Evidencebased Evaluation and Management Of Low Back Pain

Evidence-based Evaluation and Management Of Low Back Pain Roger Chou, MD, FACP Professor, Department of Medical Informatics & Clinical Epidemiology, and Department of Medicine Oregon Health & Science University Director, the Pacific Northwest Evidence-based Practice Center John D. Loeser, MD Professor, emeritus, Departments of Neurological Surgery and Anesthesia and Pain Medicine, University of Washington Oregon Pain Guidance May 6, 2017

DISCLOSURES/CONFLICT OF INTEREST Dr. Chou has received research funding from the Agency for Healthcare Research and Quality and the American College of Physicians, and is a consultant with Palladian Health. Dr. Loeser has received research funding from the National Institutes of Health. 2

Session Objectives • Describe the epidemiology and natural history of low back pain • Describe trends in evaluation and management of low back pain, outcomes, practice variations, and implications for practice • Understand an evidence-based approach to evaluation and management of low back pain

THE PATIENT: 57 yo male with LBP x 2 years, no specific inciting event • No associated leg pain or other neurological symptoms • Pain slowly worsening, to the point of not being able to walk more than 2 to 3 blocks, rated 7/10 most days • Continues to golf most weekends, but riding cart now • Works as an engineer, not physically demanding • X-rays show lumbar disc degeneration and facet joint arthropathy • Tried acetaminophen and NSAIDs and has undergone PT

LBP Burden 1 • LBP is the 5 th most common reason for U. S. office visits, and the 2 nd most common symptomatic reason – >16 million LBP office visits/year – 5% of PCP visits are for LBP – Most common reason to see a neurosurgeon or orthopedist • Up to 84 percent of adults have LBP at some time in their lives, and over one-quarter in the previous 3 months – Only 2 -5% seek health care or claim disability

LBP Burden 2 • Peaks at 55 to 64 years of age; affects all ages • The most common cause of activity limitations in persons <45 years of age • More disability than cancer + heart disease + stroke + AIDS • In 2013, nearly $90 billion dollars in spending for back and neck pain • Increase of $64 billion from 1996

TRENDS IN LBP • • • Increased utilization of imaging studies Increased incidence of surgery Increased use of injections Increased prescription of opioids Increased costs for LBP No decrease in disability October 24, 2008

“ 7 Back Pain Breakthroughs Are you hurting? Here's help. ” Reader’s Digest, July, 2007 “End Back Pain Agony” Michael J. Weiss http: //www. rd. com/content/chronic-back-pain-breakthroughs-/

Reader’s Digest “Cures” for LBP • Infrared belt - $2, 335 • “Magic Spinal Wand” • Percutaneous automatic discectomy • Flexible fusion • Stem cells • Site-directed bone growth • New bed

“Experts” on causes of low back pain • “ 80% of back pain is caused by weak or tense muscles. ” • “The majority of LBP actually originates in the sacral ligaments. ” • “In 50% or more…the facet joint is the site of dysfunction. ” • “ 90 -95% of back pain is due to disks. ” • “An extremely high percentage…have fascial problems. ” • “ 50 -70% of chronic symptoms are psychological in origin. ” Deyo RA, Spine 1993; 18: 2153 -2162

“Experts” on effectiveness of treatments for low back pain • “Mobilization and manipulation studies claim an 80% success rate. ” • “ 80% of low back pain patients get immediate relief with epidural blocks. ” • “In the YMCA’s exercise program, 80% improve. ” • “With microcurrent therapy… 82% were pain free with 10 treatments. ” • “ 70 -80% of those carefully screened for radicular symptoms benefit from surgery. ” Deyo RA, Spine 1993; 18: 2153 -2162

What makes treatments appear effective? Natural history Regression to the mean Hawthorne and other non-specific effects Fraud Placebo effects Selection of patients more likely to improve • Specific or “true” effects of treatment • • •

