ACUTE LOW BACK PAIN 1

ACUTE LOW BACK PAIN 1 Clinical Treatment Pathway and Decision Support for Treatment of Acute Uncomplicated Low Back Pain Ryan D. Church FNP-C University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice

ACUTE LOW BACK PAIN 2 Table of Contents Page Executive Summary 4 Objectives 6 Clinical Significance... 7 Theoretical Framework... 9 Search Strategy 11 Literature Review 12 Barriers to Obtaining Adequate Care. 13 Treatment Options for Care of Acute Low Back Pain.. 14 Recommended Treatment for Acute Low Back Pain: National Guidelines. 15 Costs of Acute Low Back Pain.. 18 Role of Advanced Practice Clinicians.. 19 Guidelines and Pathways.. 19 Development of a Treatment Pathway 22 Implementation and Evaluation 23 Results.. 25 The Essentials of Doctoral Education for Advanced Nursing Practice 26 Recommendations..... 27 Conclusion.. 28 References. 30 Appendix A... 33 Appendix B.... 39

ACUTE LOW BACK PAIN 3 Appendix C.... 43

ACUTE LOW BACK PAIN 4 Executive Summary Acute uncomplicated low back pain is a very common problem in the United States. Acute low back pain is defined as pain present for up to 6 weeks. There is significant variability in the approach and treatment of acute uncomplicated low back pain and unnecessary/inappropriate diagnostic studies and treatments are common. Healthcare providers need a specific evidence-based clinical pathway to increase diagnostic accuracy and improve the development of treatment plans that will lead to improved outcomes. The first objective of this project was to develop an evidence-based clinical decision support pathway and algorithm to improve assessment and management of acute low back pain. The second objective of this project was to disseminate this information to providers by authoring a scholarly article for publication consideration in the Journal of the American Academy of Nurse Practitioners. The project objectives were met by the development of a treatment pathway and decision support algorithms. Utilization of the clinical pathway and decision support algorithm will lead to decreased over utilization of diagnostic measures and treatments. Use of the pathway will also improve diagnostic accuracy of spine related conditions. The clinical pathway and algorithm also serve as a guide for training new healthcare providers who wish to improve knowledge and understanding regarding diagnosis and treatment of acute low back pain. The pathway assists providers in presenting treatment options utilizing a shared decision making format. The clinical algorithm was developed to facilitate appropriate use of the pathway. The pathway and algorithm were presented in a scholarly article submitted for publication consideration to the American Academy of Nurse Practitioners. The Academic Center for Excellence (ACE) Star Model of Knowledge Transformation (2004) was selected as the theoretical framework for this project. This model helps to clarify the cycles and characteristics of knowledge that are used in evidence-based practice. It helps to organize existing information as well as newly understood concepts that are designed to improve care in the clinical setting. The Star Model of Knowledge Transformation depicts the relationship between the various phases of knowledge transformation from the discovery of new knowledge through integration into practice and subsequent evaluation of new practices. The Essentials of Doctoral Education for Advanced Practice Nurses (2006) are made up of a number of key elements, many of which were integrated and used to guide this project. Included in this project were Essentials I. II, III, VII and VIII. DNP Essential I provided an emphasis on patient education and shared decision-making. This project was chosen to improved access to care in the hopes that outcomes could be improved. Nurses are in a unique position to improve this process and facilitate positive change which satisfies the second DNP Essential. The criterion for the third DNP Essential is the process which focuses mainly on the clinical scholarship and analytical methods of evidence based practice. DNP Essential VII, clinical prevention and population for improving the nation's health was addressed. Lastly, DNP Essential VIII, advanced nursing practice, was supported and met by improving education and experience of the advanced practice clinician in the area of acute uncomplicated low back pain.

ACUTE LOW BACK PAIN 5 Acute low back pain is a common complaint in primary care settings across the country. Acute low back pain is one of the leading reasons why people seek healthcare. According to Chou et al., (2007), low back pain is the fifth most common reason for all provider visits in the United States. Scott, Moga, and Harstall (2010) noted that Between 49% and 90% of people in developed countries will experience at least one episode of low back pain during their lifetime. Pain will resolve within two weeks for the majority of these individuals. However, 20% to 44% of patients, especially those with a history of low back pain, will experience further episodes within a year, and more than three-quarters will experience a recurrence at some point in their lives. A small minority of patients (2% to 7%) will develop chronic low back pain (p. 396). There are millions of episodes of acute low back pain treated each year in the United States. Waterman, Belmont, and Schoenfeld (2012) suggest that low back pain accounted for 3.15% of all emergency visits in the United States between 2004 and 2008. Unfortunately, many who experience back pain undergo inappropriate and/or unnecessary diagnostic studies and treatments. According to Taylor and Bussieres (2012), this is due to provider lack of knowledge and experience. Diagnostic studies and treatment options carry significant risk and cost; these risks and cost may be avoided by reducing unnecessary diagnostic procedures and treatment. Time, money and other resources may be saved with proper application of appropriate care. Srinivas, Deyo, and Berger (2012) document harm associated with early imaging for low back pain, including patient labeling, unneeded follow-up tests for incidental findings, irradiation exposure, unnecessary surgery, and significant cost. Routine imaging should not be pursued in acute low back pain. Not imaging patients with acute low back

