Back Pain Assessment, Management, and Follow-up Guideline 1

Copyright 2012 Group Health Cooperative. All rights reserved.

Back Pain
Assessment, Management, and Follow-up Guideline

Background 2
Terminology 2
Assessment
History 3
Physical exam 4
Recommended testing 5
Warning signs requiring immediate or urgent evaluation 6
Radiological exam 6
Severity of pain and degree of activity interference 7
Diagnosis 7
Management of non-specific and radicular back pain
Goals 8
Tips for communicating with patients 8
Step 1. Self-management 8
Step 2. Other management options 9
Referrals to back specialists 10
Pharmacologic options 10
Follow-up/Monitoring 12
Comorbidity Screening 13

Evidence Summary 14
References 16
Clinician Lead and Guideline Development 17
Appendix 1. Evidence of effectiveness of non-pharmacologic strategies 18


Most recent guideIine approvaI: February 2012


Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health
care for specific clinical conditions. While guidelines are useful aids to assist providers in determining appropriate
practices for many patients with specific clinical problems or prevention issues, guidelines are not meant to replace
the clinical judgment of the individual provider or establish a standard of care. The recommendations contained in the
guidelines may not be appropriate for use in all circumstances. The inclusion of a recommendation in a guideline
does not imply coverage. A decision to adopt any particular recommendation must be made by the provider in light of
the circumstances presented by the individual patient.


Back Pain Assessment, Management, and Follow-up Guideline 2
Background
Acute and chronic back pain are common conditions that result in significant misery for patients and
account for a large number of visits to primary care. There is considerable variation among primary care
providers about how to evaluate those patients, what options to offer them, how often to follow up, and
under what circumstances to refer them to specialists. For most patients with back pain, the condition will
improve within a few weeks or months; the initial focus should therefore be to offer counseling and
support, simple analgesics as needed, and encouragement to stay active and focus on functional
rehabilitation.

This guideline is intended to help primary care teams do an effective initial assessment of back pain,
maximize the patients chances for rehabilitation and functional improvement, and minimize the use of
unnecessary and potentially harmful interventions.

The treatment and follow-up recommendations in this guideline apply to patients with non-specific acute
or chronic low back pain or back pain associated with radiculopathy. This guideline does not address the
management of patients with red flag conditions or back pain resulting from underlying systemic illness,
beyond providing recommendations for initial assessment and referral.


Terminology
Acute back pain is pain lasting less than 4 weeks.
Chronic back pain is pain lasting longer than 3 months.
Non-specific back pain is pain with no signs or symptoms of a serious underlying disorder (such
as cancer, infection, or cauda equina syndrome), spinal stenosis or radiculopathy, or other
specific spinal cause (such as vertebral compression fracture or ankylosing spondylitis).
Degenerative changes on lumbar imaging are usually considered non-specific, as they correlate
poorly with symptoms (Chou 2007). Note: For evaluation and referral recommendations for
suspected red flag conditions, see Table 4.
Radiculopathy, often referred to as sciatica, is a nerve root irritation resulting in a sharp or
burning pain radiating down the posterior or lateral aspect of the lower limb, usually to the foot or
ankle. Pain radiating below the knee is more likely to represent true radiculopathy than proximal
leg pain. Radicular nerve pain is often associated with numbness or tingling.
Neurogenic claudication, also referred to as pseudoclaudication, is nerve root entrapment
caused by narrowing of the spinal canal or neural foramina; disc bulging and spondylolisthesis
may contribute to the condition. Symptoms include back pain, transient tingling in the legs, and
ambulation-induced pain or fatigue in the lower extremities, resolving with rest. This pain with
walking is clinically distinguished from vascular claudication by the presence of normal arterial
pulses.
Inflammatory back pain is pain caused by inflammation in the spinal joints, with onset typically
occurring before age 45. It is characterized by improvement with exercise but not with rest and by
morning stiffness of longer than 30 minutes duration.
Back Pain Assessment, Management, and Follow-up Guideline 3
Assessment: History

