Nontraumatic Low Back Pain Sarah Mc Pherson Oct
Nontraumatic Low Back Pain Sarah Mc. Pherson Oct. 3, 2002
Why is it important? • High disease prevalence • most expensive cause of work-related disability • wide variations in medical care
Sickness days appear to be increasing Waddell, G. Ann Rheum Dis. 1993; 52: 317 -19
Practice patterns in the USA • US National survey of 114 ER physicians • answered questionnaire of case vignettes • results reflect that practice pattern does not follow recommended guidelines or the medical literature Elam KC, J Emerg Med. 1995; 13(2): 143 -50
What causes low back pain? • May originate from many spinal structures: – ligaments – facets – periosteum – muscles – fascia – blood vessels – nerve roots – anulus fibrosus • ~ 85% no pathoanatomical diagnosis
Important questions to ask • Is there a systemic disease that is the source for the pain? • Is there any indication that surgical evaluation is required? • How can I provide the best symptomatic relief? • Can I help to prevent chronicity or recurrence?
What are the indications for further imaging? AHCPR guidelines for the ordering of radiographs: Possible Fracture: Possible tumor or infection: major trauma minor trauma age >50 chronic steroid use osteoporosis > 50 yrs < 20 yrs history of cancer constitutional symptoms recent bacterial infection iv drug use immunosuppression supine pain nocturnal pain
Problems with the AHCPR guidelines • There has been no prospective validation therefore we do not know the sensitivity or specificity • following the guidelines would increase utilization by ~ 200% Suarez-Almazor. JAMA. 1997 277(22). 1782 -86 • plain radiographs are not sensitive for the diseases that require specific therapy – 23% epidural abscess, 25% disc space infection, 68% bone tumor, 90% vertebral osteomyelitis Liang, M. Arch Intern Med. 1982, 142: 1108 -12 • radiation dose of lumbar radiographs 40 X > than CXR Whalen, JP. Dis Mon. 1982; 28: 73
What about MRI? • Advantages: – highly sensitive for the detection of infection, tumors, nerve root compression, spinal stenosis • Disadvantages: – imaging may not correlate with clinical disease • 25% of asymptotic patients have disc herniation • 50% healthy young adults will have bulging or degenerative discs on MRI Jarvik, J. Radiology. 1997; 204(2): 447 -54 – cost effectiveness
So when should you order an MRI? • No validated clinical guidelines • Recommendations: – – clinical suggestion of underlying infection clinical suggestion of underlying cancer persistent neurologic deficit evidence of cauda equina syndrome
When is surgical evaluation required? • Cauda equina syndrome (surgical emergency) – bladder or bowel dysfunction (usually urinary retention) – numbness to perineum and medial thighs (saddle distribution) – bilateral leg pain, weakness and numbness • progressive or severe neurologic deficits • persistent neuromotor deficit after 4 -6 weeks • persistent sciatica for 4 -6 weeks (not low back pain alone) Deyo, RA. NEJM. 2001; 344(5): 363 -70
Pharmaceutical treatment of LBP AHCPR Guidelines: – Recommended medications: • Acetominophen • NSAIDs – “Optional” medications: • muscle relaxants • opioids for < 2 weeks – Recommended against: • • • opioids > 2 weeks phenylbutazone oral steroids colchicine antidepressants
Evidence for NSAIDs • NSAID vs Placebo – 9 RCT (5 high quality, 4 low) – heterogeneity between studies with respect to dosing, mode of administration and type of NSAID RESULTS: – NSAIDs provide better pain control than placebo – improved global improvement in patients treated with NSAIDs – decreased need for additional analgesia in NSAID groups van Tulder, MW. Spine 2000; 25: 2501 -13
Evidence for NSAIDs • NSAID vs Acetominophen – 5 RCT (1 high quality, 4 low) RESULTS: – 2 low quality studies showed no difference – 1 low quality and 1 high quality showed superiority of NSAID for pain control Bottom line: Conflicting evidence but NSAIDs appear more effective than acetominophen van Tulder, MW. Spine 2000; 25: 2501 -13
Evidence for NSAIDs • NSAID + muscle relaxant – 3 RCT (1 high quality, 2 low quality) Results: – all 3 studies showed combined therapy to be better than NSAID alone but results not statistically significant van Tulder, MW. Spine. 2000; 25: 2501 -13
Evidence for NSAIDs • Comparisons of different NSAID types – 24 trials – looked at ibuprofen, indomethacin, diclofenac, ketorolac, tenoxicam, piroxicam, naproxen RESULTS: – equal efficacy
