Patients with low back pain (LBP) face many decisions, ranging from the nature and extent of the evaluation they should undergo to determining which treatments are likely to be most effective. These choices can be confusing not only to those who are in pain but also to their health care providers.
[Editor's Note: For Part 2 of this series, click here.]
Although several guidelines have been published on the diagnosis and treatment of acute LBP (most notably that issued by the US Department of Health and Human Services in 19941), there has been a dearth of similar guidelines based on the scientific literature for chronic LBP. Recently, the American College of Physicians and the American Pain Society (ACP/ APS) released the first comprehensive guideline on chronic LBP based on the published evidence, and it is probably the most up-to-date review of acute LBP.2
The ACP/APS guideline is divided into 3 sections: (1) an overview of diagnosis and evaluation, (2) nonpharmacological therapies, and (3) use of medications. In this column, I discuss the information covered in the first section; the other sections will be discussed in my next column.
Evaluating the patient with LBP To help identify possible causes of LBP, the guideline recommends that a focused history and physical examination should be performed in order to place the patient in 1 of 3 broad categories: nonspecific LBP, pain associated with radiculopathy or spinal stenosis, or pain potentially associated with another specific cause. The guideline notes that more than 85% of patients who present to health care providers suffer from nonspecific LBP for which there is no clear underlying cause, while LBP associated with serious illnesses, such as cancer or infection, is relatively uncommon. It provides an algorithm to aid in determining whether an underlying illness should be suspected. For example, further workup would be warranted when a history of cancer or unexplained weight loss suggests that this disease may be present or when there are progressive neurological deficits, such as weakness or fecal or urinary incontinence, indicating the presence of spinal cord compression.
Because of the relative infrequency of these more serious problems as causes of LBP and the ability of physicians to determine whether they are likely to be present from the patient's history and physical examination, the guideline advises against the routine use of diagnostic testing, including imaging studies, in patients in whom there is little reason to suspect the presence of these conditions. Unfortunately, most patients with chronic LBP and many with acute LBP who are evaluated by physicians end up undergoing diagnostic testing, most commonly MRI. Although it is widely perceived by patients and many clinicians that this is necessary to formulate a treatment plan, experts on LBP feel that rather than providing information that benefits patients, the results of these tests may be used to support interventions that at best provide little benefit and may actually make things worse.
The problem with these tests is that while structural abnormalities such as bulging intervertebral disks are commonly detected, it is questionable whether there is any correlation between their presence and LBP. This is supported by studies that have demonstrated that many people who have the same abnormalities do not have LBP. The guideline notes that even with a true herniation of a lumbar disk with accompanying radiculopathy, the majority of patients will improve within 4 weeks with noninvasive management. Thus, in these patients, imaging studies offer little benefit in treatment or predicting outcome.
The guideline recommends limiting imaging studies, preferably MRI, to patients with persistent LBP and signs or symptoms of radiculopathy or spinal stenosis "only if they are potential candidates for surgery or epidural steroid injection." The problem with this recommendation is that most of the patients with these problems are frequently considered candidates for these interventions, even though the literature indicates that only a small number of patients benefit from them.3,4
For patients who have risk factors for vertebral fractures, such as osteoporosis or long-term corticosteroid use, the guideline recommends plain radiography. It advises against the use of electrophysiological testing, such as nerve conduction velocity studies and electromyography, for evaluating patients with nonspecific LBP.
The importance of evaluating psychosocial factors Of special interest to mental health professionals is the emphasis the guideline places on assessing psychosocial factors that can play a significant role in the development and maintenance of the pain. In fact, the guideline notes that the literature indicates the following: "Psychosocial factors and emotional distress... are stronger predictors of low back pain outcomes than either physical examination findings or severity and duration of pain," and "psychosocial factors that may predict poorer low back pain outcomes include presence of depression, passive coping strategies, job dissatisfaction, higher disability levels, disputed compensation claims, or somatization."
Although the guideline includes a glossary of many of the terms it employs, it provides no definition for "somatization," which, in clinical practice, has become something of a wastebasket term that is used when patients have unexplained physical symptoms. There is no doubt of the importance of psychosocial factors; however, as the guideline notes, there is limited research on how primary care providers can identify and address them in patients with either acute or chronic LBP. On the basis of my experience, this is a major problem. Patients with pain often downplay the role of psychosocial factors for 1 or more of 3 reasons: (1) they are unable to see a connection between these factors and the pain; (2) they fear that any indication that psychosocial factors are playing a role in the pain means that it "isnt real"; and (3) for patients who may potentially be or already are involved in disability or personal injury or workers compensation cases, there may be concern that their cases will be weakened if they acknowledge the presence of any psychosocial factors before the onset of the pain.
Thus, primary care providers must walk a careful line between trying to identify these factors and avoiding giving patients the impression that there is skepticism about the presence of the pain.
Bigos SJ, Bowyer OR, Braen GR, et al. Clinical practice guideline No. 14: acute low back problems in adults. Rockville, MD: US Dept of Health and Human Services, Agency for Health Care Policy and Research, Public Health Service; 1994. AHCPR publication 95-0642.
Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356:2245-2256.
Armon C, Argoff CE, Samuels J, Backonja MM; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007;68: 723-729.