The Nonsurgical Management of Acute Low Back Pain: Cutting Through the AHCPR Guidelines [Hardcover]

Dr. Erwin Gonzalez MD (Author), Dr. Richard Materson MD (Author)

Book Description

ISBN-10: 1888799137 | ISBN-13: 978-1888799132 | Publication Date: December 1, 1997 | Edition: 1

"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. " (20100503)

Editorial Reviews

From The New England Journal of Medicine

The clinical-practice guidelines for the management of acute low back pain that were published in 1994 by the Agency for Health Care Policy and Research (AHCPR) are widely recognized to have been a watershed. On the one hand, they marked an important scientific accomplishment in that a rigorous evaluation of more than 10,000 published studies on the management of this ubiquitous condition was completed. On the other hand, the reaction from some quarters to the recommendations of the agency's expert multidisciplinary panel was so negative and, indeed, at times vitriolic, that the agency -- and the guidelines-generating business -- have not been the same since. After a coordinated attack on the agency by those who disagreed with its findings on low back pain, many of whom had vested interests in procedures found by the panel to have no evidentiary basis, the AHCPR got out of the guidelines-producing business in 1996.

This book is a critique and rebuttal of the AHCPR guidelines on low back pain, section by section, written by members and affiliates of the Association of Academic Physiatrists and based on a course offered by that organization in 1996. In introducing the book as a deliberately alternative monograph, the editors perhaps promise more than is delivered. To be sure, some of the chapters present a thoughtful challenge to the AHCPR recommendations, based largely on the authors' genuine mastery of the relevant basic biologic sciences. This expertise is helpful when, as was the case for the majority of the original guidelines, there is less than adequate evidence available on the accuracy or efficacy of a given test or treatment in terms of studies that meet the usual clinical epidemiologic standards.

There is, for example, a thorough chapter on modern imaging techniques applied to the spine and an intriguing chapter on the promise of somatosensory evoked potentials for future diagnostic use. There are also exhaustive chapters summarizing -- though not necessarily critically appraising -- virtually everything ever written on epidural steroid injections, diskography, diagnostic nerve-root blocks, lumbar facet-joint injections, sacroiliac-joint therapies, and trigger-point management, all by obvious proponents of these techniques. Unfortunately, the evaluation of the literature is uneven, with only a few chapters demonstrating an informed sense of the standard criteria for assessing study design and analysis. There is also a distressing lack of awareness of tertiary care referral bias, since much space is devoted to conditions that are rare in primary care. When it comes down to whether these advocates can cite any more high-quality evidence of efficacy for the treatments reviewed than the AHCPR panel could find, the answer is pretty much a resounding no. Instead, the reader is merely provided with interesting case material and many basic biologic rationales. In fact, when the AHCPR recommendations are directly commented on, there is generally more agreement than disagreement with the guidelines in terms of what is known about managing acute low back pain.

More fundamentally, however, the state of the evidence is not the key issue for the practicing experts in spinal medicine who wrote this book. The issue for them is rather what the appropriate conclusion should be when, as so often was the case for the literature the AHCPR panel reviewed, there is simply no good evidence one way or the other. The essential difference in perspective between the agency's panel and these would-be critics is laid out well in the introductory chapter by the editors and again in helpful chapters on the use of medications, physical treatments, manipulation, bed rest and exercise, and patient education. In the absence of sound scientific evidence, the authors collectively believe that clinical experience and a basic-science rationale for a test or treatment constitute an abundantly adequate basis to justify its use. This epistemological position is, they argue, in contrast to the implicit view of the AHCPR panel that "no evidence" is reason not to use tests and treatments unless they are virtually risk- and cost-free.

Surely the pragmatic position that most physicians subscribe to is that there are many occasions in clinical practice when high-quality evidence just isn't in yet, and may never be, and we are thus forced to use tests and treatments for which we have only a "promising" biologic rationale and an expert opinion based on experience -- and for which we must therefore very carefully weigh the benefits, risks, and costs. To this end, most of us in primary care are grateful to the AHCPR panel for expertly summarizing a huge body of evidence on low back pain. Reassuringly, in the case of the arguments advanced in this book, there seems to be more rhetoric than reality in the authors' claims of disagreement with the specifics of the AHCPR guidelines. The contributors do present, however, a provocative exposition of their opposition to the agency's philosophy of decision making in the absence of good science -- and for that they deserve recognition.

Reviewed by John Frank, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Review

"...a valuable and thorough reference for practitioners who are regularly faced with treatment decisions in the acute low back pain patient. -- Doody's Reviews

""...readable, comprehensive, and well referenced, and will be of interest to practitioners of all persuasions who treat this condition."" -- Physiotherapy Journal" (Physiotherapy Journal )

See all Editorial Reviews

Product Details

• Hardcover: 271 pages
• Publisher: Demos Medical; 1 edition (December 1, 1997)
• Language: English
• ISBN-10: 1888799137
• ISBN-13: 978-1888799132
• Product Dimensions: 11.2 x 8.6 x 0.8 inches
• Shipping Weight: 2.6 pounds (View shipping rates and policies)
• Amazon Best Sellers Rank: #2,459,452 in Books (See Top 100 in Books)