Download Evidence-based Medicine for Evaluation and Management of Low

Evidence-based Evaluation
and Management Of
Low Back Pain
Roger Chou, MD, FACP
Professor, Department of Medical Informatics & Clinical
Epidemiology, and Department of Medicine
Oregon Health & Science University
Director, the Pacific Northwest Evidence-based Practice Center
John D. Loeser, MD
Professor, emeritus, Departments of Neurological Surgery and
Anesthesia and Pain Medicine, University of Washington
Oregon Pain Guidance May 6, 2017
Disclosures/Conflict of Interest
Dr. Chou has received research funding from
the Agency for Healthcare Research and
Quality and the American College of
Physicians, and is a consultant with Palladian
Health.
Dr. Loeser has received research funding
from the National Institutes of Health.
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Session Objectives
• Describe the epidemiology and natural history
of low back pain
• Describe trends in evaluation and management
of low back pain, outcomes, practice variations,
and implications for practice
• Understand an evidence-based approach to
evaluation and management of low back pain
THE PATIENT:
57 yo male with LBP x 2 years, no specific
inciting event
• No associated leg pain or other neurological symptoms
• Pain slowly worsening, to the point of not being able to
walk more than 2 to 3 blocks, rated 7/10 most days
• Continues to golf most weekends, but riding cart now
• Works as an engineer, not physically demanding
• X-rays show lumbar disc degeneration and facet joint
arthropathy
• Tried acetaminophen and NSAIDs and has undergone PT
LBP Burden 1
• LBP is the 5th most common reason for U.S.
office visits, and the 2nd most common
symptomatic reason
– >16 million LBP office visits/year
– 5% of PCP visits are for LBP
– Most common reason to see a neurosurgeon
or orthopedist
• Up to 84 percent of adults have LBP at some
time in their lives, and over one-quarter in the
previous 3 months
– Only 2-5% seek health care or claim disability
LBP Burden 2
• Peaks at 55 to 64 years of age; affects all
ages
• The most common cause of activity
limitations in persons <45 years of age
• More disability than cancer + heart disease +
stroke + AIDS
• In 2013, nearly $90 billion dollars in
spending for back and neck pain
• Increase of $64 billion from 1996
TRENDS IN LBP
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Increased utilization of imaging studies
Increased incidence of surgery
Increased use of injections
Increased prescription of opioids
Increased costs for LBP
No decrease in disability
October 24, 2008
“7 Back Pain Breakthroughs
Are you hurting? Here's help.”
Reader’s Digest,
July, 2007
“End Back Pain Agony”
Michael J. Weiss
http://www.rd.com/content/chronic-back-pain-breakthroughs-/
Reader’s Digest “Cures” for LBP
• Infrared belt - $2,335
• “Magic Spinal Wand”
• Percutaneous automatic discectomy
• Flexible fusion
• Stem cells
• Site-directed bone growth
• New bed
“Experts” on causes of low back pain
• “80% of back pain is caused by weak or
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tense muscles.”
“The majority of LBP actually originates in
the sacral ligaments.”
“In 50% or more…the facet joint is the site of
dysfunction.”
“90-95% of back pain is due to disks.”
“An extremely high percentage…have fascial
problems.”
“50-70% of chronic symptoms are
psychological in origin.”
Deyo RA, Spine 1993;18:2153-2162
“Experts” on effectiveness of treatments for
low back pain
•“Mobilization and manipulation studies claim
an 80% success rate.”
•“80% of low back pain patients get immediate
relief with epidural blocks.”
•“In the YMCA’s exercise program, 80%
improve.”
•“With microcurrent therapy…82% were pain
free with 10 treatments.”
•“70-80% of those carefully screened for
radicular symptoms benefit from surgery.”
Deyo RA, Spine 1993;18:2153-2162
What makes treatments appear
effective?