Table 1. Key elements in history for assessment of back pain
History of this
pain episode
When did the pain start?
How did the pain start (for example, while lifting or bending, or for no apparent cause)?
Is the pain getting better or worse?
What makes it better: activities such as standing, walking, and sitting, or over the
counter medications?
Is the patient having any bladder or bowel dysfunction?
How many days a week is the patient impacted by the pain?
Pain and function
- Location of pain (e.g., limited to the low back? soft tissue? joints?)
- Pain severity and degree of disability (See Tables 6a and 6b.)
- When does it hurt?
- Is there weakness?
- Does the pain radiate to the leg/foot?
- Which leg(s)?
- How is it distributed (above knee, below knee, both) and how does the patient
describe it (pins and needles, hot/burning, numb, worse with touch)?
Physical
activity
Are there things the patient is not doing because of the pain, such as home chores,
exercise, or activities of daily living (ADLs)?
Current level of activity?
Activity level prior to this episode?
What is the patient doing to cope with the pain and limitations?
Previous
episodes
History of prior episodes of back pain
- Duration
- Location(s) of pain
- Severity of pain
What treatments or evaluations/exams have been tried in the past?
What treatments have been helpful?
What treatments have not been helpful?
Potential red
flags or
underlying
systemic
illness
(Also see
Table 4.)
History of cancer
History of osteoporosis
Immune suppression (steroid use, HIV, transplant, IV drug use)
Cauda equina syndrome: saddle numbness, motor deficit at multiple levels, urinary
retention, and fecal incontinence
Suspicious fracture
Inflammatory disease, such as psoriasis, uveitis, or enthesitis (pain and swelling at the
heel involving the Achilles tendon and insertion of the plantar fascia)
Unexpected weight loss
Fever
Pain at night
Recent infection, such as a UTI
Progressive neurological deficit
Abnormal gait
Psychosocial
risk factors
Belief that the pain is due to a serious condition and being active would cause harm
Fear that the pain is due to undiagnosed disease
Illness behavior (extended rest, symptom magnification)
Stress (e.g., family, job)
Depression screen
Employment status
Days off work? Expected return date?
Having or had problems with claims and compensation


Back Pain Assessment, Management, and Follow-up Guideline 4
Assessment: Physical exam

Table 2. Key elements in physical exam for assessment of back pain
Presence and
severity of
neurologic
deficits
Patient affect

Standing
Posture
Walk (heel walk, toe walk, partial squat, and Trendelenburg gait)
Balance (stand on one foot)
Range of motion (hip, spine, and Schber if indicated)

Sitting
Reflexes: ankle, knee
Sensory testing of lower limbs
Manual muscle testing of lower extremities (hip and ankle extension and flexion,
dorsi- and plantar flexion, great toe dorsiflexion)
Circulation
Provocative testing (straight leg raising)
Back Pain Assessment, Management, and Follow-up Guideline 5
Assessment: Recommended testing

Table 3. Recommended testing and interventions for assessment of back pain
Possible diagnosis Signs/symptoms Testing/intervention
Non-specific back
pain
Pain worsens with spine loading No imaging initially.
Consider X-ray after 6 weeks of self-
management if patient is over age 50.
Consider referral to Physical Therapy.
Radiculopathy
(sciatica) without
weakness
Back pain with leg pain or sensory
symptoms in a lumbosacral nerve
root distribution
Positive straight-leg-raise test or
crossed-straight-leg-raise test
Consider early referral to Physical
Therapy.
After 4 weeks:
- Consider referral or consultation with
Physical Medicine and Rehabilitation.
- Consider MRI.
Radiculopathy with
weakness
Back pain with leg pain or sensory
symptoms in a lumbosacral nerve
root distribution
Positive straight-leg-raise test or
crossed-straight-leg-raise test
Consider early referral to Physical
Therapy.
Consider referral to Neurosurgery.
Consider referral to Physical Medicine &
Rehabilitation for chronic pain and
impaired function.
Lumbar spinal
stenosis
Radiating leg pain, sensory
symptoms
Older age
Sometimes neurogenic claudation
After 4 weeks:
Consider referral to Physical Therapy.
Consider referral to Neurosurgery.
Consider MRI.
Inflammatory back
pain
1

Age under 40 years
Pain better with exercise
Pain not better with rest
Morning stiffness lasting longer
than 30 minutes (especially upon
rising)
Significant response to NSAIDs
Lab testing
- HLA-B27
- ESR and/or CRP
Consider X-ray anteroposterior (AP) view
of sacroiliac joints.
Refer to Rheumatology for diagnosis and
management and/or Physical Medicine &
Rehabilitation for concerns about impaired
function.
1
No rheumatologic testing or evaluation is needed for pain that is worsened with activity or relieved by
rest, or that starts after age 40. Anti-Nuclear Antibody (ANA) and Rheumatoid Factor Screen (RF)
tests provide no useful information in back pain.

