Health Care Guideline:

Adult Acute and Subacute Low Back Pain
Diagnosis Algorithm

Sixteenth Edition
March 2018

Text in blue in this algorithm
indicates a linked corresponding
annotation.

Red Flags for
Underlying
Pathology• Cauda equina
symptoms• Cancer risk
• Spinal infection risk
• Fragility fracturerisk• Unrelenting pain
• Progressive
neurologic deﬁcit• Trauma

Yellow Flags(Psychosocial Factors)• Work place• Attitudes and beliefs• Sociał/family• Behaviors• Affective/emotions

Adult patient present
with acute or subacutelow back pain

Complete assessment tools
for pain and function
History and exam:• Pain characteristics• Sensory and strength changes• Prior treatment and response

Incapacitating pain
and/or advancing
neurologic symptoms or other
underlying
pathology

yesConsider reevaluation, imaging
or referral tospecialist

noAddress modiﬁable
psychosocial factors
Routine imaging is notrecommended

See Treatment
Algorithm
Acute < 4 weeks
Subacute 4-12 weeks
Chronic ≥ 12 weeks

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Copyright © 2017 by Institute for Clinical Systems Improvement1Adult Acute and Subacute Low Back Pain
Sixteenth Edition/March 2018

Yellow Flags(Psychosocial Factors)• Work place• Attitudes and beliefs• Social /family• Behaviors• Affective/emotions

Treatment Algorithm

Acute or subacutelow back pain
diagnosis

Routine imaging is notrecommended

Establish treatment goals using shareddecision-making:• Patient goals• Clinical goals• Patient barriers• Psychosocial factors

Develop a Treatment Plan
Patient education

Self-care

Pharmacologic

Non-pharmacologic

Implement a jointly agreed upon care plan:• Patient education and training• Self-management plan
• Reassessment plan
• Return to work plan

2-3 week follow up

Goals met?
• Function• Painnono

yesContinued selfmanagement andeducation to prevent
future episodes

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Persistent or
progressive
symptoms?

Is care plan
implemented asplanned?

yesnoConsider referral for
epidural for subacuteradicular pain

Shared DecisionMaking

Consider re-evaluation,
imaging or referral tospecialist• Re-establlish treatement goals• Reassess psychosocial factors

yes- Consider alternative
diagnosis (return to Diagnosis
Algorithm)- Consider referral

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2Adult Acute and Subacute Low Back Pain
Sixteenth Edition/March 2018

Table of Contents
Work Group Leader
David Thorson, MD
Sports Medicine, Entira
Family Clinics

Work Group Members

3M
Robb Campbell, MD, MPH
Occupational Medicine

CentraCare Health System
Michael Massey, DO
Pain Medicine
Becky Mueller, DO
Family Medicine/Sports
Medicine

Fairview Health Services
Becky McCathie, MEd, ATC
Specialty
Heidi Richards, PT, MHA
Physical Therapy
OSI Physical Therapy
Steven Peterson
Physical Therapy

Park Nicollet HealthServices
Chris Kramer, PT, DPT, OCS,FAAOMPT
Physical Therapy
Physicians' Diagnostics &Rehabilitation Clinics
Todd Ginkel, DC
Spine Rehabilitation

ICSI
Jodie Dvorkin, MD, MPH
Project Manager/Health Care
Consultant
Senka Hadzic, MPH
Clinical Systems Improvement
Facilitator
Audrey Hansen, BSN, MA,
PMP
Project Manager/Health Care
Consultant

Algorithms and Annotations ........................................................................................ 1-25

Algorithm – Diagnosis .........................................................................................................1
Algorithm – Treatment .........................................................................................................2
Evidence Grading .................................................................................................................4
Recommendations Table .................................................................................................. 5-6
Foreword
Introduction .....................................................................................................................7
Scope and Target Population...........................................................................................7
Aims ................................................................................................................................7
Related ICSI Scienti ic Documents ................................................................................7
Definition ........................................................................................................................8
Annotations .................................................................................................................... 9-25
Initial Evaluation ...................................................................................................... 9-15
Treatment Plan ........................................................................................................ 15-22
Re-evaluation ................................................................................................................23
Radicular Pain - Special Considerations ................................................................. 23-24
Quality Improvement Support .................................................................................. 26-31
Aims and Measures ............................................................................................................27
Measurement Speci ications ................................................................................... 28-29
Implementation Tools and Resources .................................................................................30
Implementation Tools and Resources Table .......................................................................31
Supporting Evidence..................................................................................................... 32-43
References .................................................................................................................... 33-36
Appendices ................................................................................................................... 37-43
Appendix A – Patient Handout .....................................................................................37
Appendix B – ICSI Shared Decision-Making Model ............................................. 38-43

Disclosure of Potential Conflicts of Interest .......................................................... 44-46
Acknowledgements ..............................................................................................................47
Document History and Development ...................................................................... 48-49
Document History ..............................................................................................................48
ICSI Document Development and Revision Process .........................................................49

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3Adult Acute and Subacute Low Back Pain
Sixteenth Edition/March 2018

Evidence Grading
Literature Search

A consistent and defined process is used for literature search and review for the development and revisionof ICSI guidelines. Literature searches for this guideline were done under the following parameters:•

Time frame: January 1, 2000 – May 1, 2017.

•

Types of studies searched for: systematic reviews and meta-analysis, randomized controlled trials andobservational studies (case-control, cohort and cross-sectional studies).

•

Population: adults, 18 years of age and over, with acute and subacute low back pain or radiculopathy.

•

All studies were published in English and included humans.

In addition to the literature searches, articles were obtained by work group members and ICSI staff. Thosevetted by the work group were included in the guideline when appropriate.
Literature search terms used:
STarT Back screening tool; Keele stratified care model; imaging for low back pain; imaging for low backradiculopathy; red flags; clinical prediction rule; fear avoidance; modifiable risk factors; cognitive behavioral therapy; mindfulness-based stress reduction therapy; patient education; education; normal activity vs.
staying active; activities of daily living; exercise for prevention; exercise for treatment; bed rest; acupuncture;
dry needling; heat therapy; cold therapy; healing efficacy of cold therapy; traction; physical therapy/spinal
manipulation therapy/chiropractic care; NSAIDs for treatment; anti-inflammatories; Tylenol for treatment;
corticosteroids for treatment; opioids for treatment; tramadol for treatment; muscle relaxants; benzodiazepines; weight loss for treatment to prevent recurrence of low back pain; obesity and acute/subacute low backpain; obesity and chronic low back pain; acceptance and commitment therapy; regenerative medicine/stem
cells/platelet-rich plasma/prolotherapy; medial branch blocks; rhizotomy; functional restoration programfor subacute low back pain; cold laser therapy; radiofrequency ablation; low back pain in pregnancy.

Methodology
ICSI utilizes a modified version of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology system. GRADE involves systematically evaluating the quality of evidence(high, moderate, low, very low) and developing a strength of recommendation (strong, weak). For moredetailed information on GRADE, please visit http://www.gradeworkinggroup.org/.
When there was a paucity of systematic reveiws and randomized controlled trials, the work group could not
apply the GRADE methodology. In these cases, the work group used the best available evidence to reachconsensus recommendations. For each consensus recommendation, the releveant resources used to support
that recommendation are noted.

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4Adult Acute and Subacute Low Back Pain
Sixteenth Edition/March 2018

Recommendations Table
The following table is a list of evidence-based recommendations for adult acute and subacute low back pain.
Quality of
Evidence(For GRADE
Recommendations)

Strength of
Recommendation(For GRADE
Recommendations)

Topic

Recommendation

Initial
Evaluation

For patients with acute and subacutelow back pain, a biopsychosocial
assessment should be performed.

Imaging

Clinicians should not routinely
recommend imaging (x-ray,computed tomography [CT],magnetic resonance imaging [MRI]
for patients with nonspecific orradicular low back pain with an
absence of red flags on clinicalpresentation.

Quality of Evidence:
Moderate

StrongRecommendation

Chou 2009(Systematic Review
and Meta-analysis);
Patel, 2016
(Guideline)

All patients should receive
appropriate education on thetreatment and recovery expectations
for acute and subacute low back pain.

Quality of Evidence:
Moderate-High

StrongRecommendation

Traeger, 2015
(Systematic Review
and Meta-Analysis)

Heat may be used for pain relief for
acute and subacute low back pain.

Quality of Evidence:
Moderate

Weak
Recommendation

Cold

Cold therapy may be used for pain
relief.

N/A (Consensus Recommendation)

Chou, 2016
(Comparative
Effectiveness Review)

Activity

Clinicians should advise patientswith acute and subacute low backpain to stay active and continue
activities of daily living within thelimits permitted by their symptoms.

Quality of Evidence:
Moderate

StrongRecommendation

Dahm 2010(Systematic Review);
McIntosh 2011
(Systematic Review)

Spinal manipulation should beconsidered in early intervention for
acute and subacute low back pain.

Quality of Evidence:
Low-Moderate

StrongRecommendation

Acupuncture

Acupuncture should be considered
for subacute low back pain.

Quality of Evidence:
Low

Weak
Recommendation

Paige, 2017
(Systematic Review
and Meta-Analysis);Chou, 2016
(Comparative
Effectiveness Review)

NSAIDS

Non-steroidal anti-inflammatory
medication may be used for shortterm relief in patients with acute andsubacute low back pain. Patient
should be counseled on potential side
effects.

Quality of Evidence:
Moderate

StrongRecommendation

Education

Heat

SpinalManipulation

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N/A (Consensus Recommendation)

Relevant Resources

Papageorgiou, 1998
(Observational Study);
Waddell, 1987
(Report); Waddell,
1992 (Report)

Chou, 2016
(Comparative
Effectiveness Review)

Chou, 2016
(Comparative
Effectiveness Review)
Chou, 2016
(Comparative
Effectiveness Review)www.icsi.org
5Adult Acute and Subacute Low Back Pain
Sixteenth Edition/March 2018

Topic

Recommendation

Quality of Evidence(For GRADE Recommendations)

Acetaminophen

Acetaminophen may be used as an
option for pain relief in patients withacute and subacute low back pain.
Patients should be counseled on
potential side effects.

N/A (Consensus Recommendation)

MuscleRelaxants

Opioids
Epidural Steroid
Injections

Muscle relaxants may be used as ashort-term option (< one week) in thetreatment of acute low back pain.
Possible side effects should beconsidered.
In general, opioids are notrecommended for acute and subacutelow back pain.

Epidural steroid injections may be
used as an adjunct treatment for acuteand subacute low back pain with aradicular component to assist withpain relief.