ACUTE LOW BACK PAIN 6 pain will reduce harms and costs, without affecting clinical outcomes (Srinivas, et al., 2012, p. 1016). Objectives This scholarly project was a portion of a much larger all-inclusive endeavor. The longterm goal of this all-inclusive project was to develop a rapid care spine clinic, complete with a 24-hour call center and meticulously networked referral sources. The scope of this project is far too large for a doctoral scholarly project in this setting. Therefore, a small portion of this work was addressed. The purpose of this scholarly project was to develop a patient treatment clinical guideline including an algorithm based on evidenced literature to assist healthcare providers in managing patient care as related to acute low back pain issues. These issues are related to acute low back pain defined as low back pain present for up to six weeks (North American Spine Society, 2012). The algorithm improves rates at which patients receive quality, evidence-based spinal care that is timely and consistent with national guidelines. A scholarly article was written and submitted for possible publication. The clinical guideline along with the algorithm was to be the emphasis of the article. The goal of this scholarly project initially was to develop a patient treatment clinical guideline along with an algorithm for the treatment of acute low back pain as noted above. However, after doing the extensive literature review and looking at all the evidence based literature available it became obvious that what was needed was a patient treatment clinical pathway including an algorithm. This clinical pathway was a means to bring the already established guidelines to the clinician level for appropriate application. Thus the first objective

ACUTE LOW BACK PAIN 7 for the DNP project was changed to development of a patient treatment clinical pathway along with an algorithm based on evidenced literature to assist healthcare providers in managing patient care as related to acute uncomplicated low back pain. Acute low back pain is to be defined as low back pain present for up to six weeks (North American Spine Society, 2012). The treatment pathway and algorithm, when used appropriately, will improve rates at which patients receive quality, evidence-based spinal care that is timely and consistent with national guidelines. It will also facilitate training of new providers regarding treatment of acute low back pain. A scholarly article was written and submitted for publication consideration. The clinical pathway along with the algorithm was the emphasis of the article. Clinical Significance Implementation of a patient care pathway regarding diagnosis and treatment of acute uncomplicated low back pain as well as other ailments of the spine are expected to have a number of clinical implications. Of these, the most important will be homogenization of care. For example, if a hospital or healthcare company that controls a number of outpatient clinics, emergency rooms, clinical practice areas, and primary care clinics wishes to standardize care, they could implement the treatment pathway and others like it for commonly encountered back complaints. This is currently being done for cardiac complaints in emergency departments. Lippi et al. (2012) state that the preferable approach to deal with chest pain is to develop joint protocols that will assist the clinical decision-making to quickly and accurately to rule-out patients with non-life-threatening conditions (p. 244). Standardization of care has a number of possible benefits. Training all treating personnel in the latest and most evidence based treatment pathways improves patient care by providing decision -making support. Scott et al. (2010) points out that many providers lack current

ACUTE LOW BACK PAIN 8 education and training regarding appropriate treatment of low back pain. Providers continue to avoid suggestion related to treatment in lieu of utilization of personal beliefs and outdated training. If providers were held accountable to mandated treatment pathways, change would be forthcoming. Health related issues associated with unnecessary testing are no small concern. Most diagnostic tests carry some risk. Taylor and Bussieres (2012) explain potential adverse outcomes of overuse of imaging include inefficient and potentially inappropriate invasive diagnosis and subsequent treatment, unnecessary ionizing radiation exposure, increased waiting time for treatment, added costs, and poor utilization of human resources (p. 2). Cost is another clinical implication. Many unnecessary diagnostic studies and treatments are performed on patients each year. This leads to billions of dollars in lost assets yearly in the United States (Ivanova et al., 2011). By reducing or eliminating unnecessary diagnostics studies such as Magnetic Resonance Imaging (MRI) and by eliminating inappropriate treatments such as facet joint injections, large sums of money could be saved by policy holders, insurance companies, and government programs. There are other costs associated with these unnecessary diagnostic and treatment measures that have immeasurable effects on human health and wellbeing. Access to service would be impacted. Patients and providers would not have to waste time on unneeded treatments and tests, and time in the office for diagnostic work up and treatment planning would decrease. As health care providers become better equipped to treat common problems, such as acute low back pain, patients will spend less time in the health care setting and more time on the job. This would decrease cost and increase outcome while improving productivity.