Back Pain Assessment, Management, and Follow-up Guideline 6
Assessment: Warning signs requiring immediate or urgent evaluation

Table 4. Warning signs requiring immediate or urgent evaluation, including red flag symptoms
Possible cause Signs/symptoms Testing/intervention
Cauda equina syndrome Saddle anesthesia
Motor deficit at multiple levels
Urinary retention
Fecal incontinence
MRI
Emergent referral to Neurosurgery
Significant or progressive
neurological deficits
Progressive motor weakness
Severe leg pain
MRI
Urgent referral to Neurosurgery
History of cancer with new onset
low back pain
MRI
ESR
Consider referral to Oncology
Cancer

Unexplained weight loss
Failure to improve after 1 month
50 years old or older
Lumbosacral radiography or MRI
ESR
Consider referral to Oncology
Vertebral infection Fever
IV drug use
Recent infection
MRI
ESR and/or CRP
Consider referral to Infectious Disease
Vertebral compression
fracture
History of osteoporosis
Use of corticosteroids
Older age
Lumbosacral radiography
Consider referral to Neurosurgery


Assessment: Radiological exam

Table 5. Radiological exam for assessment of back pain
Testing Acute pain indications Chronic pain indications
X-ray Possible fracture (elderly, recent fall,
severe pain, history of osteoporosis
or steroid use)
After 6 weeks of self-management and if
indicated (e.g., age over 50 years, pain
increasing)
Suspected inflammatory back pain (Order
AP pelvis of sacroiliac joint.)
Suspected structural deformities (e.g.,
spondylolisthesis, scoliosis spondylitis)
MRI Red flags (suspicion of cancer or
infection, trauma, or cauda equina
syndrome)
Severe or incapacitating back or leg
pain (e.g., requiring hospitalization,
precluding walking, or significantly
limiting ADLs)
Progressively severe back or leg pain
Radiculopathy and major or progressive
neurological symptoms (e.g., foot drop,
functionally limiting weakness)
Radiculopathy and sensory symptoms that
are not improving after 46 weeks
Surgery or epidural steroid injection being
considered
CT In acute and chronic pain:
Contraindications to MRI or MRI results are inconclusive
Suspected fracture or bone tumor


Back Pain Assessment, Management, and Follow-up Guideline 7
Assessment: Severity of pain and degree of activity interference
There are a variety of tools for assessing pain and function. There is no evidence that one is superior to
another.

This two-item version of the Graded Chronic Pain Scale (Table 6a) is intended for brief and simple
assessment of pain severity in primary care settings. For score interpretation, see Table 6b. (Dunn 2010,
Sullivan 2010)

Table 6a. Standard Questions: Pain interference and activity interference
1. In the last month, how much has pain interfered with your daily activities? Use a scale from 0 to
10, where 0 is "no interference" and 10 is "unable to carry on any activities"?
No
interference

Unable to carry
on any activities
0 1 2 3 4 5 6 7 8 9 10
2. In the last month, on average, how would you rate your pain? Use a scale from 0 to 10, where 0
is "no pain" and 10 is "pain as bad as could be"? [That is, your usual pain at times you were in
pain.]
No pain
Pain as bad as
could be
0 1 2 3 4 5 6 7 8 9 10


Table 6b. Standard Questions: Interpretation of answers
Pain rating item Mild Moderate Severe
1. Pain-related interference with activities 13 46 710
2. Average/usual pain intensity 14 56 710




Diagnosis
Based on assessment and additional testing, categorize the patient with back pain into one of three broad
diagnostic categories:
Non-specific back pain.
Back pain associated with radiculopathy or lumbar spinal stenosisapproximately 4% and 3% of
patients, respectively.
Back pain associated with red flag conditions or possible underlying systemic illness. This guideline
does not address the management of patients with these conditions, apart from providing
recommendations for imaging and referral.

Back Pain Assessment, Management, and Follow-up Guideline 8
Management of non-specific and radicular back pain: Goals
Educate patient about the natural history of back pain.
Ask about and address the patients concerns and goals.
Maximize functional status.
Reduce pain.
Address associated symptoms, such as sleep or mood disturbances or fatigue.
Do not expose the patient to unhelpful or possibly risky interventions.

