Schilsky Chiropractic Center

Research

The following information and links to research information are provided for educational purposes. For specific help, contact our offices or request an appointment online.

View an excellent Chiropractic Research Synopses from the American Chiropractic Association, (ACA) here.

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).

Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).

Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurological deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).

Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).

Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).

Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.

Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

Low back pain is the fifth most common reason for all physician visits in the United States. Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months, and 7.6% reported at least 1 episode of severe acute low back pain within a 1-year period. Low back pain is also very costly: Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $26.3 billion in 1998. In addition, indirect costs related to days lost from work are substantial, with approximately 2% of the U.S. work force compensated for back injuries each year.

Many patients have self-limited episodes of acute low back pain and do not seek medical care. Among those who do seek medical care, pain, disability, and return to work typically improve rapidly in the first month. However, up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode, and 1 in 5 report substantial limitations in activity. Approximately 5% of the people with back pain disability account for 75% of the costs associated with low back pain.

Many options are available for evaluation and management of low back pain. However, there has been little consensus, either within or between specialties, on appropriate clinical evaluation and management of low back pain. Numerous studies show unexplained, large variations in use of diagnostic tests and treatments. Despite wide variations in practice, patients seem to experience broadly similar outcomes, although costs of care can differ substantially among and within specialties.

The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain in primary care settings. The target audience for this guideline is all clinicians caring for patients with low (lumbar) back pain of any duration, either with or without leg pain. The target patient population is adults with acute and chronic low back pain not associated with major trauma. Children or adolescents with low back pain; pregnant women; and patients with low back pain from sources outside the back (nonspinal low back pain), fibromyalgia or other myofascial pain syndromes, and thoracic or cervical back pain are not included. These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue from an evidence report by the American Pain Society. The evidence report discusses the evidence for the evaluation, and the 2 background papers summarize the evidence for management.

Treatment of Low Back Pain

Clinicians should inform all patients of the generally favorable prognosis of acute low back pain with or without sciatica, including a high likelihood for substantial improvement in the first month. Clinicians should explain that early, routine imaging and other tests usually cannot identify a precise cause, do not improve patient outcomes, and incur additional expenses. Clinicians should also review indications for reassessment and diagnostic testing (see recommendations 1 and 4). General advice on self-management for nonspecific low back pain should include recommendations to remain active, which is more effective than resting in bed for patients with acute or subacute low back pain. If patients require periods of bed rest to relieve severe symptoms, they should be encouraged to return to normal activities as soon as possible. Self-care education books based on evidence-based guidelines, such as The Back Book, are recommended because they are an inexpensive and efficient method for supplementing clinician-provided back information and advice and are similar or only slightly inferior in effectiveness to such costlier interventions as supervised exercise therapy, acupuncture, massage, and spinal manipulation. Other methods for providing self-care education, such as e-mail discussion groups, layperson-led groups, videos, and group classes, are not as well studied.

Factors to consider when giving advice about activity limitations to workers with low back pain are the patient's age and general health and the physical demands of required job tasks. However, evidence is insufficient to guide specific recommendations about the utility of modified work for facilitating return to work. For worker's compensation claims, clinicians should refer to specific regulations for their area of practice, as rules vary substantially from state to state. Brief individualized educational interventions (defined as a detailed clinical examination and advice, typically lasting several hours over 1 to 2 sessions) can reduce sick leave in workers with subacute low back pain.

Application of heat by heating pads or heated blankets is a self-care option for short-term relief of acute low back pain. In patients with chronic low back pain, firm mattresses are less likely than a medium-firm mattress to lead to improvement. There is insufficient evidence to recommend lumbar supports or the application of cold packs as self-care options.

Although evidence is insufficient to guide specific self-management recommendations for patients with acute radiculopathy or spinal stenosis, some trials enrolled mixed populations of patients with and without sciatica, suggesting that applying principles similar to those used for nonspecific low back pain is a reasonable approach (see also recommendation 4).

Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs).