Evidence for NSAIDs • NSAID vs COX-2 – RCT – N = 104 – nimesulide vs ibuprofen Results: – no difference in pain or stiffness scores – no difference in side effects Pohjolainen, T. Spine 2000; 25(12): 1579 -85
What about muscle relaxants • 14 RCT (8 high quality, 6 low quality) • 8 high quality: – 5 showed improvement in pain intensity, 3 no difference • many different muscle relaxants studied (cylcobenzaprine, tizanidine, diazepam, baclofen, butabarital) • all appear to have equal efficacy however good studies with head to head comparisons are lacking van Tulder, MW. Spine. 1997; 22(18): 2128 -56
Cyclobenzaprine (Flexeril) • 14 RCT’s reviewed in meta-analysis • all studies but 2 treated for > 14 days • dosing was 10 mg tid • Outcomes measured: – – – local pain muscle spasm tenderness to palpation range of motion activities of daily living
Cyclobenzaprine - outcomes • Moderate improvement for all outcome measures • NNT = 3 Browning, R. Arch Intern Med. 2001; 161: 1613 -20
Cyclobenzaprine - Side effects • 53% of patients experience at least one side effect compared with 28% in the placebo group
What if your patient prefers “natural” remedies? • The efficacy of willow bark extract – RCT: high (240 mg) and low dose(120 mg) willow bark vs placebo – N = 210 – outcomes measures VAS at 4 weeks, need of break-through analgesia – Results: high dose > low dose > placebo Chrubasik, S. Am J Med. 2000; 109: 9 -14
Medical Management - What should you choose? • Regular dosing of NSAID of your choice for 12 weeks • addition of muscle relaxant (warn of side effects), acetominophen or a narcotic may be of benefit • the optimal combo of meds and duration is not known
To rest or not to rest? • current guidelines advocate bed rest for a maximum of 2 days for LBP and up to 2 weeks for sciatica QUESTIONS: – Is there any evidence to suggest that bed rest may improve recovery? – Is there any evidence that bed rest may be harmful?
Bed rest has not been shown to be effective treatment for LBP Systematic review: – 10 trial identified evaluating therapeutics of bed rest – length of bed rest varied from 2 -7 days – 8 trials showed no difference in pain scores or activities of daily living – despite differences in length of rest, no trials showed a difference or efficacy of bed rest Waddell, G. Br J Gen Prac. 1997; 47: 647 -52
Could bed rest actually have negative effects? Bed rest vs Exercises vs ordinary activity? – RCT to 3 groups (N= 67, 52, 67) – outcome measures of duration & intensity of pain, absence from work, ability to work, & Oswestry back disability index – groups evaluated at 3 and 12 weeks – control group had less absenteeism, decrease pain intensity scores and similar satisfaction to bed rest group Malmivaara, A. NEJM. 1995; 332(6): 351 -55
3 week outcomes
Outcomes at 12 weeks
Bed rest for Sciatica • RCT 2 weeks bed rest vs normal activity • N = 92 & 91 • outcome measures: global assessment of function, pain scores, absenteeism, surgical requirements • evaluated at 3 and 12 weeks Vrooman, PCAJ. NEJM. 1999; 340(6): 418 -23
Bed rest for sciatica Results: – 10 % lost to follow-up – mean # days in bed 22 hr vs 10 hrs – no difference in outcome measures at 3 or 12 weeks • Bed rest is definitely not more effective in treating sciatica • Is it harmful? - this study does not answer that & no other studies were found in my review
Physiotherapy and exercise programs Systematic Review – 1991 – – 16 studies identified Only 4 high quality studies Different types of therapy studied Chronic and acute LBP – 10 studies reported no difference between treatment and nontreatment groups – 6 studies reported positive results in the PT group Koes, BW. BMJ. 1991; 302: 1572 -6
What is the role of physiotherapy? • Since 1991 5 more studies looking at PT for acute LBP Positive Studies – 1 study identified – Retrospective review of randomly selected patients with acute LBP – Looked at 3 groups (immediate PT, start at 2 -7 days or Pt started at 8 -179 days) – Delayed therapy group had increased absenteeism and more physician visits
What is the role of physiotherapy? • 4 negative studies Cherkin et al , NEJM. 1998; 339(15) 1021 -9: – prospective RCT Mc. Kenzie PT vs chiro vs educational booklet – N = 323, LBP < 7 days – PT and chiro group had less “bothersome” symptoms at 4 weeks but not at 12 weeks – no difference in Roland disability scores, absenteeism or recurrences at 1 or 2 years – PT and chiro costs similar, both +++ more expensive than educational booklet