ACUTE LOW BACK PAIN 9 As evidence based approved pathways are implemented, gaps in knowledge will be clearly identified and directions for future study clarified. As protocols are developed for acute uncomplicated low back pain and related complaints, such as acute low back pain with radiculopathy, chronic low back pain, chronic low back pain with radiculopathy and others, additional gaps will be identified and further research may be needed. Theoretical Framework In the modern healthcare model where patients seek treatments for expressed concerns, there are many specific decisions in which the health care provider must engage and negotiate. At the core of this scholarly project is the desire to provide decision support for the health care provider treating acute low back pain. The Academic Center for Excellence (ACE) Star Model of Knowledge Transformation (Stevens, 2004) was selected as the theoretical framework for this project. This model helped to clarify the cycles and characteristics of knowledge that are used in evidence-based practice. The model helped to organize existing information as well as newly understood concepts that are designed to improve care in the clinical setting. The Star Model of Knowledge Transformation (Stevens, 2004) is a simple depiction of the relationship between the various phases of knowledge transformation from the discovery of new knowledge through integration into practice and subsequent evaluation of new practices. The ACE Star Model is organized into five distinct points. Discovery, Summary, Translation, Integration, and Evaluation are the key elements of the Star Model. Discovery is the leading point of the ACE Star Model. This is where new knowledge is generated. Knowledge is discovered through the traditional research methods and through personal scientific inquiry. This stage builds on existing knowledge and previous clinical practices.

ACUTE LOW BACK PAIN 10 Summary is the second point of the ACE Star. This is the process of synthesis of current evidence-based research into meaningful concepts regarding the current state of scientific knowledge. There are two stages in the third point of the ACE Star of Translation. Phase 1 includes translation of evidence into practice recommendations and then phase 2 is integration into current practice. These packets of usable condensed evidence are directed for the use of clinicians, and are generally called clinical practice guidelines. Clinical practice guidelines are tools used to support the decision-making process of clinicians. To further refine these guidelines and assist the clinician in the decision making process, clinical pathways are developed with the further guidance of a patient treatment algorithm. After reviewing the guidelines developed by Chou et al. (2007) and the North American Spine Society it is noted that these are general guidelines. The addition of a clinical pathway and its companion algorithm puts these guidelines into context or in other words helps the clinician adapt this knowledge to a specific patient need. For example, it is recommended that a patient that has been diagnosed with acute uncomplicated low back pain should not have diagnostic imaging done of any kind (National Physicians Alliance 2011). The clinical pathway with algorithm helps the clinician first; make the diagnosis of uncomplicated low back pain, aids decision support at the point of care when diagnostic images would be considered and points to evidence that the clinician may utilize to explain to the patient why diagnostic imaging is not appropriate. In other words the clinical pathway puts national guidelines in context and perspective. The fourth point involves the changing of current practices of both individual clinicians and entire health care systems. This process can be met with significant resistance. Changing commonly held beliefs takes considerable time and energy.

ACUTE LOW BACK PAIN 11 Evaluation is the final stage of knowledge transformation. In evidence-based practice there are many details that are evaluated. It includes identifying the impact of evidence-based practice on outcomes. Satisfaction related to providers and patients are also evaluated along with cost, efficacy, and health status impact. By utilizing this theoretical framework, there will be better understanding of how health care providers discover, synthesize, and utilize emerging data from evidence-based research. This will ultimately improve outcome thereby reducing cost, improving efficacy, and reducing risk (Stevens, 2004). Search Strategy The following research questions and search terms were utilized in developing research parameters. What is the incidence and prevalence of acute low back pain in the United States? Research terms included: incidence, prevalence, acute low back pain, United States What are the barriers for Americans to receive adequate appropriate timely evidencebased care for acute low back pain? Research terms included: barriers, acute low back pain, evidence-based, and treatment. What treatment options are available for acute low back pain? Research terms: acute low back pain, treatment, options. What are the treatment recommendations/guidelines for the treatment of acute low back pain in the United States? Research terms: treatment guidelines, treatment pathways, decision assistance, acute low back pain, evidence-based, and United States.

ACUTE LOW BACK PAIN 12 Once these questions and terms were selected, PubMed and other sites were utilized as the search engine of choice. Once appropriate literature was found, references were evaluated and additional supportive literature was identified. Literature Review Acute low back pain is a leading cause of pain and healthcare expenditures. A survey of back pain prevalence and visit rates by Deyo, Mirza, and Brook (2002) revealed that nearly half of all adults have low back pain during any given year. They go on to explain that approximately two-thirds of all adults have low back pain at some point in their lives. About one fourth of these adults had at least a day of back pain during any three-months. Approximately 15% of adults report frequent or regular back pain lasting more than two weeks a year. The following figure by Waterman et al., (2012) illustrates the incidence rates of low back pain in the United States seen in the emergency setting (Figure 1). It is noted that the greatest occurrence of back pain in adults ranges from 20 to 50 years of age. The large majority of adults seek care for their low back pain through their primary care provider or chiropractor. Smaller percentages of patients seek care through the emergency setting. Figure 1. Incidence Rate of Low Back Pain by Age

