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Care Process Model
August
2014
PRIMARY CARE MANAGEMENT OF
Low Back Pain
August 2014 update
This care process model (CPM) was created by the Functional Restoration/Chronic Pain Development Team of Intermountain
Healthcare’s Pain Management Service. Based on national guidelines AIR, ICSI, KOE, NICE, emerging evidence, and expert opinion, this CPM
provides guidance for primary care providers on diagnosis and treatment of acute and chronic low back pain. This document
presents an evidence-based approach that is appropriate for most patients; it should be adapted to meet the needs of individual
patients and situations, and should not replace clinical judgment.
Why Focus ON low back pain?
• Prevalence and cost. Low back pain (LBP) is a common disorder estimated to
affect up to 84% of adults at some time in their lives. In the U.S., low back pain
causes direct and indirect economic losses of nearly $90 billion each year. FOU
• Natural history of low back pain. LBP is often a self-limiting problem; few
patients with acute LBP have a serious underlying condition, and therefore they
can be managed with self-care or conservative treatment. However, for some
patients acute LBP can lead to chronic pain — a year after an acute episode, 20%
of patients report persistent back pain that limits activity. FOU One critical challenge is
predicting which patients are at risk for chronic LBP, and intervening appropriately.
• Treatment variation and best clinical outcome. Although there is an abundance
of research-based evidence to guide best practice for managing both acute and
chronic LBP, the treatment of LBP varies widely SCO, often resulting in increased cost
and failure to meet treatment goals.
Key Points in this CPM
What’s inside
Algorithm and notes. . . . . . . . . . . . 2
Acute mechanical LBP . . . . . . . . . . . 4
Core treatment. . . . . . . . . . . . . . . . . . . . . . . . 4
TABLE 1: Medications for acute LBP . . . . 4
Additional treatment, based on risk . . . . 5
Nonsurgical back specialist referral. . . . . 6
Chronic LBP . . . . . . . . . . . . . . . . . . 7
Pain assessment. . . . . . . . . . . . . . . . . . . . . . . 7
Psychosocial evaluation. . . . . . . . . . . . . . . . 7
Patient education &
management plan. . . . . . . . . . . . . . . . . . . . . 7
Medication management. . . . . . . . . . . . . . . 7
Considering other treatment options. . . . 8
• In most cases, imaging tests are NOT needed to diagnose acute LBP. Imaging
NONSURGICAL back SPECIALIST
TREATMENT. . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . 11
• For most LBP, conservative treatment and self-care is adequate and effective.
Resources. . . . . . . . . . . . . . . . . . . . . . . 12
tests can lead to expensive, unnecessary interventions, especially in the first 6 weeks.
If there are no “red flags” (signs of serious pathology or injury), avoid imaging tests.
The core treatment for acute LBP includes education and reassurance, avoidance
of bed rest, a short course of medications, and — depending on the risk of
developing persistent LBP — a course of physical therapy.
• Certain psychosocial factors can complicate the course of LBP; a patient’s risk
for developing chronic LBP can be used to customize treatment. This CPM
recommends a tool that helps you assess a patient’s risk of developing chronic
LBP, and assign patients to an appropriate treatment pathway.
Goals
• Improve the patient’s pain management,
function, and satisfaction with care.
• Improve the efficiency of LBP care, using
a team approach where appropriate.
• Reduce the use of ineffective imaging and
therapeutic procedures.
• A nonsurgical back specialist is the best resource for patients with LBP
persisting beyond 6 weeks. A nonsurgical back specialist can obtain appropriate
• Increase the patient’s understanding of
• Chronic LBP that persists despite ongoing conservative treatment and
nonsurgical back specialist treatment is best managed using a team approach.
• Patients with an LBP diagnosis referred for
imaging studies, identify the pain generator, perform or recommend appropriate
nonsurgical interventions, and expedite care to a surgeon if necessary.
This includes physical therapy, physiatry (PM&R), anesthesia or neurology with
pain subspecialty, and mental health support if indicated.
What’s new in this update?
• Indications for ankylosing spondylitis. Five key indicators for ankylosing spondylitis and
direction to refer to a rheumatologist if it is suspected. (See page 3.)
• Goals and measures. Intermountain has data capture and reporting to measure prescriptions,
imaging, and other information for our LBP patients. (See sidebar and page 2.)
effective LBP management.
Measures
radiology and physical therapy
• Severity of patient pain over time
• Medication management of LBP
M a n ag e m e n t o f lo w bac k pa i n
Definitions
Types of leg pain: Patients with low back
pain often experience leg pain. Leg pain falls
into 3 general categories:
• Referred leg pain radiates into the groin,
buttock, and upper thigh, but without
objective neuropathic findings (listed
below). Referred leg pain is not caused
by the spinal nerve root, but the result of
sensory nerves that supply the low back,
pelvis, and thigh. (Note: legs that are tender
to palpation are usually a primary issue of
the leg, not radicular pain.)
• Radicular pain is sharp, shooting pain
that radiates along the course of a nerve
root (often extending below the knee) —
but without neurologic changes such as
sensory disturbances, muscle weakness, or
hypoactive muscle stretch reflexes.
Aug ust 2 014
ALGORITHM: LBP diagnosis and core treatment
Patient presents with acute low back pain
EVALUATION
•• Obtain Patient History (a)
•• Perform a Physical Exam (b)
Any RED FLAGS
for serious illness
or injury? (c)
LEG pain?
See definitions
at left.
yes
yes
no
Stages of low back pain: While some
guidelines define the stages of LBP solely
based on time since symptoms began, this
CPM recommends also considering function
and response to treatment in staging LBP:
• Acute LBP: Pain <6 weeks
• Subacute LBP: Continued pain after 6
weeks, but patient continues to function
well and core treatment provides some relief;
patient may also be receiving nonsurgical
back specialist treatment at this stage.
• Chronic LBP: Core LBP treatment
has failed, nonsurgical back
specialist treatment has not helped, the
patient is not a surgery candidate — and
persistent pain interferes with function and
alters the patient’s life.
Radicular
pain?
yes
Signs of
radiculopathy
(d)?
no
• Radiculopathy is caused by dysfunction
of the spinal nerve root. Signs and
symptoms include pain in the distribution of
the nerve root (often extending below the
knee), dermatomal sensory disturbances,
weakness of muscles innervated by that
nerve root, and hypoactive muscle stretch
reflexes of the same muscle.
