Attention Clinicians

The Clinical Practice Guideline on which this Quick Reference Guide for Clinicians is based was developed by a multidisciplinary, private-sector panel comprising health care professionals and a consumer representative sponsored by the Agency for Health Care Policy and Research (AHCPR).

Panel members were:

• Stanley J. Bigos, MD (Chair)

• Reverend O. Richard Bowyer

• G. Richard Braen, MD

• Kathleen C. Brown, PhD, RN

• Richard A. Deyo, MD, MPH

• Scott Haldeman, MD, PhD, DC

• John L. Hart, DO

• Ernest W. Johnson, MD

• Robert B. Keller, MD

• Daniel K. Kido, MD

• Matthew H. Liang, MD, MPH

• Roger M. Nelson, PhD, PTT

• Margareta Nordin, Dr. Med. Sc.

• Bernice D. Owen, PhD, RN

• Malcolm H. Pope, Dr. Med. Sc., PhD

• Richard K. Schwartz, MS, OTR

• Donald H. Stewart, Jr., MD

• Jeffrey L. Susman, MD

• John J. Triano, DC, MA

• Lucius Tripp, MD, MPH

• Dennis Turk, PhD

• Clark Watts, MD, JD

• James Weinstein, DO

Special consultants to the panel were: Michele Batti, PT, PhD; Claire Bombardier, MD; Nortin Hadler, MD; Alf Nachemson, MD, PhD; Gordon Waddell, MD. John Holland, MD, MPH and John Webster, MD served as project directors. Project methodologists were David Schriger, MD, MPH and Paul Shekelle, MD,MPH.

An explicit, science-based methodology was employed along with expert clinical judgment to develop specific statements on patient assessment and management on acute low back problems. Extensive literature searches were conducted and critical reviews and syntheses were used to evaluate empirical evidence and significant outcomes. Peer review and pilot testing were undertaken to evaluate the validity, reliability, and utility of the guideline in clinical practice.

This Quick Reference Guide for Clinicians presents a clinical strategy for applying the statements and recommendations from the Clinical Practice Guideline. The latter provides a description of the guideline development process, thorough analysis and discussion of the available research, critical evaluation of the assumptions and knowledge of the field, more complete information for health care decisionmaking, consideration for patients with special needs, and references. Decisions to adopt particular recommendations from either publication must be made by practitioners in light of available resources and circumstances presented by the individual patient. AHCPR invites comments and suggestions from users for consideration in development and updating of future guidelines.

Please send written comments to:

• Director, Office of the Forum for Quality and Effectiveness in Health Care

• AHCPR, Willco Building, Suite 310

• 6000 Executive Boulevard

• Rockville, MD 20852.

Abstract

This Quick Reference Guide for Clinicians contains highlights from the Clinical Practice Guideline version of Acute Low Back Problems in Adults, which was developed by a private-sector panel of health care providers and consumers. The Quick Reference Guide is an example of how a clinician might implement the panel's findings and recommendations on the management of acute low back problems in working-age adults. Topics covered include the initial assessment of patients presenting with acute low back problems, identification of red flags that may indicate the presence of a serious underlying medical condition, initial management, special studies and diagnostic considerations, and further management considerations. Instructions for clinical testing for sciatic tension, recommendations for sitting and unassisted lifting, tests for identification of clinical pathology, and algorithms for patient management are included.

Suggested citation

This document is in the public domain and may be used and reprinted without special permission. AHCPR appreciates citation as to source and the suggested format is provided below: Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, Quick Reference Guide Number. 14. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Pub. No. 95-0643. December 1994.

Purpose and Scope

Low back problems affect virtually everyone at some time during their life. Surveys indicate a yearly prevalence of symptoms in 50 percent of working age adults; 15-20 percent seek medical care. Low back problems rank high among the reasons for physician office visits and are costly in terms of medical treatment, lost productivity, and nonmonetary costs such as diminished ability to perform or enjoy usual activities. In fact, for persons under age 45, low back problems are the most common cause of disability.

Acute low back problems are defined as activity intolerance due to lower back or back-related leg symptoms of less than 3 months' duration. About 90 percent of patients with acute low back problems spontaneously recover activity tolerance within 1 month. The approach to a new episode in a patient with a recurrent low back problem is similar to that of a new acute episode.

