Best practice management of low back pain in the emergency ...

Emergency Medicine Australasia (2018) 30, 18–35

doi: 10.1111/1742-6723.12907

REVIEW ARTICLE

Review article: Best practice management of low back pain in the emergency department (part 1 of the musculoskeletal injuries rapid review series) Kirsten STRUDWICK Trevor RUSSELL3

,1,2,3 Megan MCPHEE,2 Anthony BELL,4,5 Melinda MARTIN-KHAN6 and

1

Emergency Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia, Physiotherapy Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia, 3 School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia, 4Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia, 5Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia, and 6Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia 2

Abstract Low back pain (LBP) is a common presentation to the ED, and a frequent cause of disability globally. The ED management is often associated with high rates of imaging, misuse and overuse of pharmacology and subsequent financial implications. Given this, improved quality of care for patients with LBP in ED is essential. This rapid review investigated best practice for the assessment and management of LBP in the ED. PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2015. Primary studies, systematic reviews and guidelines were considered for inclusion. English-language articles published in the past 10 years that addressed acute LBP assessment, management or prognosis in the ED or acute setting were included. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence where possible. The search revealed 1538 articles, of which 38 were

included in the review (n = 8 primary articles, n = 13 systematic reviews and n = 17 guidelines). This rapid review provides clinicians managing LBP in the ED a summary of the best available evidence to risk stratify and enhance the quality of care, optimising patient outcomes. Consistent evidence was found to support the use of ‘red flags’ to screen for serious pathologies, diagnostic tests being reserved for use only in the presence of red flags, the judicious prescribing of opioids, identification of psychosocial risk factors as predictors of poorer outcome and promotion of early return to work and function. Key words: emergency medicine, evidence-based practice, low back pain, review, sciatica.

Introduction Low back pain (LBP) is the highest ranked cause of disability globally.1 The most recent Australian data suggests one in seven Australians

Correspondence: Ms Kirsten Strudwick, Emergency Department, Queen Elizabeth II Jubilee Hospital, Locked Bag 2, Archerfield, QLD 4108, Australia. Email: kirsten. [email protected] Kirsten Strudwick, BPhty (Hons), Emergency Physiotherapy Practitioner; Megan McPhee, BPhty (Hons), Physiotherapist; Anthony Bell, MBBS, FACEM, MBA, MPH, FRACMA, Director Emergency Department; Melinda Martin-Khan, PhD, MHthSc, GCSc (Stat), BEd (Hons), BCom (Acc), DipMan, Health Scientist; Trevor Russell, BPhty, PhD, Professor. Accepted 22 March 2017

Key findings • Screen for red flags in all patients with LBP. • Use imaging and opioids judiciously. • Identify yellow flags for predicting those at risk of a poor prognosis. • Promote early return to work and function. reported back pain in 2011–2012, and over two in five of these people reported limitations in activity due to their back problems.2,3 In Australia, healthcare expenditure due to LBP is also significant, estimated to total $1.2 billion in 2008–2009, not accounting for lost productivity.4 In one Western Australian study, LBP accounted for 22 655 ED presentations (1.9% of total) between 2000 and 2004, with an average length of stay in ED of 4.4 h.5 From these presentations, 43.8% were categorised as having ‘muscular’ LBP, and 17.1% of these patients were admitted with an average length of stay at 6.4 days.5 More recent data from an Australian metropolitan hospital has reported higher prevalence, with 2.2% of all presentations in 2013 being due to LBP, and 32.2% of these patients being admitted.6 Hospital admission accounts for significantly greater expenditure,7,8 estimated at 47.6% ($560 million) of the total healthcare