ACUTE LOW BACK PAIN 13 Source: Waterman, Belmont and Schoenfeld, (2012) Low back pain in the United States: Incidence and risk factors for presentation in the emergency setting. The Spine Journal, 12, 66. Barriers to Obtaining Adequate Care Despite the incidence of acute low back pain among Americans, there are many barriers to obtaining adequate care. Much of the diagnostic workup and subsequent treatment is inappropriate and unnecessary according to recent literature (Ivanova et al., 2011). Unfortunately, there are significant barriers that prevent patients from obtaining timely, evidence-based and appropriate care for conditions related to the spine. One of the barriers is patient confusion. Many patients simply don't know where to turn for treatment for acute low back pain. Options for care may include primary care providers, chiropractors, massage therapists, physical therapists, acupuncturists or surgical clinics (Harstall et al. 2011). Confusion is not confined to the patient alone. Clinicians also seem confused regarding what they should do when it comes to the treatment of acute low back pain. According to Scott et al. (2010) there is a definite inconsistency among clinicians regarding appropriate treatment

ACUTE LOW BACK PAIN 14 recommendations for acute low back pain. Scott et al. (2010) also noted that there were significant knowledge gaps reported among the various primary care providers in the assessment of red flags, use of diagnostic imaging, provisions of advice regarding sick leave and continuing activity, administration of some medications including muscle relaxers, oral steroids and opioids (p. 392). Scott et al. (2010) goes on to explain that even if primary care physicians are well educated and well versed in current literature and practices regarding treatment of the acute low back pain, many of them will divert from recommended treatments and utilize personal experience and philosophy. Health care providers often rely on shared beliefs and personal opinion rather than research evidence to make treatment decisions (p. 394). There may be good reason for this confusion and misunderstanding. Research shows that treatment guidelines vary widely between venues. There are a number of conflicting recommendations regarding the treatment of spine related issues. Williams et al. (2010) surveyed 3533 patient visits to Australian general practitioners for 3 years before and 3 years after the publication of a clinical practice guideline for the treatment of acute low back pain and discovered that the usual care provided by GPs for low back pain does not match the care endorsed international evidence-based guidelines and may not provide the best outcomes for patients (p. 271). Another barrier to adequate healthcare regarding acute low back pain is lack of insurance. It is a well-known fact that there are millions of Americans that lack health insurance. According to the US Department of Commerce (2005) In 2005 46.6 million people were without health insurance coverage, up from 45.3 million people in 2004. The percentage of people without health insurance coverage increased from 15.6 percent in 2004 to 15.9 percent in 2005 (p. 20).

ACUTE LOW BACK PAIN 15 A more recent study by the Kaiser Commission of Medicaid and the Uninsured (The HS Kaiser Family Foundation, 2011) claims that the number of nonelderly uninsured reached 49.1 million in 2010 (p. 3). The Kaiser Commission of Medicaid and the Uninsured (2011) points out that health insurance has a considerable impact on utilization. The type of healthcare insurance determines where people receive care, when they receive care, and generally how healthy they are. The Kaiser commission also noted that people who are not insured will often forgo health care altogether. Treatment Options for Care of Acute Low Back Pain There are many options for care of acute low back pain. Each of these options comes with their own historical roots and philosophical underpinnings. Scott et al. (2010) points out that up to 25% of patients with back pain seek help from health care providers, with nearly threequarters of these patients presenting to either a physician or a chiropractor. Most patients tend to visit more than one provider and between 10% and 50% of patients receive physiotherapy. Scott et al. (2010) later explains that besides the medical management of acute low back pain by primary care providers and chiropractors, other modalities such as physical therapy, psychotherapy, massage therapy and acupuncture are utilized on a less frequent basis. The assertion of this scholarly project was that there are general best practices that should be consulted when treating acute low back pain. Best practice should be evidence-based and well documented. Recommended Treatment for Acute Low Back Pain: Recommendations There are a number of recommendations which have been published in the past for the care of acute low back pain. There has also been significant work done recently regarding the proper diagnosis, management, and treatment for patients with low back pain. Research

ACUTE LOW BACK PAIN 16 performed by North American Spine Society (2012), Chou et al. (2007) and others provide the following treatment recommendations. 1. Clinicians should conduct a focused history and physical exam and divide patients into three broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or those not with spinal stenosis or some other specific causative factor. We are screening for patients without radiculopathy or leg related symptoms to be included in this particular pathway. 2. Clinicians should not obtain imaging studies of patients with nonspecific low back pain. This guideline is supported by the National Physicians Alliance s (2011) Top 5 list of health care activities in primary care for which changes in practice could lead to higher-quality care and better use of finite clinical resources (pg. 1386). The National Physicians Alliance s first recommendation Don't do imaging for low back pain within the first 6 weeks unless red flags are present (National Physicians Alliance 2011). 3. Clinicians should obtain diagnostic studies only when there is progressive neurological deficit or underlying conditions are considered such as cancer, kidney, or gastrointestinal disorders. (North American Spine Society, 2012). Chou et al (2007) also notes this is a strong recommendation with moderate-quality evidence. 4. Clinicians should only get MRI or CT scans on patients that are being considered for surgery or epidural steroid injection. 5. Clinicians should provide patients information that is evidence based regarding treatment options and self-care measures. 6. Clinicians considering the use of medications and other treatments should do so only after consideration has been given to risks, benefits, and potential side effects. This should only

