Sample Treatment Protocol

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1 Sample Treatment Protocol 1 Adults with acute episode of LBP Definition: Acute episode Back pain lasting <4 weeks for new episode or as acute exacerbation for chronic low back pain patients Exclusions (See Box 11 also) Patients with previous low back surgery Pregnant women Children 2 Perform and document a focused history and physical examination to include: - Duration of symptoms - Risk factors for potentially serious conditions (See the Diagnostic Work-Up Checklist ) - suggesting radiculopathy or spinal stenosis - Presence and severity of neurologic deficits - Psychosocial risk factors - Employment status 12 3 Are any potentially specific conditions strongly suspected? See Diagnostic Work-Up Checklist.doc Assess and document pain and functional status 4 Repeat Box 2 with any worsening of symptom severity, or every 3-6 months with stable symptoms Patients with significant psychosocial issues require appropriate treatment or referral Perform the diagnostic studies to identify cause. Document the diagnostic workup Evaluation suggests herniated disc or spinal stenosis, but no other specific causes Evaluation suggests cancer, vertebral infection, cauda equina syndrome, vetebral compression fracture, ankylosing spondylitis, or degenerative scoliosis Severe radicular pain? Significant neurologic deficit? These patients are excluded from the remainder of the protocol. Consider consultation 8 9 Go to Box 27 Go to Box Back pain is mild with no substantial functional impairment? 14 Counsel the patient on the generally favorable prognosis of acute LBP (with or without radiculopathy). Review indications for reassessment with the patient including worsening of symptoms, failure to improve after 1 month and diagnostic testing (see boxes 3 & 4). Provide The Back Book and review self care options such as superficial heat. Patients should be advised to continue usual activities as much as possible and specifically advised against bed rest. 15 Counsel the patient on the generally favorable prognosis of acute LBP (with or without radiculopathy). Provide The Back Book and review self care options such as superficial heat and advice against bed rest. Shared decision-making should be used to determine the right treatment option among non-invasive pharmacological and non-pharmacological therapies. See Interventions.doc Clinicians to document reasons for using non-first-line treatment options and non-recommended therapies. 16 Patient accepts risks and benefit of chosen therapy? 18 Initiate time limited trial of chosen therapy. 17 Patient to try self care. Reassess in 1 month. 19 Follow-up within 4 weeks unless symptoms completely resolve Document pain and functional status 3 months after completion of care. Go to Box 20 to continue flow. Protocol adapted from 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;147:478-49

2 20 Assess response to treatment. Document pain and functional status. 21 Back pain and/or radiculopathy resolved or improved with no significant functional deficits? 22 Continue therapy and reassess in 1 month. Document pain and functional status 3 months after completion of care Signs or symptoms of radiculopathy or spinal stenosis? Employ shared decision-making regarding having a MRI for LBP Perform MRI if the patient is a candidate for surgery or epidural steroid injection (for herniated disc) 29 Reassess symptoms and risk factors and reevaluate diagnosis. See Boxes Consider imaging studies. Shared decision-making should be employed prior to MRI or CT scans. 25 Significant (concordant) nerve root impingement or spinal stenosis present on MRI? 26 Employ shared decision-making regarding surgery to determine patient interest in referral for possible surgery. Also discuss the possibility of epidural steroid injection (if herniated disk) with patients as a treatment option. 27 Patient interested in referral to surgery or ESI? es 28 o Go to Box Employ shared decision-making to consider alternative pharmacologic and nonpharmacologic interventions. For patients experiencing loss of function, consider more intensive multidisciplinary approach or referral. See Interventions.doc For patients who get surgery or ESI, pain and function status should be documented: Within 2-4 weeks of ESI Within 4-6 weeks of surgery 3, 6, 12 months post-operatively For failed back surgery syndrome with persistent radicular symptoms: Return to Box 20 Document pain and functional status 3 months after completion of care. Discuss risks/benefits of spinal cord stimulation using a shared decisionmaking framework. For patients experiencing persistent, disabling non-radicular pain for >1 year that have not responded to multiple attempts at non-invasive therapies: Discuss risks/benefits of surgery using a shared-decision-making framework Facet joint steroid injection, intradiscal steroid injection, and prolotherapy are not recommended. Patients should only be referred for consideration of radiofrequency denervation, or sacroiliac joint steroid injection if clinicians can document that they have persistent and at least moderately severe symptoms, have failed at least 3 recommended treatments, and are counseled on substantial uncertainties regarding potential benefits and harms. Use of other non-recommended therapies must be documented and explained. Protocol adapted from 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;147:478-49

3 Diagnostic Work-Up Checklist Possible Cause Cancer Vertebral infection Cauda equina syndrome Vertebral compression fracture Ankylosing spondylitis Severe/ progressive neurologic deficits Key features on history or physical examination Imaging Additional Studies History of cancer* with new onset of X-ray or ESR LBP (*ot including non-melanoma skin cancers) MRI Unexplained weight loss Lumbosacral Failure to improve after 1 month x-ray Age >50 years with new or changed low back pain Multiple risk factors present X-ray or MRI Fever MRI ESR and/or Intravenous drug use CRP Recent infection Urinary retention MRI one Motor deficits at multiple levels Fecal incontinence Saddle anesthesia History of osteoporosis Consider one Use of corticosteroids Lumbosacral Older age (>65 years, women; >75 x-ray years, men) for > 3 months Morning stiffness Improvement with exercise Alternating buttock pain Awakening due to back pain during the second part of the night ounger age (20-30s) Male Consider Anterior posterior pelvis x- ray, if multiple features present HLA-B27 Progressive motor weakness MRI Consider EMG/CV Herniated disc Spinal stenosis Back pain with leg pain in an L4, L5, or S1 nerve root distribution Positive straight-leg-raise test or crossed straight-leg-raise test Radiating leg pain Older age (>65 years, women; >75 years, men) Pseudoclaudication 1 (ote: Weak predictor) month: one present >1 month, MRI month: one month: one present >1 month, EMG/CV month: one 1 Painful cramps that are not caused by peripheral artery disease but rather by spinal, neurologic, or orthopedic disorders, such as spinal stenosis, diabetic neuropathy, or arthritis. Mosby s Medical Dictionary, 8 th. Elsevier, Print

4 present >1 month, MRI present >1 month, EMG/CV

5 Interventions Table Interventions supported by grade B evidence (at least fair-quality evidence of moderate benefit, or small benefit but no significant harms, costs, or burdens). o intervention was supported by grade A evidence (good-quality evidence of substantial benefit) First-line therapy Second-line therapy Low Back Pain (Duration) Acute (<4 Weeks) Subacute or Chronic (>4 Weeks) Self-care Advice to remain active Pharmacologic therapy onpharmacologic therapy Books, handout Application of superficial heat Acetaminophen SAIDs Skeletal muscle relaxants Antidepressants (TCA) Benzodiazepines Tramadol, opioids Spinal manipulation Exercise therapy Acupuncture oga Cognitive-behavioral therapy Progressive relaxation Interdisciplinary rehabilitation^ Injections Epidural steroid injection for radiculopathy with herniated disc* Surgery Decompressive laminectomy for symptomatic spinal stenosis* Discectomy for herniated disc with radiculopathy* Fusion for non-radicular low back pain with common degenerative changes* ^Consider interdisciplinary rehabilitation for patients with significant functional impairment or risk factors for chronic disabling low back pain *A shared decision-making approach is recommended when considering these interventions /

6 Adapted from the 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:

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