What is the role of physiotherapy? Faas, A et al. Spine 1995; 20(8): 941 -7: – – prospective RCT no treatment vs PT vs sham PT N= 473, LBP < 3 weeks Outcomes: • higher absenteeism in PT group • no difference in releif from symptoms • no decreased duration of pain episodes – follow-up at 1, 2, 4 and 12 months
What is the role of physiotherapy? Dettori, JR et al. Spine. 1995; 20(21): 2303 -12: – – prospective RCT flexion vs extension exercises vs no exercises N = 152, LBP < 7 days Outcomes: • • no difference in pain scores no difference in disability scores no difference time to return to work ~60% recurrence rate at 6 -12 months in all categories – follow-up at 1, 2& 4 weeks, and at 6 -12 months
What is the role of Physiotherapy? • Does not appear to decrease acute symptoms • does not appear to decrease recurrence of back pain • despite the literature, physiotherapists are convinced from experience that it works
What about spinal manipulation? • Meta-analysis of 7 studies • LBP 2 -4 weeks • improvement in pain at 2 -3 week post onset of treatment (50% vs 67%) • difference gone within weeks to months • studies did not look at disability scores or work absenteeism Shekelle, PG. Ann Intern Med. 1992; 117(7): 590 -8
Is there a role for Acupuncture? • Number of studies have been done looking at the role in chronic LBP (> 3 months) • no studies looking at acupuncture acutely • appears to be beneficial in reduction of pain, improved activity, and decreased analgesic requirements Ernst, E. Arch Intern Med. 1998; 158: 2235 -41 Christer, C. Clin J pain. 2001; 17(4): 296 -305 Ghoname, E. JAMA. 1999; 281(7): 818 -23
Overview of non pharmaceutical interventions • Bed rest is not helpful and is probably harmful • Physiotherapy does not appear to reduce symptomatology or prevent recurrence • spinal manipulation may reduce short term symptoms but loses its effect in the long term • accupuncture appears to be helpful in chronic LBP
Factors predicting chronicity • ~ 10% of all LBP becomes chronic • Risk factors include: – psychosocial issues primarily • • • fear avoidance model depression poor coping skills chronic daily stress poor job satisfaction – clinical • large disc protrusion Williams, R. Arch Phys Rehab Med. 1998; 79: 366 -73 Burton, K. Spine. 1995; 20(6): 722 -8 Hasenbring, M. Spine. 1994: 19(24): 2759 -65 Klenerman, L. Spine. 1995: 20(4): 478 -84
Can we influence the path to chronicity? • Prospective study of high risk patients – treatment of risk factor based cognitive behavioral intervention vs electromyographic biofeedback (relaxation techniques) vs no intervention – improved pain reduction, decreased immobility in daily life, decreased depression immediately post intervention and at 6 months – high risk patients with intervention had results similar to low risk patients Hasenbring, M. Spine. 1999; 24(23): 2525 -35
Can we influence Chronicity • Prospective RCT educational booklet vs advice consistent with current guidelines
Can we influence chronicity • Effects of the booklet – – improvement in beliefs at 1 year decreased fear avoidance beliefs improved Roland disability scores no difference in pain scores Burton, K. Spine. 1999; 24(23): 2484 -91
Can we influence patients returning to normal work? • The sooner the recommendation to return to work is made, the more likely the patient will comply • the probability of return to work decreases as length of time off work increases • subjective pain ratings does not correlate with a person’s ability to accomplish physical activities Hall, H. Spine. 1994; 19(18): 2033 -37
Influencing return to work • Prospective study looking at unrestricted return to work recommendations vs return to work with restricted duties – enrolled patients through their PT rehabilitation program – part way thorough they enforced that all patients be given unrestricted return to work instructions regardless of pain ratings – OUTCOMES: • increased return to work in unrestricted group (84% vs 47%) Hall, H. Spine. 1994; 19(18): 2033 -37
Overall recommendations • Regular NSAID +/- muscle relaxant/Tylenol • Spinal manipulation likely shortens course of symptoms • PT may be helpful • education emphasizing benign course of disease and encouragement to decrease fear avoidance behaviors
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