Evaluate for serious pathology
and refer if necessary (c)
yes
CONSIDER
early referral
to nonsurgical
back specialist
(see page 6)
no
ASSESS RISK of chronic LBP using the
Keele STarT Back Screening Tool (e)
Low risk
Moderate or high risk
INITIATE core treatment for mechanical LBP
Low risk of developing chronic LBP
Moderate/high risk
•• Education and reassurance. Cover these
Education/reassurance and
medication (see left) PLUS:
points (see page 4 for more details):
–– A history and physical did not show anything
•• Physical therapy (PT). Early PT can
dangerous. You’re likely to recover in a few weeks. decrease the likelihood of subsequent
back surgery, injections, or frequent
–– Staying active will help you recover.
LBP–related physician visits. GEL
–– Imaging tests are not needed at this stage.
Determine PT approach based on risk:
•• Medication (see page 4), based on pain severity:
–– Moderate risk: Treatment with
–– 1st line: Acetaminophen or NSAIDs
standard PT approach
–– 2nd line: Muscle relaxants, 7 days max
–– High risk: PT with practitioner trained
(not in elderly)
in psychologically informed approach
–– 3rd line: Consider short-acting opioids,
3 weeks max (opioids have no better outcomes •• Mental health screening and
treatment if needed (see page 5).
than NSAIDs in LBP)
FOLLOW UP RISK in 3–6 weeks
yes — continue
core treatment
Improving?
no
REFER to nonsurgical back
specialist (see page 6)
AND
FURTHER EVALUATE
psychosocial factors (see page 6)
If disabling pain persists despite
nonsurgical interventions and other treatment
INITIATE chronic LBP management (see page 7)
2 Intermountain measures
LBP treatments, referrals
to PT, medications, and
referrals for radiology.
©2013–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
Aug ust 2 014
m a n ag e m e n t o f lo w bac k pa i n
Algorithm notes
(a) Patient history. The patient history for acute low
back pain should include the components below.
Intermountain‘s Patient Self History: Back Pain form can
help in obtaining this information.
• Description of current pain, including time of onset
and how pain responds to positioning
• Previous back history, including tests and treatments
• Systemic disease (osteoporosis, cancer, arthritis, infection, etc.)
• Neurological symptoms
• Bowel/bladder symptoms
• Biological and psychosocial risk factors
(c) RED Flag evaluation and response
Suspected condition and signs
(b) Patient exam. The physical exam should include the
components below. Intermountain’s Patient Exam: Lumbar
Spine Evaluation form can help in the exam, and HELP2 Hot
Text (“LBPexam”) is available for import from Wayne Cannon,
Primary Care Program Medical Director. (Auto Text will be
available in iCentra.)
• Motor weakness and
• Upper motor neuron findings
reflex changes
• Localized spinal tenderness
• Sensory deficit (perineal
• Hip examination
or lower extremity)
• Dural tension (straight leg raise,
prone femoral nerve test)
Imaging (see page 6)
Referral
Suspected cauda equina syndrome:
•• New bowel or bladder dysfunction
•• Perineal numbness/saddle anesthesia
•• Persistent/increasing lower motor neuron weakness
Myelopathy/upper motor neuron changes:
•• New-onset Babinski or sustained clonus
•• New-onset gait or balance abnormalities
•• Upper motor neuron weakness
Labs
•• For suspected cauda equina: spinal MRI*
•• For myelopathy/upper motor neuron
changes: MRI* or CT, spine or brain
URGENT referral to ortho/neuro
spine surgeon
Recent trauma with suspected spinal fracture
•• X-ray: anteroposterior (AP) and cone
down, consider CT or MRI* if x-ray
is nondiagnostic
URGENT referral to ortho/neuro
spine surgeon if imaging
reveals fracture
Suspected compression fracture: Osteoporosis or osteoporosis risk
•• X-ray: AP and cone down; repeat in 2 weeks Referral to nonsurgical back
if suspicion high
specialist if imaging reveals
compression fracture
•• Consider MRI* if suspicion high
Suspected cancer: CHO1 History of cancer, multiple cancer risk factors,
or strong clinical suspicion
CBC, ESR, •• X-ray (evaluate in context with ESR)
•• If negative x-ray but strong suspicion
CRP
remains: consider T1 weighted,
noncontrasted spinal MRI*
(full study w/contrast for abnormal areas)
URGENT referral to oncologist
Suspected infection: immunocompromised patient, UTI, IV drug use, recent
spinal procedure, or fever/chills in addition to pain with rest or at night
CBC, ESR, •• Consider MRI* with gadolinium or
bone scan
CRP
URGENT referral may be needed,
depending on type of infection
Suspected spinal deformity or spondylolysis: Age <20, pain with standing,
walking, and extension (occurs more often in athletes and dancers)
Suspected spondyloarthropathies:
•• Ankylosing spondylitis (AS): at least 4 of the following: age of pain onset <40
years; insidious onset; improvement with exercise; no improvement with rest;
pain at night (with improvement upon rising) UTD; also consider morning stiffness.
•• Reactive arthritis/Reiter’s Syndrome: recent history of genitourinary
or gastrointestinal tract infection; acute onset; usually affecting lower joints;
asymmetrically painful and swollen joints; weight loss; high temperatures.
•• Spondyloarthropathy associated with inflammatory bowel disease (IBD):
abrupt onset; asymmetric, affecting lower limbs; generally subsides in 6–8 weeks;
10% develop chronic arthritis; other symptoms: uveitis, chronic skin lesions, AAFP
dactylitis, enthesitis.
•• Psoriatic arthritis: asymmetric, affecting distal joints; morning stiffness; pain
accentuated by prolonged immobility, alleviated by physical activity; psoriatic lesions.
•• Standing x-rays, 3 view, flexion,
extension, plus cone down
•• Consider MRI* to identify spondylolysis
represented by pedicle edema
Referral to sports medicine
specialist, nonsurgical back
specialist, or ortho/neuro spine
surgeon if x-ray or MRI positive
CBC, ESR, •• X-ray: lumbar spine and sacroiliac joint
Referral to rheumatologist
CRP, RF, •• Note: If clinical features lasting longer
anti-CCP,
than 3 months strongly suggest AS
HLA B27
despite negative radiographs of SI joint,
consider close follow up and/or referral to
rheumatologist.
Spinal MRI Order Guidelines
A U G U S T 2 0 14
Before ordering a spinal MRI for your patient, check for at least 1 of the following indications.
• Radiculopathy (focal neurologic deficit with progressive or
disabling features): Pain in the distribution of the nerve root
(often extending below the knee or elbow), with motor, reflex, or
sensory deficit. ICD-9: thoracic and lumbar 724.4; cervical 723.4.
• Radicular pain (radiating pain): Order an MRI only after failed
conservative treatment (see LBP CPM) for 4 to 6 weeks. ICD-9:
thoracic and lumbar 724.4; cervical 723.4.
• Myelopathy (Babinski or sustained clonus — cervical or
thoracic MRI). ICD-9: other myelopathy 336.8 — needs an
additional E code to identify the cause.