The findings and recommendations included in the Clinical Practice Guideline define a paradigm shift away from focusing care exclusively on the pain and toward helping patients improve activity tolerance. The intent of this Quick Reference Guide is to bring to life this paradigm shift. The guide provides information on the detection of serious conditions that occasionally cause low back symptoms (conditions such as spinal fracture, tumor, infection, cauda equina syndrome, or non-spinal conditions). However, treatment of these conditions is beyond the scope of this guideline. In addition, the guideline does not address the care of patients younger than 18 years or those with chronic back problems (back-related activity limitations of greater than 3 months' duration).

Initial Assessment

• Seek potentially dangerous underlying conditions.

• In the absence of signs of dangerous conditions, there is no need for special studies since 90 percent of patients will recover spontaneously within 4 weeks.

A focused medical history and physical examination are sufficient to assess the patient with an acute or recurrent limitation due to low back symptoms of less than 4 weeks duration. Patient responses and findings on the history and physical examination, referred to as "red flags" (Table 1), raise suspicion of serious underlying spinal conditions. Their absence rules out the need for special studies during the first 4 weeks of symptoms when spontaneous recovery is expected. The medical history and physical _examination can also alert the clinician to non- spinal pathology (abdominal, pelvic, thoracic) that can present as low back symptoms. Acute low back symptoms can then be classified into one of three working categories:

Table

Table 1. Red flags for potentially serious conditions.

• Potentially serious spinal condition: tumor, infection, spinal fracture, or a major neurologic compromise, such as cauda equina syndrome, suggested by a red flag.

• Sciatica: back-related lower limb symptoms suggesting lumbosacral nerve root compromise.

• Nonspecific back symptoms: occurring primarily in the back and suggesting neither nerve root compromise nor a serious underlying condition.

Medical History

In addition to detecting serious conditions and categorizing back symptoms, the medical history establishes rapport between the clinician and patient. The patient's description of present symptoms and limitations, duration of symptoms, and history of previous episodes defines the problem. It also provides insight into concerns, expectations, and nonphysical (psychological and socioeconomic) issues that may alter the patient's response to treatment. Assessment tools such as pain drawings and visual analog pain-rating scales may help further document the patient's perceptions and progress.

A patient's estimate of personal activity intolerance due to low back symptoms contributes to the clinical assessment of the severity of the back problem, guides treatment, and establishes a baseline for recommending daily activities and evaluating progress.

Open-ended questions, such as those listed below, can gauge the need for further discussion or specific inquiries for more detailed information:

• What are your symptoms?

• Pain, numbness, weakness, stiffness?

• Located primarily in back, leg, or both?

• Constant or intermittent?

• How do these symptoms limit you?

• How long can you sit, stand, walk?

• How much weight can you lift?

• When did the current limitations begin?

• How long have your activities been limited? More than 4 weeks?

• Have you had similar episodes previously?

• Previous testing or treatment?

• What do you hope we can accomplish during this visit?

Physical Examination

Guided by the medical history, the physical examination includes:

• General observation of the patient.

• A regional back exam.

• Neurologic screening.

• Testing for sciatic nerve root tension.

The examination is mostly subjective since patient response or interpretation is required for all parts except reflex testing and circumferential measurements for atrophy.

Neurologic Screening

The neurologic examination can focus on a few tests that seek evidence of nerve root impairment, peripheral neuropathy, or spinal cord dysfunction. Over 90 percent of all clinically significant lower extremity radiculopathy due to disc herniation involves the L5 or S1 nerve root at the L4-5 or L5-S1 disc level. The clinical features of nerve root compression are summarized in Figure 1.

Figure

Figure 1. Testing for lumbar nerve root compromise.

Testing for Muscle Strength

The patient's inability to toe walk (calf muscles, mostly S1 nerve root), heel walk (ankle and toe dorsiflexor muscles, L5 and some L4 nerve roots), or do a single squat and rise (quadriceps muscles, mostly L4 nerve root) may indicate muscle weakness. Specific testing of the dorsiflexor muscles of the ankle or great toe (suggestive of L5 or some L4 nerve root dysfunction), hamstrings and ankle evertors (L5-S1), and toe flexors (S1) is also important.

Circumferential Measurements

Muscle atrophy can be detected by circumferential measurements of the calf and thigh bilaterally. Differences of less than 2 cm in measurements of the two limbs at the same level may be a normal variation. Symmetrical muscle bulk and strength are expected unless the patient has a neurologic impairment or a history of lower extremity muscle or joint problem.

