1. In order to place the patient with LBP into the correct category for diagnosis and treatment, the first guideline recommendation is to obtain a focused history and a complete physical examination of the patient. When performing a focused assessment, include assessment of the pain: intensity, frequency, location, and duration, as well as any causative factors. In addition, pay special attention to all neurologic symptoms, such as foot drop, lower extremity weakness, bowel or bladder dysfunction, or numbness. When obtaining the history from the patients, be aware of red flags that indicate a source of pain that requires a fuller workup or a specialist referral. Red flags consist of:
■ Fever and chills, indicating infection or abscess
■ Night pain that is highly indicative of a malignant source for the pain
■ A history of cancer with possible reoccurrence, weight loss
■ Recent urinary tract infection, resulting in LBP
■ Intravenous drug use with resultant LBP during withdrawal or infection (Eathorne, 2007; Fishbain, Ballantyne, & Rathmell, 2010)
As part of the assessment for LBP. The straight leg raise is recommended, along with a neurologic-exam that includes great toe and foot dorsiflexion, plantar dorsiflexion, and ankle reflexes. If the straight leg raise reproduces the patient's sciatic pain at a 30° to 70° increase, there is a positive finding that is 91% sensitive but only 26% specific for diagnosing herniated disc (Chou et al., 2007; Eathorne, 2007).
2. The second recommendation in the guideline clearly states that clinicians should avoid obtaining routine imaging or other radiographic diagnostic tests in patients with nonspecific LBP (Chou, 2007). This recommendation is a result of the guideline panel research review finding that MRI, CT, and plain radiography are not related to improved outcomes (Chou, 2007). Avoiding the use of imaging decreases the amount of patient radiation exposure in the lumbar and lower abdominal area of the body. This is especially important for women of childbearing years because frequent imaging can result in exposure of reproductive organs to radiation.
3. The third recommendation of the guideline also relates to when imaging should be used and what type is advised. There is a growing body of moderate quality evidence to support a strong recommendation that patients with severe or progressive neurologic deficits or with suspected serious underlying conditions identified during the history and physical examination should have diagnostic imaging and testing (Chou, 2007). In these cases, MRI is the preferred method for imaging over CT. This is because the MRI provides increased structural visualization and reduced ionizing radiation. Immediate imaging is recommended for:
■ Cancer with suspected cord compression
■ Vertebral infection
■ Cauda equina syndrome (Chou, 2007)
When the patient has persistent LBP with/without radiculopathy or suspected spinal stenosis, MRI is preferred over CT only if the patient is a candidate for surgery or epidural steroid injection (Chou, 2007). Nerve conduction studies provide little benefit in the diagnostic process for LBP.
Thie new guidelines examine the outcomes of various diagnostic techniques. The practice recommendations reflect using imaging techniques only if they will affect the outcome of treatment. To use imaging on patients with nonspecific LBP will only increase treatment costs, increase radiation exposure, and provide no added benefit to the outcome of treatment.
How should the health care provider decide which medications to use for treating LBP? In later sections of the LBP guideline developed by the APS and ACP, information on medication use and outcomes was used to determine practice recommendations for treating LBP.
Thie primary care health care provider is often faced with the patient who does not feel he or she has had adequate treatment for pain if there is no prescription for medication. In a recent study, 80% of primary care patients who complained of LBP were prescribed at least one medication at their initial office visit and more than one-third were prescribed two or more drugs (Chou & Huffman, 2007a). The consistent use of prescription pain medications for LBP reinforces the prevailing consumer concept that medication is always needed and will relieve LBP. Unfortunately, medication alone may not relieve LBP, and pain medications will not always be effective for the individual patients.
Because American health care consumers expect to receive a prescription for LBP, it is important to determine just which medication will produce the best outcomes with minimal side effects. There are some categories of medication, such as acetaminophen, that are recommended, whereas other categories, such as opioids, have a narrower application indicated by the pain and primary care societies
Acetaminophen is an over-the-counter medication that is readily available in a variety of formulations. If medicine cabinets in America were surveyed, it would be found that most would include a container of acetaminophen or a medication that contains acetaminophen. Acetaminophen has low risk when taken in dosages lower than the recommended maximum dose of 4,000 mg/day for short periods. No medication is totally benign. At doses of 4,000 mg/day, there can be asymptomatic elevations of aminotransferase even in healthy adults, but the risk profile to these increases has not been clearly identified (Chou & Huffman, 2007a). The LBP guidelines recommend acetaminophen as the treatment for acute LBP, along with the recommendation to the patient to remain as physically active as possible.
■ Nonsteroidal Anti-inflammatory Drugs
There are two different types of NSAIDs available for treating pain: nonselective NSAIDs and COX-2 selective NSAIDs. The nonselective NSAIDs affect both COX-1 and COX-2 prostaglandin production. The sole COX-2 selective NSAID medication, celecoxib (Celebrex), is only COX-2 selective and does not affect the COX-1 prostaglandins that protect the stomach lining. Because prostaglandins are found in other organs, including the heart and the kidneys, there are risk factors for using any type of NSAID. For this reason, the primary use for NSAIDs should be for inflammatory pain. They should be used for the shortest period at the lowest dose to minimize any potential for adverse events (Chou et al., 2007a).
The COX-2 medication, celecoxib (Celebrex), is available by prescription only. The nonselective NSAIDs, such as ibuprofen (Motrin), are available in over-the-counter strength preparations that are available for purchase in drug stores, supermarkets, and a number of variety stores, such as Target. Because they are so widely available, there is a definite risk of toxicity when patients are buying and using these medications without the supervision of a health care provider. Both types of NSAIDs have received recommendations for use, and all have black box warnings incorporated into their packaging.
Two significant issues to consider when prescribing NSAIDs to treat LBP involve (a) correct patient selection and (b) evaluating the risk-benefit profile. Patients with long-term needs for NSAIDs are not good candidates related to the risk of increased renovascular and cardiovascular toxicity over time. Older patients with impaired kidney function, cardiac history, or recent heart surgery are not good candidates for NSAIDs treatment for pain relief related to the increased potential for toxicity, stroke or heart attack, and bleeding, respectively.
Both types of NSAIDs have the potential for increasing cardiovascular risks and renovascular events. Nonselective NSAIDs particularly have an increased risk of gastrointestinal (GI) bleeding and ulceration (Dorsi & Belzberg, 2005). Many older patients use aspirin as a prophylaxis, and adding an NSAID to drug regimens for these patients also increases the potential for GI bleeding because of the additive effect. (See Chapter 5 for additional information on NSAIDs.)
■ Opioid Analgesics and Tramadol
Using opioid analgesics and tramadol hydrochloride (Ultram) to treat LBP is the third recommendation of the guideline. The role of opioids for LBP is limited. The recommendation is to reserve these medications, opioids and tramadol, for patients who have tried acetaminophen or NSAIDs and found them to be ineffective. For patients who are being considered for opioid therapy, the pain should be severe and/or disabling before the opioids are used (Chou et al., 2007).
The fear of addiction with opioid use is still a concern for many health care providers. In a survey of 400 nurse practitioners who were reporting barrier to prescribing opioids, 61% reported a fear of addicting patients and 71% reported they feared regulatory oversight of their prescribing patterns (D'Arcy, 2009a). LBP patients might require opiates for long-term treatment and many prescribers are cautious or reluctant to continue to prescribe scheduled substances on a long-term basis. In the same survey of 400 nurse practitioners, the comfort level for opioid prescribing dropped dramatically from 73% to 32% when the patient in a scenario was changed from one who needed only short-term opioids to a patient who required long-term opioid therapy for LBP (D'Arcy, 2009a).
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