• Associated lumbar spine symptoms/findings WITH cancer
history, cancer symptoms, and/or infection.
• Suspected cauda equina syndrome. ICD-9: 344.61.
• New bowel or bladder dysfunction. ICD-9: unspecified
functional disorder of intestine 564.9.
• Perineal numbness / saddle anesthesia. ICD-9: numbness 782.0.
• Persistent or increasing motor weakness. ICD-9: generalized
muscle weakness 728.87.
• Significant loss of coordination in one or both legs.
• Suspected compression fracture: Osteoporosis or
osteoporosis risk. ICD-9: pathological fracture 733.13.
• Suspected spinal fracture: Significant recent trauma or fall.
• Prior surgery or planned surgery or injection.
For more information, see Intermountain’s Low Back Pain Care Process Model and Flash Card.
©2014 INTERMOUNTAIN HEALTHCARE. All rights reserved. These guidelines apply to common clinical circumstances, and may not be appropriate for certain patients and situations. The treating clinician
must use judgment in applying guidelines to the care of individual patients. Primary Care Clinical Program approval 07/17/2014. CPM009e - 08/14 (Patient and Provider Publications 801-442-2963)
*Ensuring a quality MRI. To reduce the need for a repeat MRI, ensure that the imaging center uses a 1.5 tesla magnet. Large bore and standard MRIs
usually provide better image quality than open MRIs. Order sedation if necessary to get a quality MRI. See page 6 for details on Intermountain’s Spinal MRI Order Guidelines.
(d) RADICULOPATHY. Fewer than 10% of patients have true radiculopathy, even with leg pain; the majority is mechanical or nonspecific.
Consider early referral to nonsurgical back specialist for patients with radiculopathy. Patients with signs of radiculopathy may also need more
frequent evaluation and follow-up. Signs of radiculopathy are motor deficit, reflex deficit, sensory deficit, and positive dural tension signs:
positive straight leg raise and positive prone femoral stretch.
(e) Assessing for risk of developing chronic LBP based on psychosocial factors, using the STarT Back Tool. This 9-item screening tool
identifies factors that increase a person’s risk for developing chronic low back pain; it is helpful in stratifying care HIL1,HIL2 and can alert you to factors
that can influence prognosis. See page 5 for information on using the form, and page 12 for information on accessing this form.
Scoring: On questions 1 to 8, every “Agree” answer is worth 1 point; on question 9, “Very much” or “Extremely” is worth 1 point.
• Low risk: Total score is 0 to 3
©2013–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
• Moderate risk: Total score is ≥4, score on
questions 5 through 9 is 0 to 3
• High risk: Total score is ≥4, score on
questions 5 through 9 is ≥4
3
M a n ag e m e n t o f lo w bac k pa i n
Aug ust 2 014
ACUTE mechanical LOW BACK PAIN
Once “red flags” for serious disease or pathology have been eliminated (see page 3),
approximately 85% to 90% of LBP patients have mechanical or “nonspecific” back pain.
Core treatment
This CPM recommends core treatment elements based on national guidelines ICSI,KOE,NICE and a
method for stratifying treatment based on a patient’s risk of developing chronic pain. HIL1,HIL2
Patient education
fact sheet
Intermountain’s Low Back Pain fact sheet
helps you educate patients with acute low
back pain. This 4-page handout:
• Dispels myths about
acute low back pain
• Explains why imaging is
rarely needed
• Encourages patients to
keep moving
• Answers other common questions
Education and reassurance
To correct misconceptions, calm fears, and encourage patients to participate in their
own recovery, focus on these four messages:
• A detailed history and physical didn’t reveal any serious problem. The spine is
strong and flexible, and it’s difficult to damage or dislocate anything.
• Most people recover in a few weeks. Most people with acute mechanical back pain
are symptom free within 2 weeks. Among those that don’t recover quite as quickly,
many are back to normal work and activities within 3 months.
• Staying active helps your back recover. Research shows that bed rest for more than
a day or two can be harmful. If you keep moving, your back will recover more
quickly. Walking, yoga, and pool exercise are particularly helpful — and if you sit
at your job, try to stand up and move around for 2 to 3 minutes every half hour.
• Imaging tests are NOT needed at this stage. An x-ray or MRI isn’t necessary to
know what to do, and imaging may lead to expensive, unnecessary treatment. CHO1
For example, most of us have bulging discs that cause no symptoms.
Appropriate pain medication, with a conservative approach
See the table below; note that opioids do not have better outcomes that NSAIDs. WHI
TABLE 1. Medications for acute low back pain
Class
1st
line
Medication
Usual dosing
Notes
Simple
acetaminophen (Tylenol)
analgesics
500 mg, every 4 to 6 hours
(max 3,000 to 4,000 mg daily)
NSAIDs
800 mg, 3 times daily (max 3,200 mg daily)
•• Before moving to 2nd-line meds, a 2- to 4-week course of
acetaminophen or NSAIDs is suggested.
•• Avoid NSAIDs for patients with chronic kidney disease or history of
NSAID-related dyspepsia or bleeding PUD.
•• If ibuprofen or naproxen are not effective, consider switching to
another NSAID before moving to muscle relaxants, steroids, or
opioids. Refer to the Chronic Pain CPM for details on other NSAIDs
that can be used in acute or chronic neck pain.
naproxen (Aleve, Naprosyn) 500 mg, 2 times daily (max 1,250 mg daily)
4th
line
4 •• Limit muscle relaxants to a 7-day course.
•• Muscle relaxants are contraindicated in elderly patients due
cyclobenzaprine (Flexeril) 10 mg, 3 times daily (max 60 mg daily)
to fall risk and sedation.
methocarbamol (Robaxin) 1,000 mg, 4 times daily (max 6,000 mg daily
•• Note that carisoprodol (Soma) is NOT recommended,
for first 48–72 hours, then 4,000 mg daily)
due to risk of addiction and abuse issues.
tizanidine (Zanaflex)
4 mg, 3 times daily (max 36 mg daily)
Muscle
relaxants
baclofen (Lioresal)
10 mg, 3 times daily (max 80 mg daily)
Shortacting
opioids
tramadol (Ultram)
25 mg to 100 mg every 4 to 6 hours
(max 400 mg daily)
2nd
line
3rd
line
ibuprofen (Advil, Motrin)
hydrocodone/APAP (Lortab) Hydrocodone 7.5 mg/APAP 325 mg every
4 to 6 hours (max 12 tablets daily)
oxycodone/APAP (Percocet) Oxycodone 5 mg/APAP 325 mg every
4 to 6 hours (max 12 tablets daily)
•• In most acute LBP cases, no difference has been found in pain and
overall improvement between NSAIDs and opioids. WHI
•• Limit course of opioids to 2–3 weeks; the need for extended
opioids should prompt a reevaluation of pathophysiology.