Reflexes

The ankle jerk reflex tests mostly the S1 nerve root and the knee jerk reflex tests mostly the L4 nerve root; neither tests the L5 nerve root. The reliability of reflex testing can be diminished in the presence of adjacent joint or muscle problems. Up-going toes in response to stroking the plantar footpad (Babinski or plantar response) may indicate upper motor-neuron abnormalities (such as myelopathy or demyelinating disease) rather than a common low back problem.

Sensory Examination

Testing light touch or pressure in the medial (L4), dorsal (L5), and lateral (S1) aspects of the foot (Figure 1) is usually sufficient for sensory screening.

Clinical tests for sciatic tension

The straight leg raising (SLR) test (Figure 2) can detect tension on the L5 and/or S1 nerve root. SLR may reproduce leg pain by stretching nerve roots irritated by a disc herniation.

Box

Figure 2. Instructions for the Straight Leg Raising (SLR) Test. (1) Ask the patient to lie as straight as possible on a table in the supine position. (2) With one hand placed above the knee of the leg being examined, exert enough firm (more...)

Figure

Figure 2a. [Leg raising instructions 1-3].

Figure

Figure 2b. [Leg raising instruction 5].

Figure

Figure 2c. [Dorsiflexing the ankle].

Pain below the knee at less than 70 degrees of straight leg raising, aggravated by dorsiflexion of the ankle and relieved by ankle plantar flexion or external limb rotation, is most suggestive of tension on the L5 or S1 nerve root related to disc herniation. Reproducing back pain alone with SLR testing does not indicate significant nerve root tension.

Crossover pain occurs when straight raising of the patient's well limb elicits pain in the leg with sciatica. Crossover pain is a stronger indication of nerve root compression than pain elicited from raising the straight painful limb.

Sitting knee extension (Figure 3) can also test sciatic tension. The patient with significant nerve root irritation tends to complain or lean backward to reduce tension on the nerve.

Figure

Figure 3. Instructions for sitting knee extension test. With the patient sitting on a table, both hip and knees flexed at 90 degrees, slowly extend the knee as if evaluating the patella or bottom of the foot. This maneuver stretches nerve (more...)

Inconsistent Findings and Pain Behavior

The patient who embellishes a medical history, exaggerates pain drawings, or provides responses on physical examination inconsistent with known physiology can be particularly challenging. A strongly positive supine straight leg raising test without complaint on sitting knee extension and inconsistent responses on examination raise a suspicion that nonphysical factors may be affecting the patient's responses. "Pain behaviors" (verbal or nonverbal communication of distress or suffering) such as amplified grimacing, distorted gait or posture, moaning, and rubbing of painful body parts may also cloud medical issues and even evoke angry responses from the clinician.

Interpreting inconsistencies or pain behaviors as malingering does not benefit the patient or the clinician. It is more useful to view such behavior and inconsistencies as the patient's attempt to enlist the practitioner as an advocate, a plea for help. The patient could be trapped in a job where activity requirements are unrealistic relative to the person's age or health. In some cases, the patient may be negotiating with an insurer or be involved in legal actions. In patients with recurrent back problems, inconsistencies and amplifications may simply be habits learned during previous medical evaluations. In working with these patients, the clinician should attempt to identify any psychological or socioeconomic pressures that might be influenced in a positive manner. The overall goal should always be to facilitate the patient's recovery and avoid the development of chronic low back disability.

Initial Care

• Education and assurance.

• Patient comfort.

• Activity alterations.

Patient Comfort

Comfort is often a patient's first concern. Nonprescription analgesics will provide sufficient pain relief for most patients with acute low back symptoms. If treatment response is inadequate, as evidenced by continued symptoms and activity limitations, prescribed pharmaceuticals or physical methods may be added. Comorbid conditions, side effects, cost, and provider/patient preference should guide the clinician's choice of recommendations. Table 2 summarizes comfort options.

Table

Table 2. Symptom control methods.

Physical Methods

Manipulation, defined as manual loading of the spine using short or long leverage methods, is safe and effective for patients in the first month of acute low back symptoms without radiculopathy. For patients with symptoms lasting longer than 1 month, manipulation is probably safe but its efficacy is unproven. If manipulation has not resulted in symptomatic and functional improvement after 4 weeks, it should be stopped and the patient reevaluated.

Traction applied to the spine has not been found effective for treating acute low back symptoms.

