Evidence-Based Medicine for Student Health Services
Robert J. Flaherty, MD
Swingle Student Health Service
Montana State University
Bozeman, MT 59717
 
Low Back Pain 
  
Etiology Monitoring
Epidemiology Prognosis
Diagnosis Prevention
Treatment Patient Education
  
General Information
    
EBM for Student Health   
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Specific Conditions/Diseases 
 
   
     
 		    
Etiology  
No evidence is cited.  
   
Epidemiology  
No evidence is cited.  
   
Diagnosis  
Clinical Diagnosis 
The diagnostic accuracy of history, physical examination and ESR in general practice settings remains unclear. However, it appears that combining positive findings increase diagnostic accuracy.   Laboratory/X-ray Diagnosis 
Neuroanatomic imaging studies (MRI, CT scan, CT with myelography, myelography and CT discography) capable of defining lumbar anatomy should not be done during the first month of low back pain symptoms (with or without sciatica), unless there is progressive neurologic deficit, or signs and/or symptoms of a serious underlying process, such as cauda equina syndrome, tumor, or spinal infection 

Neuroanatomic imaging should be done one month after onset of symptoms if:  

  • Clinical suspicion of radiculopathy is high (because of the patient's clinical syndrome of sciatica), and the patient has been adequately educated about the benefits and risks of surgery, and the patient prefers to proceed with surgical treatment (if imaging confirms herniated disc as the cause of his or her pain), or,
  • Imaging is necessary to confirm suspicion of malignant or infectious disease as the cause of the patient's pain.
  • Consider reviewing case with surgical consultant or radiologist to aid neuroanatomic imaging selection. 
Neuroanatomic imaging should be done 7 weeks after onset of symptoms if:  
  • Sciatica is present and is not improving. Consider reviewing case with surgical consultant or radiologist to aid neuroanatomic imaging selection, or,
  • Ordered by neuromuscular consultant to whom patient has been referred.
Since patients with no back symptoms at all frequently have abnormal neuroanatomic imaging findings, such imaging for isolated back pain - without sciatica - should be avoided. The likelihood of identifying abnormalities unrelated to the patient's illness is excessive. Furthermore, there is no evidence that surgery for herniated lumbar disc, in the absence of sciatica, is effective. 
  • Caveats
    • Age group studied: Adults
    • Type/size: Meta-analysis
    • Population characteristics: Patients with acute low back pain or sciatica of less than 3 months duration
    • Outcome measures: Contribution of a neuroanatomic study to accurate diagnosis, effective treatment, and improved outcome of the patient
    • May not apply to patients whose signs or symptoms suggest a serious cause of acute low back pain, especially the cauda equina syndrome
  • Citations
    • Neuroanatomic Imaging in Patients with Acute Low Back Pain - Reviewed by Group Health Northwest 
  
Treatment   
Non-Surgical Treatments    
Guidelines for management of uncomplicated acute low back pain include: 
  • Assessment: Carry out diagnostic triage and consider psychosocial factors.
  • Drug therapy: prescribe analgesics at regular intervals, not p.r.n.
  • Start with paracetamol (acetaminophen). If inadequate, substitute with NSAIDs (e.g. ibuprofen or diclofenac) and then acetaminophen-weak opioid compound (e.g. acetominophen+codeine) 
  • Finally consider adding short course of muscle relaxant such as diazepam or baclofen.
  • Staying active: advise patients to stay as active as possible, to continue normal daily activities and stay at work; advise patients to increase their physical activities progressively over a few days or weeks.
  • Manipulation: Consider manipulative treatment within the first 6 weeks for patients who need additional help with pain relief.
  • Back exercises: patients who have not returned to ordinary activities within 6 weeks should be referred for reactivation/rehabilitation.
  • Do not recommend or use bed rest as a treatment for simple back pain.
(The actual guideline is worth looking at.)  Among patients with uncomplicated (no neurological deficits) acute low-back pain, maintaining ordinary activity as tolerated and avoiding bed rest led to the most rapid recovery when compared with bed rest or back-mobilizing exercises.   No treatment has been shown beyond doubt to be effective in the treatment of non-specific acute and chronic low back pain. Therapies evaluated and lacking evidence of effectiveness include physiotherapy, back schools, educational packages, corsets, acupuncture, osteopathy, chiropractic, spinal manipulations, physical reconditioning, specific cognitives, behavioural interventions, pain management clinics,  transcutaneous electrical nerve stimulation, facet joint injections of steroids, epidural injections of steroids, laser therapy, ultrasound, injections of collagen proliferant substances into spinal soft tissues, family therapies and antidepressant medication.  There is insufficient evidence to recommend group education for the treatment of people with acute or chronic low back pain.  
  • Caveats
    • Age group studied: 
    • Type/size: Review: (13 studies = 2052 subjects)
    • Population characteristics: People with either acute or chronic low back pain
    • Outcome measures: Pain intensity, pain duration, sick leave duration, functional status, knowledge, spinal mobility, number of pain recurrences, functional status, spinal mobility and number of contacts with health care providers
    • Only 2 out of 13 interventions were rated as either good or very good by both expert reviewers
    • The interventions were not sufficiently described