•• Avoid abrupt withdrawal of medication.
•• Tramadol is contraindicated if history of seizures or serotonin
reuptake inhibition.
•• Products containing more than 325 mg of APAP per tablet or
capsule should not be prescribed.
If pain is severe and above therapies have not been effective, consider early referral to nonsurgical low back pain specialist for evaluation. See page 6.
©2013–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
A UGUST 2 0 1 4 m a n a g e m e n t o f l o w b a c k p a i n
Additional treatment, based on chronic LBP risk
Multiple studies have shown that specific psychosocial factors can increase the risk
of developing chronic disabling symptoms CHO2,HIL3 — and that early identification of
patients more likely to develop chronic LBP can help guide treatment.
A tool to assess risk, based on psychosocial factors
The STarT (Subgrouping for Targeted Treatment) Back Screening Tool,
developed by Keele University, is a 9-item tool that helps clinicians
stratify patients into appropriate treatment. HIL1,HIL2 It identifies patients at
low, moderate, or high risk for persistent, disabling pain. Its questions
focus on established predictors for persistent disabling LBP: radiating leg
pain, pain elsewhere, disability, fear of activity, anxiety, catastrophizing, low mood,
and how much the patient is bothered by the pain. Click the image at right to open the
form, or for information on ordering, see page 12.
Validity of the TOOL
The STarT Back Screening Tool has been
tested for reliability and validity in an array
of settings. HIL1,HIL3,HIL4,FRI
A recent, randomized clinical trial showed
that using the tool to stratify treatment
can improve efficiency in physical therapy
referrals, improve clinical outcomes, and
reduce costs. HIL2
Scoring the tool and using the results to stratify care
The Intermountain form that incorporates the STaRT Back Screening Tool includes a
scoring guide. The total score (questions 1–9) identifies low risk versus moderate/high
risk, and a distress subscale score (questions 5–9) discriminates between moderate
and high risk. See the table below for scoring and recommendations at each risk level.
TABLE 2. Stratified care based on the STarT Back Screening Tool
Risk Categories and Recommendations
Risk level
Treatment recommendations
MENTAL HEALTH INTEGRATION
Low risk:
•• Total score = 0 to 3
Education and reassurance, with appropriate pain
medications as needed — see the previous page.
(See sidebar note about considering PT for some low-risk patients.)
Moderate risk:
Education and reassurance, appropriate pain meds, plus:
•• Physical therapy (begin as soon as possible).
•• Brief depression screen using the PHQ-9; refer to mental
health specialist if depression present (see the MHI Care Process
Model and Adult Scoring Guide for more information).
Mental Health Integration (MHI) is a program
that coordinates mental health services within
the primary care clinic. For more information
on the MHI process and tools (including
baseline packets to screen for mental health
disorders), see page 12. If your clinic does
not have the MHI program, you can use the
MHI screening packets and refer to a mental
health specialist if necessary.
•• Total score = 4 or above
•• Distress subscale (q. 5–9)
score = 3 or less
High risk:
•• Total score = 4 or above
•• Distress subscale (q. 5–9)
score = 4 or above
Education and reassurance, appropriate pain meds, plus:
•• Physical therapy with a practitioner trained in
addressing psychosocial issues (begin as soon as possible).
•• Mental health screening using the MHI Adult Baseline
Packet. This packet screens for depression, anxiety/stress
disorders, mood disorders, sleep problems, personal and family
history of abuse or trauma, substance abuse, life stressors, and
overall impairment. (See the Mental Health Integration Care
Process Model for details.)
•• Referral to mental health specialist if needed (see MHI CPM).
Setting patient expectations for physical therapy
Physical therapy for
some low-risk patients
This CPM suggests that the STarT Back
Screening Tool can be used to identify
low‑risk patients who will often recover
without physical therapy. However,
current physical therapy guidelines DEL also
recommend that some low-risk patients can
benefit from early evaluation and treatment
by a physical therapist.
Help patients referred to physical therapy understand the following points:
• Physical therapy includes guided exercise and exercise plans — exercise is a
long‑term therapy for low back pain. (See page 8 for exercise advice to give
patients who are not referred to PT.)
• Patients may not get better after just one or two sessions; it takes time and daily
exercise to improve their pain.
• Physical therapy may include strategies to change their thinking patterns about
pain and activity.
©2013–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
5
m a n ag e m e n t o f lo w bac k pa i n
A UGUST 2 0 1 4
Nonsurgical back specialist referral after 6 weeks
A nonsurgical back specialist is the best treatment resource for patients with LBP
that persists beyond 6 weeks. These providers include physiatrists, anesthesia/pain
management specialists, and sports medicine specialists. They may work independently,
in spine programs, or in pain clinics.
Referral considerations
A multidisciplinary spine care program is the best option. These programs integrate
Spinal MRI Order Guidelines
A U G U S T 2 0 14
Before ordering a spinal MRI for your patient, check for at least 1 of the following indications.
• Radiculopathy (focal neurologic deficit with progressive or
disabling features): Pain in the distribution of the nerve root
(often extending below the knee or elbow), with motor, reflex, or
sensory deficit. ICD-9: thoracic and lumbar 724.4; cervical 723.4.
• Radicular pain (radiating pain): Order an MRI only after failed
conservative treatment (see LBP CPM) for 4 to 6 weeks. ICD-9:
thoracic and lumbar 724.4; cervical 723.4.
• Myelopathy (Babinski or sustained clonus — cervical or
thoracic MRI). ICD-9: other myelopathy 336.8 — needs an
additional E code to identify the cause.
• Associated lumbar spine symptoms/findings WITH cancer
history, cancer symptoms, and/or infection.
• Suspected cauda equina syndrome. ICD-9: 344.61.
• New bowel or bladder dysfunction. ICD-9: unspecified
functional disorder of intestine 564.9.
• Perineal numbness / saddle anesthesia. ICD-9: numbness 782.0.
• Persistent or increasing motor weakness. ICD-9: generalized
nonsurgical treatment, physical therapy, surgical treatment, and other modalities.
(For spine procedures, an effective procedure suite has state-of-the-art equipment,
uses fluoroscopy, has experienced staff, and can give IV sedation and antibiotics.)
muscle weakness 728.87.
• Significant loss of coordination in one or both legs.
• Suspected compression fracture: Osteoporosis or
osteoporosis risk. ICD-9: pathological fracture 733.13.
• Suspected spinal fracture: Significant recent trauma or fall.
• Prior surgery or planned surgery or injection.
For more information, see Intermountain’s Low Back Pain Care Process Model and Flash Card.