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Quality of Evidence:
Moderate

Weak
Recommendation

N/A (Consensus Recommendation)
Quality of Evidence:
Moderate

StrongRecommendation

Strength of
Recommendation(For GRADE
Recommendations)
Chou, 2016
(Comparative
Effectiveness Review;
Saragiotto, 2016
(Systematic Review)
Chou, 2016
(Comparative
Effectiveness Review)
Chou, 2016
(Comparative
Effectiveness Review)
Chou, 2015
(Technology
Assessment);
Manchikanti, 2016
(Systematic Review)www.icsi.org
6Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

Foreword
Introduction

Studies have estimated the one-year incidence of a first-ever episode of low back pain ranges between 6.3%
and 15.4%, while estimates of the one-year incidence of any episode of low back pain range between 1.5%
and 36% (Hoy, 2010).
Once a patient experiences back pain he or she is more likely to experience it again. Estimates of recurrence at one year range from 24% to 80% (Hoy, 2010). Many environmental and personal factors influence
the onset and course of low back pain. Studies have found the incidence of low back pain is highest in thethird decade, and overall prevalence increases with age until the 60-65 year age group and then gradually
declines (Hoy, 2010).
An acute episode can lead to chronicity. Factors that influence chronicity include depression, employment
status, chemical dependency and failure to treat acute episodes as indicated. Chronic low back pain (painlasting greater than 12 weeks) is a leading cause of disability and cost. The total costs of low back painin the United States exceed $100 billion per year. Two-thirds of these costs are indirect, due to lost wages
and reduced productivity. Each year, fewer than 5% of the patients who have an episode of low back pain
account for 75% of the total costs (Katz, 2006). Understanding how to identify and classify low back pain
will help develop a treatment plan that can reduce chronicity, decrease costs, and improve health and function.
Low back pain is classified as either non-specific low back pain or radicular low back pain. This guideline
will focus on pathways used to define acuity and chronicity, the limited scenarios when diagnostic testing is
indicated, and how to develop a treatment plan that is comprehensive and evidence-based. Embedded in theguideline are clinical decision points that will help direct the clinician in a treatment path that will improveoutcomes, decrease inappropriate imaging and medications, and help patients understand and partner intheir treatment. Tools for assessing biopsychosocial health and the impact that the pain has on quality oflife are recommended. The treatment plan should always include patient education. In addition, self-care,
non-pharmacologic modalities and pharmacologic options may be offered.

Scope and Target Population

Adult patients age 18 and over who have symptoms of low back pain or radiculopathy. The focus is on theacute (pain for up to 4 weeks) and subacute (pain for between 4 and 12 weeks) phases of low back pain.
Chronic pain (after 12 weeks) is beyond the scope of this guideline.

Aims

1. Decrease the percentage of adult patients with acute or subacute low back pain with or without radiculopathy who have imaging ordered for low back pain in the absence of red flags at the initial visit.
2. Decrease the percentage of adult patients with acute or subacute low back pain with or without radiculopathy who are prescribed opioids.

Related ICSI Scientific Documents
Guidelines•

Major Depression in Adults in Primary Care•

Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management

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7Adult Acute and Subacute Low Back Pain

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Definition

Clinician – All health care professionals whose practice is based on interaction with and/or treatment of apatient.

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8Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

Annotations
Initial Evaluation

Low back pain is overall a benign condition, with a majority being nonspecific low back pain. Radiculopathy
is defined as pain that is dermatomal; it may or may not be accompanied by sensory or strength deficit orchange in reflex. Diffuse or nonorganic sensory or strength changes are not considered radicular, and if
noted should be generally be treated as nonspecific low back pain. However, in rare cases it may represent
myelopathy or higher cord lesions
Initial evaluation should look to identify and address potential underlying pathology that would require further
investigation or radiculopathy with neurologic deficit. For all low back pain, but particularly those with
non-specific low back pain, it is important to do a thorough biopsychosocial evaluation. In addition, patientengagement is crucial for not only the proper assessment but also the treatment for low back pain. At theonset, clinicians should ask the patient if he or she has any specific questions or expectations from the visit.
Consensus Recommendation

For patients with acute and subacute low back pain, a biopsychosocial assessment should be performed.

BenefitStandardized assessment tools offer consistency for the documentation of biopsychosocial risk factors.
Harm
Using one measure of assessment in isolation of the clinical examination or other biopsychosocial risk factors could
lead to an ineffective care plan for the patient.
Benefits/Harms Assessment
Validated and comprehensive tools provide accurate information for the creation and the ultimate success of progresswith a treatment plan. If no tools are utilized, the assessment becomes subjective. See “Evaluate Function” and“Yellow Flags (Psychosocial Indicators” section for reference to possible tools.
Relevant Resources
Papageorgiou, 1998 (Observational Study); Waddell, 1992 (Report); Waddell, 1987 (Report)

History
The initial history evaluation of low back pain should include the following:•

History and review of systems including assessment for underlying pathology (e.g., cauda equina
syndrome, cancer, fracture, infection)•

History of previous low back pain, prior treatment and response•

Pain characteristics (location, character, intensity, exacerbating and alleviating factors, and duration); of note, pain that radiates past the knee can be mechanical or radicular in origin; if there isany activity associated with the onset of the pain or unrelenting night pain, it should be noted•

Sensory changes (the specific distribution and character)•Strength changes (a generalized sense of weakness should be differentiated from focal change suchas the inability to dorsal or plantar flex the foot or great toe)•

Indicators of psychosocial, workplace and other factors that increase the risk of develop persistent
low back pain•

Screen for depression

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9

Algorithm Annotations-

Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

Psychological factors play a significant role not only in chronic pain, but also in the etiology ofacute pain, particularly in the transition to chronic problems. Specific types of psychologicalvariables emerge and may be important in distinct developmental time frames, also implyingthat assessment and intervention need to reflect these variables (Linton, 2000). A cohort study
involving 221 primary care patients with acute or subacute low back pain found that reciprocal
effects of depressive symptoms and low back pain seem to depend on time under medical treatment. Thus, clinicians should screen for and treat depressive symptoms at the first consultation
to improve the low back pain treatment (Elfering, 2014). In another cohort study of 286 patientswith acute low back pain, the course of recovery was slower in depressive patients. Depression
was associated with low back pain, especially after six weeks (Melloh, 2013). Tools such as thePHQ-2 and PHQ-9 may be used in screening. Refer to the ICSI Major Depression in Adults
in Primary Care guideline for more information.

Red Flags
It is important to evaluate patients for underlying pathology that may warrant urgent workup and/or referral. While the presence of red flags may raise suspicion, it is important to recognize that they
do not completely rule in or rule out a particular condition. Therefore, the clinician must take into
consideration the full clinical picture and exercise judgment when choosing when a patient might
benefit from further diagnostic workup.
It is the consensus of this work group that the following red flags warrant consideration for urgent workup
and/or referral:•

Bowel/bladder dysfunction (most commonly urinary retention)•

Progressive neurologic weakness•

Saddle anesthesia•

Bilateral radiculopathy•

Incapacitating pain•

Unrelenting night pain

Additional red flags associated with malignancy and fracture are listed in the sections below.
Serious Causes of Low Back Pain
Cauda equina syndrome
Cauda equina syndrome is compression of the lumbrosacral nerve roots that form the cauda equina. Signs
or symptoms of cauda equina syndrome, in addition to low back pain, include:•

Bladder/bowel dysfunction (most commonly urinary retention)•

Motor deficits (lower extremity weakness, depressed deep tendon reflexes)•

Sensory deficits (saddle sensory loss)

All patients with back pain should be asked about urinary retention. Those reporting this symptom should
be examined for bilateral leg weakness, depressed leg deep tendon reflexes, and perineal numbness. Thesepatients may report bowel, bladder and sexual dysfunction, and severe pain. This syndrome is rare but
catastrophic and requires emergent surgical consultation.

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Algorithm Annotations

Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

Malignancy
Two systematic reviews found that a history of malignancy increases the likelihood of spinal malignancy(Downie, 2013; Henschke, 2013). The review by Downie (2013) found that other red flags cited in someguidelines such as older age, weight loss and failure to improve after one month had post-test probability
point estimates below 3% (Downie, 2013). A Cochrane review found that insidious onset, older age(> 50) and failure to improve after one month had high false-positive rates. The authors concluded that red
flags may be useful when combined or with a history of cancer, but by themselves will result in overtesting(Henschke, 2013).
FractureSingle red flags that increase the likelihood of spinal fracture in a patient with low back pain include older
age, prolonged corticosteroid use, severe trauma and the presence of contusion or abrasion. These red flags
increased the probability of fracture to between 10% and 33% (Downie, 2013).
In addition, probability of fracture was higher (increased to between 42% and 90%) with the coexistenceof multiple red flags, specifically: (Downie, 2013)•

The combination of any four of leg or buttock pain, female, older age, BMI < 23, gait abnormality,
no regular exercise, sitting pain or osteoarthritis•

Any three of female, age > 70, severe trauma, prolonged use of corticosteroids•

Trauma with neurological signs

Note: There is not sufficient data on a history of osteoporosis as a specific risk factor.
Infection
An uncommon but serious cause for back pain is infection. A spinal infection such as vertebral osteomyelitis
or spinal epidural abscess can present as back pain with a fever.
Consideration of other non-spine origins
Low back pain can be due to visceral disease. Examples include (Goldman, 2011):•

Disease of pelvic organs (prostatitis, endometriosis, chronic pelvic inflammatory disease)•

Renal disease (nephrolithiasis, pyelonephritis, perinephric abscess)•

Aortic aneurysm•

Gastrointestinal disease•

Pancreatitis•

Cholecystitis•

Penetrating ulcer•

Cardiac or pericardial disease•

Pulmonary or pleural disease

Evaluate Function
Using tools can help with proper management of low back pain. The following are some of the available
tools for low back pain evaluation. Other validated tools may be used, as well.
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Algorithm Annotations

Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

PEG [Pain intensity, interference with enjoyment of life and interference in general activity (PEG)]
is a three-item scale used to assess pain intensity and interference using scales of 0-10. Adding scores andthen dividing the total by three allows you to track change over time. It is recommended that you also document all three scores individually in order to understand the key issue. The PEG is freely available in the
public domain (Krebs, 2009).
Keele STarT Back Screening Tool (SBST) is a simple prognostic questionnaire that helps clinicians identify modifiable risk factors (biomedical, psychological and social) for back pain disability. Information isavailable at https://www.keele.ac.uk/sbst/startbacktool/.
Modified Oswestery Disability Questionnaire is used to assess the patient's subjective rating of perceived
disability related to his or her functional limitations (e.g., work status and difficulty caring for oneself). The
higher the score, the more perceived disability the patient has. Using this test helps the examiner understandthe patient's perception of how back pain is affecting his or her life. This tool has at least four versions/formats in English and more in other languages (Fairbank, 2000).
Roland-Morris Disability Questionnaire is another tool available for the assessment of low back pain
disability. A substantial number of papers have been published on the psychometric properties, validity andreliability of the RMDQ. The original questionnaire and all translations are in the public domain (Roland,1983). Information is available at http://www.rmdq.org.
Fear-Avoidance Beliefs Questionnaire (FABQ) is used to assess fear avoidance beliefs (Williamson,
2006; Waddell, 1993). Information is available at https://www.tac.vic.gov.au/files-to-move/media/upload/
fear_avoidance.pdf

Yellow Flags (Psychosocial Indicators)
Waddell published the importance of the biopsychosocial approach to low back pain over 30 years ago(Waddell, 1987). Psychosocial indicators (yellow flags) include a patient’s attitudes, emotions, behaviors,and family and workplace factors. They may lead to an increased risk of progression to long-term distressand disability. In patients with low back pain up to six months duration, fear-avoidant beliefs negatively
impacted pain and/or disability as well as return to work (Wertli, 2014). Further, high levels of fear-avoidance
beliefs occur early in low back patients (Coudeyre, 2007). George et al. (2015) found that psychologicalrisk status, depressive symptoms and pain intensity were predictive of six-month recovery status. Furthermore, elevated fear-avoidance, kinesiophobia and depressive symptoms co-occurred with nonrecovery at
six months (George, 2015).
Objective measurement of a range of yellow flags can be captured by a validated, comprehensive and reliable tool such as the STarT Back Tool (NICE, 2016). This tool is designed to allocate patients into low,
medium and high-risk groups. In a cross-sectional study of 244 primary care patients, Hill et al. (2010)
found that agreement of expert clinicians and a formal tool such as STarT Back occurred only in about half
the patients. Results of the study found that clinicians made inconsistent treatment decisions. While tools
such as STart Back may help standardize decision-making, the study also found weaknesses of the tool. It
failed to identify in some cases high-risk patients who had non-pain psychosocial stress or hard life circumstances that clinicians were able to identify (Hill, 2010). In addition, the STarT Back Tool was not able to
make a high-level synthesis of patient expectations, preferences and previous treatment history. Thus, theauthors caution that tools should be used in conjunction with, not instead of, clinician judgment (Hill, 2010).
Stratified management of low back pain has been found to be a cost-effective approach for patients at highrisk of permanent disabling low back pain, but not for those at low to medium risk (Whitehurst, 2015).