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Natural history
Regression to the mean
Hawthorne and other non-specific effects
Fraud
Placebo effects
Selection of patients more likely to
improve
• Specific or “true” effects of treatment
RISK FACTORS FOR LBP
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Congenital spine abnormalities
Smoking
Occupation
Prior episode of LBP
Physical unfitness
Increasing age
THE PATIENT:
57 yo male with LBP x 2 years, no specific
inciting event
• No associated leg pain or other neurological symptoms
• Pain slowly worsening, to the point of not being able to
walk more than 2 to 3 blocks, rated 7/10 most days
• Continues to golf most weekends, but riding cart now
• Works as an engineer, not physically demanding
• X-rays show lumbar disc degeneration and facet joint
arthropathy
• Tried acetaminophen and NSAIDs and has undergone PT
2007 American College of Physicians/American
Pain Society guidelines
2017 American College of Physicians guideline
• Emphasis on nonpharmacologic therapies,
particularly for chronic LBP
• Stronger cautions regarding opioids
• Acetaminophen no longer recommended for acute
LBP
• More evidence on mind-body interventions (yoga,
Tai Chi, mindfulness-based stress reduction)
STEPS FOR EVIDENCE-BASED
DIAGNOSIS AND TREATMENT
OF LOW BACK PAIN IN
PRIMARY CARE
STEP 1
IN THE CARE OF THE
LBP PATIENT
Listen to the patient’s story, obtain
adequate medical history and social
history. Look for psychological and
environmental factors that might
impair recovery.
STEP 2
IN THE CARE OF THE
LBP PATIENT
Perform a directed physical
examination
History and physical for diagnosing
specific conditions
• Cancer: History of cancer, elevated ESR
•
Weaker predictors: unexplained weight loss, failure to
improve after 1 month, age >50
• Herniated disc: Leg pain in radicular distribution and
positive straight leg raise test
• Spinal stenosis: Wide-based gait, lack of pain
when seated
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Weaker predictors: neurogenic claudication, age >65
• Cauda equina syndrome: Urinary retention
Epidemiology of low back pain
• >85% of patients who present to primary care have LBP
that cannot be attributed to a specific disease or spinal
pathology; therefore “non-specific lbp”
• Labeling most patients with specific diagnosis is
misleading and doesn’t improve outcomes
• Conditions to rule out: (all are rare)
• Cancer 0.7%, compression fracture 4%, ankylosing
spondylitis 0.3% to 5%, spinal infection 0.01%
• Spinal stenosis 3%, symptomatic herniated disc 4%
• Cauda equina syndrome 0.04% (usually due
to massive midline disc herniation)
STEP 3
IN THE CARE OF THE
LBP PATIENT
Review any laboratory or imaging
data and any prior medical
records.
STEP 4
ESTABLISH A PRELIMINARY
DIAGNOSIS
• Non-specific low back pain (most likely)
• Radiculopathy and/or spinal stenosis
• Another specific diagnosis
PROUST
The Remembrance of
Things Past
“For each ailment that
doctors cure with
medications (as I am told
they do occasionally
succeed in doing) they
produce ten others in
healthy individuals by
inoculating them with the
pathological agent a
thousand times more
virulent than all the
microbes—the idea that
they are ill.”
NOT A STEP
No imaging or other diagnostic
tests needed initially in a patient
with nonspecific low back pain.
When to obtain imaging and other diagnostic
tests
• Use history and physical to guide approach
• High risk for vertebral compression fracture
• Suspected infection, cauda equina syndrome,
progressive/severe neurologic deficits
• Advanced imaging usually necessary
• Risk factors for cancer
• If age only risk factor, consider time-limited
(e.g. 1 month) trial of therapy
• If previous cancer or cancer more strongly suspected,
consider x-ray plus ESR initially
• Suspected radiculopathy or spinal stenosis
• In absence of severe/progressive neurologic symptoms with
no improvement after >1 month, consider MRI or CT after >1
month in candidates for surgery or epidural steroid injections
Why isn’t routine imaging helpful?
• Favorable natural history of acute LBP
• Low prevalence of serious underlying conditions
• Almost all have identifiable risk factors
• Poor correlation between common imaging
findings and symptoms
• Labeling patients with a specific diagnosis may
cause harm
• Fear avoidance behaviors, anxiety
• Minimal impact on clinical decision-making
• Increase likelihood of unnecessary and potentially
harmful interventions
STEP 5
IMPLEMENT CONSERVATIVE
CARE
Physical activity
Medications
Education
Follow-up
STEP 5a
PHYSICAL ACTIVITY
• The role of the therapist is to educate and
monitor the patient’s progress.
