Low Back Pain: Summary of AHCPR Guidelines

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Summary of AHCPR Guideline Recommendations

The ratings in parentheses indicate the scientific evidence supporting each recommendation according to the following scale:
A = strong research-based evidence (multiple relevant and high-quality scientific studies).
B = moderate research-based evidence (one relevant, high-quality scientific study or multiple adequate scientific studies).
C = limited research-based evidence (at least one adequate scientific study in patients with low back pain).
D = panel interpretation of evidence not meeting inclusion criteria for research-based evidence.
The number of studies meeting panel review criteria is noted for each category.

ACTION
RECOMMEND OPTION RECOMMEND AGAINST

History and physical exam
34 studies

Basic history (B).
History of cancer/ infection (B).
Signs/symptoms of cauda equina syndrome (C).
History of significant trauma (C).
Psychosocial history (C).
Straight leg raising text (B).
Focused neurological exam (B).
Pain drawing and visual analog scale (D).

Patient education
14 studies

Patient education about low back symptoms (B).
Back school in occupational settings (C).
Back school in nonoccupational settings (C).

Medication
23 studies Acetaminophen (C).
NSAIDs (B). Muscle relaxants (C).
Opioids, short course (C). Opioids used > 2wks (C).
Phenylbutazone (C).
Oral steroids (C).
Colchicine (B).
Antidepressants (C).

Physical treatment methods
42 methods Manipulation of low back during first month of symptoms (B).

Manipulation for patients with radiculopathy (C).
Manipulation for patients with symptoms > 1 month (C).
Self-application of heat or cold to low back.
Shoe insoles (C).
Corset for prevention in occupational setting (C).

Manipulation for patients with undiagnosed neurologic deficits (D).
Prolonged course of manipulation (D).
Traction (B).
TENS (C).
Biofeedback (C).
Shoe lifts (D).
Corset for treatment (D).

Injections
26 studies Epidural steroid injections for radicular pain to avoid surgery (C).

Epidural injections for back pain without radiculopathy (D).
Trigger point injections (C).
Ligamentous injections (C).
Facet joint injections (C).
Needle acupuncture (D).

Bed rest
4 studies Bed rest of 2-4 days for severe radiulopathy (D). Bed rest > 4 days (B).

Activities and exercise 20 studies

Temporary avoidance of activities that increase mechanical stress on spine (D).
Gradual return to normal activities (B).
Low-stress aerobic exercise (C).
Conditioning exercises for trunk mescles after 2 weeks (C).
Exercise quotas (C).

Back-specific exercise machines (D).
Therapeutic stretching of back muscles (D).

Detection of physiologic abnormalities
14 studies

If no improvement after 1 month, consider:
Bone scan (C).
Needle EMG and H-reflex tests to clarify nerve root dysfunction (C).
SEP to assess spinal stenosis (C).

EMG for clinically obvious radiculopathy (D).
Surface EMG and F-wave tests (C).
Thermography (C).

X-rays of L-S spine
18 studies When red flags for fracture present (C).
When red flags for cancer or infection present (C). Routine use in first month of symptoms in absence of red flags (B).
Routine oblique views (B).

Imaging
18 studies

CT or MRI when cauda equina, tumor, infection, or fracture stongly suspected (C).
MRI text of choice for patients with prior back surgery (D).
Assure quality criteria for imaging tests (B).
Myelography or CT-myleography for preoperative planning (D). Use of imaging test before one month in absence red flags (B).
Discography or CT-discography (C).

Surgical considerations
14 studies

Discuss surgical options with patients with persistent and severe sciatica and clinical evidence of nerve root compromise after 1 month of conservative therapy (B).
Standard discectomy and microdiscectomy of similar efficacy in treatment of herniated disc (B).
Chymopapain, used after ruling out allergic sensitivity, acceptable but less efficacious than discectomy to treat herniated disc (C).

Disc surgery in patients with back pain alone, no red flags, and no nerve root compression (D).
Percutaneous discectomy less efficacious than chymopapain (C).
Surgery for spinal stenosis within the first 3 months of symptoms (D).
Stenosis surgery when justified by imaging test rather than patient's functional status (D).
Spinal fusion during the first 3 months of symptoms in the absence of fracture, dislocation, complications of tumor or infection (C).