RISK FACTORS FOR LBP • • • Congenital spine abnormalities Smoking Occupation Prior episode of LBP Physical unfitness Increasing age

THE PATIENT: 57 yo male with LBP x 2 years, no specific inciting event • No associated leg pain or other neurological symptoms • Pain slowly worsening, to the point of not being able to walk more than 2 to 3 blocks, rated 7/10 most days • Continues to golf most weekends, but riding cart now • Works as an engineer, not physically demanding • X-rays show lumbar disc degeneration and facet joint arthropathy • Tried acetaminophen and NSAIDs and has undergone PT

2007 American College of Physicians/American Pain Society guidelines

2017 American College of Physicians guideline • Emphasis on nonpharmacologic therapies, particularly for chronic LBP • Stronger cautions regarding opioids • Acetaminophen no longer recommended for acute LBP • More evidence on mind-body interventions (yoga, Tai Chi, mindfulness-based stress reduction)

STEPS FOR EVIDENCE-BASED DIAGNOSIS AND TREATMENT OF LOW BACK PAIN IN PRIMARY CARE

STEP 1 IN THE CARE OF THE LBP PATIENT Listen to the patient’s story, obtain adequate medical history and social history. Look for psychological and environmental factors that might impair recovery.

STEP 2 IN THE CARE OF THE LBP PATIENT Perform a directed physical examination

History and physical for diagnosing specific conditions • Cancer: History of cancer, elevated ESR • Weaker predictors: unexplained weight loss, failure to improve after 1 month, age >50 • Herniated disc: Leg pain in radicular distribution and positive straight leg raise test • Spinal stenosis: Wide-based gait, lack of pain when seated • Weaker predictors: neurogenic claudication, age >65 • Cauda equina syndrome: Urinary retention

Epidemiology of low back pain • >85% of patients who present to primary care have LBP that cannot be attributed to a specific disease or spinal pathology; therefore “non-specific lbp” • Labeling most patients with specific diagnosis is misleading and doesn’t improve outcomes • Conditions to rule out: (all are rare) • Cancer 0. 7%, compression fracture 4%, ankylosing spondylitis 0. 3% to 5%, spinal infection 0. 01% • Spinal stenosis 3%, symptomatic herniated disc 4% • Cauda equina syndrome 0. 04% (usually due to massive midline disc herniation)

STEP 3 IN THE CARE OF THE LBP PATIENT Review any laboratory or imaging data and any prior medical records.

STEP 4 ESTABLISH A PRELIMINARY DIAGNOSIS • Non-specific low back pain (most likely) • Radiculopathy and/or spinal stenosis • Another specific diagnosis

PROUST The Remembrance of Things Past “For each ailment that doctors cure with medications (as I am told they do occasionally succeed in doing) they produce ten others in healthy individuals by inoculating them with the pathological agent a thousand times more virulent than all the microbes—the idea that they are ill. ”

NOT A STEP No imaging or other diagnostic tests needed initially in a patient with nonspecific low back pain.

When to obtain imaging and other diagnostic tests • Use history and physical to guide approach • High risk for vertebral compression fracture • Suspected infection, cauda equina syndrome, progressive/severe neurologic deficits • Advanced imaging usually necessary • Risk factors for cancer • If age only risk factor, consider time-limited (e. g. 1 month) trial of therapy • If previous cancer or cancer more strongly suspected, consider x-ray plus ESR initially • Suspected radiculopathy or spinal stenosis • In absence of severe/progressive neurologic symptoms with no improvement after >1 month, consider MRI or CT after >1 month in candidates for surgery or epidural steroid injections

Why isn’t routine imaging helpful? • Favorable natural history of acute LBP • Low prevalence of serious underlying conditions • Almost all have identifiable risk factors • Poor correlation between common imaging findings and symptoms • Labeling patients with a specific diagnosis may cause harm • Fear avoidance behaviors, anxiety • Minimal impact on clinical decision-making • Increase likelihood of unnecessary and potentially harmful interventions

STEP 5 IMPLEMENT CONSERVATIVE CARE Physical activity Medications Education Follow-up

STEP 5 a PHYSICAL ACTIVITY • The role of therapist is to educate and monitor the patient’s progress. • Most of the planned activities do not require medical supervision or high technology: a gym will do. • Group activities are often helpful.

