U.S. Low Back Pain
Guidelines Released
AHCPR Guidelines
Recommend Manipulation,
Discourage Surgery
WASHINGTON D.C. -- The long awaited low back pain guidelines
were officially released by the United States Agency for Health
Care Policy and Research (AHCPR) at a December 8, 1994 press
conference attended by all of the major media, despite rumors
of a surgical company threatening a lawsuit if the guidelines
were released.
For chiropractors, the most important finding of the multidisciplinary
panel was that "manipulation can be helpful for patients
with acute low back problems without radiculopathy when used
within the first month of symptoms." The panel recommended
that if no symptomatic improvement results (i.e., increased function)
after one month of manipulative treatments, manipulation should
be stopped and the patient re-evaluated.
The clinical guidelines were
produced by a 23-member panel chaired by Stanley Bigos, MD. Representing
chiropractic were Scott Haldeman, DC, MD, PhD, and John Triano,
MA, DC. The panel also included: 10 MDs; two members each from
the osteopathy, physical therapy, and nursing professions; two
PhDs; an occupational therapist, and a consumer representative.
The guidelines are restricted
in scope to the assessment and treatment of adults with acute
low back problems. Acute is defined as back pain or discomfort
lasting a few days to several weeks. An episode lasting longer
than three months is no longer acute, but chronic.
The panel made these principal
conclusions:
According to the AHCPR, the guidelines
are "systematically developed statements to assist practitioner
and patient decisions about appropriate health care." The
guidelines were developed with a critical and extensive literature
review and evaluation of the empirical evidence. Peer and field
review evaluated the validity, reliability, and utility of the
guidelines in clinical practice. The panel's recommendations
are primarily based on the published scientific literature, and
where the scientific literature was incomplete or inconsistent,
the "recommendations reflect the professional judgment of
panel members and consultants."
The need for low back guidelines is clear, with nearly 50 percent
of all working age people experiencing low back symptoms. It
is the most common disability for persons under age 45, and the
most common reason for primary care office visits. Estimates
of the cost of back problems ranges between $20 and $50 billion.
The AHCPR guidelines will likely be considered the highest authority
by third-party payers and the courts.
There is increasing evidence
that inappropriate treatment is given to low back pain sufferers.
Rates for surgery and hospitalization for low back problems vary
greatly regionally, and some patients are more disabled after
treatment than before. The guidelines say surgery is the "most
obvious example":
"Despite an extensive medical
literature on 'failed back surgery' and evidence that repeat
surgical procedures for low back problems rarely lead to improved
outcome, there are documented examples of patients who have have
had as many 20 spine operations."
The guidelines rate treatment
and diagnostic procedures on three different cost levels: low
(under $200); moderate ($200 to $1,000); high (over $1,000).
Panel Ratings
The panel rated available evidence supporting guideline statements
on a grade-scale A to D:
A = Strong research-based evidence (multiple relevant and high-quality
scientific studies).
B = Moderate research-based evidence
(one relevant, high-quality scientific study or multiple adequate
scientific studies*).
C = Limited research-based evidence
(at least one adequate scientific study* in patients with low
back pain).
D = Panel interpretation of information
that did not meet inclusion criteria as research-based evidence.
Met minimal formal criteria
for scientific methodology and relevance to population and specific
method addressed in guideline statement.
Summary of Conclusions
The guidelines represent the panel's assessment of a method's
potential to achieve the intended assessment or treatment goals,
balanced against its potential harms and costs. This is a partial
summary of the panel's conclusions:
Patient History
Inquiries about history of cancer,
unexplained weight loss, immunosuppression, intravenous drug
use, history of urinary infection, pain increased by rest, and
presence of fever are recommended to elicit red flags for possible
cancer or infection. Such inquiries are especially important
in patients over age 50. (Strength of Evidence = B)
Inquiries about signs and symptoms
of cauda equina syndrome, such as a bladder dysfunction and saddle
anesthesia in addition to major limb motor weakness, are recommended
to elicit red flags for severe neurologic risk to the patient.