Management: Tips for communicating with patients about their back pain
Affirm/acknowledge the patients pain and suffering/loss of function.
Address the patients specific fears or worries (e.g., undiagnosed serious disease, long-term
disability). Provide reassurance, noting the likelihood that the patients back pain will start improving
in the first month.
Activate: Help the patient identify enjoyable and meaningful activities that will increase strength,
flexibility and endurance.

Management: Education and self-care (Step 1)

Table 7. Education and self-care for patients with non-specific back pain or radiculopathy
(See Appendix 1 for the level of evidence supporting these recommendations.)
Educate patients on the
natural history of back pain.
Most patients with back pain experience significant improvement
within 46 weeks; however, approximately two-thirds will experience
another episode within 12 months.
Back pain is often recurrent or persistent.
Early, routine imaging usually cannot determine a specific cause or
improve outcomes.
Promote self-care. In the absence of red flag symptoms, it is safe to resume activity.
Encourage patient to stay active and to carry on with normal activities
as much as possible.
- Advise continued routine activity while paying attention to correct
posture to minimize spine loading.
- Advise the patient to temporarily limit or avoid specific activities
known to increase mechanical stress on the spine (e.g., prolonged
unsupported sitting, heavy lifting, and bending or twisting the
back, especially while lifting).
- Advise discontinuation of any activity or exercise that causes
spread of symptoms (radiculopathy).
Build strength and endurance gradually. Move naturally and avoid
guarded or bracing behavior.
Manage physical and emotional stressors.
Offer non-pharmacologic
treatment.
Heat
Stretching
Walking
Offer pharmacologic treatment
(see Table 10).
To manage pain and help patients stay active:
Simple analgesics if not medically or otherwise contraindicated (e.g.,
NSAIDS, aspirin, acetaminophen)
Prescription options (e.g., analgesics or, in acute cases, muscle
relaxants)
Minimize/prevent patients from getting therapies that have no proven benefit.
Back Pain Assessment, Management, and Follow-up Guideline 9

Management: Options for those whose pain does not improve with education and
self-care (Step 2)

Table 8. Options for patients with back pain that does not improve with education and self-care
Continue self-care strategies.
If employing passive treatments such as manipulation and mobilization, introduce active treatment
(i.e., exercise) within a week.
Non-specific back pain
Acute back pain Active
Walking
Continue usual activities
Physical therapy

Passive
Spinal manipulation
1,2

Chronic back pain

Active
Physical therapy
Exercise (aerobic exercise, stretching, walking)
Yoga

Passive
Massage therapy
2

Acupuncture
2

Spinal manipulation
1,2

Radicular pain
Acute radicular pain Active
Exercise/physical therapy
1
Spinal manipulation may be done if pre-manipulative testing centralizes symptoms (supported by
weak evidence).
2
Continued improvement should be documented for continued therapy. Typically no more than 4 to 6
visits are needed.


Back Pain Assessment, Management, and Follow-up Guideline 10
Management: Referrals to back specialists

Table 9. Referring patients to specialty for back pain
Specialty Reason for referral/recommendation of alternative practitioner
Physical therapy Non-specific back pain
Radiculopathy (sciatica) with or without weakness
Lumbar spinal stenosis
Physical medicine and
rehabilitation/pain
specialist
Nonsurgical candidates such as radiculopathy, chronic pain, lumbar spinal
stenosis
To develop detailed treatment plans to enable an individual to carry out
rehabilitation, including exercise and self-care
Second opinion for surgical or nonsurgical patients with suboptimal response
to a conservative treatment regimen
Behavioral health Cognitive behavioral therapy for chronic pain
Neurosurgery Cauda equina syndrome (emergent referral)
Acute or progressive neurologic deficit (urgent referral)
Vertebral compression fracture
Oncology History of cancer with new onset back pain
Infectious disease When vertebral infection is suspected
Rheumatology When inflammatory disease is suspected

Treatment options that are not recommended
Check coverage if considering treatment.
Discography
Epidural steroid injections (for non-radicular pain)
Inferential therapy
Intradiscal electrothermal therapy (IDET)
Kyphoplasty
Laser therapy
Lumbar support
Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT)
Percutaneous vertebroplasty (for vertebral fracture)
Radiofrequency facet joint denervation
Spinal cord stimulation
Therapeutic ultrasound
Traction
Transcutaneous electrical nerve stimulation (TENS)
Vertebral Axial Decompression (VAX-D System) for back pain
X-stop for lumbar spinal stenosis