Exam
The purpose of the exam is to identify and document neurologic deficits, muscle weakness and biomechanicaldysfunction.
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Algorithm Annotations

Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

The exam should expand upon a patient’s history and pain drawing, and include test and measures that assess
neurologic, musculoskeletal and biomechanical dysfunction.
The following are components of the low back pain exam:•

Neurologic evaluation, including reflex sensation, and neural tension and strength-straight leg raising-ability to walk on heels and toes-

symmetrical great toe extensor strength•

Palpation of related structures•

Assessment of posture•

Evaluation of lumbar spine range of motion (quantity and quality, asymmetry/inconsistency)•

Evaluation of hip range of motion•

Single leg balance and ability to maintain level pelvis for 30 seconds (lateral hip pain within 30
seconds may suggest gluteal tendinopathy) (Grimaldi, 2017)•

Other examination of joints as indicated by history and initial exam•

Additional examination including respiratory, gastrointestinal or genital urinary examination recommended, as indicated by history

Poor lumbar segmental motion without neurologic findings could represent nonspecific or mechanical lowback pain. The presence of focal neurologic signs could suggest nerve impingement.

Imaging
Recommendation
Clinicians should not routinely recommend imaging (x-ray, computed tomography[CT], magnetic resonance imaging [MRI]) for patients with nonspecific orradicular low back pain and an absence of red flags on clinical presentation.

Quality of Evidence andStrength of
Recommendation

Quality of Evidence:
Moderate
Strength of
Recommendation: Strong

Benefit
In general, imaging for low-back pain without indication(s) of serious underlying conditions does not improve clinicaloutcomes. In addition, not imaging will avoid potential exposure to radiation.
Harm
Some underlying conditions may be missed by not imaging.
Benefits/Harms Assessment
In general, routine imaging for acute/subacute low back pain has been shown to be ineffective in altering the course oftreatment in the first six weeks. Harms of imaging include possible radiation exposure as well as potential decreased
sense of well-being by the patient. In general, these harms outweigh the benefits for patients with uncomplicated low
back pain and the absence of red flags on clinical presentation.
Relevant Resources: Chou, 2009 (Systematic Review and Meta-Analysis); Patel, 2016 (Guideline)

Clinicians should not recommend imaging (including computed tomography [CT], magnetic resonanceimaging [MRI] and x-ray) for patients with non-specific or radicular low back pain and an absence of red
flags on clinical presentation (Patel, 2016; Chou 2009).
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Algorithm Annotations

Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

A 2009 meta-analysis of six randomized trials comprising 1,804 patients with primarily acute or subacutelow back pain and no clinical or historical features that suggested a specific underlying condition, found nodifferences between routine lumbar imaging (radiography, MRI or CT) and usual care without routine imaging
in terms of pain, function, quality of life or overall patient-rated improvement. For short-term outcomes(three months), trends slightly favored usual care without routine imaging (Chou, 2009). The conclusionsof the meta-analysis did not seem to be affected by whether radiography or advanced imaging (MRI or
CT) was evaluated. With regards to radicular pain, the American College of Physicians 2011 Guideline on
imaging for low back pain stated that the results of this meta-analysis could probably be generalized to somedegree to patients with or without radiculopathy, because most of the trials enrolled at least some patientswith radiculopathy (Chou, 2011).
Regarding patient sense of psychological well-being, a prospective randomized study of patients with acutelow back pain and/or radiculopathy found that patient knowledge of imaging findings did not alter outcome
and were associated with a lesser sense of well-being (Ash, 2008).
According to the American College of Radiology Appropriateness Criteria (2016), imaging for uncomplicatedacute and subacute low back pain or radiculopathy with no red flags and no prior management is usually not
appropriate for the general patient. However, imaging for acute and subacute low back pain is usually
appropriate for the following populations (Patel, 2016):•

Elderly, and patients with low-velocity trauma, osteoporosis and chronic steroid use•

Patients in whom there is a suspicion of cancer, infection or immunosuppression•

Patients who are surgical or intervention candidates with persistent or progressive symptoms during
or following 6 weeks of conservative management•

Patients with new or progressing symptoms or clinical findings with history of prior lumbar surgery•

Low back pain with suspected cauda equina syndrome or rapidly progressive neurologic deficit

Special Population: Pregnancy
Low back pain, alone or in combination with pelvic pain, is a common problem suffered by women during
pregnancy. Studies estimate 50-80% of women will suffer from low back pain during pregnancy (Sabino,2008), and one study found that approximately 62% of pregnant women suffering from low back pain rated
it as moderately severe (Stapleton, 2002).
The typical course of low back pain during pregnancy is that it generally begins in the mid-late second
trimester, resolves during the postpartum period and, unfortunately, is likely to return in subsequent pregnancies (Sabino, 2008). Although most cases resolve in the postpartum period, Norén reported that 20%
of women with low back pain during pregnancy were found to have low back pain three years following
delivery (Norén, 2002).
The clinical history and physical examination should include elements that focus on the mother and the fetus,
and the medical care provider should consider a broad differential. The physical examination is similar tononpregnant patients with low back pain, although lumbar flexion will be limited as the pregnancy progresses.
The gravid abdominal examination can be challenging (Sabino, 2008).
Lumbar radiographs are routinely avoided during pregnancy due to concern for fetal health. Magnetic
resonance imaging is the test of choice for severe pregnancy-related low back pain (Sabino, 2008).
A 2015 systematic review of 34 randomized trials involving 5,121 pregnant woman found low-quality
evidence that exercise (any exercise on land or in water) may reduce pregnancy-related low-back pain andmoderate- to low-quality evidence suggesting that any exercise improves functional disability and reduces
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sick leave more than usual prenatal care. Evidence from single studies suggests that acupuncture or craniosacral therapy improves pregnancy-related pelvic pain, and osteomanipulative therapy or a multimodal
intervention (manual therapy, exercise and education) may also be of benefit (Liddle, 2015).

Treatment Plan

Education Is Treatment
Recommendation
All patients should receive appropriate education on the treatment and recovery
expectations for acute and subacute low back pain.

Quality of Evidence and Strengthof Recommendation

Quality of Evidence: Moderate-High
Strength of Recommendation: Strong

BenefitPatients who receive appropriate education about acute and subacute low back pain have improved outcomes and lessunnecessary health care utilization, and safely return to work with fewer missed days.
Harm
Minimal (if any) adverse effects of appropriate patient education. Harm can occur with inappropriate patient education such as
not fully addressing the recommendations above or avoiding altogether.
Benefits/Harms Assessment
Appropriate patient education is an effective treatment strategy in primary care.
Relevant Resources: Traeger, 2015 (Systematic Review and Meta-Analysis)

Patients who seek care for an episode of low back pain are frequently concerned about their current level ofpain or dysfunction. Patient education in primary care should be tailored to the individual patient’s needs,
specifically when reassuring and helping the patient set appropriate expectations for the current episode oflow back pain. Studies show objectively identifying and specifically addressing fear-avoidant, catastrophizingor anxious behavior improves patient outcomes in acute and subacute low back pain (Chou 2010, Dupeyron
2011, Traeger 2015). Therefore, implementation of screening tools such as the PEG or STartBack Tool may
be part of an effective educational care plan.
The educational treatment plan should reassure the patient and help the patient set appropriate expectations.
It should be delivered in a respectful way the patient can understand.
An educational care plan for patients with acute and subacute low back pain should include the following:•

Reassurance that there is a good outcome for nonspecific low back pain•

Reassurance that pain doesn’t mean harm and that the majority of back pain cannot be attributed
to a specific cause•

Informing patients that imaging is not helpful in the diagnosis or management of low back pain
unless the provider is concerned about a serious underlying cause such as infection, fracture orcancer•Ensuring that patients understand the role of medications for the treatment of low back pain•

Instructions on activity management, as well as work recommendations or limitations•

Patients with back pain should get back to normal activities of life as soon as possible and knowthat experiencing some discomfort during activities may be expected•

Follow-up and contact information in response to descriptions of specific warning signs of underlying pathology that may require earlier re-evaluation

Please see Appendix A for an example of a patient educational handout on low back pain.
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Return-to-Work Assessment/Social Activities
Educate patients experiencing an episode of acute back pain that their pain is likely to improve and thata large majority of patients can return to work quickly. They should understand that complete pain relief
usually occurs after, rather than before, resumption of normal activities, and their return to work can bebefore they have complete pain relief. Even though this is not a workers' compensation guideline, if there
are issues with the employer, it may be necessary to contact the employer to provide guidance on safe activities, restrictions or job modifications.
The return-to-work and resumption of normal daily activities should be based on what the clinician feels
can be performed safely. The importance of return to work should not be underestimated. The patient who
does not return to modified work or activity quickly begins to view him- or herself as disabled, and begins
fear of activity and may become deconditioned. It is important that the employer and all other stakeholders
support the concept of rapid safe reintegration into activities and that employers are encouraged to allow
return to work with modifications so this can be done safely.
If a clinician feels uncomfortable with defining work activities, referral to a person experienced in defining
work activities could be considered. We encourage engagement with employers to develop a return-to-work
plan.

Patient Barriers
Assessing the patient's resources is an important component of developing a treatment plan. Socioeconomic
factors may play a large role in whether a patient is able to adhere to the treatment plan. These factors may
include but are not limited to income, education, social support, housing and transportation. Understanding
and assisting with these patient barriers are critical to any treatment plan and the patient’s overall well-being.

Self-Care
Heat therapy
Recommendation
Heat may be used for pain relief for acute/subacute low back pain.

Quality of Evidence and Strengthof Recommendation
Quality of Evidence: Moderate
Strength of Recommendation: Weak

BenefitHeat therapy is low cost and easy to apply.
Harm
Harms of heat therapy are rarely reported, but possible overexposure to heat could cause a burn.
Benefits/Harms Assessment
Overall, these may be some benefit to heat with low risk of harm. It is an easy, cheap treatment that is a reasonable option forpatients.
Relevant Resources: Chou, 2016 (Comparative Effectiveness Review)

A 2016 AHRQ systematic review found that heat wrap can be more effective compared to placebo forpain relief at five days, decreased pain intensity at three to four days and disability at four days in patientswith acute and subacute low back pain. One study found pain relief at eight hours (Chou, 2016). When
compared with other treatments, a single trial has found some effectiveness of heat therapy in pain relief
and disability when combined with exercise versus exercise without heat, heat with an non-steroidal antiinflammatory drugs (NSAID) and an NSAID without heat. In addition, single trials have found heat to be
more effective than acetaminophen or ibuprofen in pain relief and disability (Chou, 2016). One single trial
found no difference in heat versus exercise in pain relief or function (Chou, 2016). The trials included in
the systematic review did not find evidence of serious adverse events of applying heat (Chou, 2016).
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Cold therapy
Consensus Recommendation

Cold therapy may be used for pain relief.