(Strength of Evidence = C)
Inquiries about history of significant
trauma relative to age (for example, a fall from height or motor
vehicle accident in a young adult or a minor fall or heavy lift
in a potentially osteoporotic or older patient) are recommended
to avoid delays in diagnosing fracture. (Strength of Evidence
= C)
Attention to psychological and
socioeconomic problems in the individual's life is recommended
since such nonphysical factors can complicate both assessment
and treatment. (Strength of Evidence = C)
Use of instruments such as a
pain drawing or visual analog scale is an option to augment the
history. (Strength of Evidence = D)
Recording the result of straight
leg raising (SLR) is recommended in the assessment of sciatica
in young adults. In older patients with spinal stenosis, SLR
may be normal. (Strength of Evidence = B)
A neurologic examination emphasizing
ankle and knee reflexes, ankle and great toe dorsiflexion strength,
and distribution of sensory complaints is recommended to document
the presence of neurologic deficits. (Strength of Evidence =
B)
Spinal Manipulation
Manipulation can be helpful
for patients with acute low back problems without radiculopathy
when used within the first month of symptoms. (Strength of Evidence
= B)
When findings suggest progressive
or severe neurologic deficits, an appropriate diagnostic assessment
to rule out serious neurologic conditions is indicated before
beginning manipulation therapy. (Strength of Evidence = D)
There is insufficient evidence
to recommend manipulation for patients with radiculopathy. (Strength
of Evidence = C)
A trial of manipulation in patients
without radiculopathy with symptoms longer than a month is probably
safe, but efficacy is unproven. (Strength of Evidence = C)
If manipulation has not resulted
in symptomatic improvement that allows increased function after
one month of treatments, manipulation therapy should be stopped
and the patient reevaluated. (Strength of Evidence = D)
Plain X-rays
Plain x-rays are not recommended
for routine evaluation of patients with acute low back problems
within the first month of symptoms unless a red flag is noted
on clinical examination (such as specified below). (Strength
of Evidence = B)
Plain x-rays of the lumbar spine
are recommended for ruling out fractures in patients with acute
low back problems when any of the following red flags are present:
recent significant trauma (any age), recent mild trauma (patient
over age 50), history of prolonged steroid use, osteoporosis,
patient over age 70. (Strength of Evidence = C)
Plain x-rays in combination
with CBC and ESR may be useful for ruling out tumor or infection
in patients with acute low back problems when any of the following
red flags are present: prior cancer or recent infection, fever
over 100oF, IV drug abuse, prolonged steroid use, low back pain
worse with rest, unexplained weight loss. (Strength of Evidence
= C)
In the presence of red flags,
especially for tumor or infection, the use of other imaging studies
such as bone scan, CT, or MRI may be clinically indicated even
if plain x-rays are negative. (Strength of Evidence = C)
The routine use of oblique views
on plain lumbar x-rays is not recommended for adults in light
of the increased radiation exposure. (Strength of Evidence =
B)
Physical Agents and Modalities
Under the rubric, "physical agents," a host of interventions
(acupuncture, biofeedback, diathermy, heat, ice, TENS, traction,
and ultrasound) were "not recommended" because of lack
of scientific data to support their use. Ice and heat were suggested
to be helpful on a home care basis.
Shoe Insoles and Shoe Lifts
Shoe insoles may be effective
for patients with acute low back problems who stand for prolonged
periods of time. Given the low cost and low potential for harms,
shoe insoles are a treatment option. (Strength of Evidence =
C)
Shoe lifts are not recommended
for treatment of acute low back problems when lower limb length
difference is <2 cm. (Strength of Evidence = D)
Lumbar Corsets and Back Belts
Lumbar corsets and support belts
have not been proven beneficial for treating patients with acute
low back problems. (Strength of Evidence = D)
Lumbar corsets, used preventively,
may reduce time lost from work due to low back problems in individuals
required to do frequent lifting at work. (Strength of Evidence
= C)
Traction
Spinal traction is not recommended
in the treatment of patients with acute low back problems. (Strength
of Evidence = B)
Acupuncture
Invasive needle acupuncture and other dry needling techniques
are not recommended for treating patients with acute low back
problems. (Strength of Evidence = D)
Thermography
Thermography is not recommended for assessing patients with acute
low back problems. (Strength of Evidence = C)
Bron | source: http://www.chiroweb.com
