Acute Lower Back Problems in Adults - Scope

Scope

This Clinical Practice Guideline is intended to provide primary care clinicians with information and recommended strategies for the assessment and treatment of acute low back problems in adults. To develop this guideline, AHCPR convened a private–sector, multidisciplinary panel of clinicians, researchers, and a consumer representative to evaluate the scientific evidence in the medical literature, draw conclusions, and make recommendations.

In determining the scope of the guideline, the panel focused on information needed for primary care assessment and treatment of adults with acute low back problems. "Back problems" were defined as activity intolerance due to back–related symptoms and acute as limitations of less than 3 months' duration. Back symptoms include pain in the back as well as back–related leg pain (sciatica). The panel agreed that the guideline should provide information on initial detection of underlying serious conditions (such as fracture, tumor, infection, or cauda equina syndrome) that could be causing low back problems, but that treatment of these conditions is outside the scope of the guideline.

The panel agreed further that the assessment and treatment of patients who have chronic low back problems (with symptoms lasting over 3 months) may be quite different than for patients with acute problems. Patients who become disabled due to chronic low back problems represent less than 5 percent of those with low back problems, but they account for up to 60 percent of the societal costs for this disorder. [6] <http://text.nlm.nih.gov>To a much greater extent than acute problems, chronic low back problems are influenced by complex psychological, behavioral, socioeconomic, demographic, legal, and occupational factors, many of which are not easily controlled. [8] <http://text.nlm.nih.gov>For these reasons, the panel decided that chronic low back problems are beyond the scope of a guideline on acute problems. The recommendations included in the guideline may not apply to persons younger than 18 years since diagnostic and treatment considerations for this group are often different than for adults.

Evaluation of Evidence.

The panel agreed that this guideline on acute low back problems should be anchored to published scientific evidence, and that such evidence should take priority over panel opinion in making guideline recommendations. In looking at a proposed assessment or treatment method, the panel considered: (1) efficacy, (2) potential harms, and (3) costs.

The panel considered randomized controlled trials (RCTs) that focused on patient–oriented clinical outcome measures such as symptom relief or improved level of functioning to be the acceptable method for establishing the efficacy of treatment methods. Evidence about efficacy of assessment methods was considered adequate if results of the diagnostic test studied were compared to an independent reference standard in a way that allowed calculation of standard test parameters, such as the test's true–positive rate (sensitivity) and true–negative rate (specificity).

The panel agreed to give the greatest weight to scientific research evidence that met the above criteria. When such strong scientific evidence was not available, the panel labeled the evidence as weak and indirect and used the combined expert opinion and clinical judgment of panel members for interpretation. In all cases, the guideline explicitly states the type of evidence used by the panel as the basis for recommendations. The scale used for labeling the evidence is at the end of this chapter.

Prevention Studies.

The panel found that, to date, studies of interventions aimed at preventing low back problems or their risk factors present conflicting findings and explain only a small portion of back complaints. Few of these prevention studies have been well designed, and most have been conducted in workplace settings focusing on injury claims or have used interventions that could not easily be carried out by primary care providers. When information from these studies was applicable to primary care, however, it was included under specific areas of assessment or treatment in the guidelines.

The panel agreed that a methodological problem commonly associated with studies of the prevention of back problems is lack of precision in specifying the goal(s) of the preventive intervention. Researchers often fail to establish whether the goal is to prevent the first episode of low back symptoms, activity limitations, recurrent episodes, injury claims, time lost from work, chronic disability, and/or medical care utilization and costs. In addition, some authors have suggested that efforts to prevent first or recurrent episodes of low back symptoms at work may be futile, and that research should focus instead on preventing long–term disability that results in high–cost disability claims. [6] <http://text.nlm.nih.gov>, [12] <http://text.nlm.nih.gov>, [13] <http://text.nlm.nih.gov>

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.