BenefitSome patients may find pain relief with cold therapy.
Harm
Ice burns can occur with direct application of cold to the skin. However, if applied appropriately, cold therapy poses minimal
risk.
Benefits/Harms Assessment
There is insufficient evidence on efficacy cold therapy versus placebo or no cold treatment in pain relief or function
improvement. However, given the low risk of harm, it is the consensus of the work group that cold therapy may be used forpain relief.
Relevant Resources: Chou, 2016 (Comparative Effectiveness Review)

There is insufficient evidence on efficacy cold therapy versus placebo or no cold treatment in pain relief orfunction improvement. The evidence is either lacking or the existing evidence has serious methodologicallimitations (Chou, 2016). However, given the low risk of harm, it is the consensus of the work group thatcold therapy may be used for pain relief.
Physical Activity
Activity as treatment
Clinicians should advise patients to stay active and continue ordinary activity as tolerated (Dahm, 2010;
McIntosh, 2011). Patients with acute low back pain may experience small benefits in pain relief and function from advice to stay active compared with advice to rest in bed. Back exercises may decrease recovery
time compared with no treatment, but there is considerable heterogeneity among studies with regard to thedefinition of back exercise (McIntosh, 2011; Dahm, 2010). A gradual return to normal activities is beneficial
and leads to more rapid symptom improvements, faster return to work, less chronic disability and fewerrecurrent problems. Carefully introduce activities as the patient begins to recover from the worst of the backpain episode. Light-duty activities and regular walking are good ways to reintroduce activity. Participationin activity that does not worsen symptoms.
Exercise as prevention
Currently the evidence suggests that exercise alone or in combination with education is effective forpreventing low back pain (Steffens, 2016). There is moderate quality evidence that post-treatment exercises
were more effective than no intervention for reducing the rate of recurrence at one year (Choi, 2010). Therewas moderate quality evidence that the number of reoccurrences were significantly reduced in two studies at
one-half to two years follow-up (Choi, 2010). According to a randomized trial of 600 patients with recurrent
low back pain, exercise frequency is more important than exercise type, duration or intensity in low backpain prevention (Steffens, 2016; Aleksiev, 2014).

Non-pharmacologic Treatments
Directed physical activity
Physical activity/exercise may be done by the patient as part of self-care or as part of an active rehabilitation
program with a therapist. A study by Fritz (2012) found that early-intervention patients were less likely tohave imaging, additional physician visits, surgery, injections and opioid medications compared with thosepatients with delayed physical therapy (Fritz, 2012).

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Please see “Self Care – Physical Activity” for more information about the effectiveness of activity for bothprevention and treatment of low back pain.
Spinal manipulation
Recommendation
Spinal manipulation should be considered in early intervention for acute andsubacute low back pain.

Quality of Evidence and Strengthof Recommendation

Quality of Evidence: Low-Moderate
Strength of Recommendation: Strong

BenefitAmong patients with acute low back pain, spinal manipulative therapy is associated with modest improvements in pain andfunction at up to six weeks.
HarmMinor transient adverse events such as increased pain, muscle stiffness and headache were reported.
Benefits/Harms Assessment
Spinal manipulative therapy demonstrates a safe and effective treatment modality for the reduction of acute low back pain. It iseffective without the risks associated with pharmacologic intervention. It can be combined with pharmacologic treatment if
desired but does not replace an active exercise program to avoid deconditioning.
Relevant Resources: Paige 2017 (Systematic Review and Meta-Analysis); Chou, 2016 (Comparative Effectiveness Review)

Spinal manipulation is a hands-on treatment directed toward the spine. Manipulation is a passive technique
whereby the clinician applies a specifically directed manual impulse, or thrust, to a joint at or near the endof the passive (or physiological) range of motion that can but does not have to be accompanied with an
audible crack (Rubinstein, 2013). The most notable professions that utilize spinal manipulation are physicaltherapists, chiropractors and osteopaths (Rubinstein, 2013). However, the focus of the treatment, education,
diagnostic procedures, treatment objective, and techniques as well as the philosophy of the various professions can vary greatly (Rubinstein, 2013).
A 2017 systematic review of 15 randomized trials involving 1,711 patients found that among patients withacute low back pain, spinal manipulative therapy was associated with modest improvements in pain andfunction at up to six weeks, with transient musculoskeletal harms (Paige, 2017).
A 2016 AHRQ systematic review found that for acute low back pain, spinal manipulation compared to shammanipulation was associated with better effects on function; effects on pain favored manipulation but were
small and statistically insignificant. There were no differences between spinal manipulation and inert treatment in pain relief at one week, but better longer-term pain relief is possible. There were no differences infunction at one week or three months. There was no difference between spinal manipulation versus otheractive interventions in pain relief at one week, one month, three to six months or one year. Spinal manipulation plus either exercise or advice was associated with greater improvement in function at one week versus
exercise or advice alone, but there were no differences at one month or three months. For radicular low
back pain, spinal manipulation plus home exercise and advice was associated with greater improvementin leg and back pain at 12 weeks versus home exercise and advice alone, but effects were smaller and nolonger statistically significant at 52 weeks. Harms were not well reported in the studies, but most adverse
events were related to muscle soreness and transient increases in pain (Chou, 2016).
Traction
Traction is generally not recommended for the treatment of acute low back pain (Wegner, 2013).
The current evidence indicates that traction as a single treatment or in combination with physiotherapy(physical therapy) is no more effective in treating low back pain than sham treatment, physiotherapy without
traction or other treatment methods including exercise, laser, ultrasound and corsets. These conclusions arevalid for people with and without radicular symptoms. There was no difference regarding the type of traction manual or mechanical (Wegner, 2013; Chou, 2016).
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Acupuncture
Recommendation
Acupuncture should be considered as treatment for subacute low back pain.

Quality of Evidence and Strengthof Recommendation
Quality of Evidence: Low
Strength of Recommendation: Weak

BenefitAcupuncture was found to have a small beneficial effect on subacute low back pain.
Harm
The most commonly reported harms of acupuncture include gastrointestinal problems, changes in energy, mild bleeding at theneedling site and temporarily increased pain.
Benefits/Harms Assessment
Given the low risk of harm and possible benefit, it reasonable for acupuncture to be considered among the treatment options for
subacute low back pain.
Relevant Resources: Chou, 2016 (Comparative Effectiveness Review)

Acupuncture may be described by the practice of stimulating or sedating specific points on the body byinserting filiform needles or by other means. These points may be well defined along channels or meridians.
However, there are different schools or methods of acupuncture such as articular and the use of musculoskeletal tender points (Ah Shi).
A 2016 AHRQ systematic review found that acupuncture had a small beneficial effect on pain compared tosham for subacute low back pain and a slightly higher likelihood of improvement compared to NSAID for
acute low back pain (Chou, 2016). In three of the trials, the most common adverse events from acupuncture
included gastrointestinal problems, changes in energy, mild bleeding at the needling site and temporarily
increased pain (Chou, 2016). Furthermore, a 2013 systematic review of 11 randomized trials involving
1,139 patients concludes that acupuncture may be more effective than medication in symptom improvement
and pain relief; however, more investigation is encouraged (Lee, 2013).
A 2007 randomized controlled trial of 444 patients found that patients had higher satisfaction with acupuncture
as an adjunct to care for acute low back pain despite no clinical or subjective improvements in symptoms
and higher cost of care (Eisenberg, 2007).
Dry needling
Dry needling is a skilled intervention that uses a thin solid-filament needle to penetrate the skin and stimulate
underlying myofascial trigger points and muscular and connective tissues for the management of neuromusculoskeletal pain and movement impairments (APTA Resource Paper, 2013). Dry needling and acupuncture
overlap with respect to needling techniques using solid-filiform needles as well as some fundamental theories. Dry needling should be recognized as one subcategory of Western medical acupuncture (Zhou, 2015).
Dry needling of myofascial trigger points as an adjunct to other treatments has been shown to reduce theintensity of low back pain at post-intervention. However, the effects on function and long-term symptom
reduction are unclear (Liu, 2017). Dry needling may enhance improvements in pain and function when usedin conjunction with standard conservative approach in the management of discogenic radiating low backpain (Mahmoudzadeh, 2016).
Yoga
A review of literature yielded no studies that evaluated yoga for the treatment of acute low back pain. Allof the studies evaluated efficacy of yoga for chronic low back pain (Chou, 2016; Goode, 2016).

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MassageResearch does not support massage as an effective treatment in the management of acute low back pain. In
a 2015 systematic review, massage was found to be beneficial in reducing pain in the short term in subacuteand chronic low back pain when no other interventions or inactive interventions were administered (Furlan,2015). Similarly, a 2016 AHRQ systematic review found benefit on pain relief and function of massage inthe short term for subacute to chronic low back pain when used either or alone or in combination with othertherapies, especially exercise (Chou, 2016).
Cognitive behavioral therapy (subacute pain only)
The evidence surrounding cognitive behavioral therapy (CBT) for subacute low back pain is mixed.
A 2011 systematic review found insufficient evidence to determine whether CBT is more effective than
traditional care (analgesics plus back exercises until pain subsidies) at reducing low back pain at nine to 12
months (McIntosh, 2011). There was low-quality evidence that CBT plus generic back exercise comparedwith no exercise or CBT alone or CBT plus neuromuscular training may be more effective at reducing pain
intensity at seven days (McIntosh, 2011).
A randomized controlled trial of 701 adults with troublesome subacute or chronic low back pain found thatthe group CBT intervention in addition to best practice advice had a sustained effect at a low cost to provider
over a one-year period (Lamb, 2010a). Analysis of the same trial also found long-term effectiveness andcost-effectiveness of CBT in treating subacute or chronic low back pain. Short-term (three-month) clinicaleffects were similar to those found in high-quality studies of other therapies, and benefits were maintained
and increased over the long term (12 months). Cost per quality-adjusted life year (QALY) was about halfthat of competing interventions for low back pain (Lamb, 2010b).

Pharmacologic Treatments
Non-steroidal anti-inflammatory medication
Recommendation
Non-steroidal anti-inflammatory medication may be used for short-term pain
relief in patients with acute and subacute low back pain. Patients should becounseled on potential side effects.

Quality of Evidence and Strengthof Recommendation
Quality of Evidence: Moderate
Strength of Recommendation: Strong

Benefit
NSAIDs have shown to have small beneficial effect on pain and function.
Harm
Harms of NSAIDs include but are not limited to gastritis, gastrointestinal bleeding, and possible cardiovascular complications.
Benefits/Harms Assessment
After discussing possible side effects with patients, it is reasonable to offer NSAIDs for short-term pain relief.
Relevant Resources: Chou, 2016 (Comparative Effectiveness Review)

A 2016 AHRQ systematic review found that NSAIDs may have small beneficial effect on pain intensityand function in patients with acute low back pain and a small positive effect on radicular pain (Chou,
2016). However, this same systematic review found that NSAIDS were associated with more side effects
than placebo (Chou, 2016). Patients need to be aware that all NSAIDs have harms that include but are notlimited to gastritis and gastrointestinal bleed, and possible cardiovascular implications.

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Acetaminophen
Consensus Recommendation

Acetaminophen may be used as an option for pain relief in patients with acute and subacute low back pain. Patientsshould be counseled on potential side effects.
BenefitSome patients may find pain relief with cold therapy.
HarmHigh doses of acetaminophen can lead to liver dysfunction.
Benefits/Harms Assessment
There is insufficient evidence on efficacy of acetaminophen. However, given the low risk of harm compared to otherpharmacologic agents, it is the consensus of the work group that acetaminophen may be used for pain relief.
Relevant Resources: Chou, 2016 (Comparative Effectiveness Review); Saragiotto, 2016 (Systematic review)

There is not a lot of literature examining the effectiveness of acetaminophen for low back pain. Based on
low-quality evidence, two recent systematic reviews suggest that acetaminophen is not more effective thanplacebo (Chou 2016; Saragiotto, 2016). Clinicians and patients should be aware that acetaminophen has therisk of serious liver disease. One trial found no difference between scheduled acetaminophen, as-needed
acetaminophen and placebo in risk of adverse advents. In addition, the 2016 AHRQ systematic review
found that acetaminophen was associated with lower risk of side effects than NSAIDS (Chou, 2016).
Based on consensus, the work group recommends that acetaminophen may be used as an option for pain
relief in patients with acute and subacute low back pain.
Muscle relaxants
Recommendation
Muscle relaxants may be used as a short-term option in the treatment of acute lowback pain; however, possible side effects should be considered.
Sedative hypnotics should be rarely used and if so, for short-term (< 1 week)treatment of muscle spasms related to acute pain.
Use of non sedative hypnotic muscle relaxants are of low benefit, but if used, limit
to less than four weeks.

