Musculoskeletal / Orthopedics

Getting straight on low back pain treatment

No matter what specialty area you work in, you’ll encounter patients with low back pain. Most people experience low back pain at some time in their lives. Up to 25% of the population have it in any given year. Low back pain is the second-leading reason why people seek health care in the United States, accounting for more than 13 million clinical visits yearly.

Low back pain is rarely a serious disorder; most patients with acute pain report improvement within 1 month. But recurrences are common, with 30% to 60% of patients experiencing additional episodes over the following year. What’s more, low back pain is among the leading causes of disability in this country, to the tune of $30 billion annually in work-ups and treatment. Total estimated costs (including decreased wages and lost productivity) amount to $200 billion annually.

Nurses play an important role in patient screening and education. Several tools are available to help identify risk factors for persistent low back pain that may indicate the need for interventions beyond the core treatment plan. Using the most recent evidence-based guidelines, nurses can help patients achieve better long-term outcomes and potentially prevent persistent low back pain. This article describes practice changes recommended by evidence-based guidelines and reviews nursing research that may hold the key to progress in improving patient outcomes.

Determining the cause

More than 85% of patients presenting with low back pain have a nonspecific etiology, with the pain source not reliably identified. Nonspecific signs and symptoms most likely stem from local degenerative processes involving the spine and surrounding structures, including muscles, ligaments, facet joints, nerves, periosteum, blood vessels, and intervertebral discs. These degenerative processes are a normal part of aging. Because the core treatment plan (discussed below) is indicated for degenerative processes and most patients improve or recover in 2 to 4 weeks after pain onset, diagnostic imaging isn’t recommended.

A specific cause of low back pain is found in only about 10% of patients. These causes are considered red flags. Further assessment and work-up are indicated when any of the following are present:

  • incapacitating pain for more than 2 weeks
  • progressive neurologic deficits
  • a suspected red-flag condition. (See Red flags for low back pain.)

 


Red flags for low back pain

Patients with radicular pain (pain radiating down the extremity in a dermatomal pattern) should use the core treatment plan for at least 6 weeks before diagnostic imaging is considered, because most improve within that time.

Core treatment plan

The core treatment plan for low back pain includes reassuring the patient that signs and symptoms are likely to resolve in 2 to 4 weeks, as well as providing education on the multiple causes of low back pain and the need to stay active and maintain a normal weight. Although no standardized form of education is recommended, be sure to address the commonly held belief that pain is harmful. Fear associated with this belief may stop the patient from resuming activities, which can delay recovery. If fear-avoidant behaviors continue, muscles and ligaments supporting the spine may start to deteriorate and weaken, which could lead to a cycle of persistent pain and disability.

The core treatment plan includes heat application and, when appropriate, acetaminophen or nonsteroidal anti-inflammatory drugs for short-term pain management. Muscle relaxants may be prescribed for a short period, but their benefits should be weighed against possible adverse effects and contraindications. Opioids rarely are indicated.

Some patients may require a return-to-work assessment to help them develop strategies for maintaining employment and overcoming reinjury fears. Pain and disability should be assessed early in the course of low back pain. Patients reporting high levels of perceived pain and disability may be at risk for delayed recovery and may need additional treatments to prevent persistent suffering, disability, and increased healthcare expenditures.

Screening tools for low-back-pain patients

Nurses are ideally positioned to provide screening for risk factors and educate patients and their families about low back pain. “Health Care Guideline: Adult Low Back Pain” from the Institute for Clinical Systems Improvement (released January 2012) recommends that clinicians assess perceived pain and disability at the initial visit to identify patients who might experience delayed recovery and to guide additional interventions.

During the first visit, assess the patient’s pain characteristics (including level of perceived pain) using a visual analog scale, pain diagram, or other pain-intensity rating tool. To measure perceived disability from low back pain, you can use the Oswestry Disability Questionnaire or Roland-Morris Disability Questionnaire. Patients who rate their level of pain or disability as severe or who exhibit pain behaviors out of proportion to the injury they’ve sustained are at greater risk for experiencing persistent pain. Assessing perceived pain and disability provides a way to address fears or misconceptions about low back pain, determine the need for early or more aggressive management, and monitor outcomes over time.

