Evaluation and Management of Low Back Pain

1 Guideline for the Evaluation and Management of Low Back PainC L I N I C A L G U I D E L I N E F O R T H E E V A L U A T I O N A N D M A N A G E M E N T O F LOW BACK pain Evidence Reviewroger Chou, Mdlaurie hoyt huffman, MSAmerican pain Society, PublisherGlenview, ilEVIDENCE REVIEW APS Clinical Guideline for the Evaluation and Management of Low Back pain TABLE OF CONTENTS Page Introduction 1 Purpose of evidence review ..1 Background 1 Previous guidelines ..2 Scope of evidence review 4 Key questions ..4 Populations ..6 Interventions ..6 Non-invasive interventions ..6 Invasive, non-surgical interventions ..7 Surgical interventions ..8 Invasive diagnostic tests ..8 Conflict of interest ..9 Methods 9 Literature search and strategy ..9 Inclusion and exclusion criteria ..10 Data extraction and synthesis ..11 Systematic Individual trials on efficacy and safety of interventions ..11 Observational studies of treatment Studies of invasive diagnostic Dual review.

2 13 Assessing research applicability and clinical relevance ..13 Data synthesis ..14 Rating of good Rating of fair Rating of poor quality ..14 Assessing magnitude of benefits or harms ..15 American pain Society iEVIDENCE REVIEW APS Clinical Guideline for the Evaluation and Management of Low Back pain American pain Society iiTABLE OF CONTENTS Page Results 16 Size of literature Key Question 1a. How accurate are features of the history and physical exam for predicting presence of serious underlying conditions ( red flags ) or other conditions that may be responsive to specific therapies in patients with low back pain (such as nerve root compression or spinal stenosis)?..17 Accuracy of history and physical exam features for identifying specific diagnoses associated with low back pain ..18 Cancer ..18 Infection ..19 Cauda equina Compression fracture ..19 Ankylosing Herniated disk or radiculopathy.

3 20 Spinal stenosis ..20 Key Question 1b. How accurate are features of the history and physical exam for predicting the development of persistent low back pain and associated disability ( yellow flags )?..23 Accuracy of history and physical exam features for identifying patients more likely to develop chronic and disabling low back Key Question 1 Summary Table: Systematic reviews of prognostic factors for identifying patients more likely to develop chronic and disabling low back pain ..25 Key Question 1c. How effective is identification and treatment of yellow flags for improving clinical outcomes in patients with low back pain ?..29 Efficacy of interventions for identifying and treating yellow Key Question 2a. How accurate are different diagnostic tests for identifying serious underlying conditions ( , tumor, infection, compression fracture)? ..34 Accuracy of imaging for diagnosing cancer ..35 Accuracy of imaging for diagnosing vertebral infection.

4 35 EVIDENCE REVIEW APS Clinical Guideline for the Evaluation and Management of Low Back pain American pain Society iiiTABLE OF CONTENTS Page Accuracy of imaging for diagnosing vertebral compression fracture ..35 Accuracy of elevated erythrocyte sedimentation rate for diagnosing cancer ..36 Key Question 2b. How accurate are different diagnostic tests for identifying other conditions ( nerve root compression, herniated disc, spinal stenosis) that may respond to specific therapies? ..37 Accuracy of imaging for diagnosing nerve root compression, herniated disk, and spinal Accuracy of imaging for diagnosing ankylosing spondylitis ..38 Diagnostic accuracy of other (non-imaging) Key Question 2c. In patients with red flags, how effective are different diagnostic tests for improving patient outcomes? ..40 Efficacy of diagnostic testing in patients with red flags ..40 Key Question 2d. In patients without red flags, how effective are different diagnostic tests or test strategies (including no testing) for improving patient outcomes?

5 40 Efficacy of routine, early plain radiography versus usual care or imaging only if clinically necessary (or without improvement) ..40 Efficacy of routine MRI versus MRI only if clinically necessary (or without improvement)..43 Efficacy of rapid MRI versus lumbar radiography in patients with low back pain referred for imaging ..43 Key Question 3. How effective are self-care advice, education, or other self-care interventions for improving patient outcomes? ..46 Self-care advice or education ..46 Advice to rest in bed ..46 Advice to remain Self-care back education Self-care e-mail discussion groups ..58 Self-care exercise Advice to restrict early morning flexion ..60 Lay-facilitated groups for self-care ..61 EVIDENCE REVIEW APS Clinical Guideline for the Evaluation and Management of Low Back pain American pain Society ivTABLE OF CONTENTS Page Self-help tools for back surgery Other self-care interventions.