ACUTE LOW BACK PAIN 17 be done, after a baseline of physical status and risk for long-term/serious disease has been performed. 7. Clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Generally, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. Non-pharmacologic interventions being considered for patients who fail to improve after first-line therapy would include spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage and cognitive behavioral therapy In a subsequent study in 2009, Chou et al. (2009) added additional recommendations to the 2007 recommendations. These recommendations added additional evidenced based advice on the treatment of low back pain. 1. Provocative discography is not recommended in patients with chronic low back pain. Diagnostic selective nerve root block, intra-articular facet joint injections and medial branch blocks or sacroiliac joint blocks are also discouraged as diagnostic procedures with regard to low back pain without radiculopathy. 2. For patients with chronic back pain that do not respond to usual therapies, it is recommended that clinicians consider intensive interdisciplinary interventions that include cognitive, behavioral, and occupational components. In patients with persistent low back pain without radiculopathy, the use of facet joint injections, steroid injections, and prolotherapy, and intradiscal corticosteroid injections are not recommended. There is not enough evidence to recommend botulinum injections, epidural steroid injections, intradiscal electrothermal, therapeutic medial branch block, radiofrequency denervation of the medial nerve branch,

ACUTE LOW BACK PAIN 18 sacroiliac joint injection, or intrathecal therapy with opioids or other medications for nonradicular symptoms. 4. A shared decision-making model should be used when approaching the question of spinal surgery for nonspecific, nonradicular low back pain. A detailed conversation about risks versus benefits as compared to interdisciplinary rehabilitation should be performed. 5. There is insufficient evidence that vertebral disc replacement is beneficial for nonspecific nonradicular low back pain. 6. A shared decision-making approach should be taken when discussing epidural steroid injections for the treatment of low back pain with radiculopathy secondary to herniated disc. Information regarding efficacy both for long and short-term symptom reduction should be discussed. The same is true regarding spinal stenosis. Shared decision-making regarding surgery for persistent back and leg pain secondary to herniated disc and spinal stenosis are also recommended. There is strong quality evidence supporting this recommendation. 7. It is recommended that a discussion regarding the efficacy and complication rates of spinal cord stimulation should be conducted with patients who are considering spinal cord stimulation implant after discectomy for herniated disc with persistent and continued leg pain postoperatively. Given this information, Figure 2 is an example of a treatment diagram that has been developed for the treatment of low back pain. Costs Associated With Acute Low Back Pain Estimates of the direct cost burden in the United States range considerably. Ivanova et al. (2011) estimate that spine related costs range to nearly $70 billion in incremental health-care costs and has a significant impact on the economic structure. The cost of treating spine related issues are exorbitantly high as related to other health care concerns. Ivanova et al. (2011) goes

ACUTE LOW BACK PAIN 19 on to explain that patients with low back pain had about three times higher average direct costs compared with other diagnoses (p. 629). One major cost associated with treatment of the low back in unnecessary imaging. Srinivas, et al. (2012) noted For acute low back pain patients who underwent MRI imaging within the first month had more than an 8-fold increased risk for surgery and more than a 5-fold increase in subsequent total medical costs (pg. 1017). Ivanova et al. (2011) also indicates that not only are the costs to treat low back pain higher than average, patients with low back pain need to take more days off of work than those with other illnesses, creating further financial burdens for the patient. Role of Advanced Practice Clinicians The paradigm of healthcare is changing and advanced practice clinicians find themselves in the front lines of healthcare. Physicians are pushing towards specialty areas; advanced practice clinicians will be directing the care of patients with complaints of acute low back pain. Nurse practitioners are uniquely positioned to assist in the treatment of patients with spine related issues. There is much that can be done previous to, or in place of, surgical intervention. It is a well-accepted fact that spinal surgery is often expensive and shoulders a rather extensive burden of risk. Chou et al. (2009) suggest that surgery should be carefully considered and only recommended for those patients who fit a profile that will ensure best outcomes. Everything should be done to assist patients in avoiding unnecessary surgery. With proper training and experience, an advanced practice clinician can adequately assess patients and direct the care they need. The majority of patients with acute low back pain can be supported with minimal intervention and resolution of symptoms will occur in less than four weeks. If symptoms do not resolve or if there are "red flags", advanced practice clinicians can evaluate and treat as clinically indicated or provide appropriate referrals. Advanced practice

ACUTE LOW BACK PAIN 20 clinicians can review additional diagnostic studies, interventional management, physical therapy, surgery, or other appropriate action. Following a treatment or diagnostic study, patients will need continuing education and management of their care. Once resolution of symptoms has been achieved, re-assimilation back into society and the workforce can be facilitated by the advanced practice clinician. Guidelines and Pathways Since there are multiple well researched clinical guidelines regarding the treatment of

ACUTE LOW BACK PAIN 21 Figure 2. Initial Evaluation of Low Back Pain.

