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Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.
Methods: Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. Updated searches were performed through November 2016. Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.
Target Audience and Patient Population: The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.
Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).
Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).
Recommendation 3: In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).
Abstract/Text
OBJECTIVE: To determine the prevalence of serious pathology in patients presenting to primary care settings with acute low back pain, and to evaluate the diagnostic accuracy of recommended "red flag" screening questions.
METHODS: An inception cohort of 1,172 consecutive patients receiving primary care for acute low back pain was recruited from primary care clinics in Sydney, Australia. At the initial consultation, clinicians recorded responses to 25 red flag questions and then provided an initial diagnosis. The reference standard was a 12-month followup supplemented with a specialist review of a random subsample of participants.
RESULTS: There were 11 cases (0.9%) of serious pathology, including 8 cases of fracture. Despite the low prevalence of serious pathology, most patients (80.4%) had at least 1 red flag (median 2, interquartile range 1-3). Only 3 of the red flags for fracture recommended for use in clinical guidelines were informative: prolonged use of corticosteroids, age >70 years, and significant trauma. Clinicians identified 5 of the 11 cases of serious pathology at the initial consultation and made 6 false-positive diagnoses. The status of a diagnostic prediction rule containing 4 features (female sex, age >70 years, significant trauma, and prolonged use of corticosteroids) was moderately associated with the presence of fracture (the area under the curve for the rule score was 0.834 [95% confidence interval 0.654-1.014]; P = 0.001).
CONCLUSION: In patients presenting to a primary care provider with back pain, previously undiagnosed serious pathology is rare. The most common serious pathology observed was vertebral fracture. Approximately half of the cases of serious pathology were identified at the initial consultation. Some red flags have very high false-positive rates, indicating that, when used in isolation, they have little diagnostic value in the primary care setting.
Abstract/Text
BACKGROUND: Low back pain has a high prevalence and morbidity, and is a source of substantial health-care spending. Numerous published guidelines support the use of so-called red flag questions to screen for serious pathology in patients with low back pain. This paper examines the effectiveness of red flag questions as a screening tool for patients presenting with low back pain to a multidisciplinary academic spine center.
METHODS: We conducted a retrospective review of the cases of 9,940 patients with a chief complaint of low back pain. The patients completed a questionnaire that included several red flag questions during their first physician visit. Diagnostic data for the same clinical episode were collected from medical records and were corroborated with imaging reports. Patients who were diagnosed as having a vertebral fracture, malignancy, infection, or cauda equina syndrome were classified as having a red flag diagnosis.
RESULTS: Specific individual red flags and combinations of red flags were associated with an increased probability of underlying serious spinal pathology, e.g., recent trauma and an age of >50 years were associated with vertebral fracture. The presence or absence of other red flags, such as night pain, was unrelated to any particular diagnosis. For instance, for patients with no recent history of infection and no fever, chills, or sweating, the presence of night pain was a false-positive finding for infection >96% of the time. In general, the absence of red flag responses did not meaningfully decrease the likelihood of a red flag diagnosis; 64% of patients with spinal malignancy had no associated red flags.
CONCLUSIONS: While a positive response to a red flag question may indicate the presence of serious disease, a negative response to 1 or 2 red flag questions does not meaningfully decrease the likelihood of a red flag diagnosis. Clinicians should use caution when utilizing red flag questions as screening tools.
Abstract/Text
Studies of oral corticosteroid dose and loss of bone mineral density have reported inconsistent results. In this meta-analysis, we used information from 66 papers on bone density and 23 papers on fractures to examine the effects of oral corticosteroids on bone mineral density and risk of fracture. Strong correlations were found between cumulative dose and loss of bone mineral density and between daily dose and risk of fracture. The risk of fracture was found to increase rapidly after the start of oral corticosteroid therapy (within 3 to 6 months) and decrease after stopping therapy. The risk remained independent of underlying disease, age and gender. We conclude that oral corticosteroid treatment using more than 5 mg (of prednisolone or equivalent) daily leads to a reduction in bone mineral density and a rapid increase in the risk of fracture during the treatment period. Early use of preventive measures against corticosteroid-induced osteoporosis is recommended.
Abstract/Text
BACKGROUND: Although sneezing is known to induce low back pain, there is no objective data of the load generated when sneezing. Moreover, the approaches often recommended for reducing low back pain, such as leaning with both hands against a wall, are not supported by objective evidence.
METHODS: Participants were 12 healthy young men (mean age 23.25 ± 1.54 years) with no history of spinal column pain or low back pain. Measurements were taken using a three-dimensional motion capture system and surface electromyograms in three experimental conditions: normal for sneezing, characterized by forward trunk inclination; stand, in which the body was deliberately maintained in an upright posture when sneezing; and table, in which the participants leaned with both hands on a table when sneezing. We analyzed and compared the intervertebral disk compressive force, low back moment, ground reaction force, trunk inclination angle, and co-contraction of the rectus abdominis and erector spinae muscles in the three conditions.
FINDINGS: The intervertebral disk compressive force and ground reaction force were significantly lower in the stand and table conditions than in the normal condition. The co-contraction index value was significantly higher in the stand condition than in the normal and table conditions.
INTERPRETATION: When sneezing, body posture in the stand or table condition can reduce load on the low back compared with body posture in the normal sneezing condition. Thus, placing both hands on a table or otherwise maintaining an upright body posture appears to be beneficial for reducing low back load when sneezing.
Copyright © 2014 Elsevier B.V. All rights reserved.
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BACKGROUND: We suggested a standing back extension exercise 'One Stretch' based on the McKenzie method, to examine the ability to improve or prevent low back pain (LBP) in Japanese care workers.
