7 Colo. Code Regs. § 1101-3-17-01-3
Introduction. Low back pain is a common condition with a lifetime prevalence of 84% and a high recurrence rate. However, only about 15% of the population has severe pain with functional/disability limitations. Most low back pain responds to therapy and self-management and does not require invasive measures. These guidelines outline a biopsychosocial approach to low back pain care and integrate biological, psychological, and social elements.
Significant trauma resulting in fractures and/or spinal cord dysfunction are not covered in these guidelines. Early imaging and surgical evaluation should be reserved for more severe issues outlined in recommendation 1. Most patients will respond to conservative care as outlined in recommendations 2 through 5 and will not require invasive treatment. Additional interventions, as indicated for less common cases, are covered by the remaining recommendations.
Recommendations.
Core Requirements.
Recommendation 1. Early imaging and surgical evaluation is required for patients with evidence of any of the following:
* trauma with concern for acute fracture or dislocation,
* epidural abscess,
* myelopathy,
* cauda equina syndrome, or
* progressive neurologic deficits (e.g., motor weakness and abnormal reflexes) that specifically correlate with spinal cord or nerve root impingement.
Recommendation 2. Initial conservative management without imaging is strongly recommended for all low back pain patients who do not meet the criteria in recommendation 1, focusing on the following:
* education that prolonged periods of immobility are detrimental,
* education on the positive impact of movement on recovery,
* appropriate use of over the counter medications, and
* application of ice or heat.
Recommendation 3. Bed rest is not recommended (table 1).
Recommendation 4. Close follow-up and subsequent neurologic examinations are required for patients with radicular low back pain who do not meet the criteria in recommendation 1or recommendation 8.
Recommendation 5. Participation in self-directed exercise or an active therapy program that includes core stabilization, strengthening, and endurance is recommended as a principal low back pain treatment. See the Active Therapies section.
Recommendation 6. Individuals with barriers to functional recovery may benefit from an interdisciplinary approach to care. See the Diagnosis section.
Recommendation 7. Referral for epidural steroid injection (ESI) evaluation within 6 weeks of pain onset is permitted when all of the following criteria are met:
* severe function-limiting pain in legs greater than the back that interferes with return to work, activities of daily living (ADLs), and/or participation in active therapy; and
* positive correlation among clinical findings, the clinical course, and diagnostic tests.
See the Epidural Steroid Injections section.
Recommendation 8. Referral for discectomy evaluation within 6 weeks of pain onset is permitted when all of the following criteria are met:
* function-limiting pain in legs greater than the back that interferes with return to work, ADLs, and/or participation in active therapy;
* physical exam findings of abnormal reflexes, motor weakness, or radicular sensory deficits;
* findings on magnetic resonance imaging (MRI) indicate impingement of nerves or the spinal cord that specifically correlate with reproducible physical exam findings; and
* the observed pathology is amenable to surgical intervention.
See the Discectomy section.
Recommendation 9. Referral for spinal injections is indicated when all of the following criteria are met:
* positive correlation among clinical findings, the clinical course, and diagnostic tests;
* positive functional response to diagnostic injection, if required;
* persistent functional impairment despite engagement in 6 weeks of active therapy; and
* confounding psychosocial risk factors have been screened for and clinically addressed (see the Behavioral and Psychological Interventions section).
See the Injections section.
Recommendation 10. Referral for surgical evaluation at 6 weeks or greater is indicated when the expected functional outcome of surgery is better than non-operative management and all of the following criteria are met:
* symptomatic and functional improvement has plateaued with unacceptable functional disability;
* greater pain in the legs relative to back that interferes with function, return to work, and/or active therapy;
* physical exam findings of abnormal reflexes, motor weakness, or radicular sensation deficits;
* findings on MRI that indicate impingement of nerves or the spinal cord that specifically correlate with reproducible physical examination findings; and
* diagnostic elimination of confounding psychological or physical conditions that may respond to non-surgical techniques but may be refractory to surgical intervention (see the Behavioral and Psychological Interventions section). Also see the Surgical Interventions section.
Evidence Table.
Table 1. Evidence Table: Return to Daily Activities and Avoidance of Bed Rest in Low Back Pain | ||
Summary: Bed rest is not helpful for treating uncomplicated low back pain. Mobilization in subacute low back pain reduces disability. | ||
Strong evidence | Evidence statement | Design |
There is strong evidence against the use of bed rest in acute low back pain cases without neurologic symptoms. | RCT | |
Good evidence | Evidence statement | Design |
Education and mobilization of subacute low back pain reduces disability. | RCT | |
Some evidence | Evidence statement | Design |
Among a cohort of 33,908 healthy study volunteers, new cases of depression were potentially preventable by participation in at least 1 hour of weekly exercise. | Cohort study | |
See related sections for additional evidence tables.
7 CCR 1101-3-17-01-3