© 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

19

MUSCULOSKELETAL RAPID REVIEW SERIES: LOW BACK PAIN

expenditure on LBP.4 This suggests LBP is a common complaint requiring a significant outlay of healthcare resources and continues to be a substantial source of disability in the wider population. On presentation to the ED, the primary aim is to exclude serious pathology, which may require immediate intervention (such as fractures, malignancies, spinal cord or cauda equina compression). Thereafter, the ED management of LBP ideally focuses on controlling pain and restoring patient function.9 This usually includes patient education, reassurance, advice and simple analgesics.10 Patients with LBP often present to ED with high expectations of analgesia and investigations, which can make adhering to assessment and management guidelines challenging.11 In addition, the National Emergency Access Target focuses on time-related outcomes, increasing the pressure to diagnose, manage and discharge patients rapidly, which may impact on the quality of care.12,13 Thus, despite clear management aims and the availability of clinical guidelines, the practical and environmental pressures of ED often lead to wide variations in care.14,15 It has been shown that compliance with evidence-based clinical guidelines for the management of patients with LBP can offer improvements in pain relief and patient satisfaction, and reduce the need for ongoing care.16 In such guidelines, practitioners are strongly advised to limit the use of imaging17,18 and use a stepwise approach in prescribing analgesics.19 Despite these guidelines, American data from the past decade indicates there has been a three-fold increase in the use of advanced imaging techniques (both magnetic resonance imaging and computed tomography, up to 11.3%), with stable use of radiographs (17%), and an increase in prescription opioid use (29.1%, up to 61% at discharge) in place of simple analgesics.20,21 In Australia, the available data also suggest high rates of imaging in ED, with radiography requested for 26.2% of patients and advanced imaging

requested for 5.6% of patients.6 These approaches offer no improvements to patient outcomes, increase exposure to the risks of opioid medications use and unnecessary radiation and lead to increases in the economic burden of LBP.16,22–24 There are multiple reasons why a patient may attend an ED rather than seeking general practitioner (GP) care. Reasons that are not specific to the LBP population include: reduced availability of and access to GPs; limited access to after-hours GP care; the gradual shift in GPs charging co-payments for consultations and the rise in ambulance utilisation where the ED is the universal destination point. Specific to the LBP patient population, they may also perceive a more urgent need for medical attention due to high levels of pain or inability to function. The ED may also be viewed as a ‘onestop shop’ that provides the relevant medications and diagnostics for their LBP, at no cost to the patient, whereas they are likely to incur these costs in the primary care setting.25 For most patients with LBP, the condition is self-limiting, with rapid improvements in pain and function experienced in the first 6 weeks.26,27 However, in patients who seek treatment outside of the ED, high recurrence rates have been reported,28 and nearly one-third may not have recovered at 12 months after their first presentation.29 There is increasing emphasis on the role of psychosocial factors in identifying patients at risk of transitioning to chronic pain, but early screening and appropriate management of these risk factors is not routinely performed in the ED.30 These patients, with a lack of resolution of symptoms, may also contribute to the large number of LBP presentations to the ED. Given the burden of disease and financial impacts, high quality care of patients with LBP in the ED is essential. A rapid review was undertaken to identify the current best evidence for patients with acute LBP in the ED setting across the clinical cycle of care, including assessment, diagnostics, treatment and considerations for discharge and follow

up. This rapid review forms part of a larger series, which is outlined in the corresponding methodology paper.31

Methods Search strategy A rapid review, which is a streamlined approach to synthesising evidence, was conducted in March– April 2015 of the past 10 years of scientific literature, including guidelines, primary articles and systematic reviews pertaining to quality care of LBP in the ED. The methodology for the review is outlined in more detail in the corresponding methodology paper.31 Table 1 provides details of the literature search and selection process for this review.

Study selection and analysis Primary studies, systematic reviews and guidelines were considered for inclusion. Articles were screened at title, abstract and full-text level by applying the inclusion/exclusion criteria. The National Health and Medical Research Council (NHMRC) levels of evidence hierarchy32 was chosen to rate the levels of evidence as the scope of the review was quite broad, yielding articles utilising many different research designs (i.e. intervention, diagnosis, prognosis, aetiology and screening studies). Each primary article and systematic review was independently assigned a level of evidence by two members of the research team. Disagreement was resolved by reaching consensus and the research team was consulted if agreement could not be reached. All guidelines reported their own quality grading system within the guideline; therefore, insufficient information was available to be able to grade these articles against the NHMRC levels of evidence. Of the primary studies, only Level II studies, as per the NHMRC levels of evidence hierarchy, were included (i.e. highest level of intervention, diagnostic accuracy and prognostic studies). Studies that were Level III-1 or lower were included in which


20

K STRUDWICK ET AL.

TABLE 1.

