By Annette M. Boyle

WASHINGTON—If VA clinicians are surprised by the significant changes in the updated recommendations recently issued by the VA and DoD for the diagnosis and management of low back pain, they are not alone. The evidence review even shocked many members of the work group that wrote the new clinical practice guidelines.

Sanjog Pangarkar, MD

“It was surprising for me how little evidence there was for techniques used diagnostically and therapeutically,” pointed out Sanjog Pangarkar, MD, director of the inpatient and interventional pain service at the West Los Angeles VAMC. For instance, Pangarkar said, “we didn’t find robust evidence that epidural injections provide a benefit. It didn’t seem as clean-cut as it’s practiced today.”

Friedhelm Sandbrink, MD

Friedhelm Sandbrink, MD, chief of the pain management program at the Washington, DC, VAMC, and deputy national director of pain management for the VHA went further. While “very commonly used in practice, steroid injections for acute exacerbation in the emergency department have no supporting evidence. It’s associated with potential harm and a lack of evidence of benefit, so we made a strong recommendation against it.”

More generally, the “literature review provided limited evidence of the effectiveness of pain medication,” Sandbrink told U.S. Medicine. “Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for chronic or acute low back pain and we made a weak recommendation for duloxetine. For temporary use, a muscle relaxant may be helpful, but that’s it really.”

The recommended list is even shorter than Sandbrink’s comments might indicate, with the absence of one ubiquitous NSAID. “It surprised me that the review of acetaminophen showed that there may be more side effects or problems than benefits. We made a strong recommendation against its use in low back pain,” said Daniel Kang, MD, an orthopedic spine surgeon at Madigan Army Medical Center in Tacoma, WA.

The most-notable change in the guidelines for pharmacological treatment, however, came in the clear warning against the use of opioids for low back pain. “The number one recommendation in the guidelines for chronic pain issued in February was against long-term opioid therapy,” Sandbrink emphasized. “That was instrumental for the low back pain recommendation against initiating long-term opioid therapy and our referral back to the clinical practice guidelines for opioid therapy, which emphasize an individualized approach and recognizes the challenges in opioid dosage reduction for those already on long-term opioid therapy.”

With the evidence review supporting few of the treatments frequently used to manage one of the most common presentations at clinics, what do the guidelines recommend?

“For physicians seeing patients in the DoD, readiness is a priority. Our young patients might be referred to spine surgeons, but they are likely to respond to things that clinical providers may not have thought about. We found a lot can be treated with nonoperative options,” Kang told U.S. Medicine.

“Not all pain is addressed through medication, therapies or surgery,” echoed Pangarkar. “Our patients use acupuncture, yoga, tai chi and other techniques to manage their pain and we wanted to understand if there is value in those integrative therapies.”

The work group found mixed results in the literature. “There was a surprising lack of evidence for many integrative therapies,” said Adam Bevevino, MD, chief of spine surgery service at the William Beaumont Army Medical Center in El Paso, TX.


Exercise Programs

The group did find sufficient evidence for tai chi, Pilates and yoga to make a weak recommendation for integrative exercise programs that encourage patients to “keep active in a nonimpactful way that does not worsen pain and allows them to proceed at their own pace,” Pangarkar said.

“There is some movement toward making acupuncture a more common treatment. While it did not have sufficient evidence to support its use in acute situations, there was good evidence for it for chronic low back pain,” he noted.

“There was also positive evidence for spinal mobilization for chronic and acute low back pain,” added Sandbrink, who suggested a less physical approach also has good support: “One particularly strong nonpharmacological recommendation was for the use of cognitive behavioral therapy (CBT). CBT protocols are specifically validated in patients with chronic low back pain,” he said.

While clinicians tend to want to do something, anything, for patients in distress, might be to do less for low back pain, according to the new guidance. “The take home from our review, is to start small, educate patients on self-care. Low back pain is usually a self-limited problem that can be managed without a lot of tests, specialists, pharmacological interventions and imaging,” said Bevevino.

His recommendation is based, in part, on input from patients who had subacute, chronic back pain. “We had a small session at the beginning of the process where we asked patients their desires and fears,” recounted James Sall, PhD, FNP-BC, clinical quality program specialist in the evidence-based practice program at the VA.

What patients do not want was as notable as what they do want. “Patients’ main concern was that they were given options. They wanted to be listened to, not talked down to. They were not looking for particular drugs or treatments,” added Elaine Stuffel, BSN, MHA, RN, chronic disease clinical practice guideline coordinator, US Army Medical Command, Fort Sam Houston, TX.

The bottom line?

Providers can meet many patients needs by providing simple guidance. “They’re not looking for what to do as much as how to navigate the military system better, how to tell superiors they have an injury that they need time to recover from,” Bevevino said.

Because there are limited options for symptomatic resolution of low back pain, “we need to emphasize self-care and preventing low back pain altogether by improved life choices, such as nutrition, being active, regular exercise,” said Sandbrink.

As surprising as the changes to the guidelines may be, “there is an evidence-based background for every recommendation we made,” Kang told U.S. Medicine. “The guidelines give physicians a tool to to use to treat their patients and get them back to fighting strength.”