ACUTE LOW BACK PAIN 22 Source: Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007) Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society, Annals of Internal Medicine, 147, 482-482.

ACUTE LOW BACK PAIN 23 acute low back pain, it was determined that the development of a clinical pathway was the next step to assist the provider in appropriate treatment of the spine. The difference between national clinical guidelines and pathways are that guidelines are designed to include all available options that are within reason for the presentation of disease being discussed. Pathways are designed to add additional layers of scrutiny to the available treatment options for a specific presentation of disease to further standardize treatment patterns (Rodgers, 2012). Rogers (2012) suggests that guidelines usually show all treatment options whereas pathways may be developed around the treatment that they deem superior in terms of efficacy, side effect profile, or cost-benefit when efficacy and side effects are equal. Development of a Treatment Pathway Treatment pathways are gaining acceptance and support in all areas of healthcare. They are increasingly being recognized as tools that can be used to decrease cost, streamline care, and improve outcomes. Jackson and Feder (1998) indicate that clinicians need simple, patient specific, user-friendly guidelines. They highlight three basic components that are needed in a clinical pathway: identification of the key decisions and their consequences, review of the relevant, valid evidence on the benefits, risks, and costs of alternative decisions, and presentation of the evidence required to inform key decisions in a simple, accessible format that is flexible to stakeholder preferences (p. 428). There are a number of small and crucial decisions involved in each patient encounter. If all of these decisions were addressed in a patient care algorithm or clinical pathway it would become far too cumbersome to be useful. Jackson and Feder (1998) indicate that only the basic

ACUTE LOW BACK PAIN 24 and most important decisions should be addressed initially and recommended that a diagram or algorithm be developed that identifies the key decisions and important outcomes relevant to patients care. Valid evidence is a requisite for best practice outcomes. An increasing interest in evidence-based practice and guidelines has highlighted the gaps in the evidence. Jackson and Feder (1998) also state that a systematic review of the prevailing evidence is necessary. Special attention should be paid to appropriateness of the underlying data. Treatment pathways should be guided by the absolute risk and benefit of the treatment proposed (Chou et al., 2007). These measures can be presented in units such as the number of events occurring in 100 patients treated per year or the number of patients who would need to be treated to prevent an event. Explicit statements about the benefits and risks of a treatment can then be weighed by patient preference and the available resources. This is currently difficult to achieve for most clinical problems, making it difficult to write some evidence-based accurate pathways. Pathway developers are encouraged to follow the process outlined above by Jackson and Feder (1998) and acknowledge where recommendations are based on inadequate evidence. Another component of a successful pathway is the presentation of evidence and recommendations in a concise accessible format. Decision makers must be able to retrieve and assimilate information quickly. Moreover, information must be presented in a flexible format that is applicable to the specific patients or circumstances. Implementation and Evaluation As the purpose of this project was to develop a clinical pathway with an algorithm for the treatment of acute uncomplicated low back pain, an extensive literature review was done to procure the latest, evidence based information dealing with acute low back pain diagnosis and

ACUTE LOW BACK PAIN 25 treatment. This information was then organized into a clinical pathway and an algorithm which outlines the basics of the pathway for providers. A publishable article was written. The article includes the clinical pathway along with the algorithm. The article was submitted with the accompanying algorithm and the pathway to the Journal of the American Academy of Nurse Practitioners according to the journal's publication rules. Evaluation of the pathway and the algorithm was coordinated with content experts and the chairperson related to this scholarly project. Their input was solicited to ensure accurate representation of the literature, content, and face validity of the products. The value of this project was discussed at length with Diana Thurston, PhD., Dr. Kade Huntsman, Dr. Gary Snook, and Amber Wright, MBA. It was noted through these conversations that there are a number of phenomenons noted regarding treatment of low back pain, particularly early treatment, which could be improved upon. As addressed earlier in this project, primary care providers and patients are quite disjointed regarding proper evidence-based treatment of low back pain. There is much variability in patient care and patients enter the care system unaware of the best course of care. Spine surgeons prefer to see patients that are surgical candidates and many primary care providers would rather have complaints of the spine be treated elsewhere, especially complicated issues. Through these discussions and observation, it was noted that a process could be implemented to increase quality in early evaluation and treatment, utilizing national guidelines that would streamline the entire process. This would enable patients to receive appropriate evidence-based healthcare early in the treatment cycle while helping spine surgeons and other providers eliminate patients from their practice that may be more appropriately treated elsewhere. When and if patients were referred to see a surgeon they would