Other recommended assessments include screening for fear-avoidance beliefs and risk of depression. The Fear-Avoidance Beliefs Questionnaire (available at www.asszisztencia.hu/mot/down/PK2_4.pdf) measures patients’ level of agreement on how physical activity and work affect their low back pain. To assess depression risk, consider using the Patient Health Questionnaire-2 (www.cqaimh.org/pdf/tool_phq2.pdf) or Patient Health Questionnaire-9 (www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf). Consider treatment of depression for patients at significant risk for depression, along with the core treatment plan for low back pain. Early in the course of low back pain, spinal manipulative therapy should be considered, based on results of the Clinical Prediction Rule, which projects whether this treatment will succeed. (See Clinical prediction rule.)

 

Clinical prediction rule

Patients who continue to have severe pain or functional impairment after 2 weeks should be reevaluated and screened for delayed-recovery risk factors. Several instruments are available to measure overall risk of persistent low back pain, including the Back Disability Risk Questionnaire, Örebrö Musculoskeletal Pain Screening Questionnaire, and Keele STarT Back Screening Tool. Ongoing research is examining which screening methods are best for identifying patients at higher risk for persistent pain, as well as which therapeutic interventions may improve outcomes.

Guidelines from the Institute for Clinical System Improvement and the American College of Physicians/American Pain Society suggest using nonpharmacologic therapies with proven benefit. (See Nonpharmacologic treatments.) Therapies not recommended include bed rest, cold application, and traction. Currently, too little research exists on transcutaneous electrical nerve stimulation, low-level laser therapy, and prolotherapy (injection therapy) to make recommendations.

 

Nonpharmacologic treatments

A key to improving adherence and treatment success for patients with low back pain is to identify their preferences and determine which therapies they believe will benefit them. To help reduce or prevent recurrent pain episodes, focus on interventions that emphasize self-management strategies and core body strengthening.

Nursing research on low back pain

Nurses have long been attuned to the mind-body-spirit connection and the impact of psychosocial and behavioral factors on low back pain outcomes. Nurse researchers are using this knowledge to identify patients’ resiliency and vulnerability characteristics that may contribute to low back pain outcomes, with the goal of developing more tailored therapeutic strategies. Identifying the best screening methods for psychosocial and behavioral risk factors and using interventions that help the mind, body, and spirit may enhance the opportunity to reduce the impact of low back pain for the millions affected each year.

Increased recognition that genetic and epigenetic mechanisms influence the risk of persistent pain has led to new ideas that may better predict persistent low back pain and potentially target these mechanisms for treatment. Patients with persistent low back pain or other forms of chronic pain show functional changes in peripheral and central nervous system pain processing. Nurse researchers are investigating the contribution of genetic polymorphisms and gene expression patterns on nervous-system alterations in patients with persistent low back pain. A deeper understanding of the underlying mechanism may lead to targeted interventions designed to halt or reverse the transition to persistent low back pain. Ultimately, this area of research may help overcome a major obstacle in research and clinical practice by providing more accurate measures for predicting the risk of persistent low back pain and fostering new treatment strategies.

Angela Starkweather is an associate professor at the Virginia Commonwealth University School of Nursing in Richmond.

Selected references

Carragee EJ. Clinical practice. Persistent low back pain. N Engl J Med. 2005 May 5;352:1891-8.

Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American Pain Society Low Back Pain Guidelines Panel. 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 Oct 2;147(7):478-91.

Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009 Feb 9;169(3):251-8.

Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Physical Ther. 2007 Jun;37:290-302.

Institute for Clinical Systems Improvement. Health care guideline: Adult low back pain. Bloomington, MN: Institute for Clinical Systems Improvement; 2012. www.icsi.org/public_comment_on_lbp_gl/adult_low_back_paint__guideline_.html. Accessed September 5, 2012.

Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington DC: National Academies Press; 2010.

Soni A. Back problems: Use and Expenditures for the U.S. Adult Population, 2007. Medical Expenditure Panel Survey Statistical Brief No. 289. Agency for Healthcare Research & Quality. July 2010. www.meps.ahrq.gov/mepsweb/data_files/publications/st289/stat289.pdf. Accessed September 5, 2012.

Waddell G, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993 Feb;529(2):157-68.

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