British Study

Managing Back Pain: New Clinical Guidelines [Clinician Reviews 7(11):57-59, 62, 64, 67-68, 1997. © 1997 Clinicians Publishing Group and Williams & Wilkins.] Britain's Royal College of General Practitioners recently released new and easily accessible national clinical guidelines for managing acute low back pain. These latest principles expand on the 1994 guidelines issued by the US Agency for Health Care Policy and Research, and include a new diagnostic triage to differentiate between simple backache, nerve root pain, and more serious spinal pathology. National guidelines draw evidence from a wide network of sources and use the information to construct easily accessible recommendations. Britain's Royal College of General Practitioners' (RCGP) recent release of Clinical Guidelines for the Management of Acute Low Back Pain1 marks the first publication of a comprehensive evidence review of low back pain studies since a similar study was issued by the US Agency for Health Care Policy and Research (AHCPR 1994). Notably, the Guidelines confirm AHCPR findings on the treatment of simple low back pain. In the absence of serious pathology, the condition will resolve faster with a gradual increase in the patient's activity than it will with bed rest, traction, and corsets. The new report also underscores the importance of biopsychosocial assessment and patient information in managing acute back pain cases, and reviews the various medical management and treatment options. The RCGP Guideline Development Group concludes that diagnostic triage is an important component of the clinical management of back pain. The findings of a detailed clinical history and a thorough physical examination form the basis of diagnostic triage. Simple Backache "Mechanical" pain is present in the lumbosacral region, buttocks, and thighs of otherwise healthy patients aged 20 to 55 years. Prognosis good. Nerve Root Pain Unilateral leg pain (more severe than low back pain), numbness, and paresthesia are characteristic, together with reduced straight leg raising. Neurologic pain is limited to one nerve root. Half of all patients recover in 6 weeks. Referral required if symptoms fail to resolve. Serious Spinal Pathology Red flags include age younger than 20 years or older than 50 years; significant trauma, such as a fall from a height or an auto accident; constant/progressive nonmechanical pain; thoracic pain; carcinoma; use of systemic steroids; drug abuse; infection with human immunodeficiency virus; systemic illness; weight loss; persisting severe restriction of lumbar flexion; and widespread neurologic involvement. Prompt referral required. Cauda Equina Syndrome/Widespread Neurological Disorder Patients may present with loss of anal sphincter tone; impaired micturition; incontinence; saddle anesthesia at the anus, perineum, or genitals; widespread or progressive loss of strength in the legs; or gait disturbances. Prompt referral required. Inflammatory Disorders (Ankylosing Spondylitis and Related Disorders) Significant morning stiffness, making a gradual onset prior to age 40, with continuing limited spinal movements in all directions, and involving some peripheral joints; iritis; skin rashes, such as psoriasis; colitis, and urethral discharge may also be evident. Family history is a factor. Prompt referral required. Assessment Guidelines Patient assessment should consider psychosocial as well as physical factors. The Guidelines also discuss radiology's role in assessment. Psychosocial Factors The RCGP concurred with the AHCPR that psychosocial and socioeconomic problems in a patient's life can affect response to treatment. Psychosocial problems pose more important risk factors for chronic, recurring back pain than biomedical symptoms, according to one study cited. Physical Assessment During the physical examination, the clinician should be alert for the signs and symptoms described in the "Diagnostic Triage" section. The RCGP also recommends the following: Straight Leg Raising/Reflexes: Straight leg raising should be evaluated in young adults with sciatica. Examination for neurologic involvement should emphasize ankle and knee reflexes, dorsiflexion strength in the ankle and great toe, and distribution of sensory complaints. Radiography The Guidelines discourage the use of radiography in diagnosis except where clinical "red flags" are present. Unless x-rays are so indicated, the use of oblique views on plain lumbar x-rays is not recommended for adults, given the high level of radiation exposure (150 times that of a chest x- ray). Medical Management and Patient Information Good initial management and accurate patient information have been demonstrated to improve both clinical outcomes and patient satisfaction, according to the RCGP. Adequate initial management should do the following: Include a complete clinical history and a brief physical examination. Verify that there are no indications of serious spinal pathology. Allay patient concerns (eg, reassure the patient that there is no need for special diagnostic procedures). Offer accurate information on the prognosis for quick recovery. Tell the patient that light physical activity is beneficial for recovery. Practitioners should provide practical advice on resuming daily activity and returning to work. Information can also help the patient understand the probable outcome of back pain treatment. Although most cases improve in a few weeks, patients should be advised that mild symptoms may persist. Recurrences are not uncommon, but do not indicate a chronic or worsening case. The patients who return to normal activities usually feel better and use fewer analgesics than those who do not (see Table, "Risk Factors for Chronicity"). Treatment Recommendations The RCGP evaluated all recommendations on a three-star evidence rating system, based on large, randomized controlled trials (RCTs), except in areas in which such trials are not applicable. Evidence on assessment, epidemiology, complications from treatment, and natural history was primarily gathered from prospective cohort studies of acute low back pain in primary care. The RCGP uses the following rating system for comparing the evidence for the various treatment approaches: *** = Strong research-based evidence ** = Moderate