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## Complete Summary

#### GUIDELINE TITLE

Management of acute low back pain.

#### BIBLIOGRAPHIC SOURCE(S)

Michigan Quality Improvement Consortium. Management of acute low back
pain. Southfield (MI): Michigan Quality Improvement Consortium; 2008
Mar. 1 p.

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute low back pain

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurology

#### INTENDED USERS

Advanced Practice Nurses\
Health Plans\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To achieve significant, measurable improvements in the management of
    acute low back pain through the development and implementation of
    common evidence-based clinical practice guidelines

-   To design concise guidelines that are focused on key management
    components of acute low back pain to improve outcomes

#### TARGET POPULATION

Adults with low back pain or back-related leg symptoms for less than 6
weeks

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation/Diagnosis**

1.  Assess patients for \"red flag\" indicators of serious disease
    (e.g., cauda equina, cancer, fracture, infection)

2.  Imaging (plain X-rays, bone scan, computed tomography \[CT\], 
    magnetic resonance imaging \[MRI\]), if indicated

3.  Laboratory tests (complete blood count \[CBC\], urinalysis,
    erythrocyte sedimentation rate \[ESR\]), if necessary

**Management/Treatment**

1.  Reassure patients and encourage to stay active

2.  Ice for painful areas, stretching exercises, and McKenzie exercises

3.  Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs)

> **Note**: COX-2 inhibitors and opiates were considered but not
> recommended.

4.  Referral, if necessary

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The Michigan Quality Improvement Consortium (MQIC) project leader
conducts a search of current literature in support of the guideline
topic. Computer database searches are used to identify published
studies, existing protocols and/or national guidelines on the selected
topic developed by organizations such as the American Diabetes
Association, American Heart Association, American Academy of Pediatrics,
etc. If available, clinical practice guidelines from participating MQIC
health plans and Michigan health systems are also used to develop a
framework for the new guideline.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Levels of Evidence for the Most Significant Recommendations

A.  Randomized controlled trials

B.  Controlled trials, no randomization

C.  Observational studies

D.  Opinion of expert panel

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Using information obtained from literature searches and available health
plan guidelines on the designated topic, the Michigan Quality
Improvement Consortium (MQIC) project leader prepares a draft guideline
to be reviewed by the medical directors\' committee at one of their
scheduled meetings. Priority is given to recommendations with \[A\] and
\[B\] levels of evidence (see \"Rating Scheme for the Strength of the
Evidence\" field).

The initial draft guideline is reviewed, evaluated, and revised by the
committee resulting in draft two of the guideline. Additionally, the
Michigan Academy of Family Physicians participates in guideline
development at the onset of the process and throughout the guideline
development procedure. The MQIC guideline feedback form and draft two of
the guideline are distributed to the medical directors, as well as the
MQIC measurement and implementation group members, for review and
comments. Feedback from members is collected by the MQIC project leader
and prepared for review by the medical directors\' committee at their
next scheduled meeting. The review, evaluation, and revision process
with several iterations of the guideline may be repeated over several
meetings before consensus is reached on a final draft guideline.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

When consensus is reached on the final draft guideline, the medical
directors approve the guideline for external distribution to
practitioners with review and comments requested via the Michigan
Quality Improvement Consortium (MQIC) health plans (project leader
distributes final draft to medical directors\' committee, measurement
and implementation groups to solicit feedback).

The MQIC project leader also forwards the approved guideline draft to
appropriate state medical specialty societies for their input. After all
feedback is received from external reviews, it is presented for
discussion at the next scheduled committee meeting. Based on feedback,
subsequent guideline review, evaluation, and revision may be required
prior to final guideline approval.

The MQIC Medical Directors approved this updated guideline in March
2008.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The level of evidence grades (**A-D**) are provided for the most
significant recommendations and are defined at the end of the \"Major
Recommendations\" field.

**Eligible Population**

Adults with low back pain or back-related leg symptoms for \< 6 weeks

**Patients with Low Risk of Serious Pathology (No Red Flags)**

Reassure patient that 90% of episodes resolve within six weeks
regardless of treatment **\[C\]**. Advise that minor flare-ups may occur
in the subsequent year.

*Therapy*

-   Stay active and continue ordinary activity within the limits
    permitted by pain. Avoid bedrest **\[A\]**. Early return to work is
    associated with less disability.

-   Injury prevention (e.g., use of proper body mechanics, safe back
    exercises)

-   Recommend ice for painful areas and stretching exercises **\[D\]**.

-   McKenzie exercises **\[A\]** are helpful for pain radiating below
    the knee.

*Referral*

-   If no improvement at 1 to 2 weeks, refer for goal-directed manual
    physical therapy, not modalities such as heat, traction, ultrasound,
    transcutaneous electrical nerve stimulation (TENS).

-   Surgical referral usually not required if no \"red flags.\"

*Medication Strategies*

-   Medication treatment depending on pain severity with acetaminophen
    or non-steroidal anti-inflammatory drugs (NSAIDs) **\[A\]**

-   COX-2 inhibitors and muscle relaxants have **not** been shown to be
    more effective than NSAIDs **\[A\]**.

-   Opiate analgesics have **not** been shown to be more effective than
    NSAIDS in acute low back pain.

*Testing*

-   Diagnostic tests or imaging usually not required.

-   If no improvement after 6 weeks, consider imaging.