Quality of Evidence and Strengthof Recommendation
Quality of Evidence: Moderate
Strength of Recommendation: Weak

Benefit
Skeletal muscle relaxants have been found to help with short-term pain relief in acute low back pain.
Harm
Muscle relaxants are central nervous system (CNS) depressants and cause additive sedation and other adverse effects, especiallyin combination with opioids. Sedative hypnotics have significant side effects, specifically in the geriatric population. Additiveside effects when taken with other CNS depressants are potential for dependence and withdrawal symptoms.
Benefits/Harms Assessment
Muscle relaxants should not be used as the standard first-line treatment but may provide short-term benefit in some patients.
Risk of significant side effects, and potential for dependence and withdrawal outweigh the benefit for long-term use.
Relevant Resources: Chou 2016 (Comparative Effectiveness Review)

In addition, it is the consensus of this work group to recommend against the use of carisoprodol for pain.
Muscle relaxants should not be used as the standard first-line treatment but may provide short-term benefit(less than one week) in some patients. Risk of significant side effects, and potential for dependence andwithdrawal outweigh the benefit for long-term use.
A 2016 AHRQ systematic review found muscle relaxants were superior to placebo for short-term pain relief(Chou, 2016). There was no difference between a skeletal muscle relaxant plus NSAID and NSAID alone in
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Sixteenth Edition/March 2018the likelihood of experiencing pain relief, though the estimate favored combination therapy. There were nodifferences in outcomes among different muscle relaxants for acute or chronic low back pain (Chou, 2016).
Most muscle relaxants are central nervous system (CNS) depressants and cause additive sedation and otheradverse effects, especially in combination with opioids (Chou, 2016). Sedative hypnotics have significant
side effects, specifically in the geriatric population. Benzodiazepines should rarely be used and if so, forshort-term (<1 week). Additive side effects when taken with other CNS depressants are potential for dependence and withdrawal symptoms (Chou, 2016).
Corticosteroids
A 2016 AHRQ systematic review found low evidence based on two RCTs that compared to placebo, systemic
corticosteroids had no effect on pain or function (Chou, 2016). For radicular pain, there was moderate
evidence based on five RCTs that showed no effect on pain or function (Chou, 2016). A randomized trialof 269 adults with radicular pain found that patients with acute radiculopathy from a herniated lumbar disk
who received a short course of oral steroids had modest improvement in function with no improvement in
pain and no reduction in surgery incidence (Goldberg, 2015).
Corticosteroids have side effects that patients need to be aware of, including osteonecrosis, mood changes,
anxiety, blurred vision, numbness or tingling in the arms or legs, swelling of the extremities, insomnia,
appetite changes, increased sweating and acne (Buchman, 2001).
Opioids
Consensus Recommendation

In general, opioids are not recommended for acute and subacute low back pain.
If non-opioid options have been tried and the clinician feels that a trial of opioids are necessary, the first opioidprescription for acute pain should be the lowest possible effective strength of a short-acting opioid, not to exceed 100
MME total. Patients should be instructed that three days or less will often be sufficient.

Benefit
Restricting opioid prescriptions will lead to decreased adverse events from opioids, including those as significant as addiction
and death.
Harm
There are some patients who may benefit from opioids for pain relief.
Benefits/Harms Assessment
In general, the risks of opioids outweigh the pain relief that opioids may provide. Non-pharmacologic and other pharmacologic
treatments should be used.
Relevant Resources: Chou, 2016 (Comparative Effectiveness Review)

In general, opioids are not recommended for acute and subacute low back pain. If non-opioid options havebeen tried and the clinician feels that a trial of opioids are necessary, the first opioid prescription for acutepain should be the lowest possible effective strength of a short-acting opioid, not to exceed 100 MME
total. Patients should be instructed that three days or less will often be sufficient. Please see the ICSI Pain:
Assessment, Non-Opioid Treatment Approaches and Opioid Management Guideline for detailed recommendations on opioid prescribing.
Evidence of efficacy of opioids in acute low back pain is insufficient (Chou, 2016). A 2016 AHRQ systematic
review found one trial that showed no significant differences between opioids and acetaminophen in days
to return to work (Chou, 2016). This same review found two trials that showed buprenorphine patches wereassociated with greater short-term improvement in pain versus placebo patches for subacute or chronic low
back pain; effects on function showed no clear effect or were unclearly reported (Chou, 2016). Moderatequality evidence suggests that short-term use of opioids was associated with higher risk of side effects
such as nausea and dizziness. There were no trials that assessed risks of overdose, abuse and addiction, or
long-term harms (Chou, 2016).
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Re-evaluation

If symptoms are not improving, consider that there may be a misdiagnosis, inadequate treatment, patientbarriers or alternative non-spine-related factors inhibiting recovery.
It is the expert opinion of this working group to instruct the patient to return for the following reasons:•Pain that doesn't seem to be getting better after two to three weeks•

Pain and weakness traveling down the leg below the knee•

Leg, foot, groin or rectal area feeling numb•Unexplained fever, nausea/vomiting, stomachaches, weakness or sweating•

Loss of control of urine or stool•

Pain is so intense the patient can't move around or get comfortable•

Redness or swelling on the back or spine•

Desire for further reassurance or education

Re-evaluation of low back pain should include the following:•

Pain reassessed•

Sensory changes•

Strength changes•

Job and activity associations considered and noted•

Presence or absence of underlying pathology and psychosocial factors

Radicular Pain – Special Considerations
Referral

When there is concern for underlying pathology for radicular pain, urgent referral to a specialist is needed.
In addition, if improvement is not seen in four to six weeks, referral for a spine expert may be appropriate.
The subacute phase of low back pain is the optimum time to decide whether a patient may benefit fromsurgery or an interventional pain procedure.

Treatment Options
The initial treatment for radicular pain includes the same options as for nonspecific low back pain. Pleaserefer to those sections for more detailed information.
•

Self-Care•

Non-pharmacologic Treatment•

Pharmacologic Treatment

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Epidural Steroid Injections
Recommendation
Epidural steroid injections may be used as an adjunct treatment for acute andsubacute low back pain with a radicular component to assist with short-term pain
relief.

Quality of Evidence and Strengthof Recommendation

Quality of Evidence: Moderate
Strength of Recommendation: Strong

Benefit
Epidural steroid injections may offer short-term pain relief for acute and subacute low back pain with radicular component.
Harm
Adverse effects of epidural steroid injections include bleeding, infection and nerve damage.
Benefits/Harms Assessment
For selected patients, epidural steroid injections are a reasonable adjunct to help with radicular pain.
Relevant Resources: Chou, 2015 (Technology Assessment); Manchikanti, 2016 (Systematic review)

The recent literature reviews on epidural steroid injections are mixed, with significant differences in methodology. Most studies focus on chronic low back pain.
In a 2015 technology assessment of 23 RCTs, Chou et al. concluded that epidural corticosteroid injections for radiculopathy are associated with immediate improvements in pain and might be associated withimmediate improvements in function, but benefits are small and not sustained, and there is no effect on thelong-term risk of surgery (Chou, 2015). Moreover, the effectiveness did not seem to vary based on injection
technique, corticosteroid, dose or comparator (Chou, 2015). For nonradicular back pain and spinal stenosis,
there was limited evidence that epidural steroid injections are not effective (Chou, 2015). In addition, theyfound that there were no serious adverse events and few harms associated with epidural steroid injections,although for some studies, methods for assessing harms were not always well reported and harms data wassparse (Chou, 2015).
A comparative systematic review and meta-analysis of 39 RCTs found that for radiculopathy or spinal
stenosis, injections with sodium chloride solution or bupivacaine were ineffective. However, lidocaine alone
or lidocaine in conjunction with steroids were significantly effective for pain and function with a minimum
12-month follow-up (Manchikanti, 2016).
Given these conflicting evidence reviews, it appears the magnitude of benefit of epidural steroid injections is unclear. However, with low risk of serious adverse events, the work group concludes that epiduralsteroid injections may be used as an adjunct treatment for acute and subacute low back pain with a radicularcomponent to assist with pain relief.
Consider epidural steroid injections after initial appropriate conservative treatment program. How long to
wait until offering an injection is a matter of clinical judgment. For instance, in cases of severe symptoms,
injections are often performed earlier in the treatment course. If the patient responds to the epidural steroid
injection, it may allow him or her to advance in a nonsurgical treatment program and avoid surgery. It is
generally agreed that if possible, epidural steroid injections should not be used as a monotherapy. Patientsshould be made aware of the general risks of short- and long-term use of steroids – particularly temporary
alterations in glucose control.
It is now considered standard of care to perform the injections under image guidance and with contrast inorder to deliver the injectate as close to the disc herniation, area of stenosis or nerve root impingement as
determined by advanced imaging.
There are three approaches to the epidural space: interlaminar, transforaminal and caudal (McLain, 2005;
Cannon, 2000). The different approaches allow the treatment to be tailored to the needs of the individual.
With each of the three approaches – interlaminar, transforaminal and caudal – there is the typical risk of
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bleeding, infection and nerve damage. Patients should be informed of the possible risks that could occur
using each of the three approaches (Somayaji, 2005; Tiso, 2004; Botwin, 2000).
Please see the ICSI Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management Guideline
section on “Interventional Treatments” for more detailed discussion of epidural steroid injections as well asother interventional pain treatment.
The following may be considered when referring a patient for epidural steroid injection. The final decisionof whether a patient is appropriate for the procedure will be made by the specialist.
•

Patients typically have symptoms of radicular pain. Examination findings for radiculopathy (reflexchanges, possible motor weakness and root tension signs) need not be present. In addition, thepain should be of a severity that significantly limits function and quality of life, and that has not
responded to oral analgesic medications and other conservative care measures.

•

Advanced imaging is needed – either magnetic resonance imaging or computerized tomography torule out other causes of pain (e.g., infection, cancer).

•

Patients should have no contraindications to an injection, including these:-

No signs or symptoms of active infection either systemically or locally.

-

No history of bleeding disorders or current use of anticoagulants such as warfarin or clopidogrel. Epidural injections carry a higher risk of bleeding. Patients taking antithrombotics havean increased risk, and the standard of care should be followed. Guidelines have been developed
to limit the risk. Assessment of the risk versus benefit should be done prior to the procedure.
Consult with the individual performing the procedure for appropriate anticoagulation guidelines.

•

Patients with nonanaphylactic reaction to iodine-based contrast may still be treated. Consult withthe provider performing the procedure. Those with documented anaphylaxis to iodine-based contrast
can be treated with a non-iodine-based contrast such as gadolinium (Safriel, 2006).

•

No allergies to local anesthetic agents, contrast agents or corticosteroids.

•

No prior complications to corticosteroid injections.

•

Pregnancy is a contraindication due to the use of fluoroscopy.

•

Use caution in diabetic patients because of altered glycemic control, which is typically transient.
Patients with diabetes need to be informed and aware that their blood glucose levels will rise andalterations in sliding scales will likely be needed.

•

Patients with congestive heart failure need to be aware of steroid-induced fluid retention.