ACUTE LOW BACK PAIN 26 be well prepared with the appropriate treatment measures completed that are necessary to an effective surgical consultation. It was noted through these discussions that this would save time, frustration, and cost for the patient and for the physician as well as expedite and improve patient care. Evaluation of the dissemination of the clinical pathway will be done after the project s completion through quarterly performance evaluation for each provider utilizing the treatment algorithm and is outside the scope of the DNP project. The goal will be that caseloads are sampled and charts reviewed for adherence to algorithmic data. Long term plans for this project involve the development of an outpatient nurse practitioner -driven back pain clinic. Following completion of this scholarly project, the treatment algorithm/protocol will be used to guide the treatment of patients in this outpatient setting. At some time in the future, the goal will be to introduce the pathway into emergency departments and clinics that treat for patients for acute uncomplicated low back pain. Evaluation of efficacy of the pathway is beyond the scope of this scholarly project, but will be done later. As the use of the protocol is adopted, ongoing utilization review and improvements will be made as necessary. Results As stated earlier, in proceeding with the original objectives for this project, it was soon discovered that to develop a patient treatment clinical guideline including an algorithm based on evidenced literature to assist healthcare providers in managing patient care as related to acute low back pain issues was not a feasible work as much of this work has previously been done and published by Chou et al. (2007). Therefore a new set of objectives was developed and approved by the Capstone Chair. The results section now details the work done on the new objective of developing a patient treatment clinical pathway, including an algorithm for the treatment of acute

ACUTE LOW BACK PAIN 27 low back pain. Given the previous work that has been reported in the literature, this objective seemed to be the next step in application of the recommendations in the literature. The goals of this scholarly project were changed to: 1. Develop a patient treatment clinical pathway including an algorithm based on evidenced literature. This goal was completed by searching the literature and discovering evidence-based data that was applicable to this goal. Appendix A shows the treatment clinical pathway. Appendix B shows the treatment algorithms. 2. Production of a scholarly article that was submitted for publication consideration. An article based on the content of this project was developed and submitted to the Journal of the American Academy of Nurse Practitioners in accordance with their submission rules and guidelines (see Appendix C). This article was written using the structure of quality improvements reports suggested by Smith (2007) as the JAANP does not have a specific structure for reports involving clinical quality improvements. The Essentials of Doctoral Education for Advanced Practice Nurses The Essentials of Doctoral Education for Advanced Practice Nurses (American Association of Colleges of Nursing, 2006) are made up of a number of key elements, many of which were integrated and used to guide this project. Included were Essentials I. II, III VII, and VIII. DNP Essential I focus on the scientific underpinnings of nursing practice. This essential element deals primarily with the scientific basis of the project. Care was taken to ensure that all suggestions, treatment options, and clinical pathways were based on evidenced literature. This literature directs the way patients are screened, evaluated, diagnosed and treated throughout the clinical pathway. An emphasis on patient education and shared decision-making was utilized.

ACUTE LOW BACK PAIN 28 Acute low back pain sufferers negotiate a gauntlet of therapies, treatments, and protocols that are often misguided and expensive. This patient population is underserved because of the dysfunctional nature of our current system with regards to appropriate and timely management of spinal related complaints. This project was chosen to improved access to appropriate care in the hopes that outcomes could be improved. Advanced practice clinicians are in a unique position to improve this process and facilitate positive change which satisfies the DNP Essential II. Drawing upon current evidenced-based research and utilizing well supported clinical guidelines, a clinical pathway for acute uncomplicated low back pain was developed. The criterion for DNP Essential III is the process which focuses mainly on the clinical scholarship and analytical methods of evidence based practice. DNP Essential VII, clinical prevention and population for improving the nation's health was addressed. One overall goal was to improve access to appropriate care and treatment for acute uncomplicated low back pain. Another goal was to improve the general understanding and education of those suffering from spine related issues. This goal was accomplished in the patient teaching aspects of the pathway. Lastly, DNP Essential VIII advanced nursing practice, was supported and met by improving education and experience of the advanced practice clinician in the area of acute uncomplicated low back pain. As the advanced practice clinician applies the patient care pathway and algorithm, that has been developed for the treatment of acute uncomplicated low back pain, they will be better able to accurately evaluate, diagnose, and treat patients. Recommendations It is recommended that this project be expanded and extended to complete development of patient care pathways for the evaluation and treatment of the spine. These patient care pathways will include clinical direction for the assessment and treatment of patients with acute

