Top POEMs of 2015: Back Pain

Top 20 POEMs of 2015

Early Imaging for Low Back Pain in Elderly Raises Costs Without Improving Quality

Clinical question
Does early imaging of older adults with back pain improve outcomes?

Bottom line
Among adults, 65 years or older, who present to primary care clinicians for a new episode of back pain, early imaging (before 6 weeks) resulted in no improved outcomes at 1 year, but increased overall health care costs by almost 30%. Indications for early imaging include major risk factors for cancer, signs of cauda equina syndrome, severe neurologic deficits, and fever with a history of intravanous drug use or recent infection. (LOE = 2b-)(www.essentialevidenceplus.com)

Reference
Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA 2015;313(11):1143-1153.

Study design: Cohort (prospective)

Funding source: Government

Setting: Outpatient (primary care)

Synopsis
Early imaging (before 6 weeks) of adults with back pain is associated with increased costs and worse outcomes (Ann Intern Med 2011;154(3):181-189). However, most studies have included few, if any, adults 65 years or older. These investigators prospectively enrolled 5239 adults, 65 years or older, who presented to a participating primary care clinician for a new episode of back pain. Of these, 1264 patients (26%) received early back imaging (within 6 weeks of the initial visit), including 1174 who underwent plain film radiography and 349 who underwent either computed tomography or magnetic resonance imaging. Case patients were propensity-matched when possible for multiple variables, including sex, race/ethnicity, age, education, smoking, comorbidities, back pain, leg pain, and various quality-of-life and function scoring tools, with similar control patients not undergoing early imaging (approximately 93% match rate). Outcomes were assessed at 3, 6, and 12 months using validated back pain–related disability and quality-of-life scoring tools. Complete follow-up occurred for approximately 90% of patients at 12 months. Although fractures were detected more often in the early imaging group, no statistically significant differences in disability or quality of life occurred between the early-imaging group and the control group at any points in the evaluation process. In addition, no differences occurred in the proportion of patients with cancer diagnoses. Overall costs were approximately 30% higher in the early-imaging group.

David Slawson, MD
Director of Information Sciences
University of Virginia Health System
Charlottesville, VA

Acetaminophen (Paracetamol) Minimally Effective for Back Pain and Osteoarthritis

Clinical question
Is acetaminophen (paracetamol) effective for the treatment of low back pain or osteoarthritis?

Bottom line
Although acetaminophen was hoped to be a safer alternative to nonsteroidal anti-inflammatory drugs and opioids for the treatment of common musculoskeletal problems, on average it only provides minimal pain relief and improvement in function for patients with low back pain or osteoarthritis. Some people may benefit with full dosages but most will not. (LOE = 1a)(www.essentialevidenceplus.com)

Reference
Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ 2014;350:h1225.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Synopsis
To identify all randomized controlled trials the authors searched 9 databases, including the Cochrane Registry. Two investigators independently selected articles for inclusion and extracted the data. Two investigators evaluated the quality of the 13 research studies, most of which were of good quality. Most of the studies used full dosages (3900 mg - 4000 mg daily). There was no evidence of publication bias. For patients with low back pain, high-quality research in more than 1000 patients found a lack of effectiveness on pain and disability in either the immediate (< 2 weeks) or short-term (2 weeks - 3 months) follow-up periods. For hip or knee osteoarthritis, acetaminophen produced a statistically significant but clinically unimportant effect on pain and disability over the immediate or short terms. The research results were homogeneous except for immediate-term disability. Adverse effects were minimal. Patients receiving acetaminophen were more likely to have higher liver function test results (>1.5 times normal) than patients receiving placebo.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Naproxen Alone May Be Best for Acute Low Back Pain

Clinical question
What is the optimal medication regimen for treating adults with acute low back pain?

Bottom line
Naproxen alone is as effective as naproxen plus oxycodone/acetaminophen or naproxen plus cyclobenzaprine in reducing pain and improving function in adults with acute musculoskeletal low back pain (LBP) without radicular symptoms. Adverse events were significantly more common in patients additionally treated with either muscle relaxants or opioids. Be sure to note the exclusion criteria in the synopsis. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain. A randomized clinical trial. JAMA 2015;314(15):1572-1580

Study design: Randomized controlled trial (double-blinded)

Funding source: Unknown/not stated

Allocation: Concealed

Setting: Emergency department

Synopsis
Clinicians frequently treat acute LBP with a combination of nonsteroidal anti-inflammatory drugs, muscle relaxants, and opioids. These investigators identified adults (N = 323), aged 21 to 64 years, presenting to the emergency department for LBP clinically diagnosed as acute musculoskeletal LBP, defined as pain between the lower border of the scapulae and the upper gluteal folds. Exclusion criteria included radicular pain below the gluteal folds, direct trauma to the back within the previous month, pain duration longer than 2 weeks, and recent history of more than one LBP episode per month. Eligible patients randomly received (concealed allocation assignment) naproxen (500 mg twice daily for 10 days) plus either (1) placebo; (2) 5 mg cyclobenzaprine; or (3) 5 mg oxycodone / 32 mg acetaminophen, all taken as 1 or 2 tablets every 8 hours. Individuals masked to treatment group assignment assessed pain and functional outcomes at 7 days and at 3 months after emergency department discharge using a validated scoring tool. Complete follow-up occurred for 96% of participants at 7 days and 87% at 3 months. Using intention-to-treat analysis, there were no significant differences in pain and function scores between the 3 treatment groups at both 7 days and 3 months of follow-up. Use of additional health care resources was infrequent but not significantly different between the 3 groups. Adverse effects, including drowsiness, dizziness, dyspepsia, and nausea or vomiting were, however, significantly increased compared with naproxen plus placebo for both oxycodone/acetaminophen (number needed to treat to harm [NNTH] = 5.3; 95% CI 3-14) and cyclobenzaprine (NNTH=7.8; 4-129).