©2014 INTERMOUNTAIN HEALTHCARE. All rights reserved. These guidelines apply to common clinical circumstances, and may not be appropriate for certain patients and situations. The treating clinician
must use judgment in applying guidelines to the care of individual patients. Primary Care Clinical Program approval 07/17/2014. CPM009e - 08/14 (Patient and Provider Publications 801-442-2963)
Spinal MRI order Guidelines
Intermountain has developed guidelines for
ordering spinal MRI exams at Intermountain
facilities. This list of appropriate indications
for spinal MRI imaging enables you to
identify medical necessity and can assist with
preauthorization. These guidelines are not
designed to limit your ability to order spinal
MRI exams; they facilitate appropriate use of
spinal imaging.
Click the image above to open the
guidelines, or see page 12 for information
on accessing this document.
Imaging considerations
Keep in mind that routine imaging at the acute stage does not improve
outcomes in mechanical low back pain — and may lead to unnecessary or
ineffective treatment. ICSI,KOE,NICE,CHO1 Avoid imaging for patients who do not have
signs of serious pathology (see red f lags on page 3), unless pain has persisted
longer than 6 weeks.
Common questions about imaging tests as part of a referral:
• Should I order imaging tests as part of a nonsurgical back specialist referral?
In most cases, no — unless there are obvious signs of radiculopathy or red flags
for serious pathology.
• Who should recommend interventions based on imaging tests? A nonsurgical back
specialist can evaluate imaging to identify which interventions (if any) may be
helpful. It is not generally recommended for primary care providers to order
interventions directly. However, it may be appropriate for a PCP to order
an intervention for established patients who have been helped by a specific
procedure in the past, if the same symptoms recur.
Goals of nonsurgical back specialist care
A nonsurgical back specialist aims to do the following (see page 10 for further details):
• Identify the pain generator through physical exam, history, and imaging
• Perform or recommend appropriate nonsurgical interventions (e.g., manipulation
or manual therapy, local injections, or spinal injections)
• Initiate and encourage a regular aerobic exercise and conditioning program
• Expedite care to a surgeon if necessary
Setting patient expectations for nonsurgical specialist treatment
Patients should understand that the specialist evaluation may or may not reveal
the cause of their pain and that it does not always result in procedures or a surgery
referral. Remind patients that while the nonsurgical back specialist is evaluating or
treating them, they should continue to remain as active as possible.
Further psychosocial evaluation after 6 weeks, if needed
If a patient’s pain and/or function have not improved after 6 weeks, and the patient
has not yet been evaluated using the MHI Adult Baseline Packet, consider administering
the packet. See the MHI Care Process Model for more information.
6 ©2013–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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Chronic LOW BACK PAIN
Patients with LBP that does not improve with core treatment or nonsurgical back
specialist treatment — and that interferes with work and/or life activities — will
need chronic management.
Pain assessment
• For patients who have received core LBP treatment and nonsurgical specialist
treatment without success: Follow the advice in Intermountain’s Management
of Chronic Non-Cancer Pain Care Process Model (CPM) (see sidebar) to assess
psychosocial factors, medication-related risks, and other factors that can impact
chronic pain management.
• For patients who present to you with LBP of 12 weeks or more: Screen for red
flags that may indicate serious pathology (see page 3); refer if needed. If the
patient has not yet been assessed by a nonsurgical back specialist, refer the patient
for evaluation. If nonsurgical back specialist treatment is not helpful, follow the
assessment advice in the Chronic Non-Cancer Pain CPM (see sidebar).
Chronic pain Care
process model (CPM)
Intermountain’s Management
of Chronic Non-Cancer
Pain CPM provides guidance
on assessing chronic pain,
managing treatment, and
monitoring safety.
The CPM is accompanied by
a suite of tools, including:
• A pain history and coping style assessment
• A pain management plan
• Assessments to screen for risk of pain
Psychosocial evaluation
If a patient has not yet been evaluated using the MHI Adult Baseline Packet, administer
the packet and create a treatment plan for any mental health conditions that are
identified, based on their complexity and severity. See the MHI CPM for more
information about the MHI process and supporting tools.
Patient education and pain management plan
medication addiction or abuse, with
monitoring advice based on risk level
• An opioid therapy agreement (which can be
scanned into the electronic medical record)
and a medication side effects form
Click the image to open the document, or see
page 12 for ordering information.
Intermountain’s booklet Managing Chronic Pain: Reclaiming Your Life
helps patients take an active approach to pain management. Self-care
education books are an efficient way to supplement provider advice,
and self care has been shown to be as effective as modalities such
as spinal manipulation or acupuncture. CHO3 The booklet educates
patients on proven strategies for low back pain such as mindfulness
meditation, ROS along with medication safety and other topics.
The Pain Management Plan that accompanies the Chronic Non-Cancer
Pain CPM is a shared decision-making tool that documents the patient’s
pain management goals, treatments, exercise, and other self-care
approaches, and it can help engage patients in self-management. Click the
images to open these tools or see page 12 for ordering information.
Medication management
Intermountain’s Chronic Non-Cancer Pain CPM contains a table listing chronic
pain medications and links to tools for medication management. Key points on
medication for chronic LBP are as follows:
• Consider NSAIDs as first-line treatment. While NSAIDs and opioids are both
effective for chronic LBP, NSAIDs should be considered as first-line treatment.
Avoid opioids if possible, based on the significant rate of opioid side effects and
lack of convincing superiority of opioids over NSAIDs. FOU,WHI
• Monitor carefully. Effective pain medication management includes regular
monitoring of analgesia, adverse effects, aberrant behavior, activity, and affect. GOU
• Consider sleep. Assess for sleep disturbance due to pain, and consider treating sleep
problems with low-dose tricyclic antidepressants, unless contraindicated. NICE
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Considering other treatment options
Patients with back pain that persists long term — pain that is not helped by
nonsurgical back specialist treatment — should consider treatment beyond pain
medication. In discussing treatment options with patients, keep these points in mind:
• Continue to encourage movement. Exercise and everyday activity help to preserve
function, delay or prevent further disability, and ease pain. Common exercise
strategies for low back pain include:
–– Walking and aerobic exercises, which increase baseline physical activity levels,
improve blood flow, and may increase endurance of postural muscles.
–– Core strengthening exercises, which focus on abdominal, paraspinal, gluteal,
diaphragm, and pelvic floor muscles to foster lumbar stability.
–– End-range flexion/extension stretches with repeated movements (such as the
McKenzie method), which are likely to be most effective when customized by a
physical therapist or physician for each patient.
–– Yoga, which has been proven effective for pain management (see the table at right).
–– Aquatic exercise, which may be preferred by some patients, as warm water can
enhance flexibility and support movement.
• Consider a team-based approach. Functional restoration programs, which provide
Keys to enhancing
communication
Conversational techniques that foster
effective communication with patients
and families ICSI include the following:
• Open-ended questions that don’t require
a yes/no answer. Ex: “What concerns or
questions do you have about this plan?”