Management: Pharmacologic options
Consider the risks of any medication and prescribe the lowest effective dose for the shortest
period of time.
Muscle relaxants are not indicated for treatment of chronic low back pain; limit use to 714 days.
Opioids are rarely indicated for the treatment of low back pain. Opioids appear to be similarly
efficacious to acetaminophen and NSAIDs, but have more risks and side effects. Patients
receiving more than 7 days of opioids or more than one prescription within 6 weeks of the first
visit for back pain had higher rates of work disability at 1 year. (See Chronic Opioid Therapy
Safety Guideline.)
The primary goal of treatment is maximal function, rather than complete relief from pain. Some
ongoing or recurrent pain is normal and not indicative of a serious problem.
Back Pain Assessment, Management, and Follow-up Guideline 11

For information on side effects, contraindications, formulary status (e.g., prior authorization), and other
pharmacy-related issues, see the Group Health Drug Formulary online.

Table 10. Recommended pharmacologic options for the treatment of back pain
Line Medication
class
Medication Initial dose Max. daily
dose
Acute back pain
Acetaminophen 500650 mg three times daily 3,000 mg
1

Ibuprofen 600800 mg three times daily
with food
2,400 mg
Naproxen 250500 mg twice daily with food 1,250 mg
Nabumetone
3
500 mg two times daily with food 2,000 mg
1st NSAIDs
2

Etodolac
3
300400 mg two to three times daily
with food
1,200 mg
Cyclobenzaprine 5 mg three times daily or
10 mg daily at bedtime
30 mg 2nd Skeletal muscle
relaxants
4

Methocarbamol 500 mg three to four times daily 4,000 mg
Hydrocodone-
acetaminophen
5 mg/325 mg
to 1 tab one to four times daily
3,000 mg
1
(acetaminophen
component)
3rd Opioids
Oxycodone 5 mg one to four times daily 80 mg
Chronic back pain
Acetaminophen 500650 mg three times daily 2,500 mg
1
1
st
NSAIDs

Consider other NSAIDs options listed above for acute back pain. For chronic
use, maximum dose for ibuprofen is 2,400 mg/day and for naproxen is
1,000 mg/day.

2
nd
Opioids

See Chronic Opioid Therapy Safety Guideline.

1
Not to exceed 1,0001,500 mg daily for patients with liver disease or alcohol problems.
2
All patients over age 65 are considered at moderate risk for NSAID-induced GI toxicity and should
receive gastroprotective therapy. Use caution in patients with cardiovascular comorbidities, at risk
for GI bleed, or with hepatic or renal dysfunction. Chronic administration may increase the risk for
adverse GI, cardiovascular, or renal effects.
3
Nabumetone and etodolac are partially selective NSAIDs. Moderate-strength evidence suggests
that nabumetone has decreased risk of GI adverse effects compared to non-selective NSAIDs in
short-term studies. The risk of GI adverse effects for etodolac compared to non-selective NSAIDs
is unknown. Low-strength evidence suggests that etodolac has no increased risk of GI adverse
effects compared to nonuse.
4
Limit use to 714 days. Avoid use in patients over age 65 years. Use caution in patients with
cardiovascular comorbidities or hepatic impairment.

Back Pain Assessment, Management, and Follow-up Guideline 12
Pharmacologic options that are not recommended

Acute back pain
Systemic corticosteroids

Chronic back pain
Gabapentin
Celecoxib (NF)
Duloxetine
Topiramate
Skeletal muscle relaxants


Follow-up/Monitoring

Table 11. Recommended follow-up for patients with acute and chronic back pain
Patient population Frequency of follow-up
Acute back pain
Have patient check back at 2 weeks, unless earlier
follow-up is advised. Options for follow-up include
phone, secure e-mail message, or visit.
All
Additional follow-up as indicated.
Patients considered high-risk based on
psychosocial risk factor evaluation
Earlier and more frequent in-person follow-up may
be appropriate.
Older patients
or
Patients with
Symptom progression or no significant
improvement
Severe pain or functional deficits
Signs of radiculopathy or lumbar spinal stenosis
Earlier and more frequent re-evaluations may be
appropriate.
Patients referred to spinal manipulation,
acupuncture, or massage
Have patient check back after 4 visits with referred
specialty to demonstrate improved functionality.
Chronic back pain
Stable As needed.
With fluctuating pain Periodic.
On medications Periodic.
(See the Chronic Opioid Therapy Safety Guideline
if applicable.)