**Assessment to Identify Potential Serious Pathology**

*Assess for \"Red Flag\" Indications of Serious Disease*

[Cauda Equina]{.underline}

-   Severe or progressive neurologic deficit

-   Recent bowel or bladder dysfunction

-   Saddle anesthesia

[Cancer]{.underline}

-   Men and women age \>50

-   Cancer history

-   Insidious onset

-   No relief at bedtime or worsening when supine

-   Constitutional symptoms (e.g., fever, weight loss)

-   Male with diffuse osteoporosis or compression fracture

[Fracture]{.underline}

-   Traumatic injury or onset, cumulative trauma

-   Steroid use history

-   Women age \>50

[Infection]{.underline}

-   Steroid use history

-   Diabetes mellitus

-   Immune suppression

-   History of urinary tract infection (UTI) or other infection

-   Constitutional symptoms (e.g., fever, weight loss)

-   No relief at bedtime or worsening when supine

-   Human immunodeficiency virus (HIV)

-   Previous surgery

-   Insidious onset

-   Intravenous (IV) drug use

**Patients with High Risk of Serious Pathology (Red Flags)**

-   Cauda Equina syndrome or severe or progressive neurologic deficit
    --- Refer for emergency studies and definitive care **\[C\]**

-   Spinal fracture or compressions --- Plain lumbosacral (LS) spine
    X-ray **\[B\]**. After 10 days, if fracture still suspected or
    multiple sites of pain, consider either bone scan **\[C\]** or
    referral **\[D\]** before considering computed tomography (CT) or
    magnetic resonance imaging (MRI).

-   Cancer or infection --- complete blood count (CBC), urinalysis,
    erythrocyte sedimentation rate (ESR) **\[C\]**. If still suspicious
    consider referral or seek further evidence (e.g., bone scan
    **\[C\]**, other labs --- negative plain film X-ray does not rule
    out disease).

**Definitions**:

**Levels of Evidence for the Most Significant Recommendations**

A.  Randomized controlled trials

B.  Controlled trials, no randomization

C.  Observational studies

D.  Opinion of expert panel

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is provided for the most significant
recommendations (See \"Major Recommendations\" field).

This guideline is based on several sources, including the ICSI Adult Low
Back Pain Guideline, Institute for Clinical Systems Improvement, 2006
([www.icsi.org](http://www.icsi.org/)).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Through a collaborative approach to developing and implementing common
clinical practice guidelines and performance measures for management of
acute low back pain, Michigan health plans will achieve consistent
delivery of evidence-based services and better health outcomes. This
approach also will augment the practice environment for physicians by
reducing the administrative burdens imposed by compliance with diverse
health plan guidelines and associated requirements.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline lists core management steps. Individual patient
considerations and advances in medical science may supersede or modify
these recommendations.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Approved Michigan Quality Improvement Consortium (MQIC) guidelines are
disseminated through email, U.S. mail, and websites.

The MQIC project leader prepares approved guidelines for distribution.
Portable Document Format (PDF) versions of the guidelines are used for
distribution.

The MQIC project leader distributes approved guidelines to MQIC
membership via email.

The MQIC project leader submits request to website vendor to post
approved guidelines to MQIC website
([www.mqic.org](http://www.mqic.org/)).

The MQIC project leader completes a statewide mailing of the
comprehensive set of approved guidelines and educational tools annually.
The guidelines and tools are distributed in February of each year to
physicians in the following medical specialties:

-   Family Practice

-   General Practice

-   Internal Medicine

-   Other Specialists for which the guideline is applicable (e.g.,
    endocrinologists, allergists, pediatricians, cardiologists, etc.)

The statewide mailing list is derived from the Blue Cross Blue Shield of
Michigan (BCBSM) provider database. Approximately 95% of the state\'s
M.D.s and 96% of the state\'s D.O.s are included in the database.

The MQIC project leader submits request to the National Guidelines
Clearinghouse (NGC) to post approved guidelines to NGC website
([www.guideline.gov](http://www.guideline.gov/)).

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Michigan Quality Improvement Consortium. Management of acute low back
pain. Southfield (MI): Michigan Quality Improvement Consortium; 2008
Mar. 1 p.

#### ADAPTATION

This guideline is based on several sources, including the ICSI Adult Low
Back Pain Guideline, Institute for Clinical Systems Improvement, 2006
([www.icsi.org](http://www.icsi.org/)).

#### DATE RELEASED

2008 Mar

#### GUIDELINE DEVELOPER(S)

Michigan Quality Improvement Consortium - Professional Association

#### SOURCE(S) OF FUNDING

Michigan Quality Improvement Consortium

#### GUIDELINE COMMITTEE

Michigan Quality Improvement Consortium Medical Directors\' Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Physician representatives from participating Michigan Quality
Improvement Consortium health plans, Michigan State Medical Society,
Michigan Osteopathic Association, Michigan Association of Health Plans,
Michigan Department of Community Health and Michigan Peer Review
Organization

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Standard disclosure is requested from all individuals participating in
the Michigan Quality Improvement Consortium (MQIC) guideline development
process, including those parties who are solicited for guideline
feedback (e.g., health plans, medical specialty societies).
Additionally, members of the MQIC Medical Directors\' Committee are
asked to disclose all commercial relationships as well.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Michigan Quality Improvement Consortium Web
site](http://www.mqic.org/pdf/MQIC 2008 LOW BACK PAIN GUIDELINE.pdf).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on July 18, 2008. The
information was verified by the guideline developer on July 21, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which may be
reproduced with the citation developed by the Michigan Quality
Improvement Consortium.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
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those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
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Readers with questions regarding guideline content are directed to
contact the guideline developer.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008