The Nonsurgical Management of Acute Low Back Pain

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Practice guidelines have recently become prominent as a response to rising health care costs, reported regional practice variations, and reports of 'inappropriate' medical care. They are now expected to meet a number of agendas, including improvement of the quality of health care, protection of professional autonomy, reduction of litigation risk, minimization of practice variation, provision of standards for auditing medical records, reduction of health care costs (and therefore health care premiums), defining areas of practice, improvement in efficiency of practice, and identification of inappropriate care. The federal government has become particularly interested in guideline development and promotion of their development in the interest of rising health care costs and the extreme variation in medical practice noted nationally.

This volume is intended for all spine care practitioners. It challenges its readers to weigh the recommendations of the authors against those of the Agency for Health Care Policy Research (AHCPR) Guideline Number 14: Acute Low Back Problems in Adults. The chapters are personal opinions of the individual authors, based on published scientific studies, their own writings, and, more importantly, their clinical experiences.

The author of each topic-based chapter indicates agreement or disagreement with the guidelines and provides literature and experience-based reasons for their position. Specific clarification of the references cited by the AHCPR is included where appropriate, and newer literature available since the AHCPR guidelines were written is provided. The reader is encouraged to attempt to understand the rationale of the guideline's authors and decide on the veracity of the guidelines versus the chapter author's or the reader's own information and experience. In this manner, a thoughtful reexamination of our thinking regarding the management of acute low back pain will occur, and the missions of both the AHCPR and the editors of this book will be fulfilled. Chapter 1 describes the backdrop for the proliferation of guideline development from a historical perspective, outlines the methodologies used in development of guidelines, and discusses the effectiveness of guidelines on patient care and practice behaviors. Chapter 2 is an overview of practice guidelines in general. The book is divided into several sections, detailing assessment and management. A significant portion of the book deals with diagnostic and therapeutic injection techniques in response to the growing popularity of these modalities. Because the AHCPR guidelines rely on statistical odds that most acute LBP will resolve on its own, the guidelines invoke a 'wait and see' approach for the first three months unless red flags exist. This is in sharp contrast to what the general medical community and patients with low back pain would generally opine. Herein was the basis for the enormous counter-reaction to the guidelines. Because only a distinct minority of acute LBP patients present with frank radiculopathy and serious spinal conditions, most patients with nonspecific LBP do fall into the group that will see resolution with a less aggressive approach. However, serious questions remain:

• Will this approach do more harm than good?
• Will adhering to the guidelines increase the likelihood of an acute episode of LBP turning into chronic LBP, at greater suffering and expense to the individual and society?
• Will patient satisfaction, a recognized outcome measure, erode because of this approach?

This volume provides the basis on which to evaluate these problems and their eventual resolution.