Back Pain Assessment, Management, and Follow-up Guideline 13
Comorbidity screening

Table 12. Recommended comorbidity screening for patients with back pain
Condition Test(s)
Depression Consider screening for depression with the
Patient Health Questionnaire (PHQ-9).
1,2

Alcohol or drug abuse Consider screening with the AUDIT Alcohol Use Questionnaire (adults),
the DAST-10 Drug Use Questionnaire (adults), or
the CRAFFT Drug and Alcohol Use Survey (adolescents).
1
See the Adult Depression Guideline for additional guidance. Patients with major depression can be treated in
primary care or offered a referral to Behavioral Health Services for counseling and/or drug therapy.
2
Evidence suggests that patients with depression are less likely to be adherent to recommended management
plans and less likely to be effective at self-management of chronic conditions.






Back Pain Assessment, Management, and Follow-up Guideline 14
Evidence summary
This guideline was adapted from the following sources:
Agency for Healthcare Research and Quality. Complementary and Alternative Therapies for Back
Pain II. 2011; Evidence Report/Technology Assessment Number 194. Available at:
http://www.ahrq.gov/downloads/pub/evidence/pdf/backpaincam/backcam2.pdf. Accessed January
2012.

Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of
the evidence for an American Pain Society/American College of Physicians clinical practice guideline.
Ann Intern Med. 2007 Oct 2;147(7):492504.

Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary
rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain
Society. Spine (Phila Pa 1976). 2009 May;34(1):10661077.

National Institute for Health and Clinical Excellence (NICE). Low back pain: early management of
persistent non-specific low back pain. 2009; Clinical guidelines CG88. Available at:
http://www.nice.org.uk/nicemedia/live/11887/44345/44345.pdf. Accessed January 2012.

Washington State Health Care Authority. Spinal Injections: Health Technology Assessment. 2011.
Available at: http://www.hta.hca.wa.gov/documents/updated_final_report_spinal_injections_0310-
1.pdf. Accessed January 2012.


The Group Health guideline team reviewed additional evidence in the following areas of non-pharmacologic
treatment.
Spinal manipulation
A recent Cochrane review that included 26 randomized controlled trials (RCTs) and 6,070 participants
examined the effectiveness of spinal manipulative therapy (SMT) on pain and functional status
compared to control treatments for adults with chronic low back pain. Results from this analysis
suggest that there was no significant difference in pain relief between SMT and simulated (sham)
SMT. Compared to other interventions such as exercise and physiotherapy, evidence suggests that
SMT provides significantly better pain relief at 1, 3, and 6 months; however, there was no significant
difference in pain relief at 12 months. Results also suggest that compared to another intervention,
SMT significantly improves functional status at 1 month. There was no significant difference in
functional status at 3, 6, and 12 months (Rubinstein 2011).
Acupuncture
A recent RCT that included 638 subjects evaluated the effectiveness of three different types of
acupuncture (individualized, standardized, or simulated [sham]) for the treatment of chronic low back
pain compared to usual care. The primary outcome was back-related dysfunction and symptom
bothersomeness at 8 weeks. After 8 weeks, participants who received one of the acupuncture
treatments had significant improvements in back-related dysfunction and symptom bothersomeness
compared to usual care; however, there was no significant difference between the acupuncture
treatment groups in back-related dysfunction or symptom bothersomeness. After 1 year, there was no
significant difference in symptom bothersomeness between the four treatment groups; however,
participants who received real acupuncture continued to have less dysfunction compared to those
who received usual care. The number needed to treat (NNT) with acupuncture to improve function
ranged from 5 for short-term benefit to 8 for long-term benefit (Cherkin 2009).

Another RCT that included 84 subjects examined whether treatment with acupuncture or the muscle
relaxant baclofen alone or in combination would alleviate symptoms of chronic non-specific low back
pain in men. Results from this study suggest that after 5 and 10 weeks of follow-up the combined
Back Pain Assessment, Management, and Follow-up Guideline 15
group and the acupuncture alone group experienced significantly greater reductions in pain and
disability compared to the control group or the baclofen alone. The combined group also experienced
significantly greater reductions in pain and disability compared to the group that received only
acupuncture (Zaringhalam 2010).
Massage
A Cochrane meta-analysis that included 13 RCTs with 1,596 participants assessed the effectiveness
of massage therapy for low back pain. Results from this meta-analysis suggest that massage therapy
may be beneficial for patients with subacute (pain lasting 4 to 12 weeks) and chronic back pain (pain
lasting more than 12 weeks); however, more research is needed to determine the ideal massage
therapy method, duration, and frequency (Furlan 2008).