Literature search and selection criteria

Databases searched

PubMed, CINAHL, EMBASE, TRIP Database Grey literature search of relevant websites and organisations

Search terms

Combined MESH and keyword search using terms related to emergency medicine AND best practice AND low back pain (and variations of back pain) Individual database searches are presented in Appendix S1

Inclusion criteria

English language Published between 2005 and April 2015 Concerning low back pain of musculoskeletal origin, or ‘red flag’ conditions that can mimic musculoskeletal low back pain Adults only

Exclusion criteria

Chronic low back pain without acute flare up Surgical techniques or surgical management of fractures, cauda equina/cord compression Study setting or intended users external to the ED or findings not applicable to ED practice Qualitative studies, case studies, conference abstracts, commentaries and Letters to the Editor

Quality assessment

Data extraction by one author against a standardised form; checked by a second author Articles assigned NHMRC level of evidence32 by two authors independently (see page 15 of this reference for further details https://www.nhmrc. gov.au/_files_nhmrc/file/guidelines/developers/ nhmrc_levels_grades_evidence_120423.pdf) Disagreements were discussed to reach a consensus

safety and ethics concerns may have limited prospective research in that area, such as in the case of cauda equina. Systematic reviews of all evidence levels were included. Guidelines were included if the methodology for development was clearly documented.

Results Search results The initial search, following exclusion of duplicates and non-English articles, identified 1538 articles for screening (Fig. 1). At full text, eightprimary articles,33–40 13 review articles27,41–52 and 17 guidelines53–69 were included.

Article characteristics and levels of evidence Characteristics of the 38 included articles are shown in Tables 2–4. The included articles ranged from Level I to IV evidence, with Level I being considered highest in the NHMRC hierarchy, based on the probability that the research designs at this level have minimised the impact of bias on the results. Of the primary articles, five were interventional randomised controlled trials providing Level II evidence, and the remaining three articles were retrospective chart reviews describing diagnostic accuracy and/or prognosis of Level II–IV evidence. These lower level studies were included to offer a comprehensive picture given the

safety and ethical concerns with performing prospective research in some conditions. The systematic review articles included a mix of Level II interventions (n = 4), Level III-2 interventions (n = 1), Level II diagnostic accuracy (n = 4), Level II combined intervention and diagnostic accuracy (n = 1), Level II prognosis (n = 2) and a Level II qualitative review (n = 1). All included guidelines were based on literature review and expert consensus, but varied in formatting and use of critical appraisal tools.

Evidence across the clinical cycle of care in the ED The included articles covered many aspects of the clinical cycle of care for the ED management of LBP, and the major findings and recommendations have been summarised in Figure 2. The findings from each included article have been synthesised into different aspects of the clinical cycle and are presented in Appendix S2.

Initial assessment There is evidence to support screening for ‘red flags’ to exclude serious pathologies. The specific conditions and ‘red flag’ signs varied between articles and are listed in Figure 2. This recommendation is supported by primary articles (n = 1 article of Level II evidence, n = 2 articles of Level III-2 evidence), systematic reviews (n = 6 articles of Level II evidence) and guidelines (n = 8). The importance of identifying psychosocial risk factors, known as ‘yellow flags’, was recommended in systematic reviews (n = 2 articles of Level II evidence) and guidelines (n = 6), reflecting the suggested value of this information in predicting those at risk of a poor prognosis.

Imaging and diagnostic tests Evidence supporting the selection, or non-selection, of imaging was covered in systematic reviews (n = 3 articles of Level II evidence), and guidelines (n = 11). It was consistently concluded that imaging should only be used in the case of trauma or


21


Referrals and follow up Records identified through database search (n = 1571 ) PUBMED: n = 60 CINAHL: n = 112 EMBASE: n = 245 TRIP (systematic reviews): n = 118 TRIP (guidelines): n = 1036

Additional records identified through grey literature search (n = 8)

Records screened for duplicates and non-English language (n = 1579) Duplicates and non-English language articles removed (n = 41) Records screened on title and abstract (n = 1538)

Records excluded at title and abstract (n = 1401) Title: n = 1261 Abstract: n = 140

Full-text articles assessed for eligibility (n = 137)

Records excluded at full-text (n = 99)

Studies included in review (n = 38)

Results data not specific to LBP: n = 5 Setting not applicable to the ED: n = 9 Failed level of evidence criteria: n = 44 Failed guideline methodology criteria: n = 35 Primary article included in a systematic review: n = 3 Demographics only reported: n = 4

Primary studies: n = 8 Systematic reviews: n = 13 Guidelines: n = 17

Figure 1. PRISMA flow diagram.

when red flags were present in the assessment. Specific recommendations for each imaging modality are presented in Figure 2. Pathology tests were not routinely recommended in the management of LBP, but should be reserved for the role of excluding serious conditions. This was supported by evidence in a systematic review (n = 1 article of Level II evidence) and guidelines (n = 4).