ACUTE LOW BACK PAIN 29 and chronic low back pain with and without radiculopathy. Patients with complaints of intermittent pseudo-claudication or signs and symptoms of lumbar stenosis will also be addressed. All of these are outside the scope of this DNP project. The support of St. Mark's hospital, the chief executive officer Steve Bateman, the chief operations officer, Matt Dixon and other supporting staff including the manager of the spine department will be involved in the future development of these treatment pathways. It is projected that these pathways will be in place and completed by July 2013. Once successfully completed, these clinical pathways could be used in other facilities. Improvement of rates at which patients receive quality, evidencebased spinal care that is timely and consistent with national guidelines. There is no way given the constraints of this scholarly project that this could be effectively evaluated. The literature does offer some evidence as what could be expected with adherence to national guidelines, but as for the purposes of this project as it is pertaining to a particular clinic it would take a significant amount of time and data collection to be able to show improved rates at which patients receive quality evidence-based care. Key barriers include lack of time and constraints of the scholarly project. Facilitate training of new providers regarding treatment of acute low back pain. Again, this training has yet to be implemented. This is also outside of the constraints of the DNP scholarly project. Plans are being made to implement this project and its content into the training of new advanced practice clinicians with regards to the spine clinic. Barriers include lack of time and constraints of the scholarly project. Conclusion Initially this scholarly project undertook the daunting task of developing clinical guidelines for the treatment of low back related issues. With research and continued

ACUTE LOW BACK PAIN 30 understanding this was found to be far outside the scope of this scholarly project. Therefore, one aspect of this endeavor was identified as an appropriate starting point and became the emphasis of this scholarly project. The focus was development of a clinical pathway and algorithm for the treatment of acute uncomplicated low back pain. This clinical pathway will be utilized in the future by St. Mark's hospital as a template for the development of additional pathways related to spine disease. Utilizing evidenced-based research, the pathway and algorithm was developed to streamline and to improve accuracy of the patient course through the care process. This pathway and algorithm was completed and plans for additional pathways and algorithms have been made. To assist the advanced practice clinician, at the point of care, a treatment algorithm was developed. To disseminate this information to the body of advanced practice clinicians a scholarly article containing this information was submitted to the Journal of the American Academy of Nurse Practitioners for publication.

ACUTE LOW BACK PAIN 31 References American Association of Colleges of Nursing. (2006, October). The Essentials of Doctoral Education. Washington, DC: American Association of Colleges of Nursing Chou, R., Loeser, J. D., Owens, D. K., Rosenquist, R. W., Atlas, S. J., Baisden, J., Carragee, E. J.,... American Pain Society Low Back Pain Guideline Panel. (2009). Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: An evidencebased clinical practice guideline from the American pain society. Spine, 34(10), 1066-1077. Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147, 481-491. Deyo, R. A., Mirza, S. K., & Martin, B. I. (2006). Back pain prevalence and visit rates estimates from U.S. national surveys. Spine, 31(23), 2724-2727. Harstall, C., Taenzer, P., Angus, D. K., Moga, C., Schuller, T., & Scott, N. A. (2011). Creating a multidisciplinary low back pain guideline: Anatomy of a guideline adaptation process. Journal of Evaluation in Clinical Practice, 17, 693-704. The Henry J. Kaiser Family Foundation. (2011, October). The uninsured a primer key facts about Americans without health insurance. Washington, DC: The Henry J. Kaiser Family Foundation Ivanova, J. I., Birnbaum, H. G., Schiller, B. A., Kantor, E., Johnstone, B. M., & Swindle, R. W. (2011). Real-world practice patterns, health-care utilization, and costs in patients. The Spine Journal, 11, 622-632. Jackson, R., & Feder, G. (1998). Guidelines for clinical guidelines. BMJ, 317, 427-428.

ACUTE LOW BACK PAIN 32 Lippi, G., Plebani, M., Di Somma, S., Mozani, V., Tubaro, M., Volpe, M., Moscatelli, P... Peracino, A. (2012). Considerations for early acute myocardial infarction rule-out for emergency department chest pain patients: The case of copeptin. Clinical Chemistry and Laboratory Medicine, 50(2), 243-253. National Physicians Alliance, The Good Stewardship Working Group. (2011). The "Top 5" lists in primary care. Archives of Internal Medicine, 171(15), 1385-1390. North American Spine Society. (2012, October 15). Acute Low Back Pain. Retrieved October 15, 2012, from North American Spine Society http://www.knowyourback.org/pages/ SpinalConditions/LowBackPain/Acute.aspx Rogers, E. (2012, October 27). Difference between clinical guidelines and clinical pathways. Retrieved October 27, 2012, from http://www.healthinformaticsforum.com/forum/topics/ difference-between-clinical-guidelines-and-clinical-pathways Scott, N. A., Moga, C., & Harstall, C. (2010). Managing low back pain in the primary care setting: The know-do gap. Pain Research & Management, 15(6), 392-400. Smith, R. (2000). Quality improvement reports: A new kind of article. BMJ, 321, 1428. Srinivas, S. V., Deyo, R. A., & Berger, Z. D. (2012). Application of "less is more" to low back pain. Archives of Internal Medicine, 172(13), 1016-1020. Stevens, K. R. (2004). ACE Star Model of EBP: Knowledge Transformation. Academic Center for Evidence-based Practice. The University of Texas Health Science Center at San Antonio. Taylor, J. A., & Bussieres, A. (2012). Diagnostic imaging for spinal disorders in the elderly: A narrative review. Chiropractic & Manual Therapies, 20(16), 1-36.