–– Reflecting back the speaker’s
feelings and perspectives. Ex: “It
sounds like you’re worried about your
back pain keeping you from getting back
to work full-time.”
–– Paraphrasing key statements and
giving a general summary based
on those statements. Condensing key
statements and giving a summary of the
situation can clarify content, show you’ve
understood the patient’s perspective, and
help the patient and family focus on the
broader perspective rather than being
mired in the details. Ex: “From what
you’ve said, it sounds like you’d like to…”
–– Asking for teach-back. Ask patients
to repeat key points (information about
benefits and risks, etc.) in their own
words. Ex: “Can you explain back to me
the pros and cons of this plan?”
8 multidisciplinary team care with a biopsychosocial approach, have been shown
to improve function and reduce pain (see the table at right). If a full functional
restoration program is not available in your region, consider a team-based approach
that incorporates some of the elements of functional restoration (such as using
MHI providers and creating plans for consistent communication with physical
therapists and other specialists to whom the patient is referred).
• Take a shared decision-making approach when discussing other treatment options.
This approach helps patients and families weigh the information about a treatment
option, clarify their goals and values, and make the decision that’s right for them. ICSI
Key elements of shared decision-making include:
–– Using conversational techniques that enhance communication (see sidebar).
–– Helping patients and families weigh the risk and cost of an option against its
potential benefits. See the table at right for evidence-based outcomes research
on a range of common treatment options patients may consider. (Intermountain
Healthcare is piloting several online shared decision-making tools for low back
pain; this CPM will include links to recommended tools as the pilot concludes.)
• If patients want to try a benign, low-cost therapy, supporting this decision may
be helpful — even if the research is not conclusive about outcomes. The sense of
self-efficacy that may come from pursuing an option can bring its own benefits in
terms of pain and function.
–– If the patient asks about surgery, stress the guidance that a nonsurgical back
specialist can provide. An evaluation (or repeated evaluation) by a nonsurgical
back specialist may be more helpful than a direct referral to a surgeon. If the
specialist feels the patient needs a surgical evaluation, then a referral can be made.
©2013–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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TABLE 3. Treatment options for chronic low back pain: outcomes research
Treatments
Treatment*
Research on outcomes

Exercise therapy
Exercise therapy reduces pain and improves function in patients with chronic nonspecific LBP, as shown
by several studies. VAN Exercise therapy can be guided by a physical therapist or nonsurgical back specialist.
Independent exercise can also be recommended by the primary care provider — see the general suggestions
on the previous page.

Physical therapy
Spinal manipulation and mobilization, patient education/counseling, and exercise plans — guided by a
physical therapist — can improve mobility and reduce pain/disability in some patients with subacute and
chronic LBP. DEL

Yoga
Several studies showed that yoga brought significantly better pain reduction than usual care, education, or
conventional exercises. POS

Team-based programs Functional restoration programs that integrate medical and psychosocial treatment improve function and
reduce pain in patients with chronic LBP. GUZ,MAY,GAT If a functional restoration program is not available, consider
incorporating as many features of team-based care within your clinic as possible — such as incorporating MHI
and planning for consistent communication with physical therapists and other specialists.

Cognitive behavioral
therapy (CBT)
Cognitive behavior therapy or psychoeducation are recommended to treat chronic LBP in multiple
evidence‑based guidelines. AIR,NICE Multiple trials have shown that CBT is more effective for pain, functional
status, and behavioral outcomes than placebo or no treatment. AIR

Surgery for lumbar
spinal stenosis,
radiculopathy,
or deformity
•• Lumbar spinal stenosis: In highly symptomatic patients (with or without degenerative spondylolisthesis),
the best proven intervention is surgery. WAT
•• Radiculopathy or radicular pain: In general, surgery brings moderate benefits, according to American
Pain Society Guidelines. CHO4 (Note that radiculopathy with progressive neurologic deficit or cauda equina
syndrome is an absolute indication for surgery.)
•• Deformity: Surgery is an effective treatment for scoliosis or spondylolisthesis.
?
?
Massage therapy
Massage may benefit some patients with chronic nonspecific low back pain if combined with exercise
and education. FUR
Acupuncture
Two recent systematic reviews YUA,RUB indicated that acupuncture was more effective than no treatment and
could be a useful supplement to conventional therapies, but patient beliefs may play an important role in
the effectiveness of this treatment.
?
Surgery for chronic
mechanical back pain
According to American Pain Society Guidelines, surgery has small to moderate benefits, but the majority
of patients do not have an optimal outcome (defined as minimum or no pain, no pain medications or only
occasional use, and return of high-level function).CHO4

TENS
A 2008 systematic review KHA reported conflicting evidence about whether TENS reduced back pain intensity,
and two trials showed TENS did not improve back-specific functional status.

Traction
Traction is not recommended to treat low back pain; this advice is consistent across a number of
major guidelines. AIR,ICSI

•• A 2011 evidence review in Spine FOU concluded that surgery is not recommended if it is based on
Surgery for
degenerative changes on MRI.
degenerative changes
shown on MRI
•• Surgical strategies: A 2008 systematic review DON concluded that lumbar spinal fusion is beneficial for
treating fractures, infections, or spondylolisthesis, but offers no or limited benefits over nonoperative
management for common degenerative changes. Disc arthroplasty offers similar outcomes to fusion.
There is no convincing evidence to support dynamic stabilization surgery for chronic LBP.
*Key to symbols:
 = Research shows good outcomes and/or treatment is recommended in major guidelines.
? = Research is uncertain on outcomes.

= Research shows limited benefits and/or treatment is not recommended in major guidelines.
©2013–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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Nonsurgical back specialist treatment
The table below describes problems that can generate low back pain, how a nonsurgical back specialist evaluates for each problem,
and treatments that the specialist may consider.