Physical modalities such as massage, diathermy, ultrasound, cutaneous laser treatment, biofeedback, and transcutaneous electrical nerve stimulation (TENS) also have no proven efficacy in the treatment of acute low back symptoms. If requested, the clinician may wish to provide the patient with instructions on self-application of heat or cold therapy for temporary symptom relief.

Invasive techniques such as needle acupuncture and injection procedures (injection of trigger points in the back; injection of facet joints; injection of steroids, lidocaine, or opioids in the epidural space) have no proven benefit in the treatment of acute low back symptoms.

Other miscellaneous therapies have been evaluated. No evidence indicates that shoe lifts are effective in treating acute low back symptoms or limitations, especially when the difference in lower limb length is less than 2 cm. Shoe insoles are a safe and inexpensive option if requested by patients with low back symptoms who must stand for prolonged periods. Low back corsets and back belts, however, do not appear beneficial for treating acute low back symptoms.

Work Activities

When requested, clinicians may choose to offer specific instructions about activity at work for patients with acute limitations due to low back symptoms. The patient's age, general health, and perceptions of safe limits of sitting, standing, walking or lifting (noted on initial history) can help provide reasonable starting points for activity recommendations. Table 3 provides a guide for recommendations about sitting and lifting. The clinician should make clear to patients and employers that:

• Even moderately heavy unassisted lifting may aggravate back symptoms.

• Any restrictions are intended to allow for spontaneous recovery or time to build activity tolerance through exercise.

Table

Table 3. Guidelines for sitting and unassisted lifting.

Activity restrictions are prescribed for a short time period only, depending upon work requirements (no benefits apparent beyond 3 months).

Special Studies and Diagnostic Considerations

Routine testing (laboratory tests, plain x-rays of the lumbosacral spine) and imaging studies are not recommended during the first month of activity limitation due to back symptoms except when a red flag noted on history or examination raises suspicion of a dangerous low back or non- spinal condition. If a patient's limitations due to low back symptoms do not improve in 4 weeks, reassessment is recommended. After again reviewing the patient's activity limitations, history, and physical findings, the clinician may then consider further diagnostic studies, and discuss these with the patient.

Selection of Special Studies

Prior to ordering imaging studies the clinician should have noted either of the following:

• The emergence of a red flag.

• Physiologic evidence of tissue insult or neurologic dysfunction.

Figure 1

Laboratory tests such as erythrocyte sedimentation rate (ESR), complete blood count (CBC), and urinalysis (UA) can be useful to screen for nonspecific medical diseases (especially infection and tumor) of the low back. A bone scan can detect physiologic reactions to suspected spinal tumor, infection, or occult fracture.

Should physiologic evidence indicate tissue insult or nerve impairment, discuss with a consultant selection of an imaging test to define a potential anatomic cause (CT for bone, MRI for neural or other soft tissue). Anatomic definition is commonly needed to guide surgery or specific procedures. Selection of an imaging test should also take into consideration any patient allergies to contrast media (myelogram) or concerns about claustrophobia (MRI) and costs. A discussion with a specialist on selection of the most clinically valuable study can often assist the primary care clinician to avoid duplication. Table 4 provides a general comparison of the abilities of different techniques to identify physiologic insult and define anatomic defects. Missing from the table is discography, which is not recommended for assessing patients with acute low back symptoms.

Table

Table 4. Ability of different techniques to identify and define pathology.

Table

Table 5. Summary of Guideline Recommendations.

In general, an imaging study may be an appropriate consideration for the patient whose limitations due to consistent symptoms have persisted for 1 month or more:

• When surgery is being considered for treatment of a specific detectable loss of neurologic function.

• To further evaluate potentially serious spinal pathology.

Reliance upon imaging studies alone to evaluate the source of low back symptoms, however, carries a significant risk of diagnostic confusion, given the possibility of falsely identifying a finding that was present before symptoms began.

Management Considerations After Special Studies

Definitive treatment for serious conditions (see Table 1) detected by special studies is beyond the scope of this guideline. When special studies fail to define the exact cause of symptoms, however, no patient should receive an impression that the clinician thinks "nothing is wrong" or that the problem could be "in their head." Assure the patient that a clinical workup is highly successful in detecting serious conditions, but does not reveal the precise cause of most low back symptoms.

Further Management Consideration

Following diagnostic or surgical procedures, the management of most patients becomes focused on improving physical conditioning through an incrementally increased exercise program. The goal of this program is to build activity tolerance and overcome individual limitations due to back symptoms. At this point in treatment, symptom control methods are only an adjunct to making prescribed exercises more tolerable.