Medications in several classes have been shown to have moderate, primarily short-term benefits for patients with low back pain. Each class of medication is associated with unique trade-offs involving benefits, risks, and costs. For example, acetaminophen is a slightly weaker analgesic than NSAIDs (<10 points on a 100-point visual analogue pain scale) but is a reasonable first-line option for treatment of acute or chronic low back pain because of a more favorable safety profile and low cost. However, acetaminophen is associated with asymptomatic elevations of aminotransferase levels at dosages of 4 g/d (the upper limit of U.S. Food and Drug Administration–[FDA] approved dosing) even in healthy adults, although the clinical significance of these findings are uncertain. Nonselective NSAIDs are more effective for pain relief than is acetaminophen, but they are associated with well-known gastrointestinal and renovascular risks. In addition, there is an association between exposure to cyclooxygenase-2–selective or most nonselective NSAIDs and increased risk for myocardial infarction. Clinicians should therefore assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs and recommend the lowest effective doses for the shortest periods necessary. Clinicians should also remain alert for new evidence about which NSAIDs are safest and consider strategies for minimizing adverse events in higher-risk patients who are prescribed NSAIDs (such as co-administration with a proton-pump inhibitor). There is insufficient evidence to recommend for or against analgesic doses of aspirin in patients with low back pain).

Opioid analgesics or tramadol are an option when used judiciously in patients with acute or chronic low back pain who have severe, disabling pain that is not controlled (or is unlikely to be controlled) with acetaminophen and NSAIDs. Because of substantial risks, including aberrant drug-related behaviors with long-term use in patients vulnerable or potentially vulnerable to abuse or addiction, potential benefits and harms of opioid analgesics should be carefully weighed before starting therapy. Failure to respond to a time-limited course of opioids should lead to reassessment and consideration of alternative therapies or referral for further evaluation. Evidence is insufficient to recommend one opioid over another.

The term skeletal muscle relaxants refers to a diverse group of medications, some with unclear mechanisms of action, grouped together because they carry FDA-approved indications for treatment of musculoskeletal conditions or spasticity. Although the antispasticity drug tizanidine has been well studied for low back pain, there is little evidence for the efficacy of baclofen or dantrolene, the other FDA-approved drugs for the treatment of spasticity. Other medications in the skeletal muscle relaxant class are an option for short-term relief of acute low back pain, but all are associated with central nervous system adverse effects (primarily sedation). There is no compelling evidence that skeletal muscle relaxants differ in efficacy or safety. Because skeletal muscle relaxants are not pharmacologically related, however, risk–benefit profiles could in theory vary substantially. For example, carisoprodol is metabolized to meprobamate (a medication associated with risks for abuse and overdose), dantrolene carries a black box warning for potentially fatal hepatotoxicity, and both tizanidine and chlorzoxazone are associated with hepatotoxicity that is generally reversible and usually not serious.

Tricyclic antidepressants are an option for pain relief in patients with chronic low back pain and no contraindications to this class of medications. Antidepressants in the selective serotonin reuptake inhibitor class and trazodone have not been shown to be effective for low back pain, and serotonin–norepineprhine reuptake inhibitors (duloxetine and venlafaxine) have not yet been evaluated for low back pain. Clinicians should bear in mind, however, that depression is common in patients with chronic low back pain and should be assessed and treated appropriately.

Gabapentin is associated with small, short-term benefits in patients with radiculopathy and has not been directly compared with other medications or treatments. There is insufficient evidence to recommend for or against other antiepileptic drugs for back pain with or without radiculopathy. For acute or chronic low back pain, benzodiazepines seem similarly effective to skeletal muscle relaxants for short-term pain relief but are also associated with risks for abuse, addiction, and tolerance. Neither benzodiazepines nor gabapentin are FDA-approved for treatment of low back pain (with or without radiculopathy). If a benzodiazepine is used, a time-limited course of therapy is recommended.

Herbal therapies, such as devil's claw, willow bark, and capsicum, seem to be safe options for acute exacerbations of chronic low back pain, but benefits range from small to moderate. In addition, many of the published trials were led by the same investigator, which could limit applicability of findings to other settings.

Systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, because they have not been shown to be more effective than placebo.

