Acute Lower Back Problems in Adults - Overview

1. Overview

Purpose and Rationale

There are four principal reasons acute low back problems were selected as a subject for guideline development. One reason is their prevalence. Most people report low back problems at some time in their lives, and national statistics indicate a general yearly prevalence in the U.S. population of 15–20 percent. [1]<http://text.nlm.nih.gov> Among working–age people surveyed, 50 percent admit to back symptoms each year. [2]<http://text.nlm.nih.gov>, [3]<http://text.nlm.nih.gov> Back symptoms, in fact, are the most common cause of disability for persons under age 45. [4]<http://text.nlm.nih.gov> At any given time, about 1 percent of the U.S. population is chronically disabled because of back problems, and another 1 percent temporarily disabled. [1]<http://text.nlm.nih.gov>

A second reason for a guideline on assessment and treatment of acute low back problems is cost. Low back problems are expensive. Their total costs to society are difficult to calculate, but evidence indicates that both the economic and psychosocial costs are substantial. Low back problems are the second most common symptomatic reason expressed by patients for office visits to primary care physicians. [5]<http://text.nlm.nih.gov> They are the most common reason for office visits to orthopedic surgeons, neurosurgeons, and occupational medicine physicians. They rank third among the reasons for surgical procedures.
Moreover, although medical costs are high, loss of time from work as well as the disability payments for work–related low back problems can together cost up to three times as much as medical treatment. [6]<http://text.nlm.nih.gov> About 2 percent of the U.S. work force has compensable back problems each year. [7]<http://text.nlm.nih.gov> Various estimates of the total annual societal cost of back pain in the United States range from $20 to $50 billion. [8]<http://text.nlm.nih.gov> Nonmonetary costs of low back problems can also be substantial. The inability to function normally at work and in other daily activities has an impact on both patients and their families.

A third important reason for this guideline is the increasing evidence that many patients with activity intolerance due to low back symptoms may be receiving care that is inappropriate or at least less than optimal. Rates for hospitalization and surgery for low back problems vary substantially among regions of the United States as well as among small areas within states. [9]<http://text.nlm.nih.gov>–[11] <http://text.nlm.nih.gov> Marked regional variations also occur in the use of diagnostic tests for assessing low back problems. [9]<http://text.nlm.nih.gov> These variations imply a lack of consensus about appropriate assessment and treatment of low back problems, suggesting that some patients may be receiving inappropriate or suboptimal care.
In addition, some patients appear to be more disabled after treatment than before, another potential indicator of suboptimal care. Perhaps the most obvious examples involve surgery. Despite an extensive medical literature on failed back surgery and evidence that repeat surgical procedures for low back problems rarely lead to improved outcome, there are documented examples of patients who have had as many as 20 spine operations. [9]<http://text.nlm.nih.gov>However, surgery is not the only treatment that can lead to increased disability. Common treatment methods such as extended bed rest or extended use of high–dose opioids can prolong symptoms and further debilitate patients.

A fourth reason for the guideline is a growing body of research on low back problems, allowing a systematic evaluation of commonly used assessment and treatment methods. Although the existing literature has shortcomings, there is sufficient scientific evidence for a number of conclusions about the efficacy and safety of current assessment and treatment methods.

Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults.
Clinical Practice Guideline No. 14. AHCPR Publication No. 95–0642.
Rockville, MD: Agency for Health Care Policy and Research, Public Health
Service, U.S. Department of Health and Human Services. December 1994.