A recent RCT that was published after the meta-analysis and included 401 participants evaluated
whether massage (relaxation or structural) would reduce pain and improve function in patients with
chronic low back pain compared to usual care. The primary outcome measures were back pain
related dysfunction (Roland Morris Disability Questionnaire [RMDQ]) and symptom bothersomeness
at 10 weeks. Secondary outcome measures evaluated the primary outcome measures at 26 and 52
weeks. Results suggest that after 10 weeks of follow-up, treatment with relaxation or structural
massage significantly improved function and symptom bothersomeness in patients with chronic low
back pain compared to usual care. There was no significant difference in function or symptom
bothersomeness between the two massage groups. Effects decreased after the 10-week treatment;
however, at 26 weeks patients who received massage therapy still had statistically significant
differences in functional improvement compared to the usual care group. At 52 weeks, relaxation
massage was modestly more effective than structural massage and usual care. There were no
significant differences in symptom bothersomeness at 26 or 52 weeks (Cherkin 2011).
Interdisciplinary rehabilitation
A recent RCT followed 286 subjects for 24 months to compare the efficacy of a multidisciplinary
biopsychosocial rehabilitation program with an intensive therapist-assisted individual back muscle
exercise program for the treatment of chronic low back pain. Outcome measures were change in pain
(100 mm VAS) and disability (RMDQ) at 3 months. There was no significant difference in pain
between the two groups at any time point. Compared to patients in the exercise program, patients in
the multidisciplinary rehabilitation program experienced significantly greater reductions in disability at
3 months (3.0 vs. 1.5, P < 0.05). This improvement was maintained throughout the 24-month follow-
up period; however, it should be noted that this difference may not be clinically significant (Dufour
2010).

Another RCT that followed 109 patients for 12 months compared the effects of functional
multidisciplinary rehabilitation with those of physiotherapy on functional status and work status in
patients with subacute or chronic low back pain. Results suggest that compared to outpatients,
physiotherapy patients who received functional multidisciplinary rehabilitation were more likely to be
working full time and had less disability at 12 months. Results should be interpreted with caution as
baseline characteristics were not similar and there were a large number of patients lost to follow-up.
Additionally, when the analysis method for disability outcomes was changed, the between-group
differences were no longer significant (Henchoz 2010).
Mindfulness-based stress reduction
There is insufficient evidence to make a recommendation for or against mindfulness-based stress
reduction for the treatment of chronic low back pain.


Back Pain Assessment, Management, and Follow-up Guideline 16
References
Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated
acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009 May 11;169(9):858866.

Cherkin DC, Sherman KJ, Kahn J, et al. A comparison of the effects of 2 types of massage and usual
care on chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2011 Jul 5;155(1):19.

Dufour N, Thamsborg G, Oefeldt A, Lundsgaard C, Stender S. Treatment of chronic low back pain: a
randomized, clinical trial comparing group-based multidisciplinary biopsychosocial rehabilitation and
intensive individual therapist-assisted back muscle strengthening exercises. Spine (Phila Pa 1976). 2010
Mar 1;35(5):469476.
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Back Pain Assessment, Management, and Follow-up Guideline 17
Clinician lead and guideline development

Clinician Lead
David K. McCulloch, MD
Medical Director, Clinical Improvement

Content Expert
Randi Beck, MD
Service Line Chief, Physical Medicine & Rehabilitation

Guideline Team Members
Rosemary Agostini, MD, Sports Medicine
Hugh Allen, MD, Anesthesiology
Arne Andersen, MD, Family Medicine, Neurosciences
Beth Arnold , PharmD, Pharmacy Administration
Ben Balderson, PhD, Psychologist, Group Health Research Institute
Jo-Ellen Callahan, Manager, Radiology Services
Dan Cherkin, PhD, Group Health Research Institute
Rebecca Doheny, Clinical Epidemiologist, Clinical Improvement & Prevention
Abid Haq, MD, Occupational Medicine
Bill Huff, MD, Family Medicine, Sports Medicine
Steve Lavine, MD, Anesthesiology
Jennifer Macuiba, Guideline Coordinator, Clinical Improvement & Prevention
Robyn Mayfield, Patient Health Education Resources, Clinical Improvement & Prevention
Donna Moore, MD, Physiatry/Physical Medicine
Ina Oppliger, MD, Rheumatology
Tom Paulson, MD, Medical Director, Care Review and Utilization
Grant Scull, MD, Family Medicine
Michelle Seelig, MD, Family Medicine
Rajiv Sethi, MD, Neurosurgery
Karen Severson, RN, Nursing
Ann Stedronsky, Clinical Publications, Clinical Improvement & Prevention
John Vandergrift, MD, Emergency Medicine
Michael Von Korff, ScD, Group Health Research Institute