Psychosocial factors Social, economic, and psychological factors can alter patient response to symptoms and treatment (D). Referral for extensive evaluation/treatment prior to exploring patient expectations or psychosocial factors (D).

Table 5. Summary of Guideline Recommendations

The ratings in parentheses indicate the scientific evidence supporting each recommendation according to the following scale:
A = strong research-based evidence (multiple relevant and high-quality scientific studies).
B = moderate research-based evidence (one relevant, high-quality scientific study or multiple adequate scientific studies).
C = limited research-based evidence (at least one adequate scientific study in patients with low back pain).
D = panel interpretation of evidence not meeting inclusion criteria for research-based evidence.
The number of studies meeting panel review criteria is noted for each category.

ACTION RECOMMEND OPTION RECOMMEND AGAINST

History and physical exam
34 studies

Basic history (B).
History of cancer/ infection (B).
Signs/symptoms of cauda equina syndrome (C).
History of significant trauma (C).
Psychosocial history (C).
Straight leg raising text (B).
Focused neurological exam (B).
Pain drawing and visual analog scale (D).

Patient education
14 studies

Patient education about low back symptoms (B).
Back school in occupational settings (C).
Back school in nonoccupational settings (C).

Medication
23 studies Acetaminophen (C).
NSAIDs (B). Muscle relaxants (C).
Opioids, short course (C). Opioids used > 2wks (C).
Phenylbutazone (C).
Oral steroids (C).
Colchicine (B).
Antidepressants (C).

Physical treatment methods
42 methods Manipulation of low back during first month of symptoms (B).

Manipulation for patients with radiculopathy (C).
Manipulation for patients with symptoms > 1 month (C).
Self-application of heat or cold to low back.
Shoe insoles (C).
Corset for prevention in occupational setting (C).

Manipulation for patients with undiagnosed neurologic deficits (D).
Prolonged course of manipulation (D).
Traction (B).
TENS (C).
Biofeedback (C).
Shoe lifts (D).
Corset for treatment (D).

Injections
26 studies Epidural steroid injections for radicular pain to avoid surgery (C).

Epidural injections for back pain without radiculopathy (D).
Trigger point injections (C).
Ligamentous injections (C).
Facet joint injections (C).
Needle acupuncture (D).

Bed rest
4 studies Bed rest of 2-4 days for severe radiulopathy (D). Bed rest > 4 days (B).

Activities and exercise 20 studies

Temporary avoidance of activities that increase mechanical stress on spine (D).
Gradual return to normal activities (B).
Low-stress aerobic exercise (C).
Conditioning exercises for trunk mescles after 2 weeks (C).
Exercise quotas (C).

Back-specific exercise machines (D).
Therapeutic stretching of back muscles (D).

Detection of physiologic abnormalities
14 studies

If no improvement after 1 month, consider:
Bone scan (C).
Needle EMG and H-reflex tests to clarify nerve root dysfunction (C).
SEP to assess spinal stenosis (C).

EMG for clinically obvious radiculopathy (D).
Surface EMG and F-wave tests (C).
Thermography (C).

X-rays of L-S spine
18 studies When red flags for fracture present (C).
When red flags for cancer or infection present (C). Routine use in first month of symptoms in absence of red flags (B).
Routine oblique views (B).

Imaging
18 studies

CT or MRI when cauda equina, tumor, infection, or fracture stongly suspected (C).
MRI text of choice for patients with prior back surgery (D).
Assure quality criteria for imaging tests (B).
Myelography or CT-myleography for preoperative planning (D). Use of imaging test before one month in absence red flags (B).
Discography or CT-discography (C).

Surgical considerations
14 studies

Discuss surgical options with patients with persistent and severe sciatica and clinical evidence of nerve root compromise after 1 month of conservative therapy (B).
Standard discectomy and microdiscectomy of similar efficacy in treatment of herniated disc (B).
Chymopapain, used after ruling out allergic sensitivity, acceptable but less efficacious than discectomy to treat herniated disc (C).

Disc surgery in patients with back pain alone, no red flags, and no nerve root compression (D).
Percutaneous discectomy less efficacious than chymopapain (C).
Surgery for spinal stenosis within the first 3 months of symptoms (D).
Stenosis surgery when justified by imaging test rather than patient's functional status (D).
Spinal fusion during the first 3 months of symptoms in the absence of fracture, dislocation, complications of tumor or infection (C).