•

Though NSAID use is not a contraindication to injections, some practitioners discontinue NSAIDs
several days prior to injection.

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Quality Improvement Support:

Adult Acute and Subacute Low Back Pain

The Aims and Measures section is intended to provide protocol users with a menu
of measures for multiple purposes that may include the following:• population health improvement measures,• quality improvement measures for delivery systems,• measures from regulatory organizations such as Joint Commission,• measures that are currently required for public reporting,• measures that are part of Center for Medicare Services Physician Quality
Reporting initiative, and• other measures from local and national organizations aimed at measuring
population health and improvement of care delivery.
This section provides resources, strategies and measurement for use in closing
the gap between current clinical practice and the recommendations set forth in theguideline.
The subdivisions of this section are:
• Aims and Measures• Implementation Recommendations• Implementation Tools and Resources• Implementation Tools and Resources Table

Copyright © 2017 by Institute for Clinical Systems Improvement26

Adult Acute and Subacute Low Back Pain

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Aims and Measures
1. Decrease the percentage of adult patients with acute or subacute low back pain with or without radiculopathy who have imaging ordered for low back pain in the absence of red flags at the initial visit.
Measure for accomplishing this aim:a.

Percentage of patients with acute or subacute low back pain with or without radiculopathy who
have imaging ordered for low back pain in the absence of red flags at the initial visit.

2. Decrease the percentage of adult patients with acute or subacute low back pain with or without radiculopathy who are prescribed opioids.
Measure for accomplishing this aim:a.

Percentage of patients with acute or subacute low back pain with or without radiculopathy who areprescribed opioids.

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Aims and Measures

Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

Measurement Specifications
Measurement #1

Percentage of patients with acute or subacute low back pain with or without radiculopathy who have imaging
ordered for low back pain in the absence of red flags at the initial visit.

Population Definition

Patients, 18 years and older, seen in primary care and diagnosed with acute or subacute low back pain withor without radiculopathy.

Data of Interest# of patients who have imaging ordered for low back pain in the absence of red flags# of patients with acute or subacute low back pain diagnosis with or without radiculopathy

Numerator and Denominator Definitions

Numerator: Number of patients who have imaging ordered for low back pain in the absence of red flags.
Red flags:•

Bowel/bladder dysfunction (most commonly urinary retention)•

Progressive neurologic weakness•

Saddle anesthesia•

Bilateral radiculopathy•

Incapacitating pain•

Unrelenting night pain

Denominator: Number of patients with acute or subacute low back pain with or without radiculopathy
diagnosis.

Method/Source of Data Collection

Query EMR for the number that meets the denominator criteria for population as defined in Population
Definition. Out of that number, identify the number that meets the numerator criteria.

Notes

This is a process measure, and improvement is noted as a decrease in the rate.

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Adult Acute and Subacute Low Back Pain

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Aims and Measures

Measurement #2

Percentage of patients with acute or subacute low back pain with or without radiculopathy who are prescribed
opioids.

Population Definition

Patients, 18 years and older, seen in primary care and diagnosed with acute or subacute low back pain withor without radiculopathy.

Data of Interest# of patients prescribed opioids# of patients diagnosed with acute or subacute low back pain with or without radiculopathy

Numerator/Denominator Definitions
Numerator:

Number of patients who were prescribed opioids.

Denominator: Number of patients diagnosed with acute or subacute low back pain with or without
radiculopathy.

Method/Source of Data Collection

Query EMR for the number that meets the denominator criteria for population as defined in Population
Definition. Out of that number, identify the number that meets the numerator criteria.

Time Frame Pertaining to Data Collection
Monthly.

Notes

This is a process measure, and improvement is noted as a decrease in the rate.

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Adult Acute and Subacute Low Back Pain

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Implementation Tools and Resources
Criteria for Selecting Resources
The following tools and resources specific to the topic of the guideline were selected by the work group.
Each item was reviewed thoroughly by at least one work group member. It is expected that users of thesetools will establish the proper copyright prior to their use. The types of criteria the work group used are:•

The content supports the clinical and the implementation recommendations.

•

Where possible, the content is supported by evidence-based research.

•

The author, source and revision dates for the content are included where possible.

•

The content is clear about potential biases and conflicts of interests and/or disclaimers are noted
where appropriate.

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Adult Acute and Subacute Low Back Pain

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Implementation Tools and Resources Table
Author/Organization

Title/Description

Audience

Web Sites/Order Information

GeneralCochrane

Website provides systematic reviews on
evidence-based medicine.

Health Care
Professionals

http://www.cochrane.org

Website provides a PDF document entitled Patients and"Handout or Health: Back." The booklet
Families
is for patients and families who have backpain and want to learn more about it.

http://www.niams.nih.gov

National Library ofFederal government source of back healthMedicines MEDLINE related information and research, related
Plus/National Institutes links.
of Health
NIAMS: National
Institute of Arthritis
and Musculoskeletal
and Skin Diseases
UpToDate

Website provides information for healthprofessionals related to evidence-based
clinical information. There may be a fee
for access.

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Health Care
Professionals;
Patients andFamilies

http://www.nlm.nih.gov/hinfo.
html

Health Care
Professionals

http://www.uptodate.com

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31Supporting Evidence:

Adult Acute and Subacute Low Back Pain

The subdivisions of this section are:• References• Appendices

Copyright © 2017 by Institute for Clinical Systems Improvement32Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

References
Aleksiev AR. Ten-year follow-up of strengthening versus flexibility exercises with or without abdominal
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American Physical Therapy Association. Description of Dry Needling in Clinical Practice: An Educational
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Ash LM, Modic MT, Obuchowski NA, et al. Effects of diagnostic information, per se, on patient outcomesin acute radiculopathy and low back pain. AJNR Am J Neuroradiol 2008;29:1098-103.
Botwin KP, Gruber RD, Bouchlas CG, et al. Complications of fluoroscopically guided transforaminal
lumbar epidural injections. Arch Phys Med Rehabil 2000;81:1045-50.
Buchman AL. Side effects of corticosteroid therapy. J Clin Gastroenterol 2001;33(4):289-94.
Cannon DT, Aprill CN. Lumbosacral epidural steroid injections. Arch Phys Med Rehabil 2000;81:S87-98.
Choi BK, Verbeek JH, Tam WW, Jiang JY. Exercises for prevention of recurrences of low back pain.
Cochrane Database Syst Rev 2010;(1):CD006555.
Chou R, Deyo R, Friedly J, et al. Noninvasive treatments for low back pain. Rockville (MD): Agency for
Healthcare Research and Quality (US). Report No. 16-EHC004-EF. 2016
Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review andmeta-analysis. Lancet 2009;373(9662):463-72.
Chou R, Hashimoto R, Friedly J, et al. Pain management injection therapies for low back pain. Technology Assessment Report ESIB0813. (Prepared by the Pacific Northwest Evidence-based PracticeCenter under Contract No. HHSA 290-2012-00014-(.) Rockville, MD: Agency for Healthcare Research
and Quality; July 2015.
Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American Collegeof Physicians. Ann Intern Med 2011;154(3):181-9.
Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA 2010;303:1295302.
Coudeyre E, Tubach F, Rannou F, et al. Fear-avoidance beliefs about back pain in patients with acute
LBP. Clin J Pain 2007;23:720-25.
Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for
acute low back pain and sciatica. Cochrane Database Syst Rev 2010;(6):CD007612.
Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patientswith low back pain: systematic review. BMJ 2013;347:f7095.
Dupeyron A, Ribinik P, Gélis A, et al. Education in the management of low back pain: literature review
and recall of key recommendations for practice. Ann Phys Rehabil Med 2011;54:319-35.
Eisenberg DM, Post DE, Davis RB, et al. Addition of choice of complementary therapies to usual care
for acute low back pain: a randomized controlled trial. Spine 2007;32:151-58.
Elfering A, Käser A, Melloh M. Relationship between depressive symptoms and acute low back pain at
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Fairbank JC, Pynsent PB. The Oswestry disability index. Spine 2000;25:2940-52.

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References

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Sixteenth Edition/March 2018Friedman BW, Esses D, Solorzano C, et al. A randomized placebo-controlled trial of single-dose IM
corticosteroid for radicular low back pain. Spine 2008;33:E624-29.
Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain tophysical therapy: impact on future health care utilization and costs. Spine 2012;37:2114-21.
Furlan AD, Giraldo M, Baskwill A, et al. Massage for low back pain. Cochrane Database Syst Rev
2015;(9):CD001929.
George SZ, Beneciuk JM. Psychological predictors of recovery from low back pain: a prospective
study. BMC Musculoskelet Disord 2015;16:49.
Goldberg H, Firtch W, Tyburski M, et al. Oral steroids for acute radiculopathy due to a herniated lumbar
disk: a randomized clinical trial. JAMA 2015;313:1915-23.
Goldman L. In Goldman's Cecil Medicine 24th Edition. 2011.

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References

Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

Goode AP, Coeytaux RR, McDuffie J, et al. An evidence map of yoga for low back pain. Complement
Ther Med 2016;25:170-77.
Grimaldi A, Mellor R,Nicolson, et al. Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. Br J Sports Med 2017; 519-24.
Henschke N, Maher CG, Ostelo RW, et al. Red flags to screen for malignancy in patients with low backpain. Cochrane Database Syst Rev 2013;(2):CD008686.
Hill JC, Vohora K, Dunn KM, et al. Comparing the STarT back screening tool's subgroup allocation ofindividual patients with that of independent clinical experts. Clin J Pain 2010;26:783-87.
Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin
Rheumatol 2010;24:769-81.
Katz JN. Lumbar disc disorders and low back pain: socioeconomic factors and consequences. J Bone
Joint Surg Am 2006;88:21-24.
Kent P, Mjøsund HL, Petersen DHD. Does targeting manual therapy and/or exercise improve patient
outcomes in nonspecific low back pain? A systematic review. BMC Medicine 2010;8:22.
Krebs EE, Lorenz KA, Bair MJ, et al. Development and initial validation of the PEG, a three-item scaleassessing pain intensity and interference. J Gen Intern Med 2009;24:733-38.
Lamb SE, Hansen Z, Lall R, et al. Group cognitive behavioural treatment for low back pain in primarycare: a randomised controlled trial and cost-effectiveness analysis. Lancet 2010a;375:916-23.
Lamb SE, Lall R, Hansen Z, et al. A multicentred randomised controlled trial of a primary care-based
cognitive behavioural programme for low back pain: the back skills training (BeST) trial. Health Technol
Assess 2010b;14:1-253, iii-iv.
Lee JH, Choi TY, Lee MS, et al. Acupuncture for acute low back pain: a systematic review. Clin J Pain
2013;29:172-85.
Liddle SD, Pennick V. Interventions for preventing and treating low back and pelvic pain during pregnancy. Cochrane Database Syst Rev 2015;(9):CD001139.
Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000;25:1148-56.
Liu L, Huang QM, Liu QG, Thitham N, Li LH, Ma YT, Zhao JM. Evidence for dry needling in the management of myofascial trigger points associated with low back pain: a systematic review and meta-analysis.
Arch Phys Med Rehabil 2017.
Mahmoudzadeh A, Rezaeian ZS, Karimi A, Dommerholt J. The effect of dry needling on the radiating
pain in subjects with discogenic low-back pain: a randomized control trial. J Res Med Sci 2016;21:86.
Manchikanti L, Knezevic M, Boswell M, et al. Epidural injections for lumbar radiculopathy and spinal
stenosis: A comparative systematic review and meta-analysis. Pain Physician 2016; 19:E365-E410.
McIntosh G, Hall H. Low back pain (acute). BMJ Clin Evid 2011;2011.
McLain RF, Kapural L, Mekhail NA. Epidural steroid therapy for back and leg pain: mechanismsof action and efficacy. Spine J 2005;5:191-201.
Melloh M, Elfering A, Käser A, Salathé CR, Barz T, Aghayev E, Röder C, Theis JC. Depression impacts
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References

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Norén L, Östgaard S, Johansson G, Östgaard HC. Lumbar back and posterior pelvic pain during
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36Adult Acute and Subacute Low Back Pain

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Appendix A – Patient Handout
Get Back to Life!
Low back pain is a very common condition. Similar to the common cold, low back pain usually resolves
on its own and is rarely dangerous. In most cases of back pain, the specific cause is unknown, but the goodnews is that similar things will help you get back to enjoying life sooner.
What can I do?
Don’t worry!
oKnowing that your back pain isn’t serious is the first step.

