Sample Treatment Protocol
Adults with acute episode of LBP
Perform and document a focused history and physical examination to include:
- Duration of symptoms
- Risk factors for potentially serious conditions (See the Diagnostic Work-Up Checklist ) - Symptoms suggesting radiculopathy or spinal stenosis
- Presence and severity of neurologic deficits - Psychosocial risk factors
- Employment status
Are any potentially specific conditions strongly suspected?
Perform the diagnostic studies to identify cause.
Document the diagnostic workup.
Back pain is mild with no substantial functional impairment?
Assess and document pain and functional status
N
Counsel the patient on the generally favorable prognosis of acute LBP (with or without radiculopathy). Review indications for reassessment with the patient including worsening of symptoms, failure to improve after 1 month and diagnostic testing (see boxes 3 & 4). Provide The Back Book and review self care options such as superficial heat. Patients should be advised to continue usual activities as much as possible and specifically advised against bed rest.
Counsel the patient on the generally favorable prognosis of acute LBP (with or without radiculopathy).
Provide The Back Book and review self care options such as superficial heat and advice against bed rest.
Shared decision-making should be used to determine the right treatment option among non-invasive pharmacological and non-pharmacological therapies.
Clinicians to document reasons for using non-first-line treatment options and non-recommended therapies.
N
Patient accepts risks and benefit of chosen therapy?
Patient to try self care. Reassess in 1 month.
N
Initiate time limited trial of chosen therapy.
Y
Follow-up within 4 weeks unless symptoms completely resolve 1
2
4
12
13 14
15
16 18
Go to Box 20 to continue flow.
Y
Repeat Box 2 with any worsening of symptom severity, or every 3-6 months with stable symptoms
Patients with significant psychosocial issues require appropriate treatment or referral
See
“Diagnostic Work-Up Checklist.doc”
See “Interventions.doc”
3
Evaluation suggests cancer, vertebral infection, cauda equina syndrome, vetebral compression fracture, ankylosing spondylitis, or degenerative scoliosis Evaluation suggests herniated disc or spinal stenosis, but no other specific causes
Significant neurologic deficit?
These patients are excluded from the remainder of the protocol.
Consider consultation
Go to Box 12
Y
Y
5
6
10 11
17 19
Definition: Acute episode Back pain lasting <4 weeks for new episode or as acute exacerbation for chronic low back pain patients
Exclusions (See Box 11 also)
● Patients with previous low back surgery
● Pregnant women
● Children
Protocol adapted from 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;147:478-49
Document pain and functional status 3 months after completion of care.
Severe radicular pain?
N
N Go to Box 27 Y
7 9
8
Back pain and/or radiculopathy resolved or improved with no significant functional deficits?
Continue therapy and reassess in 1 month.
Y
Signs or symptoms of radiculopathy or spinal stenosis?
N
Employ shared decision-making regarding having a MRI for LBP
Perform MRI if the patient is a candidate for surgery or epidural steroid injection (for herniated disc) Y
Significant (concordant) nerve root impingement or spinal stenosis present on MRI?
Employ shared decision-making regarding surgery to determine patient interest in referral for possible surgery.
Also discuss the possibility of epidural steroid injection (if herniated disk) with patients as a treatment option.
Y
Reassess symptoms and risk factors and reevaluate diagnosis. See Boxes 2-11.
Consider imaging studies.
Shared decision-making should be employed prior to MRI or CT scans.
N
N
Employ shared decision-making to consider alternative pharmacologic and nonpharmacologic interventions.
For patients experiencing loss of function, consider more intensive multidisciplinary approach or referral.
Return to Box 20
21 22
23 24
25 26
29
30
Assess response to treatment.
Document pain and functional status.
20
For failed back surgery syndrome with persistent radicular symptoms:
Discuss risks/benefits of spinal cord stimulation using a shared decision- making framework.
For patients experiencing persistent, disabling non-radicular pain for >1 year that have not responded to multiple attempts at non-invasive therapies:
Discuss risks/benefits of surgery using a shared-decision-making framework
Facet joint steroid injection, intradiscal steroid injection, and prolotherapy are not recommended.
Patients should only be referred for consideration of radiofrequency denervation, or sacroiliac joint steroid injection if clinicians can document that they have persistent and at least moderately severe symptoms, have failed at least 3 recommended treatments, and are counseled on substantial uncertainties regarding potential benefits and harms.
Use of other non-recommended therapies must be documented and explained.
See “Interventions.doc”
Protocol adapted from 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;147:478-49
For patients who get surgery or ESI, pain and function status should be documented:
● Within 2-4 weeks of ESI
● Within 4-6 weeks of surgery
● 3, 6, 12 months post-operatively Patient interested in referral to surgery or ESI?
Go to Box 30 No
Yes
Document pain and functional status 3 months after completion of care.
27 Document pain and functional status 3 months after completion of care.
28
Diagnostic Work-Up Checklist
Possible Cause Key features on history or physical examination
Imaging Additional Studies Cancer History of cancer* with new onset of
LBP
(*Not including non-melanoma skin cancers)X-ray or MRI
ESR Unexplained weight loss Lumbosacral
x-ray Failure to improve after 1 month
Age >50 years with new or changed low back pain
Multiple risk factors present X-ray or MRI Vertebral
infection
Fever MRI ESR and/or
CRP Intravenous drug use
Recent infection Cauda
equina syndrome
Urinary retention MRI None
Motor deficits at multiple levels Fecal incontinence
Saddle anesthesia Vertebral
compression fracture
History of osteoporosis Consider Lumbosacral x-ray
None Use of corticosteroids
Older age (>65 years, women; >75 years, men)
Ankylosing spondylitis
Symptoms for > 3 months Consider Anterior posterior pelvis x- ray, if multiple features present
HLA-B27 Morning stiffness
Improvement with exercise Alternating buttock pain
Awakening due to back pain during the second part of the night
Younger age (20-30s) Male
Severe/
progressive neurologic deficits
Progressive motor weakness MRI Consider
EMG/NCV
Herniated disc
Back pain with leg pain in an L4, L5, or S1 nerve root distribution
If symptoms present for < 1 month: None
Symptoms present >1 month, consider:
MRI
If symptoms present for < 1 month: None
Symptoms present >1 month, consider:
EMG/NCV Positive straight-leg-raise test or
crossed straight-leg-raise test
Spinal stenosis
Radiating leg pain If symptoms
present for < 1 month: None Symptoms
If symptoms present for < 1 month: None Symptoms Older age (>65 years, women; >75
years, men)
Pseudoclaudication
11