• Most of the planned activities do not require
medical supervision or high technology: a
gym will do.
• Group activities are often helpful.
RAPID RETURN TO
NORMAL ACTIVITIES
Bed rest is bad
for your health.
Recommend a gradual and
progressive increase in physical
activities on a quota system.
Never “…let pain be your guide”.
Educate the patient:
HURT AND HARM
ARE NOT SYNONYMS.
PASSIVE THERAPIES ARE
OF LITTLE VALUE.
Recommendation:
Self-care and education
Provide patients with evidence-based
information about their expected course,
advise patients to remain active, and
provide information about effective selfcare options.
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STEP 5b
MEDICATIONS
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Adjuncts to comprehensive therapies
Antidepressants are most useful class
No role for anxiolytics (benzos) in most pts
Opioids for short-term use only
NSAIDs may be helpful; watch for side-effects
STEP 5d
FOLLOW-UP
• Planned follow-up reduces health care
consumption.
• Re-assess if unsatisfactory progress or any
yellow flags for adverse outcomes.
• Physician as teacher and leader and
reinforcer
STEP 6:
REASSESSMENT AT 4-6 WEEKS
• If symptoms persist unabated, look for
impediments to recovery.
• Consider imaging studies if clinical signs and
symptoms are suspicious.
• Know the consultant to whom you refer the
patient.
PREVENTION OF DISABILITY
SHOULD BE THE PRIMARY
OUTCOME GOAL FOR ALL
PATIENTS WITH LOW BACK AND
LEG PAIN.
THE NATURAL HISTORIES OF
ACUTE, RECURRENT AND
CHRONIC LOW BACK PAIN AND
SCIATICA ARE RELATIVELY BENIGN.
Why didn’t they
tell me that in my
residency?
Identify and address risk factors for chronicity
Small proportion of patients with acute LBP go on to develop
persistent LBP, but account for the majority of costs
• Psychosocial factors the strongest predictor for chronicity,
environmental factors also play a role
STarT Back Trial
• 1573 UK patients with LBP (+/- radiculopathy), any duration
• Randomized to stratified care based on prognosis (low, medium, or
high-risk) or usual care
• Low-risk intervention: educational video and booklet
• Medium and high-risk interventions: referred for psychologically
informed physiotherapy (3 vs. 9 days of additional training)
• Stratified care more effective than usual care for function (1.8
points at 4 months and 1.1 pts at 12 months); also cost effective
• STarT Back approach being tested in the U.S.
Hill JC et al. Lancet 2011;378:1560
Advice and self-care for low back pain
• Inform patients of generally favorable prognosis of
acute LBP with or without sciatica
• Discuss need for re-evaluation if not improved
• Advise to remain active
• Counsel that hurt and harm are not synonymous
• Consider self-care education books
• Superficial heat moderately effective for acute low
back pain
• No evidence to support use of lumbar supports
• No evidence to support use of traction
Recommendation:
Nonpharmacological therapies
• For patients who do not improve with self-care
options, consider the use of non-pharmacologic
therapy with proven benefits.
• For chronic low-back pain, options include: intensive
interdisciplinary rehabilitation, exercise therapy,
cognitive-behavioral therapy, yoga, mindfulnessbased stress reduction, acupuncture, massage
therapy, or spinal manipulation.
• For acute low-back pain, options include: exercise,
acupuncture, manipulation.