Hurt doesn’t equal harm!
oPain is a normal experience. Get back to activities; pain will get better with time and movement.

Be active!
o

It might sound odd to move when you have pain, but your body was made to move. You should
walk for several minutes at a time, walking more minutes each day. If you sit during the day,getting up to move will help. It will lessen your pain if you stand or walk each hour.

Have a good outlook!
o

You will start to feel better when you get moving and have a positive outlook.

What should I avoid?
Bed resto

Even if it bothers you to be active, walking and doing your normal activities are the best formsof treatment.

Pain medicineso

Prescription medication is usually not needed in management of low back pain.

Imaging is generally not helpful.
How can I lower my chances of back pain in the future?
Stay active and be positive about the outlook. You may have pain for a few weeks again, but it should
get better like it did last time.
When should I call my provider?
Your back pain should get better over a few weeks, but call your provider if:o

If you lose your ability to control your bladder or bowels; call immediatelyo

You feel generally unwell or sicko

You feel tingling in your groin or legsoYour pain spreads down your leg and into your footoYour toes, feet or legs feel weako Your pain gets worse, not better
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Adult Acute and Subacute Low Back Pain

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Appendix B – ICSI Shared Decision-Making Model

The Collaborative Conversation™ Shared Decision-Making
and the Translation of Evidence into Practice

A consistent finding from clinical and health services research is the failure to translate research into practice. The translation of evidence into practice can be advanced through the use of shared decision-making
since shared decision-making results in evidence being incorporated into patient and clinician consultations.
Shared decision-making (SDM) is a process in which patient and clinicians collaborate to clarify all acceptable options, ensure that the patient is well-informed and chose a course of care consistent with patient values
and preferences and the best available medical evidence. (Minnesota Shared Decision-Making Collaborative[MSDMC], 2011).
Evidence-based guidelines may recommend the use of shared decision-making for decisions in instanceswhere the evidence is equivocal, when patient action or inaction (such as medication adherence or lifestylechanges) can impact the potential outcome, or when the evidence does not indicate a single best recommendation.
SDM is a patient-centered approach that involves a conversation between the patient and the clinician. It is
ideal to involve caregivers and family members in these conversations as well. Family members and caregivers can participate in discussions, ask questions, hear content the patient may miss and provide invaluable support in decision follow-through. Although only patients and clinicians are specifically mentioned
throughout this document for brevity purposes, this does not diminish the importance of caregivers andfamilies in patient-centered care.
Both the patient and the clinician bring expertise to the shared decision-making conversation. Clinicians’
expertise includes disease etiology, prognosis, options for treatment including the burden and benefit to thepatient, and outcome probabilities. Patients’ expertise lies in their knowledge of their risk tolerance, body,
priorities, family and financial issues, as well as their daily experience with the condition (adapted from
Making Shared Decision-Making a Reality. No decision about me, without me. Coulter, A., Collins, A.,
The King’s Fund 2011).
Treatment options vary in their burden on a patient. SDM offers an opportunity to help the patient select atreatment to which they can adhere. When conversations discussing options occurs, patients and clinicians
are actively engaged while considering the attributes and issues of the available options. This empathic
approach results in the clinician and patient co-creating a decision and a plan of care (adapted from Montori,V., the Mayo Clinic KER UNIT, April 2015). Decision aids can be supportive of this conversation when
they communicate the best available evidence to inform the patient and clinician discussion.
Without a conversation, clinicians may make assumptions about what the patient prefers. This creates thepotential for discrepancies between what clinicians assume and what patients want, resulting in a “preference misdiagnosis” (adapted from Health Policy Publishing, LLC, May 2013).
Difficulty in initiating a conversation is cited by patients and clinicians as one of the barriers to shareddecision-making. To address this impediment, ICSI worked with patients, practicing clinicians, and otherstakeholders to develop the Collaborative Conversation™ model for use across the care continuum.
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ICSI Shared Decision-Making Model

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Collaborative Conversation™
A collaborative approach towards decision-making is a fundamental tenet of Shared Decision-Making (SDM).
The Collaborative Conversation™ is an interprofessional approach that nurtures relationships; enhances
patients’ knowledge, skills and confidence as vital participants in their health; and encourages them tomanage their health care. Within a Collaborative Conversation™, the perspective is that the patient, rather
than the clinician, knows which course of action is most consistent with the patient’s values and preferences.
Use of Collaborative Conversation™ elements and tools is even more necessary to support patient, careclinician and team relationships when patients and families are dealing with high stakes or highly charged
issues. A diagnosis of a life-limiting illness is one example of such a circumstance.
The overall objective for the Collaborative Conversation™ approach is to create an environment in which
the patient, family and care team work collaboratively to reach and carry out a decision that is consistent
with the patient’s values and preferences, along with the best available evidence. A rote script, completed
form or checklist does not constitute this approach. Rather it is a set of skills employed appropriately forthe specific situation. These skills need to be used artfully to address all aspects of the person involved in
making a decision: cognitive, affective, social and spiritual.
Key communication skills help build the collaborative conversation approach. These skills include (Adaptedfrom O’Connor, Jacobsen Decisional Conflict: Supporting People Experiencing Uncertainty about Options
Affecting their Health [2007], and Bunn H, O’Connor AM, Jacobsen MJ Analyzing decision support andrelated communication [1998, 2003])
1. Listening skills
Encourage patient to talk by providing prompts to continue such as go on, and then? and uh huhor by repeating the last thing a person said, It’s confusing.
Paraphrase content of messages shared by patient to promote exploration, clarify content andto communicate that the person’s unique perspective has been heard. The clinician should use theirown words rather than just parroting what they heard.
Reflection of feelings usually can be done effectively once trust has been established. Until the clinician feels that trust has been established, short reflections at the same level of intensity expressed by
the patient without omitting any of the message’s meaning are appropriate. Reflection in this mannercommunicates that the clinician understands the patient’s feelings and may work as a catalyst for
further problem solving. For example, the clinician identifies what the person is feeling and responds
back in his or her own words like this: “So, you’re unsure which choice is the best for you.”
Summarize the person’s key comments and reflect them back to the patient. The clinician should
condense several key comments made by the patient and provide a summary of the situation. This
assists the patient in gaining a broader understanding of the situation rather than getting mireddown in the details. The most effective times to do this are midway through and at the end of theconversation. An example of this is “You and your family have read the information together,
discussed the pros and cons, but are having a hard time making a decision because of the risks.”
Perception checks ensure that the clinician accurately understands a patient or family member
perspective, and may be used as a summary or reflection. They are used to verify that the clinician
is interpreting the message correctly. The clinician can say, “So you are saying that you’re notready to make a decision at this time. Am I understanding you correctly?”

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2. Questioning Skills
Open and closed questions are both used, with the emphasis on open questions. Open questions ask
for clarification or elaboration and cannot have a yes or no answer. An example would be, “Whatelse would influence you to choose this?” Closed questions are appropriate if specific informationis required, such as “Does your daughter support your decision?”
Other skills such as summarizing, paraphrasing, and reflection of feeling can be used in the questioning process so that the patient doesn’t feel pressured by questions.
Verbal tracking, referring back to a topic the patient mentioned earlier, is an important foundational
skill (Ivey & Bradford-Ivey). An example of this is the clinician saying, “You mentioned earlier…”
3. Information-Giving Skills
Providing information and providing feedback are two methods of information giving. The
distinction between providing information and giving advice is important. Information giving
allows a clinician to supplement his or her knowledge and helps to keep the conversation patient
centered. Giving advice, on the other hand, takes the attention away from the patient’s unique goals
and values, and places it on those of the clinician.
Providing information can be sharing facts or responding to questions. An example is “If we lookat the evidence, the risk is…” Providing feedback gives the patient the clinician’s view of thepatient’s reaction. For instance, the clinician can say, “You seem to understand the facts and value
your daughter’s advice.”

When to Initiate a Collaborative Conversation™
Certain seminal events occur along the care continuum, creating especially opportune times for collaborative conversations. More than one of these opportunities may present at a time, and they will occur in no
specific order.

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Cues for the Care Team to Initiate a Collaborative Conversation™:•

Life goal changes: Patient’s priorities change related to things the patient values such as activities,
relationships, possessions, goals and hopes, or things that contribute to the patient’s emotional andspiritual well-being.

•

Diagnosis/prognosis changes: Additional diagnoses, improved or worsening prognosis.

•

Change or decline in health status: Improving or worsening symptoms, change in performancestatus or psychological distress.

•

Change or lack of support: Increase or decrease in caregiver support, change in caregiver, change
in caregiver status, change in financial standing, difference between patient and family wishes.

•

Disease progression: Change in physical or psychological status as a result of the disease progression.

•

Clinician/caregiver contact: Each contact between the clinician/ caregiver presents an opportunity
to reaffirm with the patient that the care plan and the care he or she is receiving are consistent withhis or her values.

Patient and Family Needs within a Collaborative Conversation™
•

Request for support and information: Decisional conflict is indicated by, among other things, thepatient verbalizing uncertainty or concern about undesired outcomes, expressing concern about
choice consistency with personal values, or exhibiting behavior such as wavering, delay, preoccupation, distress or tension. Support resources may include health care professionals, family,
friends, support groups, clergy and social workers. When patient expresses a need for information
regarding options and their potential outcomes, the patient should understand the key facts about
the options, risks and benefits, and have realistic expectations. The method and pace with which
this information is provided to the patient should be appropriate for the patient’s capacity at thatmoment.

•Advance Care Planning: With the diagnosis of a life-limiting illness, conversations around advancecare planning open up. This is an opportune time to expand the scope of the conversation to othertypes of decisions that will need to be made as a consequence of the diagnosis of a life-limiting
illness.

•

Consideration of Values: The personal importance a patient assigns potential outcomes must be
respected. If the patient is unclear how to prioritize his or her preferences, value clarification canbe achieved through the use of decision aids, detailing the benefits and harms of potential outcomesin terms of how they will directly affect the patient, and through collaborative conversations withthe clinician.

•Trust: The patient must feel confident that his or her preferences will be communicated to andrespected by all caregivers.

•

Care Coordination: Should the patient require care coordination, this is an opportune time to discuss
the other types of care-related decisions that need to be made. These decisions will most likely need
to be revisited often. Further, the care delivery system must be capable of delivering coordinatedcare throughout the continuum of care.

•

Responsive Care System: The care system needs to support the components of patient- and familycentered care so the patient’s values and preferences are incorporated into the care he or she receives
throughout the care continuum.

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ICSI Shared Decision-Making Model

Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

The Collaborative Conversation™ Map is the heart of this process. The Collaborative Conversation Map™
can be used as a stand-alone tool that is equally applicable to clinicians and patients, as shown in Table 2.
Clinicians use the map as a clinical workflow. It helps get the shared decision-making process initiated andprovides navigation for the process. Care teams can use the Collaborative Conversation™ to document teambest practices and to formalize a common lexicon. Organizations can build fields from the Collaborative
Conversation™ Map in electronic medical records to encourage process normalization. Patients use themap to prepare for decision-making, to help guide them through the process and to share critical information with their loved ones.