Treatment Several articles addressed the importance of differentiating LBP between different diagnoses: the majority of LBP as those that have no pathoanatomical cause, those that are associated with radiculopathy or spinal stenosis and the minority of cases whose pain is caused by a serious

condition with a specific diagnosis. This evidence was reflected in systematic reviews (n = 3 articles of Level II evidence) and guidelines (n = 5). The diagnosis and severity of symptoms should then guide the management, where the judicious use of analgesia, particularly opioids, was supported by evidence in primary articles (n = 4 articles of Level II evidence), systematic reviews (n = 2 articles of Level II evidence) and guidelines (n = 8). It was recommended that the management of LBP in ED also include nonpharmacological strategies such as targeted education and reassurance, cold or heat and exercise recommendations. These were evidenced in a primary article (n = 1 article of Level II evidence), systematic reviews (n = 2 articles of Level II evidence) and guidelines (n = 8).

Follow up was considered in systematic reviews (n = 4 articles of Level II evidence, n = 1 article of Level III-2 evidence) and guidelines (n = 8), which broadly included GP, surgical, specialist and allied health referrals. Early follow up for patients with identified ‘yellow flags’ was recommended in a systematic review (n = 1 article of Level II evidence) and guidelines (n = 4). For those patients with a chronic history or persistent pain, guidelines (n = 4) indicated community health involvement or referral to a multidisciplinary pain management team. It was suggested in guidelines (n = 5) that an early return to work, even if on modified duties, should be encouraged to promote better patient outcomes.

Discussion This rapid review identified several key points integral to providing quality care for musculoskeletal patients within the ED. Broadly, this includes the exclusion of sinister pathologies, identification of psychosocial risk factors for poor prognosis, imaging only in the presence of ‘red flags’, first-line use of simple analgesics, judicious use of shortacting opioid analgesics in severe pain (if at all), education to regain function and increase general exercise, encouraging GP follow up and promoting early return to work in some capacity. Some of these key points, such as excluding sinister pathology, may already be common practice in many EDs. However, other key points such as psychosocial screening, judicious use of imaging and opioid analgesics and early return to work or activity promotion, may represent areas where inconsistencies in care exist.

Medical imaging and other diagnostic tests Articles reviewed consistently recommended avoiding routine imaging in patients with acute LBP. In line with this, the recent ‘Choosing Wisely Australia’ campaign made the


2010

2007

2008

Garra et al.37

Jalloh and Minhas38

Lau et al.39

Outcome

Presenting S&S of spinal cord and cauda equina syndrome & incidence of misdiagnosis

Reasons for delay in management of cauda equina syndrome and determine commonly presented features

Retrospective chart review (diagnostic accuracy)

Risk factors associated with serious pathology

RCT Effect of early (intervention) physiotherapy intervention

Retrospective chart review (prognosis and diagnostic accuracy)

RCT Analgesic effect of heat (intervention) vs cold

RCT Analgesic effect of (intervention) i.v. paracetamol vs i.v. morphine vs i.v. dexketoprofen given at presentation

Retrospective chart review (diagnostic accuracy)

RCT Analgesic effect of (intervention) promethazine as adjunct to morphine vs morphine alone

RCT Analgesic effect of (intervention) i.v. dexamethasone in addition to routine treatment

Study design

√

NA

√

√

√

√

X

√

√

X

NA

√

√

X

√

√

Sample size Appropriate calculation randomisation

NA

†

NA

X

‡

NA

†

‡

Blinded

√

NA

NA

NA

NA

X

NA

NA

√

√

√

X

√

NA

√

√

√

√

√

NA

NA

√

NA

NA

NA

NA

√

NA

NA

NA

NA

NA

NA

√

NA

√

√

NA

√

√

n = 329

n = 99

n = 32

n = 60

n = 137

n = 63

n = 59

n = 58

NHMRC level of evidence

Level II

Level II

Level II

1. Proportion with Level II risk factors not completed.

1. Unclear statistical significance.

1. No statistical Level IV methods. prognosis; 2. Sample size not Level III-2 powered. diagnosis

1. Results favour null hypothesis, likely type 2 error. 2. No control or blinding.

1. Only i.v. used. Level II 2. No superiority does not mean all drugs equal. 3. Outcomes at 30 min only.

1. Not statistically Level III-2 powered. 2. Not blinded.

1. Different halflives but outcomes taken at same time point.

1. 50% outcomes observations and >80% considerations

scale.