      •  
  • Citations
The value of "back school" for treatment of patients with low back pain has not been convincingly demonstrated.  Treatment of fibromyalgia with both amitriptyline (25 mg at bedtime) and fluoxetine (20 mg in the morning) resulted in significant improvement in Fibromyalgia Impact Scores as well as scores for global well-being, pain and sleep. The combined regimen was more effective than either drug alone or placebo.   Both pharmacologic (non-opioid analgesics, topical analgesics, NSAIDs, intraarticular corticosteroids, opioid analgesics and hyaluronan injections) and nonpharmacologic measures (exercise, occupational therapy, weight loss, self-help groups, joint arthroplasty, joint replacement, joint lavage) can contribute to the treatment of pain from osteoarthritis.    Glucosamine (500mg tid) is better than placebo and as effective as NSAIDs in the treatment of arthritis.   
  • Caveats
    • Age group studied: Mean ages 58-75 years
    • Type/size: Systematic Review of 8 randomized trials
    • Population characteristics: Patients with arthritis
    • Outcome measures: Lesquesne index, pain, swelling, global assessment
  • Citations
Cognitive behavioral therapy (CBT) was investigated for the treatment of patients with medically unexplained physical symptoms. CBT reduced the frequency and intensity of physical symptoms, impairment of social interactions and sleep, and illness behavior at 12-month follow-up. The recovery rate was higher with cognitive behavioral therapy at 6 months but not at 12 months of follow-up.  Surgical Treatment  
Surgery is not indicated for herniated lumbar intervertebral disc during the first month of low back pain symptoms (with or without sciatica ), unless progressive neurologic impairment, including cauda equina syndrome, occurs. Surgery is a reasonable option to treat a patient's herniated lumbar intervertebral disc, if sciatica is present and symptoms persist longer than one month without improvement. Since good outcomes are possible without surgery, informed patient choice should dictate surgical or non-surgical management. Postponing consideration of surgery an additional 3 weeks is also a reasonable option. Even after 7 weeks of pain due to a herniated disc, non-surgical treatment remains a reasonable option because very long term (4-10y) outcomes are equivalent. In the absence of sciatica, there is no evidence that surgery is beneficial. 
  • Caveats
    • Age group studied: Adults
    • Type/size: EBM guideline
    • Population characteristics: Patients with low back pain 
    • Outcome measure: Pain relief and improved function
  • Citations
    • Surgery in Patients with Herniated Lumbar Disk - Reviewed by Group Health Northwest 
    
Monitoring 
No evidence is cited. 
  
Prognosis   
Most cases of low back pain seen in primary care practice have no specific cause. Recovery usually takes more than just a few weeks, but 90% recover within a year. Nevertheless, 75% have relapses, usually within 1 year.      
Prevention  
There is limited evidence to recommend exercise to prevent low back pain in asymptomatic individuals. There is insufficient 
evidence to recommend education (including "back schools"), mechanical supports (corsets) or risk factor modification. 
  • Caveats
    • Age group studied: Unknown
    • Type/size: Meta-analysis (64 studies = 731 patients)
    • Population characteristics: asymptomatic patients with or without prior acute back pain; patients with a history of chronic back pain were excluded
    • Outcome measures: Prevention of low back pain, knowledge about back pain, absenteeism from work
  • Citations
    •  
Comprehensive educational programs, such as "back schools," designed to reduce the occurrence of low back injuries are not effective. The intervention-group had a slightly higher injury rate than the control group (reporting bias?).    
Patient Education 
The following patient education materials are consistent with the available evidence. 
Rev. 8/3/99
   
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This Web site developed and maintained by Robert J. Flaherty, MD. 
Comments, additions and corrections are encouraged.