6 64 Lumbar supports ..64 Mattresses ..65 Superficial heat or cold ..67 Key Question 3 Summary Tables: Systematic reviews on efficacy of self-care therapies for low back Summary of evidence on self-care therapies for acute low back Summary of evidence on self-care therapies for chronic or subacute low back pain ..73 Summary of evidence on self-care therapies for radiculopathy or sciatica ..75 Key Question 4. How effective are different non-invasive interventions for non-radicular low back pain , radicular low back pain , or spinal stenosis, and under what circumstances? ..76 Medications ..76 Non-steroidal anti-inflammatory drugs (NSAIDs) ..78 Non-selective NSAIDs ..78 COX-2 selective Other Benzodiazepines ..86 Antiepileptic drugs ..87 Skeletal muscle Opioid analgesics ..92 Tramadol ..98 Systemic Topical lidocane ..103 EVIDENCE REVIEW APS Clinical Guideline for the Evaluation and Management of Low Back pain American pain Society vTABLE OF CONTENTS Page Herbal therapies.

7 103 Key Question 4 Summary Tables: Systematic reviews on efficacy of medications and herbal therapies for low back Summary of evidence on medications and herbal therapies for acute low back Summary of evidence on medications and herbal therapies for chronic or subacute low back pain ..113 Summary of evidence on medications for sciatica or radicular low back pain ..115 Acupuncture and related interventions ..116 Acupuncture and dry needling ..116 Neuroreflexotherapy ..122 Educational interventions ..124 Back Brief educational Exercise and related interventions ..129 Exercise ..129 Hydrotherapy ..134 Yoga ..135 Interdisciplinary interventions ..137 Interdisciplinary rehabilitation (multidisciplinary rehabilitation)..137 Functional restoration (physical conditioning, work conditioning, or work hardening) ..140 Physical modalities ..142 Interferential therapy ..142 Low level laser therapy ..144 Shortwave diathermy.

8 147 Transcutaneous electrical nerve stimulation (TENS) ..151 EVIDENCE REVIEW APS Clinical Guideline for the Evaluation and Management of Low Back pain American pain Society viTABLE OF CONTENTS Page Percutaneous electrical nerve stimulation (PENS) ..153 Ultrasound ..156 Other non-invasive interventions ..157 Psychological therapies ..157 Massage ..159 Modified Spa therapy and Spinal manipulation ..165 Key Question 4 Summary Tables: Systematic reviews on efficacy of non-pharmacologic therapies for low back pain ..172 Summary of evidence on non-pharmacologic therapies for acute low back Summary of evidence on non-pharmacologic therapies for chronic or subacute low back pain ..187 Summary of evidence on non-pharmacologic therapies for radiculopathy or Key Question 5. How effective are decision tools or other methods for predicting which patients are more likely to respond to specific therapies like spinal manipulation or different types of exercise therapy?

9 191 Reliability and validity of manual spinal palpatory exam or clinical tests of the sacroiliac Utility of clinical prediction rules for spinal manipulation ..191 Clinical prediction rules for exercise ..193 Patient classification systems for individualizing physical therapy interventions ..193 Key Question 6. How effective is referral from primary care providers to back specialty providers for improving patient outcomes? What are the outcomes for patients who are managed by different types of care providers or by multidisciplinary or interdisciplinary clinics? ..195 EVIDENCE REVIEW APS Clinical Guideline for the Evaluation and Management of Low Back pain American pain Society viiTABLE OF CONTENTS Page Key Question 7. What is the diagnostic accuracy and what are the potential harms associated with invasive tests for identifying patients who may benefit from invasive procedures? How effective is prior use of these tests for selecting patients for invasive procedures in improving outcomes?

10 197 Provocative discography ..197 Diagnostic selective nerve root blocks ..205 Diagnostic intra-articular facet joint blocks and medial branch blocks ..206 Diagnostic sacroiliac joint blocks ..208 Key Question 8. How effective are injections (and different injection interventions) and other interventional therapies for non-radicular low back pain , radicular low back pain , or spinal stenosis, and under what circumstances? ..209 Injections outside the spine ..209 Local injections ..209 Botulinum toxin ..212 Prolotherapy ..213 Intraspinal steroid injection and Epidural steroid Intradiscal steroid Radiofrequency denervation, intradiscal electothermal therapy (IDET), and related procedures ..243 Radiofrequency denervation ..243 Intradiscal electothermal therapy (IDET) ..249 Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) and Coblation nucleoplasty ..252 Spinal cord Key Question 8 Summary Tables: Systematic reviews on efficacy of interventional therapies for low back EVIDENCE REVIEW APS Clinical Guideline for the Evaluation and Management of Low Back pain American pain Society viiiTABLE OF CONTENTS Page Summary of evidence on interventional therapies for low back Key Question 9.