†, Single blinding; ‡, double blinding; √, yes; X, no; D/C, discharge; LOS, length of stay; NA, not applicable; OPD R/V, outpatient review; RCT, randomised controlled trial; S&S, signs and symptoms; SLR, straight leg raise; VAS, visual analogue

Thiruganasam2013 bandamoorthy et al.40

2014

Eken et al.36

2013

Behrbalk et al.34

2011

2014

Balakrishnamoorthy et al.33

Dugas et al.35

Year

Reference

TABLE 2. Primary article characteristics

22 K STRUDWICK ET AL.



et al.44

Henschke

et al.45

Henschke

et al.43

Downie

Search dates and

always stated and there is no

2. Levels of evidence are not

have citations throughout.

imaging in the ED

assessment and radiologic

pertaining to laboratory

√

√

√

more of the 11 methodological quality items).

at two independent authors at each stage

hand-searched reference lists

by taking a clinical history and conducting a physical examination

2. Small number of studies

studies scored fulfilled six or

patients appraisal performed by EMBASE, CINAHL,

characteristics identified

accuracy)

systematic review (3/8 of the

performance of clinical

(diagnostic

n = 6622

n = 8 papers, 1. Poor quality of studies in

blinding.

extraction and critical

Literature review, data

of bias). 2. Most studies have unclear

MEDLINE, OldMedline,

2013 Cochrane review To assess the diagnostic

Inception – 2012,

two independent authors

reference lists

(3/12 studies had a low risk

methodological quality items

patients appraisal performed by

CINAHL, hand-searched

fracture in LBP patients

accuracy)

diagnosing vertebral

n = 12 papers, 1. Low number of studies and inadequate reporting of


n = 7147

Inception – 2007,


of clinical features in

(diagnostic

MEDLINE, EMBASE,

2008 Systematic review To determine the accuracy

care

secondary or tertiary

with LBP to primary,

in patients presenting

poorly described.

2. Reference standards or

varied.

1. Methodological quality

diagnostic criteria were often

n = 14

authors at each stage

√

√

fracture or malignancy

appraisal performed by

√

of heterogeneity.

at least two independent

EMBASE, CINAHL

red flag signs and

accuracy)


Level II

Level II

Level II

Level II

1. Meta-analysis has high level Level III-2

symptoms to screen for


diagnostic accuracy of

(diagnostic


searched reference lists

cauda equina syndrome

(intervention) Inception – 2013,

evidence

Scholar, Scopus, hand-

surgical intervention for

analysis

2013 Systematic review To review the evidence on

NHMRC levels of

Cochrane, Google

Searched 2013: MEDLINE, Categorised according to

regarding the timing of

and meta-

author.

3. Performed by only one

included studies.

n = 24

113 listed

1. Clinical pathway does not

and considerations Unknown,

level of evidence

observations

NHMRC

Methodological

Number of inclusions

table of the characteristics of

?

√

assessment

bias

risk stratification

√

?

methods

Statistical Risk and

provides guidance on

into recommendations

appraisal and synthesis

Cochrane

evaluation of the patient with LBP, and it

extraction, critical

Literature review with data

Data collection process

Ovid MEDLINE,

1990–2013 – PubMed,

information sources

based rationale for the

Chau et al.42 2014 Systematic review To review the evidence

(intervention)

2013 Systematic review To explore an evidence-

Objective

Borczuk41

Study design

Year

Reference

TABLE 3. Review article characteristics


23

47

et al.51

Kumar

Koes et al.49

Jenkins et al.

Notley48

and

recommendations, the membership of the guideline committee, the target population and

Institute for Health and Clinical Excellence, hand-searched reference lists

(intervention)


Search Premier, ANZRC, CINAHL,

LBP

© 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine PsycINFO, ProQuest

Scopus, Web of Science,

Cochrane Library,

SPORTDiscus, PubMed,

HealthSource,

considered weak. appraisal performed by

ICONDA, Academic

treatment of non-specific

1. The methodological quality

critically analysed.