• Begin with low-stress aerobic activities to improve general stamina (walking, riding a bicycle, swimming, and eventually jogging).

• Exercises to condition specific trunk muscles can be added a few weeks after. The back muscles may need to be in better condition than before the problem occurred. Otherwise, the back may continue to be painful and easily irritated by even mild activity. Following back surgery, recovery of activity tolerance may be delayed until protective muscles are conditioned well enough to compensate for any remaining structural changes.

• Finally, specific training to perform activities required at home or work can begin. The objective of this program is to increase the patient's tolerance in carrying out actual daily duties.

When patients demonstrate difficulty regaining the ability to tolerate the activities they are required (or would like) to do, the clinician may pose the following diagnostic and treatment questions:

• Could the patient have a serious, undetected medical condition? A careful review of the medical history and physical examination is warranted.

• Are the patient's activity goals realistic? Exploring briefly the patient's expectations, both short- and long-term, of being able to perform specific activities at home, work, or recreation may help the patient assess whether such activity levels are actually achievable.

• If for any reason the achievement of activity goals seems unlikely, what are the patient's remaining options? To answer this question, the patient is often required to gather specific information from family, friends, employers, or others. If, on followup visits, the patient has made no effort to gather such information, the clinician has the opportunity to point out that low back symptoms alone rarely prevent a patient from addressing questions so important to his or her future. This observation can lead to an open, nonjudgmental discussion of common but complicated psychosocial problems or other issues that often can interfere with a patient's recovery from low back problems. The clinician can then help the patient address or arrange further evaluation of any specific problem limiting the patient's progress. This can usually be accomplished as the patient continues, with the clinician's encouragement, to build activity tolerance through safe, simple exercises.

Availability of Guidelines

For each clinical practice guideline developed under the sponsorship of the Agency for Health Care Policy and Research (AHCPR), several versions are produced to meet different needs.

The Clinical Practice Guideline presents recommendations for health care providers with brief supporting information, tables and figures, and pertinent references.

The Quick Reference Guide for Clinicians is a distilled version of the Clinical Practice Guideline,with summary points for ready reference on a day-to-day basis.

The Consumer Version, available in English and Spanish, is an information booklet for the general public to increase patient knowledge and involvement in health care decisionmaking.

To order single copies of guideline products or to obtain further information on their availability, call the AHCPR Publications Clearinghouse toll-free at 800-358-9295 or write to: AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.

Single copies of the Clinical Practice Guideline are available for sale from the Government Printing Office, Superintendent of Documents, Washington, DC 20402, with a 25 percent discount given for bulk orders of 100 copies of more. The Quick Reference Guide for Clinicians and the Consumer Version in English are also available for sale in bulk quantities only. Call (202) 512-1800 for price and ordering information.

The Guideline Technical Report contains complete supporting materials for the Clinical Practice Guideline, including background information, methodology, literature review, scientific evidence tables, recommendations for research, and a comprehensive bibliography. It is available from the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161. Call (703) 487-4650 for price and ordering information.

The full text of guideline documents for online retrieval may be accessed through a free, electronic service from the National Library of Medicine called HSTAT (Health Services/Technology Assessment Text). Guideline information is also available through some of the computer- based information systems of the National Technical Information Service, professional associations, nonprofit organizations, and commercial enterprises.

A fact sheet describing Online Access for Clinical Practice Guidelines (AHCPR Publication No. 94-0075) and copies of the Quick Reference Guide for Clinicians and the Consumer Version of each guideline are available through AHCPR's InstantFAX, a fax-on-demand service that operates 24 hours a day, 7 days a week. AHCPR's InstantFAX is accessible to anyone using a facsimile machine equipped with a touchtone telephone handset: Dial (301) 594-2800, push "1," and then press the facsimile machine's start button for instructions and a list of currently available publications.

U.S. Department of Health and Human Services, Public Health Service Agency for Health Care Policy and Research, Executive Office Center, Suite 501 2101 East Jefferson Street, Rockville, MD 20852 AHCPR Publication No. 95-0643 December 1994.

Figures

Algorithm 1. Initial evaluation of acute low back problem.

Algorithm 2. Treatment of acute low back problem on initial and followup visits.

Algorithm 3. Evaluation of the slow-to-recover patient (symptoms > 4 weeks)

Algorithm 4. Surgical considerations for patients with persistent sciatica.

Algorithm 5. Further management of acute low back problem.

AHCPR Publication No. 95-0643.