David Slawson, MD
Director of Information Sciences
University of Virginia Health System
Charlottesville, VA

Early Physical Therapy for Adults with Acute Low Back Pain Is Minimally Effective

Clinical question
Is early physical therapy more effective than usual care in treating adults with acute low back pain?

Bottom line
Early referral to physical therapy (within 72 hours of study enrollment) compared with usual care for adults with recent-onset low back pain (LBP) is minimally, if at all, effective for reducing measures of disability and pain or for improving quality of life. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Fritz JM, Magel JS, McFadden M, et al. Early physical therapy vs usual care in patients with recent-onset low back pain: A randomized clinical trial. JAMA 2015;314(14):1459-1467.

Study design: Randomized controlled trial (single-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (primary care)

Synopsis
These investigators conducted a randomized controlled trial of early physical therapy (n = 108) vs usual care (n = 112) for adults presenting to a primary care physician with recent-onset LBP. Eligibility criteria included adults, aged 18 to 60 years, with uncomplicated LBP for less than 16 days and with an Oswestry Disability Index (ODI) score of 20 or higher (scores range from 0 to 100 with higher scores indicating greater disability). The ODI is a validated, 10-item measure of function in patients with LBP. Patients were excluded if their pain had extended below the knee in the past 72 hours, or if they had been treated for LBP in the past 6 months. All patients received education about the favorable prognosis of LBP, advice to remain active, and a booklet providing information consistent with standard LBP education guidelines. The usual care control group received no further intervention. The intervention group underwent four physical therapy sessions, beginning within 72 hours of the primary care visit and continuing for 3 weeks. Physical therapy included an assessment followed by spinal manipulation and instructions to perform daily home exercises focusing on both spinal range-of-motion and trunk-strengthening. Individuals masked to treatment group assignment assessed the primary outcome using changes in ODI scores. The authors assessed several secondary outcomes (including physical activity, return to work, and quality of life) at 4 weeks, at 3 months, and at 1 year using additional scoring tools. Complete follow-up occurred for 94% of participants at 1 year of follow-up. The mean baseline ODI score of study participants was 41. Using intention-to-treat analysis, a statistically significant reduction in ODI scores occurred in the physical therapy group at 3 months compared with the usual care group [mean difference -3.2; 95% CI -5.9 to -0.47). However, this difference did not meet the predetermined minimally clinically important difference in ODI score of 6. In addition, the group difference in ODI scores was no longer significant at 1 year. The authors found statistically significant improvements in some, but not all, secondary outcomes at 4 weeks, 3 months, and 1 year, but these differences were modest at best. Please attribute the authorship of this POEM to Kristina Gern Johnson, MD, Assistant Professor, Department of Family Medicine, University of Virginia, Charlottesville, VA.

David Slawson, MD
Director of Information Sciences
University of Virginia Health System
Charlottesville, VA

Walking Program Effective For Chronic Low Back Pain

Clinical question
For adults with chronic low back pain, is a prescribed walking program as effective as physical therapy?

Bottom line
Giving patients a pedometer, a walking diary, and instructions to walk at least 4 days per week then gradually increase the walk’s duration and intensity (see synopsis) results in improvement in pain and disability similar to usual physical therapy or a group exercise program. Patient satisfaction and days lost from work are similar, and patients are more likely to continue treatment for at least 1 year. In our office, many clinicians wear a pedometer and we have a box of inexpensive ($1) ones available to give to patients with low back pain and other problems that would benefit from some get-up-and-go. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Hurley DA, Tully MA, Lonsdale C, et al. Supervised walking in comparison with fitness training for chronic back pain in physiotherapy: results of the SWIFT single-blinded randomized controlled trial (ISRCTN17592092).Pain 2015;156(1):131-147.

Study design: Randomized controlled trial (nonblinded)

Funding source: Foundation

Allocation: Concealed

Setting: Outpatient (specialty)

Synopsis
These Irish researchers enrolled 246 patients referred for physical therapy for the treatment of low back pain that was either chronic (at least 3 months) or recurrent (3 or more episodes in the past year). Patients also reported low levels of physical activity and 76% were overweight or obese. The patients were randomized, using concealed allocation, to receive 1 of 3 interventions for up to 8 weeks: (1) standard tailored physical therapy; (2) a weekly exercise class specifically aimed at patients with back pain; or (3) a tailored graduated program of walking. The patients in the walking program were given a walking diary and a pedometer and asked to walk at least 4 days per week. Patients started with at least a 10-minute walk (1200 steps daily) with the goal of achieving 30 minutes of moderate-intensity physical activity (such as a brisk walk) 5 days per week. They were supported by weekly telephone calls. All patients also were given a booklet that explains back pain. Using intention-to-treat analysis, pain and function as measured by the Oswestry Disability Index similarly improved an average 6 points in all groups (from an average 35 points of a possible 100). Significantly more walkers, though, achieved a clinically important difference in the score. Scores were higher in all 3 groups in the patients who adhered to treatment. Patient satisfaction with treatment was similar among the groups. Cost was lowest for the walking program and sustained adherence with treatment was highest. Time lost from work was similar among the 3 groups. These were likely highly motivated patients

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

Advertisement