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

This is the current release of the guideline.

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

Eligible Population

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

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

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

Therapy

• Stay active and continue ordinary activity within the limits permitted by pain. Avoid bedrest [A]. Early return to work is associated with less disability.
• Injury prevention (e.g., use of proper body mechanics, safe back exercises)
• Recommend ice for painful areas and stretching exercises [D].
• McKenzie exercises [A] are helpful for pain radiating below the knee.

Referral

• If no improvement at 1 to 2 weeks, refer for goal-directed manual physical therapy, not modalities such as heat, traction, ultrasound, transcutaneous electrical nerve stimulation (TENS).
• Surgical referral usually not required if no "red flags."

Medication Strategies

• Medication treatment depending on pain severity with acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) [A]
• COX-2 inhibitors and muscle relaxants have not been shown to be more effective than NSAIDs [A].
• Opiate analgesics have not been shown to be more effective than NSAIDS in acute low back pain.

Testing

• Diagnostic tests or imaging usually not required.
• If no improvement after 6 weeks, consider imaging.

Assessment to Identify Potential Serious Pathology

Assess for "Red Flag" Indications of Serious Disease

Cauda Equina

• Severe or progressive neurologic deficit
• Recent bowel or bladder dysfunction
• Saddle anesthesia

Cancer

• Men and women age >50
• Cancer history
• Insidious onset
• No relief at bedtime or worsening when supine
• Constitutional symptoms (e.g., fever, weight loss)
• Male with diffuse osteoporosis or compression fracture

Fracture

• Traumatic injury or onset, cumulative trauma
• Steroid use history
• Women age >50

Infection

• Steroid use history
• Diabetes mellitus
• Immune suppression
• History of urinary tract infection (UTI) or other infection
• Constitutional symptoms (e.g., fever, weight loss)
• No relief at bedtime or worsening when supine
• Human immunodeficiency virus (HIV)
• Previous surgery
• Insidious onset
• Intravenous (IV) drug use

Patients with High Risk of Serious Pathology (Red Flags)

• Cauda Equina syndrome or severe or progressive neurologic deficit — Refer for emergency studies and definitive care [C]
• Spinal fracture or compressions — Plain lumbosacral (LS) spine X-ray [B]. After 10 days, if fracture still suspected or multiple sites of pain, consider either bone scan [C] or referral [D] before considering computed tomography (CT) or magnetic resonance imaging (MRI).
• Cancer or infection — complete blood count (CBC), urinalysis, erythrocyte sedimentation rate (ESR) [C]. If still suspicious consider referral or seek further evidence (e.g., bone scan [C], other labs — negative plain film X-ray does not rule out disease).

Definitions:

Levels of Evidence for the Most Significant Recommendations

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational studies
4. Opinion of expert panel

None provided

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

2008 Mar

Michigan Quality Improvement Consortium - Professional Association

Michigan Quality Improvement Consortium

Michigan Quality Improvement Consortium Medical Directors' Committee

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

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

This is the current release of the guideline.

None available

None available

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

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