RAPID RETURN TO NORMAL ACTIVITIES Bed rest is bad for your health.

Recommend a gradual and progressive increase in physical activities on a quota system. Never “…let pain be your guide”.

Educate the patient: HURT AND HARM ARE NOT SYNONYMS.

PASSIVE THERAPIES ARE OF LITTLE VALUE.

Recommendation: Self-care and education Provide patients with evidence-based information about their expected course, advise patients to remain active, and provide information about effective selfcare options. 34

STEP 5 b MEDICATIONS • • • Adjuncts to comprehensive therapies Antidepressants are most useful class No role for anxiolytics (benzos) in most pts Opioids for short-term use only NSAIDs may be helpful; watch for side-effects

STEP 5 d FOLLOW-UP • Planned follow-up reduces health care consumption. • Re-assess if unsatisfactory progress or any yellow flags for adverse outcomes. • Physician as teacher and leader and reinforcer

STEP 6: REASSESSMENT AT 4 -6 WEEKS • If symptoms persist unabated, look for impediments to recovery. • Consider imaging studies if clinical signs and symptoms are suspicious. • Know the consultant to whom you refer the patient.

PREVENTION OF DISABILITY SHOULD BE THE PRIMARY OUTCOME GOAL FOR ALL PATIENTS WITH LOW BACK AND LEG PAIN.

THE NATURAL HISTORIES OF ACUTE, RECURRENT AND CHRONIC LOW BACK PAIN AND SCIATICA ARE RELATIVELY BENIGN. Why didn’t they tell me that in my residency?

Identify and address risk factors for chronicity Small proportion of patients with acute LBP go on to develop persistent LBP, but account for the majority of costs • Psychosocial factors the strongest predictor for chronicity, environmental factors also play a role STar. T Back Trial • 1573 UK patients with LBP (+/- radiculopathy), any duration • Randomized to stratified care based on prognosis (low, medium, or high-risk) or usual care • Low-risk intervention: educational video and booklet • Medium and high-risk interventions: referred for psychologically informed physiotherapy (3 vs. 9 days of additional training) • Stratified care more effective than usual care for function (1. 8 points at 4 months and 1. 1 pts at 12 months); also cost effective • STar. T Back approach being tested in the U. S. Hill JC et al. Lancet 2011; 378: 1560

Advice and self-care for low back pain • Inform patients of generally favorable prognosis of acute LBP with or without sciatica • Discuss need for re-evaluation if not improved • Advise to remain active • Counsel that hurt and harm are not synonymous • Consider self-care education books • Superficial heat moderately effective for acute low back pain • No evidence to support use of lumbar supports • No evidence to support use of traction

Recommendation: Nonpharmacological therapies • For patients who do not improve with self-care options, consider the use of non-pharmacologic therapy with proven benefits. • For chronic low-back pain, options include: intensive interdisciplinary rehabilitation, exercise therapy, cognitive-behavioral therapy, yoga, mindfulnessbased stress reduction, acupuncture, massage therapy, or spinal manipulation. • For acute low-back pain, options include: exercise, acupuncture, manipulation.