TABLE 4. Nonsurgical back specialist approach
Nonsurgical Back Specialist Evaluation and Treatment of Low Back Pain
Pain generator
Evaluation
Treatments the specialist may consider
Lumbar spinal stenosis: Bony and
ligamentous narrowing of the spinal
canal that compresses nerves; typically
degenerative, most common in patients
>50 years old
•• Symptoms: Buttock, leg, and back pain when
•• Epidural steroid injection trial
Degenerative spondylolisthesis:
Often associated with spinal stenosis in
patients >50 years old, especially women
•• Symptoms: Back pain when standing and walking,
standing and walking, relieved when sitting
•• Exam: Kyphotic gait, variable weakness, numbness,
and loss of DTR; negative straight leg raise test (SLR)
•• Imaging: MRI imaging of choice
relieved when sitting
•• Physical exam: Kyphotic gait; pain with
lumbar extension
Facet pain
•• Physical therapy trial
•• Surgical referral: In highly symptomatic patients, the
best proven intervention is surgical decompression,
with or without fusion WAT
•• Physical therapy with lumbar-based stabilization
(core strength) and leg stretching/strengthening
•• Facet cortisone injections and/or
radiofrequency ablation
•• Imaging: Standing x-ray and flexion and extension
•• Surgical referral for lumbar fusion
•• Symptoms: Mechanical back pain with or without
•• Physical therapy
proximal lower limb pain
•• Physical exam: Exam does not predict the source of
pain; degeneration of facets is a normal finding
•• Facet cortisone injection and/or
radiofrequency rhizotomy
•• Imaging: Not helpful; facet degeneration is a
normal finding
Herniated disc
•• Symptoms: Acute and often severe buttock, leg,
•• Education to explain the natural history of this
and back pain, usually worse when sitting, bending,
problem (favorable to improvement)
lifting, or sneezing
•• Epidural cortisone injections
•• Physical exam: Positive SLR; variable numbness,
•• Surgery referral indicated with progressive
weakness, and loss of DTR
neurologic deficit, profound weakness, or lack of
•• Imaging: MRI
Degenerative disc: This is a normal
finding that may also cause mechanical
back pain; more commonly symptomatic
in younger people
•• Physical exam: Pain with lumbar flexion; negative
straight leg test
•• Imaging: Not helpful; disc degeneration is a
normal finding
improvement in 3 months
•• Physical therapy
•• Education to continue activity/exercise, vary
activities, and avoid prolonged sitting or driving
•• Manipulation (may be considered)
•• Long-term home exercise program for
stabilization, core endurance and leg flexibility;
McKenzie-style extension exercises
•• Rarely indicated: Discography, intradiscal
procedures, and surgery
Sacroiliac (SI) joint: SI joint pain is
more common in pregnant women,
inflammatory spondyloarthropathy, or
after a fall on the buttocks
Often overdiagnosed
•• Symptoms: Buttock and proximal leg pain, which
may be worse when sitting, bending, or lifting
•• Physical exam: Exam often nonspecific but points
to upper buttock or mid-buttock as most painful
location; positive FABER (flexion, abduction, and
external rotation) test
•• Manual therapy with mobilization and
stabilization, provided by a physician or
physical therapist
•• Image-guided SI joint cortisone injection
•• Surgery almost never indicated
•• Imaging: Imaging tests often not helpful; diagnosis
often made by image-guided injection
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References
AAFP Rajesh K, Brent L. Spondyloarthropathies. American Family Physicians.
http://www.aafp.org/afp/2004/0615/p2853.html. Published June 15, 2014.
Accessed August 18, 2014.
AIR
Airaksinen O, Brox JI, Cedraschi C, et al; COST B13 Working Group on
Guidelines for Chronic Low Back Pain. Chapter 4. European guidelines for the
management of chronic nonspecific low back pain. Eur Spine J. 2006;15 Suppl
2:S192-S300. Accessed December 5, 2012.
CHO1 Chou R, Qaseem A, Owens DK, Shekelle P; Clinical Guidelines Committee of the
American College of Physicians. Diagnostic imaging for low back pain: advice
for high-value health care from the American College of Physicians. Ann Intern
Med. 2011;154(3):181-189. Accessed December 5, 2012.
CHO2 Chou R, Shekelle P. Will this patient develop persistent disabling low back pain?
JAMA. 2010;303(13):1295-1302. Accessed Dec. 5, 2012.
CHO3 Chou R. Subacute and chronic low back pain: Pharmacologic and
noninterventional treatment. In: UpToDate. Atlas SJ, Lin FH, eds. Waltham,
Mass; 2012. http://ww.uptodate.com. Accessed January 24, 2013.
CHO4 Chou R, Loeser JD, Owens DK, et al; American Pain Society Low Back Pain
Guideline Panel. Interventional therapies, surgery, and interdisciplinary
rehabilitation for low back pain: an evidence-based clinical practice guideline
from the American Pain Society. Spine (Phila Pa 1976). 2009;34(10):1066-1077.
Accessed December 5, 2012.
DEL
Delitto A, George SZ, Van Dillen LR, et al; Orthopaedic Section of the American
Physical Therapy Association. Low back pain. J Orthop Sports Phys Ther.
2012;42(4):A1-A57. Accessed December 14, 2012.
DON Don AS, Carragee E. A brief overview of evidence-informed management of
chronic low back pain with surgery. Spine J. 2008;8(1):258-265. Accessed
December 5, 2012.
FOU Fourney DR, Andersson G, Arnold PM, et al. Chronic low back pain: a
heterogeneous condition with challenges for an evidence-based approach.
Spine (Phila Pa 1976). 2011;36(21 Suppl):S1-S9. Accessed December 5, 2012.
HIL3 Hill JC, Fritz JM. Psychosocial influences on low back pain, disability, and
response to treatment. Phys Ther. 2011;91(5):712-721. Accessed December 5, 2012.
HIL4 Hill JC, Dunn KM, Main CJ, Hay EM. Subgrouping low back pain: a comparison
of the STarT Back Tool with the Orebro Musculoskeletal Pain Screening
Questionnaire. Eur J Pain. 2010;14(1):83-89. Accessed December 5, 2012.
ICSI
Institute for Clinical Systems Improvement (ICSI). Low Back Pain, Adult Acute
and Subacute (Guideline). https://www.icsi.org/guidelines__more/catalog_
guidelines_and_more/catalog_guidelines/catalog_musculoskeletal_guidelines/
low_back_pain/. Published January 2012. Accessed December 5, 2012.
KHA Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical
nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane
Database of Syst Rev. 2008;(4):CD003008. doi: 10.1002/14651858.
CD003008.pub3. Accessed December 5, 2012.
KOE Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. 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. Accessed December
5, 2012.
MAY Mayer TG, Gatchel RJ, Mayer H, Kishino ND, Keeley J, Mooney V. A prospective
two-year study of functional restoration in industrial low back injury. An
objective assessment procedure. JAMA. 1987;258(13):1763-1767. Accessed
December 5, 2012.
NICE National Institute for Health and Clinical Excellence (NICE). Early management
of persistent non-specific low back pain (Guideline). http://www.nice.org.uk/
cg88. Published May 2009. Accessed December 5, 2012.
POS Posadzki P, Ernst E. Yoga for low back pain: a systematic review of randomized
clinical trials. Clin Rheumatol. 2011;30(9):1257-1262. Accessed December 5, 2012.
ROS Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley D.
Mindfulness-based stress reduction for chronic pain conditions: variation
in treatment outcomes and role of home meditation practice. J Psychosom
Res. 2010;68(1):29-36. Accessed January 24, 2013.