Most Recent Guideline Approval: February 2012

Process of Development
The recommendations in this guideline were adapted from externally developed, evidence-based
guidelines from the Agency for Healthcare Research and Quality, the American Pain Society and
American College of Physicians, the National Institute for Health and Clinical Excellence, and the
Washington State Health Care Authority. (See Evidence Summary for details.)

The following specialties were represented on the development and/or update teams: anesthesiology,
behavioral health, complementary and alternative medicine, emergency medicine, family medicine, Group
Health Research Institute, neurosurgery, nursing, occupational medicine, orthopedics, pharmacy,
physiatry and rehabilitation, and rheumatology.

Back Pain Assessment, Management, and Follow-up Guideline 18
Appendix 1. Evidence of effectiveness for non-pharmacologic strategies for the
management of back pain

Definitions
Small benefit =
Mean 5- to 10-point improvement in pain on a 100-point VAS
Mean 5- to 10-point improvement in function on the Oswestry Disability Index
Mean 1- to 2-point improvement in function on the Roland-Morris Disability Questionnaire

Moderate benefit =
Mean 10- to 20-point improvement in pain on a 100-point VAS
Mean 10- to 20-point improvement in function on the Oswestry Disability Index
Mean 2- to 5-point improvement in function on the Roland-Morris Disability Questionnaire


Table a. Level of evidence supporting SELF-CARE options for ACUTE back pain
Treatment Small/moderate
benefit
No
benefit
Unable to estimate
benefit
Active treatment
Advice to remain active X
Passive treatment
Superficial heat X
Bed rest (limit to less than 48 hours) X
Lumbar support X
Superficial cold X

Table b. Level of evidence supporting SELF-CARE options for CHRONIC back pain
Treatment
Small/moderate
benefit
No
benefit
Unable to estimate
benefit
Advice to remain active X


Progressive relaxation
1
X
Lumbar support
X
1
Progressive relaxation requires intensive initial training.

Table c. Level of evidence supporting NON-PHARMACOLOGIC options for ACUTE back pain
Treatment Small/moderate


benefit
No benefit Unable to estimate
benefit
Spinal manipulation X
Exercise therapy X
Acupuncture X
Back school X
Interferential therapy X
Low-level laser therapy X
Massage X
Transcutaneous electrical nerve
stimulation (TENS)
X
Back Pain Assessment, Management, and Follow-up Guideline 19

Table d. Level of evidence supporting NON-PHARMACOLOGIC options for CHRONIC back pain
Treatment Small/moderate


benefit
No benefit Unable to estimate
benefit
Exercise X
Education X
Spinal manipulation X
Massage X
Acupuncture X
Intensive interdisciplinary rehabilitation X
Psychological therapy (cognitive
behavioral therapy or progressive
relaxation)
X
Yoga X
Traction X
Back school X
Interferential therapy X
Low-level laser therapy X
Transcutaenous electric nerve
stimulation (TENS)
X
Therapeutic ultrasound X
Mindfulness-based stress reduction X

Table e. Level of evidence supporting INVASIVE TREATMENT options for CHRONIC NON-SPECIFIC
back pain
Treatment
Recommended Not recommended/insufficient
evidence
Nerve root blocks
X
Intra-discal electrothermal therapy (IDET)
X
Lumbar (spinal) fusion
1
X
Prolotherapy
X
Radiofrequency facet joint denervation X
Sacroiliac joint injections X
Trigger point/soft tissue injections X
Epidural steroid injections
2
X
Spinal cord stimulation X
1
Referral for an opinion on spinal fusion may be appropriate for a small group of selected individuals who
have failed to respond to a combined physical and psychological intervention (NICE 2009).
2
There is insufficient evidence for epidural steroid injections. Only consider epidural steroid injections after
initial appropriate conservative treatment programs have failed. Successful epidural steroid injections may
allow patients to advance in a conservative treatment program. Patients should be made aware of the
general risks of short-term and long-term use of steroids (ICSI 2010).


Back Pain Assessment, Management, and Follow-up Guideline 20