, “Clinical Prediction Rule,” in the original guideline document). The rule projects successful treatment of low back pain with spinal manipulative therapy at greater than 90%. Although much work has been done related to the clinical prediction rule, at this point, evidence is not sufficient to strongly recommend it. However, studies currently underway may add further support. Therefore, the work group suggests consideration of this rule in this category of early low back pain patients.
Late Acute Phase Treatment Consideration
Recommendations in this phase include those found in Annotation #11, “Core Treatment Plan,” in addition to the following: •Delayed-recovery assessment is not fully developed; however, much progress has been made and it is recommended that the clinician use one or more approaches to identify a patient who is at risk and intervene with specific interventions [Weak Recommendation, Low Quality Evidence].
Core Treatment Plan
Incorporate core treatment plan into plan of care. See Annotation #11, “Core Treatment Plan,” for more information.
If the patient presents with low back pain symptoms for two to six weeks of severe limits in function and/or severe pain, add the following care to the core treatment plan.
Focused Review of Treatment to Date
Complete a focused review of treatment to date to determine successes and failures in treatment modalities thus far.
Because the majority of acute low back pain sufferers improve within the first two weeks from onset, it is difficult to identify before this time the 10% to 15% who will experience chronic pain or disability. The period from two to six weeks is a key time to assess for risk factors and if possible, to begin approaches to manage them. Though progress has been made over the last 20 years, this is still an imprecise process. The chart in the original guideline document (page 24) describes three approaches – structured self report, open questions and observation – that can be used to assess risk. Each approach can increase focus and in many situations trigger an intervention plan to address the risk early in the continuum of disability and pain.
Individual risk factors with stronger predictive ability include the following:
•Fear-avoidance beliefs •Catastrophizing •Somatization •Depressed mood •Distress and anxiety •Early disability or decreased function •High initial pain levels •Increased age •Radiation of pain •Poor general health status •Non-organic signs
Subacute Phase Treatment Consideration
Recommendations in this phase include those found in Annotation #11, “Core Treatment Plan,” in addition to the following:
- Delayed-recovery risk assessment is not fully developed; however, much progress has been made and it is recommended that the clinician use one or more approaches to identify a patient who is at risk and intervene with specific interventions [Weak Recommendation, Low Quality Evidence].
- Exercise is recommended in the treatment of subacute low back pain [Strong Recommendation, Moderate Quality Evidence].
- Spinal manipulative therapy should be considered in the early intervention of low back pain [Strong Recommendation, Moderate Quality Evidence].
- Clinicians should consider cognitive behavioral therapy in the treatment of subacute low back pain [Weak Recommendation, Moderate Quality Evidence].
- Acupuncture may be used as an adjunct treatment for subacute low back pain [Weak Recommendation, Low Quality Evidence].
Progressive Exercise Plan
The use of a progressive exercise program in the treatment of subacute low back pain is supported. Progressive exercise is based on a number of variables that include but are not limited to increasing physical activity, education regarding pain and an exercise program that is graded with a de-emphasis on pain.