research-based evidence * = Limited research-based evidence Bed Rest The RCGP advises against using bed rest as a treatment for simple back pain. Some patients may stay in bed as a consequence of their pain, but this should not generally be considered a treatment option (evidence rating: ***). Short bed rest may be used as treatment for disc prolapse, but there is scarce evidence for such treatment. In fact prolonged bed rest has been found to lead to chronic disability (evidence rating: **). Staying Active The RCGP recommends encouraging patients to continue their normal daily activities. Faster symptomatic recovery is seen in patients who follow this advice than in those who employ traditional medical treatments, such as analgesics. According to the RCGP, clinicians should tell patients, "Let pain be your guide" when it comes to resuming former daily activity level (evidence rating: ***). Counsel patients to increase their physical treatment incrementally over a few days or weeks, to prevent chronic pain and work loss (evidence rating: ***). Advising patients to return to work early may lead to less work loss and fewer days off (evidence rating: *). Manipulation Manipulation may be helpful for patients who do not resume normal activity or who need additional help with pain relief within the first 6 weeks of the onset of acute low back pain. Compared with other treatments, manipulation offers optimal pain relief within this period. However there is no firm evidence guiding practitioners to select patients who will benefit most (evidence rating: ***). Nor have studies demonstrated what kind of manipulation works best. Longer manipulation treatments (beyond 6 weeks) have no conclusive support from clinical trials thus far (evidence rating: **). Choose trained therapists for referral, and make careful selection of patients. Manipulation is not recommended for patients with severe or progressive neurology in light of the risk of complications (evidence rating: **). Back Exercises Although the efficacy of back exercises for all low back pain patients has not yet been demonstrated, some patients who have not resumed their normal activities in 6 weeks realize symptom relief through back exercise and physical reconditioning (evidence rating: ***). McKenzie exercises may produce short-term pain relief (evidence rating: **). Theoretical arguments support starting an exercise program within 6 weeks of the onset of pain (evidence rating: ***). Other Treatment Approaches The following treatments were not among the RCGP's primary recommendations for low back pain. However, evidence for and against such treatment in the literature was reviewed in some detail, and is briefly excerpted here. Drug Therapy Acetaminophen and NSAIDS: Acetaminophen compounds prescribed at regular intervals alleviate low back pain, including nerve root pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) have a similar effect on simple backache, but cause adverse effects at high doses and with the elderly. Ibuprofen followed by diclofenac has the least risk of gastrointestinal disturbances. Acetaminophen-weak opioid compounds are strong pain reducers, but the side effects include constipation and drowsiness. Muscle Relaxants: Diazepam, baclofen, and dantrolene have been shown to reduce acute back pain effectively, but with high risk of drowsiness and potential physical dependence after relatively short courses. Strong Opioids: No evidence shows that strong opioids are more effective in relieving low back pain than safer analgesics such as acetaminophen, aspirin, or other NSAIDs. Adverse effects of strong opioids include slow reaction time, clouded judgment, and potential physical dependence. Antidepressants: Although these are in wide use for chronic low back pain, RCTs do not demonstrate their efficacy. Physical Therapy ________________ Physical agents: Ice, heat, short-wave diathermy, massage, and ultrasound, although used for symptomatic relief, do not have a significant effect on clinical outcomes. Traction: Traction has not been proven efficacious for low back pain. Transcutaneous Electrical Nerve Stimulation (TENS): There is no conclusive evidence to support the use of TENS for patients with acute low back pain. Shoe insoles and lifts: Insoles and lifts, while alleviating mild back pain in some cases, have no effect on long-term recovery. Lumbar corsets and supports: Corsets and supports have not been proven to reduce low back pain. Trigger point and ligamentous injections: Such injections may pose serious complications, and there is little evidence that they alleviate acute low back pain. Acupuncture: Although some weak evidence exists that acupuncture brings a greater latitude of movement and less pain for some patients, acupuncture has not been shown to be an efficacious treatment for long-term back pain. Epidural steroid injections: Such injections relieve low back pain with sciatica better than some other treatments. This treatment method is associated with grave but rare risks. Facet joint injections: No evidence supports the use of these injections to improve clinical outcomes. Biofeedback: Biofeedback has not been shown to be efficacious in acute low back pain, although some equivocal evidence supports biofeedback for chronic pain. Group education, back school: These programs vary greatly in format, and although two Swedish RCTs show beneficial results, the overall efficacy of back schools has not yet been proven. Hazardous Treatments The following treatments have been associated with adverse outcomes and are not indicated for low back pain: Narcotics for longer than 2 weeks Diazepam for longer than 2 weeks Colchicine Systemic steroids Bed rest with traction Manipulation under general anesthesia Plaster jacket Conclusion By establishing these comprehensive and accessible national guidelines, the RCGP has provided a basis on which local guidelines can easily be developed. It is hoped that this will, in turn, lead to improved management of acute low back pain on a global level. 1From Waddell G, Feder G, McIntosh A, et al for the Royal College of General Practitioners Guideline Development Group. Low Back Pain Evidence Review. London, England: RCGP; 1996. Available at: http://www.rcgp.org.uk/backpain/index.htm. Accessed November 5, 1997.