Psychosocial factors Social, economic, and psychological factors can alter patient response to symptoms and treatment (D). Referral for extensive evaluation/treatment prior to exploring patient expectations or psychosocial factors (D).

The ratings in parentheses indicate the scientific evidence supporting each recommendation according to the following scale:
A = strong research-based evidence (multiple relevant and high-quality scientific studies).
B = moderate research-based evidence (one relevant, high-quality scientific study or multiple adequate scientific studies).
C = limited research-based evidence (at least one adequate scientific study in patients with low back pain).
D = panel interpretation of evidence not meeting inclusion criteria for research-based evidence.
The number of studies meeting panel review criteria is noted for each category.
ACTION	RECOMMEND	OPTION	RECOMMEND AGAINST
History and physical exam 34 studies	Basic history (B). History of cancer/ infection (B). Signs/symptoms of cauda equina syndrome (C). History of significant trauma (C). Psychosocial history (C). Straight leg raising text (B). Focused neurological exam (B).	Pain drawing and visual analog scale (D).
Patient education 14 studies	Patient education about low back symptoms (B). Back school in occupational settings (C).	Back school in nonoccupational settings (C).
Medication 23 studies	Acetaminophen (C). NSAIDs (B).	Muscle relaxants (C). Opioids, short course (C).	Opioids used > 2wks (C). Phenylbutazone (C). Oral steroids (C). Colchicine (B). Antidepressants (C).
Physical treatment methods 42 methods	Manipulation of low back during first month of symptoms (B).	Manipulation for patients with radiculopathy (C). Manipulation for patients with symptoms > 1 month (C). Self-application of heat or cold to low back. Shoe insoles (C). Corset for prevention in occupational setting (C).	Manipulation for patients with undiagnosed neurologic deficits (D). Prolonged course of manipulation (D). Traction (B). TENS (C). Biofeedback (C). Shoe lifts (D). Corset for treatment (D).
Injections 26 studies		Epidural steroid injections for radicular pain to avoid surgery (C).	Epidural injections for back pain without radiculopathy (D). Trigger point injections (C). Ligamentous injections (C). Facet joint injections (C). Needle acupuncture (D).
Bed rest 4 studies		Bed rest of 2-4 days for severe radiulopathy (D).	Bed rest > 4 days (B).
Activities and exercise 20 studies	Temporary avoidance of activities that increase mechanical stress on spine (D). Gradual return to normal activities (B). Low-stress aerobic exercise (C). Conditioning exercises for trunk mescles after 2 weeks (C). Exercise quotas (C).		Back-specific exercise machines (D). Therapeutic stretching of back muscles (D).
Detection of physiologic abnormalities 14 studies	If no improvement after 1 month, consider: Bone scan (C). Needle EMG and H-reflex tests to clarify nerve root dysfunction (C). SEP to assess spinal stenosis (C).		EMG for clinically obvious radiculopathy (D). Surface EMG and F-wave tests (C). Thermography (C).
X-rays of L-S spine 18 studies	When red flags for fracture present (C). When red flags for cancer or infection present (C).		Routine use in first month of symptoms in absence of red flags (B). Routine oblique views (B).
Imaging 18 studies	CT or MRI when cauda equina, tumor, infection, or fracture stongly suspected (C). MRI text of choice for patients with prior back surgery (D). Assure quality criteria for imaging tests (B).	Myelography or CT-myleography for preoperative planning (D).	Use of imaging test before one month in absence red flags (B). Discography or CT-discography (C).
Surgical considerations 14 studies	Discuss surgical options with patients with persistent and severe sciatica and clinical evidence of nerve root compromise after 1 month of conservative therapy (B). Standard discectomy and microdiscectomy of similar efficacy in treatment of herniated disc (B). Chymopapain, used after ruling out allergic sensitivity, acceptable but less efficacious than discectomy to treat herniated disc (C).		Disc surgery in patients with back pain alone, no red flags, and no nerve root compression (D). Percutaneous discectomy less efficacious than chymopapain (C). Surgery for spinal stenosis within the first 3 months of symptoms (D). Stenosis surgery when justified by imaging test rather than patient's functional status (D). Spinal fusion during the first 3 months of symptoms in the absence of fracture, dislocation, complications of tumor or infection (C).
Psychosocial factors	Social, economic, and psychological factors can alter patient response to symptoms and treatment (D).		Referral for extensive evaluation/treatment prior to exploring patient expectations or psychosocial factors (D).