Most medication trials evaluated patients with nonspecific low back pain or mixed populations with and without sciatica. There is little evidence to guide specific recommendations for medications (other than gabapentin) for patients with sciatica or spinal stenosis. Evidence is also limited on the benefits and risks associated with long-term use of medications for low back pain. Therefore, extended courses of medications should generally be reserved for patients clearly showing continued benefits from therapy without major adverse events.

Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

For acute low back pain (duration <4 weeks), spinal manipulation administered by providers with appropriate training is associated with small to moderate short-term benefits. Supervised exercise therapy and home exercise regimens are not effective for acute low back pain, and the optimal time to start exercise therapy after the onset of symptoms is unclear. Other guidelines suggest starting exercise after 2 to 6 weeks, but these recommendations seem to be based on poor-quality evidence. Other nonpharmacologic treatments have not been proven to be effective for acute low back pain.

For subacute (duration >4 to 8 weeks) low back pain, intensive interdisciplinary rehabilitation (defined as an intervention that includes a physician consultation coordinated with a psychological, physical therapy, social, or vocational intervention) is moderately effective, and functional restoration with a cognitive-behavioral component reduces work absenteeism due to low back pain in occupational settings. There is little evidence on effectiveness of other treatments specifically for subacute low back pain. However, many trials enrolled mixed populations of patients with chronic and subacute symptoms, suggesting that results may reasonably be applied to both situations.

For chronic low back pain, moderately effective nonpharmacologic therapies include acupuncture, exercise therapy, massage therapy, Viniyoga-style yoga, cognitive-behavioral therapy or progressive relaxation, spinal manipulation, and intensive interdisciplinary rehabilitation, although the level of supporting evidence for different therapies varies from fair to good. In meta-regression analyses, exercise programs that incorporate individual tailoring, supervision, stretching, and strengthening are associated with the best outcomes. The evidence is insufficient to conclude that benefits of manipulation vary according to the profession of the manipulator (chiropractor vs. other clinician trained in manipulation) or according to presence or absence of radiating pain. With the exception of continuous or intermittent traction, which has not been shown to be effective in patients with sciatica, few trials have evaluated the effectiveness of treatments specifically in patients with radicular pain or symptoms of spinal stenosis. In addition, there is insufficient evidence to recommend any specific treatment as first-line therapy. Patient expectations of benefit from a treatment should be considered in choosing interventions because they seem to influence outcomes. Some interventions (such as intensive interdisciplinary rehabilitation) may not be available in all settings, and costs for similarly effective interventions can vary substantially. There is insufficient evidence to recommend the use of decision tools or other methods for tailoring therapy in primary care, although initial data are promising.

Transcutaneous electrical nerve stimulation and intermittent or continuous traction (in patients with or without sciatica) have not been proven effective for chronic low back pain. Acupressure, neuroreflexotherapy, and spa therapy have not been studied in the United States, and percutaneous electrical nerve stimulation is not widely available. There is insufficient evidence to recommend interferential therapy, low-level laser therapy, shortwave diathermy, or ultrasonography. Evidence is inconsistent on back schools, which have primarily been evaluated in occupational settings, with some trials showing small, short-term benefits.

It may be appropriate to consider consultation with a back specialist when patients with nonspecific low back pain do not respond to standard noninvasive therapies. However, there is insufficient evidence to guide specific recommendations on the timing of or indications for referral, and expertise in management of low back pain varies substantially among clinicians from different disciplines (including primary care providers). In general, decisions about consultation should be individualized and based on assessments of patient symptoms and response to interventions, the experience and training of the primary care clinician, and the availability of specialists with relevant expertise. In considering referral for possible surgery or other invasive interventions, other published guidelines suggest referring patients with nonspecific low back pain after a minimum of 3 months to 2 years of failed nonsurgical interventions. Although specific suggestions about timing of referral are somewhat arbitrary, one factor to consider is that trials of surgery for nonspecific low back pain included only patients with at least 1 year of symptoms. Other recommendations for invasive interventions are addressed in a separate guideline from the APS.

This information was written by Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS, was developed for the American College of Physicians' Clinical Efficacy Assessment Subcommittee and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel. For members of these groups, see end of text. Approved by the American College of Physicians Board of Regents on 14 July 2007. Approved by the American Pain Society Board Executive Committee on 18 July 2007.