Approach to use of non-pharmacologic
therapies for LBP
• A number of therapies appear similarly effective
• Emphasis on active rather than passive therapies
• Exercise therapies, cognitive-behavioral therapy as first-line
treatments
• Focus on function, not just pain
• Address maladaptive coping behaviors such as fearavoidance, catastrophizing
• Yoga, mindfulness-based stress reduction, Tai Chi options
• Interdisciplinary rehabilitation for patients with severe
functional impairment or strong psychosocial component
• Manipulation, acupuncture, massage as adjunctive therapy
• Physical modalities passive and not well supported by
evidence
Recommendation: Medications
• Use as adjunctive therapies in persons receiving
non-pharmacological therapies
• Consider medications in conjunction with back
care information and self care
• For most patients, NSAIDs are the first line
medication option
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Pharmacological interventions
• First-line: NSAIDs
• Small benefits, but low cost and generally good safety
profile
• ?Effectiveness of acetaminophen for acute LBP
• Second-line
• Skeletal muscle relaxants (acute)
• Antidepressants (chronic)
• ?Antiseizure medications
• Avoid in most patients: Benzodiazepines (acute),
opioids (use with caution!)
• Not recommended: Systemic corticosteroids
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Case
57 yo male with LBP x 2 years, no specific inciting
event
• No associated leg pain or other neurological symptoms
• Pain slowly worsening, to the point of not being able to
walk more than 2 to 3 blocks, rated 7/10 most days
• Continues to golf most weekends, but riding cart now
• Working as engineer
• X-rays show lumbar disc degeneration and facet joint
arthropathy
• Tried acetaminophen and NSAIDs and has undergone PT
Case—Risk Assessment
• Mr. S. has no personal or family history of substance abuse
• No history of depression or other psychological disorders
• No serious comorbid conditions that are contraindications to
opioid therapy
• STarT Back Score: 1 (only able to walk short distances)
• Opioid Risk Tool score: 0
• Urine drug test negative
• Assessed risk for misuse/abuse: Low
Case—Management Plan and Initial
Follow-up
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Set goal of walking 30 minutes 4 times a week
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Longer term goal walking 9 holes of golf
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Low-dose opioid therapy (oxycodone 5 mg twice daily) initiated
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At 4 week follow-up, pain decreased from 7/10 to 4/10
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Able to walk 20-30 minutes 4 times a week
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No signs of aberrant behaviors
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Plan: Continue opioid therapy at the same, low dose, follow-up in 2
months
Case—Follow-up 2 Months
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Walking 20 minutes once or twice a week. “I can’t walk more because
it makes things worse.”
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Still not able to walk 9 holes of golf
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Has taken an “extra” oxycodone on several days with increased pain
and has run out of prescription one or two days early
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“I feel like I’m never going to improve”
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No signs of aberrant behaviors
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UDS: No oxycodone or other opioids, no illicit drugs
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PDMP: No controlled substances from other providers
Case—Management Plan
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Counsel on need to stick with prescribed doses
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Counsel on importance of activity and exercise
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Increase oxycodone to 10 mg twice daily
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Add duloxetine 10 mg po qD
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Refer back to physical therapy
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Follow-up in 1 month
Case—Follow-up 3 Months
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Still having pain and not walking
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Started PT but stopped attending because it hurt too much
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States taking oxycodone as directed, UDS shows hydrocodone
but no oxycodone
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Duloxetine made him “feel funny” and he stopped it
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PDMP: OK
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Requesting more opioids
Case—Management Plan
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Refer for cognitive-behavioral therapy
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Taper opioids
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Trial of pregabalin instead of duloxetine
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1 month follow-up
Case—Follow-up 5 Months
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No improvement in pain or function
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Has attended some CBT and PT sessions, says they
are not helping
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Taking pregabalin but doesn’t think it’s helping
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Off oxycodone
Case—Management Plan
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Continue off oxycodone
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Referred for intensive interdisciplinary
rehabilitation
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Titrated up pregabalin
The main concepts from this session are:
• Rates of LBP and associated costs are increasing despite
more aggressive testing and treatment
• Use evidence-based principles to inform more effective and
efficient care
• Shift away from routine imaging and diagnostic testing
• Early identification and management of psychosocial
contributors to pain
• Focus on function, not just pain
• Set achievable functional goals
• Self-care and education in all patients
• Focus on use of active nonpharmacological therapies
• Passive therapies in adjunctive role
• Cautious use of opioids
• Non-invasive approaches to most LBP
THANK YOU
October 24, 2008