Clinical Efficacy Assessment Subcommittee of the American College of Physicians; 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

Oregon Health & Science University, Portland, Oregon, USA.
Annals of internal medicine (Impact Factor: 17.81). 11/2007; 147(7):478-91.
Source: PubMed


RECOMMENDATION 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). RECOMMENDATION 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). RECOMMENDATION 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). RECOMMENDATION 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). RECOMMENDATION 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). RECOMMENDATION 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. RECOMMENDATION 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits-for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

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    • "Antidepressants are suggested in some guidelines (Balagu e et al., 2011) as well as cognitive functional therapy (O'Keeffe et al., 2015; O'Sullivan et al., 2015). Evidence based guidelines also recommend conventional clinical assessment of patients presenting with LBP (NHMRC, 2004; Chou et al., 2007; NICE, 2009), which informs the diagnosis and initial management. Key components to a low back assessment include: taking a detailed history and conducting a physical examination , neurological evaluation and psychosocial screening. "
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    ABSTRACT: Consensus guidelines for the management of low back pain recommend that the clinician use contemporary best practice for assessment and treatment, consider biopsychosocial factors and, if chronic, use a multimodal and multi-disciplinary approach. Where guidelines are not followed and basic assessment is inadequate the diagnosis may be compromised and the sequelae of errors compounded. Factors such as a lack of knowledge or recognition of the common structure specific pain referral patterns, poor clinical reasoning, inappropriate referral and predilection for popular management approaches also contribute to mis-diagnosis and mis-management. This report describes two cases of chronic low back pain with lengthy histories of multiple failed interventions to highlight the consequences of focussing on a singular approach to the exclusion of evidence based pathways and the resulting risk of a missed diagnosis. The eventual management to mitigate these problems is reported with the aid of low back pain outcome measures, computer-aided combined movement examination, disability and pain questionnaires and health quality of life surveys.
    Full-text · Article · Nov 2015 · Manual therapy
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    • "Moreover, back pain without clinical symptoms of a CMD can be directly addressed via antidepressants, although the literature is inconclusive in this respect. While the scientific evidence related to the treatment of neuropathic or chronic back pain with tricyclic antidepressants (TCAs) has been assessed as good, the use of modern antidepressants including selective serotonin reuptake inhibitors (SSRIs) has a weak evidence base with regard to alleviation of symptoms of chronic pain (Swedish Council on Health Technology Assessment, 2006; Chou et al. 2007; Dharmshaktu et al. 2012). It is likely that in our study, some severe forms of chronic back pain with or without neuropathic pain might have been treated with TCAs, even in the absence of clinical symptoms of a CMD. "
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    ABSTRACT: Background: The aim of this study was to analyse a possible synergistic effect between back pain and common mental disorders (CMDs) in relation to future disability pension (DP). Method: All 4 823 069 individuals aged 16-64 years, living in Sweden in December 2004, not pensioned in 2005 and without ongoing sickness absence at the turn of 2004/2005 formed the cohort of this register-based study. Hazard ratios (HRs) and 95% confidence intervals (CIs) for DP (2006-2010) were estimated. Exposure variables were back pain (M54) (sickness absence or inpatient or specialized outpatient care in 2005) and CMD (F40-F48) [sickness absence or inpatient or specialized outpatient care or antidepressants (N06a) in 2005]. Results: HRs for DP were 4.03 (95% CI 3.87-4.21) and 3.86 (95% CI 3.68-4.04) in women and men with back pain. HRs for DP in women and men with CMD were 4.98 (95% CI 4.88-5.08) and 6.05 (95% CI 5.90-6.21). In women and men with both conditions, HRs for DP were 15.62 (95% CI 14.40-16.94) and 19.84 (95% CI 17.94-21.94). In women, synergy index, relative excess risk due to interaction, and attributable proportion were 1.24 (95% CI 1.13-1.36), 0.18 (95% CI 0.11-0.25), and 2.08 (95% CI 1.09-3.06). The corresponding figures for men were 1.45 (95% CI 1.29-1.62), 0.29 (95% CI 0.22-0.36), and 4.21 (95% CI 2.71-5.70). Conclusions: Co-morbidity of back pain and CMD is associated with a higher risk of DP than either individual condition, when added up, which has possible clinical implications to prevent further disability and exclusion from the labour market.
    Full-text · Article · Oct 2015 · Psychological Medicine
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    • "The exclusion criteria for the LG were as follows: patients with low back pain whose clinical history suggests a specific etiology; identification of red flags suggesting need for medical referral; patients with osteomuscular injuries in other joints and neurological diseases; patients with histories of spinal surgery, pregnancy, cardiovascular, or lung diseases, or limitation of walking ability in relation to the preferred self-selected speed (PS); and significant increase in pain during the tests, to the point that walking activity becomes intolerable according to the patient's perception (Chou et al., 2007; Leerar, Boissonnault, Domholdt , & Roddey, 2007). "
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    ABSTRACT: The authors investigated the effects of chronic low back pain (LBP) and walking speed (WS) on metabolic power and cost of transport (CT). Subjects with chronic nonspecific LBP (LBP group [LG]; n = 9) and healthy (control group [CG]; n = 9) were included. The test battery was divided into 3 blocks according to WS as follows: preferred self-selected speed (PS), and lower and higher than the PS. In each block, the volunteers walked 5 min, during which oxygen consumption was measured. Although without differences between groups, the LG had CT lower in slower speeds than in faster speeds. Walking speed affected CT only in the LG, which the group had the greatest walking economy at slower speeds.
    Full-text · Article · Sep 2015 · Journal of Motor Behavior
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