Table 2Return to Table of Contents
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ICSI Shared Decision-Making Model

Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

Evaluating Shared Decision-Making
It has proven challenging to assess shared decision-making. Measuring shared decision-making remains
important for continued adoption of shared decision-making as a mechanism for translating evidence into
practice; promoting patient-centered care; and understanding the impact of shared decision-making on
patient experience, outcomes and revenues. Many assessments exist, but they are often proxy measures.
Two suggested methods for measuring shared decision-making are the CollaboRATE tool and the SURE
Test. These two tools measure different aspects of shared decision-making, as described below.
The CollaboRATE tool measures the level of shared decision-making in the clinical encounter from thepatient’s perspective. It is a brief patient-reported measure of shared decision-making. The tools and guidance on their use can be found at http://www.collaboratescore.org/.
The SURE Test is a brief screening questionnaire the patient uses to access his or her readiness and capacity
to make a decision or to determine whether he or she is comfortable with the choice that was made. In otherwords, it provides information on how likely a patient may be experiencing decisional conflict. If the SURE
Test indicates decisional conflict may exist, the Decisional Conflict Scale should be completed in order toassess clinically significant decisional conflict.
Shared decision-making is a useful mechanism for translating evidence into practice. While research on
the impacts of shared decision-making continues to grow, there is mounting evidence that both patientsand clinicians benefit from SDM. Shared decision-making offers the opportunity to bring evidence and thepatient’s values into the patient/clinician discussion of health choices.
Copyright © 2012, 2016 by Institute for Clinical Systems Improvement. All rights reserved.

8009 34th Avenue South, Suite 1200 • Bloomington, MN 55425 • Phone: 952-814-7060 • www.icsi.org© 2012 Institute for Clinical Systems Improvement. All rights reserved.

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Disclosure of Potential Conflicts of Interest:

Adult Acute and Subacute Low Back PainICSI has long had a policy of transparency in declaring potential conflicting andcompeting interests of all individuals who participate in the development, revision
and approval of ICSI guidelines and protocols.
In 2010, the ICSI Conflict of Interest Review Committee was established by the
Board of Directors to review all disclosures and make recommendations to the board
when steps should be taken to mitigate potential conflicts of interest, including
recommendations regarding removal of work group members. This committee
has adopted the Institute of Medicine Conflict of Interest standards as outlined in
the report, Clinical Practice Guidelines We Can Trust (2011).
Where there are work group members with identified potential conflicts, these aredisclosed and discussed at the initial work group meeting. These members are
expected to recuse themselves from related discussions or authorship of related
recommendations, as directed by the Conflict of Interest committee or requestedby the work group.
The complete ICSI policy regarding Conflicts of Interest is available at
http://bit.ly/ICSICOI.
Funding Source

The Institute for Clinical Systems Improvement provided the funding for thisguideline revision. ICSI is a not-for-profit, quality improvement organization
based in Bloomington, Minnesota. ICSI's work is funded by the annual duesof the member medical groups and three sponsoring health plans in Minnesota.
Individuals on the work group are not paid by ICSI but are supported by their
medical group for this work.
The only exception to this, patient and public members of a work group, areprovided with a small stipend to cover meeting attendance.
ICSI facilitates and coordinates the guideline development and revision process.
ICSI, member medical groups and sponsoring health plans review and provide
feedback but do not have editorial control over the work group. All recommendations are based on the work group's independent evaluation of the evidence.

Copyright © 2017 by Institute for Clinical Systems Improvement

44Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

Disclosure of Potential Conflicts of Interest

Robb Campbell, MD, MPH (Work Group Member)
Senior Occupational Physician, Occupational Medicine; 3M
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Received stock options as part of compensation. This member
works for a large employer in the Twin Cities and is a stockholder in Glaxo Smith Kline.
Todd Ginkel, DC (Work Goup Member)
Spine Rehabilitation, Physicians' Diagnostics & Rehabilitation Clinics
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None
Chris Kramer, PT, DPT, OCS, FAAOMPT (Work Group Member)
Physical Therapist, Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None
Michael Massey, DO (Work Group Member)Medical Director, Pain Medicine, CentraCare Health System
National, Regional, Local Committee Affiliations: Board of Trustee NWHSU
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None
Becky McCathie, MEd, ATC (Work Group Member)
Senior Project Manager, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: Participates on the Minnesota Community Measurement Low Back Pain workgroup
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Two scientific journal citations
Becky Mueller, DO (Work Group Member)
Physician, Family Medicine/Sports Medicine, CentraCare Health System Becker
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None
Steven Peterson (Work Group Member)
Clinic Manager, Physical Therapy, OSI Physical Therapy
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

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Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018

Heidi Richards, PT, MHA (Work Group Member)
Clinic Administrator, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: NoneDavid Thorson, MD (Work Group Leader)
Medical Director, Sports Medicine, Entira Family Clinics
National, Regional, Local Committee Affiliations: President – MN Medical Association (MMA)
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Financial relationship with Twin Cities Orthopedics Outpatient visit in senior living center for post-op joint replacement

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External Review and Acknowledgements:

Adult Acute and Subacute Low Back PainICSI seeks review from members and the public during the revision process.

Member Review
All ICSI documents are available for member review at two points in the ICSI revision process.
The ICSI Response Report is sent to members at the beginning of a document revision. The
goal of this report is to solicit feedback about the guideline, including but not limited to thealgorithm, content, recommendations, and implementation. Members are also welcome toparticipate in the public comment period (see below).
The work group would like to thank the following organizations for participating in the prerevision review:••

Hudson Physicians
Stillwater Medical Group

Public Comment
ICSI makes a draft of the guideline available to the public on the ICSI website. The public is
invited to comment in an effort to get feedback prior to its finalization. All comments will be
reviewed by the ICSI facilitator and work group members when needed. ICSI work group
may or may not make changes to the guideline based on public comment responses.
The work group would like to thank all those who took time to thoughtfully and thoroughly
review our draft and submitted comments for the depression guideline.

Invited Reviews
For some guidelines, ICSI will invite experts in the community to comment on a guideline
draft prior to finalization. This is done during the public comment period.
The work group would like to thank the following individual for participating in an invitedreview:
Brian Bonte, DO, Hutchinson Health

ICSI Patient Advisory Council (PAC)
The ICSI Patient Advisory Council responds to any guideline review requests put forth by ICSI
facilitators and work groups. The PAC members may be involved at the beginning, middle,
and/or end of the revision process. Patient advisors who serve on the council consistently share
their experiences and perspectives in either a comprehensive or partial review of a document.
The ICSI Patient Advisory Council provided feedback at the onset of the revision process.

Copyright © 2017 by Institute for Clinical Systems Improvement

47

Document History and Development:

Adult Acute and Subacute Low Back Pain
Original Work Group Members

Document Drafted
Apr – Jul 1993

Mark DePaolis, MD
Family PracticePark Nicollet Medical
CenterSherwin Goldman, MD
Orthopedic Surgery
Mayo Clinic
Brenda Gorder, RN
Facilitator
Group Health, Inc.
Robert Gorman, MD, MPH
Occupational Medicine, WorkGroup Leader
Park Nicollet Medical
CenterFred Hamacher
Business Health Care Action
Group
Dayton Hudson
Corporation

First Edition
Jun 1994
Second Edition
Aug 1995
Third Edition
Dec 1996
Fourth Edition
Nov 1997
Fifth Edition
Dec 1998
Sixth Edition
Dec 1999
Seventh Edition
Jun 2001
Eighth Edition
Oct 2002
Ninth Edition
Oct 2003
Tenth Edition
Oct 2004
Eleventh Edition
Oct 2005

Peter Marshall, MD
Michael Koopmeiners, MD
Family Practice
Family PracticeGroup Health, Inc.
Group Health, Inc.
Jane Norstrom
Dominic Korbuly, MD
Health Education
Radiology
Park Nicollet Medical
Park Nicollet Medical
Foundation
CenterDavid C. Thorson, MD
George Kramer, MD
Physical Medicine and Rehab Sports Medicine
MinnHealth, P.A.
Park Nicollet Medical
CenterCatherine Wisner, PhD
Measurement Advisor
Kathy Kurdelmeier, PT
Group Health Foundation
Physical Therapy
Park Nicollet Medical
CenterSteven Lewis, DC
Chiropractics
Group Health, Inc.

Document History• This document underwent a complete revision and was rewritten in

Twelfth Edition
Oct 2006

2011. The GRADE methodology for reviewing evidence was also
incorporated.

Thirteenth Edition
Dec 2008
Fourteenth Edition
Dec 2010
Critical Review
Aug 2011
Fifteenth Edition
Dec 2012
Public Comment
Nov 2017

Sixteenth Edition
Dec 2017

The next revision will be no later than April 2023.

Contact ICSI at:
8009 34th Avenue South, Suite 1200; Bloomington, MN 55425; (952) 814-7060; (952) 858-9675 (fax)
Online at http://www.ICSI.org
Copyright © 2017 by Institute for Clinical Systems Improvement48

Adult Acute and Subacute Low Back Pain

Sixteenth Edition/March 2018ICSI Document Development and Revision Process
Overview

Since 1993, the Institute for Clinical Systems Improvement (ICSI) has developed more than 60 evidence-based
health care documents that support best practices for the prevention, diagnosis, treatment or management of agiven symptom, disease or condition for patients.

Audience and Intended Use

The information contained in this ICSI health care guideline is intended primarily for health professionals andother expert audiences.

This ICSI health care guideline should not be construed as medical advice or medical opinion related to any
specific facts or circumstances. Patients and families are urged to consult a health care professional regarding theirown situation and any specific medical questions they may have. In addition, they should seek assistance froma health care professional in interpreting this ICSI health care guideline and applying it in their individual case.
This ICSI health care guideline is designed to assist clinicians by providing an analytical framework for theevaluation and treatment of patients, and is not intended either to replace a clinician's judgment or to establish a
protocol for all patients with a particular condition.

Document Development and Revision Process
The development process is based on a number of long-proven approaches and is continually being revised
based on changing community standards. The ICSI staff, in consultation with the work group and a medical
librarian, conduct a literature search to identify systematic reviews, randomized clinical trials, meta-analysis,other guidelines, regulatory statements and other pertinent literature. This literature is evaluated based on the
GRADE methodology by work group members. When needed, an outside methodologist is consulted.
The work group uses this information to develop or revise clinical flows and algorithms, write recommendations,and identify gaps in the literature. The work group gives consideration to the importance of many issues as they
develop the guideline. These considerations include the systems of care in our community and how resources
vary, the balance between benefits and harms of interventions, patient and community values, the autonomy ofclinicians and patients and more. All decisions made by the work group are done using a consensus process.

ICSI's medical group members and sponsors review each guideline as part of the revision process. They provide
comment on the scientific content, recommendations and implementation strategies. This feedback is used byand responded to by the work group as part of their revision work. Final review and approval of the guideline
is done by ICSI's Committee on Evidence-Based Practice. This committee is made up of practicing clinicians
and nurses, drawn from ICSI member medical groups.

Implementation Recommendations and Measures

These are provided to assist medical groups and others to implement the recommendations in the guidelines.
Where possible, implementation strategies are included that have been formally evaluated and tested. Measures
are included that may be used for quality improvement as well as for outcome reporting. When available, regulatory or publicly reported measures are included.

Document Revision Cycle

Scientific documents are revised as indicated by changes in clinical practice and literature. ICSI staff monitors
major peer-reviewed journals for any pertinent evidence that would affect a particular guideline and recommendation.

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