FRI
Fritz JM, Beneciuk JM, George SZ. Relationship between categorization with the
STarT Back Screening Tool and prognosis for people receiving physical therapy
for low back pain. Phys Ther. 2011;91(5):722-732. Accessed December 5, 2012.
RUB Rubinstein SM, van Middelkoop M, Kuijpers T, et al. A systematic review on the
effectiveness of complementary and alternative medicine for chronic non-specific
low-back pain. Eur Spine J. 2010;19(8):1213-1228. Accessed December 5, 2012.
FUR
Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low back pain: an updated
systematic review within the framework of the Cochrane Back Review Group.
Spine (Phila Pa 1976). 2009;34(16):1669-1684. Accessed December 5, 2012.
SCO Scott NA, Moga C, Harstall C. Managing low back pain in the primary care
setting: the know-do gap. Pain Res Manag. 2010;15(6):392-400. Accessed
December 5, 2012. Accessed December 5, 2012.
GAT Gatchel RJ, Mayer TG. Evidence-informed management of chronic low back pain
with functional restoration. Spine J. 2008;8(1):65-69. Accessed December 5, 2012.
GEL
Gellhorn AC, Chan L, Martin B, Friedly J. Management patterns in acute low
back pain: the role of physical therapy. Spine (Phila Pa 1976). 2012;37(9):775782. Accessed December 5, 2012.
GOU Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a
rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107–112.
Accessed December 5, 2012.
UTD Yu David. Diagnosis and differential diagnosis of ankylosing spondylitis in
adults. UpToDate. www.uptodate.com/contents/diagnosis-and-differentialdiagnosis-of-ankylosing-spondylitis-in-adults. Published October 2012.
Updated Feb 2014. Accessed March 11, 2014.
VAN van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van
Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract
Res Clin Rheumatol. 2010;24(2):193-204. Accessed December 5, 2012.
GUZ Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C.
Multidisciplinary rehabilitation for chronic low back pain: systematic review.
BMJ. 2001;322(7301):1511-1516. Accessed December 5, 2012.
WAT Watters WC 3rd, Baisden J, Gilbert TJ, et al; North American Spine Society.
Degenerative lumbar spinal stenosis: an evidence-based clinical guideline
for the diagnosis and treatment of degenerative lumbar spinal stenosis.
Spine J. 2008;8(2):305-310. Accessed December 11, 2012.
HIL1 Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening
tool: identifying patient subgroups for initial treatment. Arthritis Rheum.
2008;59(5):632-641. Accessed December 5, 2012.
WHI White AP, Arnold PM, Norvell DC, Ecker E, Fehlings MG. Pharmacologic
management of chronic low back pain: synthesis of the evidence. Spine.
2011;36(21 Suppl):S131-S143. Accessed December 5, 2012.
HIL2 Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care
management for low back pain with current best practice (STarT Back): a
randomised controlled trial. Lancet. 2011;378(9802):1560-1571. Accessed
December 5, 2012.
YUA Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S.
Effectiveness of acupuncture for low back pain: a systematic review. Spine.
2008;33(23):E887-E900. Accessed December 5, 2012.
©2013–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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M a n ag e m e n t o f lo w bac k pa i n
WEB resources
for PROVIDERS
• American Pain Society:
www.ampainsoc.org
• American Academy of Pain Management:
www.aapainmanage.org
• American Academy of Pain Medicine:
www.painmed.org
• Back Pain CME Learning Center:
www.medscape.org/resource/back-pain/cme
A UGUST 2 0 1 4
Summary of intermountain resources
For providers:
To find the tools listed below, go to
intermountainphysician.org/
clinicalprograms, choose Clinical
Topics A–Z, and then choose “Pain
Management” from the A to Z menu.
A Clinical Topic Page (see the example
at right) provides access to CPMs and
supporting tools. Resources include:
WEB resources AND BOOKS
for patients
Websites:
• Back pain overview on MedLinePlus:
www.nlm.nih.gov/medlineplus
/backpain.html
Low Back Pain CPM
• Back Pain Health Center on WebMD:
Spine Evaluation
•• STarT Back Screening Tool
• Spinal MRI Order Guidelines
www.theacpa.org
Books:
• Do You Really Need Back Surgery?: A Surgeon’s
Guide to Back and Neck Pain and How to
Choose Your Treatment, Aaron G. Filler, MD.
Oxford University Press, 2007.
• Harvard Medical School Low Back Pain:
Healing Your Aching Back, Jeffrey Katz, MD,
et al. Harvard Medical School, 2012.
• The Pain Survival Guide: How to Reclaim Your
Life (APA Lifetools), American Psychological
Association, 2005.
• Younger Next Year, Chris Crowley and Henry
S. Lodge, MD. Workman, 2007.
• Younger Next Year for Women, Chris Crowley
and Henry S. Lodge, MD. Workman, 2007.
Assessment tools and
care plans to support
the Chronic Pain CPM
•• Patient Exam: Lumbar
• American Chronic Pain Association:
www.painaction.com/members/Home.
aspx?paintypeid=1
Chronic Pain Care
Process Model
Back Pain
www.webmd.com/back-pain/guide/
default.htm
• The Pain Action Back Pain Library:
Supporting forms:
•• Patient Self-History:
For patients:
• Clinicians can access Intermountain
patient education materials using the
Clinical Topic Pages described above, and
order copies via i-printstore.com. Call
801-442-3186 for more information.
• Clinicians can access additional patient
education from Krames from the PEL page.
Type PEL in the browser window (from within
the firewall) and click Krames On-Demand.
Type “low back pain” to search for available
materials. Appropriate materials will also
appear in iCentra based on diagnosis code or
can be found through the Education Module.
Fact sheets:
•• Low Back Pain
•• Leftover Medications:
How to Dispose of
Them Safely
Managing Chronic Pain:
Reclaiming Your Life
This 44-page handbook helps
patients take an active role in self
care, continue physical activity,
and manage treatments (including
medication) effectively.
• Patients can also be referred to
Intermountain’s public website at
intermountainhealthcare.org for resources.
To find resources, patients should open the
Health Topic Library and search for “low
back pain.”
Functional Restoration/Chronic Pain Development Team: Core members for development
of this CPM were Timothy Houden, MD; Bridget Shears, RN, MA; Gerard Brennan, PT, PhD; Kurt
Dudley, PT; Paula Haberman, MD; Michael Jaffe, MD; and Stephen Warner, MD. Additional review and
assistance was provided by Wayne Cannon, MD; Liz Joy, MD; Jack Ruckdeschel, MD; Tom Sanders, MD,
and Roy Gandolfi, MD.
12
©2013–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications 801-442-2963 CPM009 - 08/14