*This is an archive page. The links are no longer being updated. 1994. 12.08 : New Practice Guidelines for Acute Low Back Problems Contact: PHS/AHCPR Public Affairs (301)594-1364 Bob Isquith ext. 173 Bob Griffin ext. 169 Paula Zeller ext. 148 Harriett Bennett ext. 174 December 8, 1994 MOST ACUTE LOW BACK PROBLEMS GO AWAY; ONLY SOME TREATMENTS BENEFICIAL, SAY NEW PRACTICE GUIDELINES Clinical practice guidelines released today by the federal Agency for Health Care Policy and Research recommend treating most acute, painful low back problems with nonprescription painkillers and mild exercise such as walking or swimming, followed by conditioning exercises in about two weeks. Most adults suffer from acute low back problems at some time in their lives. Many patients traditionally have been confined to bed, sometimes in traction. But the guidelines, developed under AHCPR's auspices by a private-sector panel of experts and consumers, and tested in clinics and doctors' offices before their release, say inactivity can weaken needed muscles. The guidelines reassure people with these acute episodes (as opposed to persistent, chronic back problems) that nine of 10 will recover on their own within a month. Philip R. Lee, M.D., HHS assistant secretary for health and director of the Public Health Service, said in releasing the AHCPR guidelines today, "By encouraging people with acute low back problems to resume normal activities, using only those treatments that have been scientifically shown to be effective, these guidelines could save Americans considerable anguish, time and much money now spent on unneeded or unproved medical care. "Up to 80 percent of Americans will have had a low back problem of some type at least once by age 50, and the condition is the most frequent cause of temporary disability for persons under age 45." Dr. Lee also said low back problems are second only to the common cold in reasons for visiting family or other primary care doctors. "In 1990 alone, the United States spent more than $20 billion just for the direct medical costs of all low back problems. While there are no precise estimates for the cost of treating acute low back problems, a preliminary cost analysis of these guidelines suggests the nation could save as much as a third of the medical expense of treating this condition without any loss of quality of care," said Clifton R. Gaus, Sc.D., administrator of AHCPR. Dr. Gaus said the cost of acute low back problems was only one factor behind the agency's decision to develop practice guidelines. Other, equally important, factors included the wide variations in the ways acute low back problems are diagnosed and treated and concern about the quality of care being provided. Acute low back problems are characterized by short episodes of pain or discomfort in the lower back, or by pain or numbness that moves down the leg (sciatica). The guidelines suggest that spinal manipulation can be helpful in relieving pain, especially within the first four weeks -- and that surgery may be appropriate when there is a serious spinal condition or when people have severe, disabling and persistent sciatica. The guidelines panel said that overall, surgery benefits only about one in 100 people with acute low back problems. According to the 23-member guidelines panel, research shows that a thorough examination by a clinician can make special studies and diagnostic tests unnecessary during the first month after symptoms begin, unless there is an indication of possible fracture, tumor, infection or severe nerve involvement. The guidelines indicate that early use of tests such as x-rays, CT (computed tomography) scans, MRI (magnetic resonance imaging), myelography and bone scans are appropriate only when there are specific clinical findings of a potentially serious underlying condition in the patient's medical history and examination. The panel found that, as a whole, low back problems rarely have a serious cause. However, if after four weeks the patient continues to be limited by symptoms, the guidelines say it may be appropriate to consider using special tests to seek a reason for the slow recovery. The chair of the guidelines panel, Stanley J. Bigos, M.D., professor of orthopedic surgery at the University of Washington School of Medicine in Seattle, said, "One very important goal of these guidelines is to prevent long-term back problems and disability by improving care provided during the acute phase." Dr. Bigos said that the guidelines do not deal with chronic low back problems, which are the subject of ongoing studies. The panel found that acetaminophen or nonsteroidal anti- inflammatory drugs (NSAIDs), including aspirin, are effective and safe. The guidelines consider muscle relaxants and opioid analgesics -- a stronger type of prescription medicine -- to be options for short-term treatment, but they appear to be no more effective than NSAIDs and appear to cause more side effects. The guidelines emphasize the importance of low-stress exercise, such as walking, swimming or biking, for maintaining and even improving the patient's activity tolerance. These types of exercise usually can be started gradually during the first two weeks after symptoms appear. Conditioning exercises for trunk muscles can be started after the first two weeks. The guidelines panel did not find a sound scientific basis for certain treatment methods, including: o Spinal traction, TENS (transcutaneous electrical nerve stimulation) and acupuncture. o Lumbar corsets (except perhaps when used preventively by persons who do frequent lifting on the job), support belts and back machines. The panel also did not find evidence of effectiveness to justify potential risks of harmful side effects for: o Extended bed rest (more than four days), since it can weaken muscles and bones and delay recovery. o Oral steroids, colchicine, antidepressants and phenylbutazones, whose potential side effects range from gastrointestinal irritation to bone marrow suppression. o Therapies involving the injection of local anesthetics, corticosteroids or other substances into the back. The potential harms include rare but serious problems such as nerve damage and hemorrhage. The guidelines do not recommend other treatments because their insufficiently proven benefits do not justify their costs. These treatments are: o Heat/diathermy, massage, ultrasound, cutaneous laser treatment and electrical stimulation (other than TENS). The panel conducted an exhaustive review of over 3,900 studies and held a public meeting in developing the guidelines, which were then reviewed by more than 100 other back care experts and tested in health maintenance organizations, private and group medical practices and occupational medicine clinics. The panel consisted of experts in orthopedic surgery, family practice, internal medicine, emergency medicine, physical and rehabilitation medicine, industrial medicine, occupational medicine, neurosurgery, neurology, neuroradiology, rheumatology, osteopathic medicine, orthopedic research, community health nursing, chiropractic, physical therapy and occupational therapy, and a consumer representative with acute low back problem experience. AHCPR will disseminate the new guidelines, including consumer versions in English and Spanish, to primary care practitioners, orthopedic surgeons, chiropractors, other back care professionals, managed care organizations and consumers. Free copies of Acute Low Back Problems in Adults: Assessment and Treatment, Quick Reference Guide for Clinicians, and the consumer version of the guidelines, Understanding Acute Low Back Problems, which is available in English and Spanish, may be obtained from the AHCPR Publications Clearinghouse, 1-800/358-9295, P.O. Box 8547, Silver Spring, Md. 20907. Free copies are also available from AHCPR Instant Fax (301/594-2800). The 160-page, Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14, is available through the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C., 20402; tel: 202/512-1800. ###