**Table 5. Summary of Guideline Recommendations**

The ratings in parentheses indicate the scientific evidence supporting each recommendation according to the following scale:
A = strong research-based evidence (multiple relevant and high-quality scientific studies).
B = moderate research-based evidence (one relevant, high-quality scientific study or multiple adequate scientific studies).
C = limited research-based evidence (at least one adequate scientific study in patients with low back pain).
D = panel interpretation of evidence not meeting inclusion criteria for research-based evidence.
The number of studies meeting panel review criteria is noted for each category.
ACTION	RECOMMEND	OPTION	RECOMMEND AGAINST
History and physical exam 34 studies	Basic history (B). History of cancer/ infection (B). Signs/symptoms of cauda equina syndrome (C). History of significant trauma (C). Psychosocial history (C). Straight leg raising text (B). Focused neurological exam (B).	Pain drawing and visual analog scale (D).
Patient education 14 studies	Patient education about low back symptoms (B). Back school in occupational settings (C).	Back school in nonoccupational settings (C).
Medication 23 studies	Acetaminophen (C). NSAIDs (B).	Muscle relaxants (C). Opioids, short course (C).	Opioids used > 2wks (C). Phenylbutazone (C). Oral steroids (C). Colchicine (B). Antidepressants (C).
Physical treatment methods 42 methods	Manipulation of low back during first month of symptoms (B).	Manipulation for patients with radiculopathy (C). Manipulation for patients with symptoms > 1 month (C). Self-application of heat or cold to low back. Shoe insoles (C). Corset for prevention in occupational setting (C).	Manipulation for patients with undiagnosed neurologic deficits (D). Prolonged course of manipulation (D). Traction (B). TENS (C). Biofeedback (C). Shoe lifts (D). Corset for treatment (D).
Injections 26 studies		Epidural steroid injections for radicular pain to avoid surgery (C).	Epidural injections for back pain without radiculopathy (D). Trigger point injections (C). Ligamentous injections (C). Facet joint injections (C). Needle acupuncture (D).
Bed rest 4 studies		Bed rest of 2-4 days for severe radiulopathy (D).	Bed rest > 4 days (B).
Activities and exercise 20 studies	Temporary avoidance of activities that increase mechanical stress on spine (D). Gradual return to normal activities (B). Low-stress aerobic exercise (C). Conditioning exercises for trunk mescles after 2 weeks (C). Exercise quotas (C).		Back-specific exercise machines (D). Therapeutic stretching of back muscles (D).
Detection of physiologic abnormalities 14 studies	If no improvement after 1 month, consider: Bone scan (C). Needle EMG and H-reflex tests to clarify nerve root dysfunction (C). SEP to assess spinal stenosis (C).		EMG for clinically obvious radiculopathy (D). Surface EMG and F-wave tests (C). Thermography (C).
X-rays of L-S spine 18 studies	When red flags for fracture present (C). When red flags for cancer or infection present (C).		Routine use in first month of symptoms in absence of red flags (B). Routine oblique views (B).
Imaging 18 studies	CT or MRI when cauda equina, tumor, infection, or fracture stongly suspected (C). MRI text of choice for patients with prior back surgery (D). Assure quality criteria for imaging tests (B).	Myelography or CT-myleography for preoperative planning (D).	Use of imaging test before one month in absence red flags (B). Discography or CT-discography (C).
Surgical considerations 14 studies	Discuss surgical options with patients with persistent and severe sciatica and clinical evidence of nerve root compromise after 1 month of conservative therapy (B). Standard discectomy and microdiscectomy of similar efficacy in treatment of herniated disc (B). Chymopapain, used after ruling out allergic sensitivity, acceptable but less efficacious than discectomy to treat herniated disc (C).		Disc surgery in patients with back pain alone, no red flags, and no nerve root compression (D). Percutaneous discectomy less efficacious than chymopapain (C). Surgery for spinal stenosis within the first 3 months of symptoms (D). Stenosis surgery when justified by imaging test rather than patient's functional status (D). Spinal fusion during the first 3 months of symptoms in the absence of fracture, dislocation, complications of tumor or infection (C).
Psychosocial factors	Social, economic, and psychological factors can alter patient response to symptoms and treatment (D).		Referral for extensive evaluation/treatment prior to exploring patient expectations or psychosocial factors (D).

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