METHODS: We conducted a single-center, non-randomized, controlled study in Japan. Care workers in an intervention group received an exercise manual and a 30-minute seminar on LBP and were encouraged with a group approach, while care workers in a control group were given only the manual. All care workers answered questionnaires at the baseline and end of a 1-year study period. The subjective improvement of LBP and compliance with the exercise were evaluated.
RESULTS: In all, 64 workers in the intervention group and 72 in the control group participated in this study. More care workers in the intervention group exercised regularly and improved or prevented LBP than in the control group (P = 0·003 and P<0·0001, respectively). In the intervention group, none had a first medical consultation or were absent from disability for LBP by the end of the study period.
CONCLUSION: The exercise 'One Stretch' would be effective to improve or prevent LBP in care workers. Our group approach would lead to better compliance with the exercise.
Abstract/Text
BACKGROUND: We examined the effectiveness of an intervention using a standing back extension exercise called "One Stretch", based on the McKenzie method, in improving or preventing low back pain and disability in Japanese care workers.
METHODS: We conducted a non-randomized controlled trial in Japan. Care workers in the intervention group received an exercise manual and a 30-minute seminar on low back pain and were encouraged to exercise in groups, while care workers in a control group were given only the manual. All care workers answered questionnaires at baseline and after one year on the subjective improvement in low back pain, whether they had had a medical consultation for low back pain, and the exercise compliance. Low back pain with disability was assessed by the Oswestry Disability Index.
RESULTS: Participants included 89 workers in the intervention group and 78 in the control group. Background characteristics did not differ significantly between the two groups. Compared to the control group, a greater number of care workers in the intervention group showed improvements in low back pain or prevented it, did not have a medical consultation for low back pain, and exercised regularly. Furthermore, significantly fewer care workers in the intervention group suffered from low back pain with disability by the end of the study period than in the control group.
CONCLUSION: The population approach about the exercise "One Stretch" led to better compliance with the exercise, and was effective for improving or preventing low back pain and in decreasing the likelihood of having a medical consultation for low back pain.
Copyright © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Hiroyuki Oka, Takuo Nomura, Fuminari Asada, Kenichiro Takano, Yasuhiko Nitta, Yasutomo Uchima, Tomonori Sato, Masafumi Kawase, Sayoko Sawada, Kazushi Sakamoto, Makoto Yasue, Satoshi Arima, Junji Katsuhira, Kayo Kawamata, Tomoko Fujii, Sakae Tanaka, Hiroaki Konishi, Hiroshi Okazaki, Kota Miyoshi, Junko Watanabe, Ko Matsudaira
The effect of the 'One Stretch' exercise on the improvement of low back pain in Japanese nurses: A large-scale, randomized, controlled trial.
Mod Rheumatol. 2019 Sep;29(5):861-866. doi: 10.1080/14397595.2018.1514998. Epub 2019 Jan 3.
Abstract/Text
Objectives: To evaluate the 'One Stretch' exercise's effect on improvements in low back pain (LBP), psychological factors, and fear avoidance in a large number of nurses. Methods: Between July 2015 and June 2016, we performed a prospective, randomized, parallel-group, multi-center study with central evaluations. Eligible patients were randomly assigned (1:1:1 ratio) to either the control group (Group A) or an intervention group (Group B: 30-min seminar about the 'One Stretch' exercise, Group C: B + physical and psychological approaches to LBP treatment). The primary outcome was subjective improvement from baseline to 6 months (improved/unchanged/worsened) and overall exercise habits (good/poor). Results: There were 4767 participants: 1799, 1430, and 1548 in Groups A, B, and C, respectively. We collected data on 3439 participants (949, 706, and 751 in Groups A, B, and C, respectively) at the 6-month follow-up. The improvement rates in Groups A, B, and C were 13.3%, 23.5%, and 22.6%, respectively. The worsened pain rates were 13.0%, 9.6%, and 8.1%, which decreased as the intervention degree increased (the Cochran-Armitage trend test: p < .0001). In Groups A, B, and C, 15.6%, 64.9%, 48.8% of the patients, respectively, exhibited exercise habits. Conclusion: The 'One Stretch' exercise is useful for improving LBP.
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OBJECTIVE: To develop and validate a tool that screens for back pain prognostic indicators relevant to initial decision making in primary care.
METHODS: The setting was UK primary care adults with nonspecific back pain. Constructs that were independent prognostic indicators for persistence were identified from secondary analysis of 2 existing cohorts and published literature. Receiver operating characteristic curve analysis identified single screening questions for relevant constructs. Psychometric properties of the tool, including concurrent and discriminant validity, internal consistency, and repeatability, were assessed within a new development sample (n = 131) and tool score cutoffs were established to enable allocation to 3 subgroups (low, medium, and high risk). Predictive and external validity were evaluated within an independent external sample (n = 500).
RESULTS: The tool included 9 items: referred leg pain, comorbid pain, disability (2 items), bothersomeness, catastrophizing, fear, anxiety, and depression. The latter 5 items were identified as a psychosocial subscale. The tool demonstrated good reliability and validity and was acceptable to patients and clinicians. Patients scoring 0-3 were classified as low risk, and those scoring 4 or 5 on a psychosocial subscale were classified as high risk. The remainder were classified as medium risk.
CONCLUSION: We validated a brief screening tool, which is a promising instrument for identifying subgroups of patients to guide the provision of early secondary prevention in primary care. Further work will establish whether allocation to treatment subgroups using the tool, linked with targeting treatment appropriately, improves patient outcomes.