Approach to use of non-pharmacologic therapies for LBP • A number of therapies appear similarly effective • Emphasis on active rather than passive therapies • Exercise therapies, cognitive-behavioral therapy as first-line treatments • Focus on function, not just pain • Address maladaptive coping behaviors such as fearavoidance, catastrophizing • Yoga, mindfulness-based stress reduction, Tai Chi options • Interdisciplinary rehabilitation for patients with severe functional impairment or strong psychosocial component • Manipulation, acupuncture, massage as adjunctive therapy • Physical modalities passive and not well supported by evidence

Recommendation: Medications • Use as adjunctive therapies in persons receiving non-pharmacological therapies • Consider medications in conjunction with back care information and self care • For most patients, NSAIDs are the first line medication option 44

Pharmacological interventions • First-line: NSAIDs • Small benefits, but low cost and generally good safety profile • ? Effectiveness of acetaminophen for acute LBP • Second-line • Skeletal muscle relaxants (acute) • Antidepressants (chronic) • ? Antiseizure medications • Avoid in most patients: Benzodiazepines (acute), opioids (use with caution!) • Not recommended: Systemic corticosteroids 45

Case 57 yo male with LBP x 2 years, no specific inciting event • No associated leg pain or other neurological symptoms • Pain slowly worsening, to the point of not being able to walk more than 2 to 3 blocks, rated 7/10 most days • Continues to golf most weekends, but riding cart now • Working as engineer • X-rays show lumbar disc degeneration and facet joint arthropathy • Tried acetaminophen and NSAIDs and has undergone PT

Case—Risk Assessment • Mr. S. has no personal or family history of substance abuse • No history of depression or other psychological disorders • No serious comorbid conditions that are contraindications to opioid therapy • STar. T Back Score: 1 (only able to walk short distances) • Opioid Risk Tool score: 0 • Urine drug test negative • Assessed risk for misuse/abuse: Low

Case—Management Plan and Initial Follow-up • Set goal of walking 30 minutes 4 times a week • Longer term goal walking 9 holes of golf • Low-dose opioid therapy (oxycodone 5 mg twice daily) initiated • At 4 week follow-up, pain decreased from 7/10 to 4/10 • Able to walk 20 -30 minutes 4 times a week • No signs of aberrant behaviors • Plan: Continue opioid therapy at the same, low dose, follow-up in 2 months

Case—Follow-up 2 Months • Walking 20 minutes once or twice a week. “I can’t walk more because it makes things worse. ” • Still not able to walk 9 holes of golf • Has taken an “extra” oxycodone on several days with increased pain and has run out of prescription one or two days early • “I feel like I’m never going to improve” • No signs of aberrant behaviors • UDS: No oxycodone or other opioids, no illicit drugs • PDMP: No controlled substances from other providers

Case—Management Plan • Counsel on need to stick with prescribed doses • Counsel on importance of activity and exercise • Increase oxycodone to 10 mg twice daily • Add duloxetine 10 mg po q. D • Refer back to physical therapy • Follow-up in 1 month

Case—Follow-up 3 Months • Still having pain and not walking • Started PT but stopped attending because it hurt too much • States taking oxycodone as directed, UDS shows hydrocodone but no oxycodone • Duloxetine made him “feel funny” and he stopped it • PDMP: OK • Requesting more opioids

Case—Management Plan • Refer for cognitive-behavioral therapy • Taper opioids • Trial of pregabalin instead of duloxetine • 1 month follow-up

Case—Follow-up 5 Months • No improvement in pain or function • Has attended some CBT and PT sessions, says they are not helping • Taking pregabalin but doesn’t think it’s helping • Off oxycodone

Case—Management Plan • Continue off oxycodone • Referred for intensive interdisciplinary rehabilitation • Titrated up pregabalin

The main concepts from this session are: • Rates of LBP and associated costs are increasing despite more aggressive testing and treatment • Use evidence-based principles to inform more effective and efficient care • Shift away from routine imaging and diagnostic testing • Early identification and management of psychosocial contributors to pain • Focus on function, not just pain • Set achievable functional goals • Self-care and education in all patients • Focus on use of active nonpharmacological therapies • Passive therapies in adjunctive role • Cautious use of opioids • Non-invasive approaches to most LBP

THANK YOU October 24, 2008