2. Guidelines included not

country.

therapy for the

n=9

stated. 1. Only one guideline per

varied, overall articles were

√

n = 15


X

√

MEDLINE, AMED,


based on evidence

recommendations were

?

effectiveness of massage

2000–2012 – EMBASE,

on content of the

Clearinghouse, National

management of LBP

accuracy)

2013 Systematic review To investigate the

extracting information

Guideline

guidelines for the

and diagnostic

the extent

to four guidelines,

PEDro, National

international clinical

(intervention

Each author extracted three

2. Chronicity of LBP not

important effects.

despite potentially clinically


Cochrane

imaging for LBP

lack of statistical significance


EMBASE, CINAHL,

reducing the use of

1. Lack of power within some

2. Qualitative study designs.

other countries.

limited generalisability to

1. Most studies were British,

studies.

interventions aimed at

n=7

included. 3. Unclear blinding in most

included studies resulted in

√

n = 28

observations and considerations

Methodological



?

√

assessment

bias

2014, MEDLINE,


X

methods


effectiveness of

Beginning of databases –


analysis performed by

grey literature search

dissatisfaction

thematic content

CINAHL, PsycINFO,

critical appraisal and

Literature review with


sources of satisfaction or

MEDLINE, EMBASE,

Inception – 2012,

2010 Systematic review To compare the content of 2000–2008 – MEDLINE,

(intervention)

Search dates and information sources

sciatica patients and the

of healthcare of LBP and

2015 Systematic review To investigate the

(qualitative)

LBP

patients presenting with

spinal malignancy in

(‘red flags’) to screen for

2013 Systematic review To describe the experience

Objective

Hopayian

Study design

Year

Reference

TABLE 3. Continued

Level II

Level II

Level II

Level II

of evidence

level

NHMRC


Year

Reference

46


√, yes; X, no; LBP, low back pain.

at each stage

lists

examination to screen for

LBP

patients presenting with

vertebral fracture in


hand-searched reference

history or physical

studies.

3. Unclear blinding in some

included.

in systematic review. 2. Small number of studies

1. Poor quality of most studies Level II appraisal performed by

n=8

EMBASE, CINAHL,

√

obtained in a clinical

accuracy)

√

of included studies.


accuracy of red flags

(diagnostic

limited statistical power. 3. Low methodological quality


2013 Cochrane review To assess the diagnostic

et al.52

state

baseline of a pain-free

transition to LBP from a


necessarily first time.

Inception – 2012,

intermittent symptoms, not


associated with either

(prognosis)

2. Heterogeneity of studies

to be recurrent but have


SPORTDiscus, Cochrane

first-time LBP or

Level II

Level II

of evidence

level

NHMRC

1. Possible for included patients Level II

of LBP and risk factors

n = 41

analysis

√


CINAHL,

√

others did not specify.

excluded sciatica/leg pain,

1. Some included studies

estimate of the incidence

Inception – 2012, PubMed, Literature review, data

n = 24

and meta-

2014 Systematic review To provide a current

similar courses

Williams

Taylor et al.

critical appraisal

pain and disability have

Data extraction and

and to investigate whether

third author if required.

lists

disability in patients with acute and persistent LBP,

authors with consensus by

hand-searched reference

course of pain and

(prognosis)

abstracts screened by two

analysis

CINAHL, EMBASE,

et al.27

literature on the clinical

and meta-

2012 Systematic review To systematically review the

√

evaluation greatly.

evaluation √

unlikely to impact economic

economic

Literature review. Title and

methodological quality but

for full

each stage

for sciatica

model

1950–2011 – MEDLINE,

studies and hence variable

n = 12

at least two authors at

(intervention)

2. Large number of included

review,



management strategies

analysis.

effectiveness of different

systematic

n = 270 for 1. Meta-analysis for cost

and considerations

observations

Methodological

economic

√


analysis and

√

assessment

bias



methods


28 databases, hand-

Inception – 2009,


Costa

Menezes

Search dates and information sources

effectiveness and cost-

To determine clinical

Objective

review, meta-

Lewis et al.50 2011 Systematic

Study design

Continued

TABLE 3.


25

Cantrill et al.

55

of Radiologists66

Canadian Association

Bussieres et al.54

Not stated

sources

Search dates and information

opinion

References listed, expert


testing

in adults with potentially

2012 Guideline

methodology not published

1. Guideline development

extraction and critical appraisal, expert consensus

MEDLINE InProcess, Cochrane, hand-searched reference lists

recommendations for prescribing short-acting opioids for adult ED patients conditions while attempting

with painful acute or chronic


2000–2011 – MEDLINE,

To provide evidence-based

recommendations.

1. No higher level

is not stated.

3. Number of included articles

recommendation.

of evidence and strength of

2. Used own system for levels

viewing.

n = 20

Not stated

on CAR website at date of

√

√

for LBP

working group

3. Aimed at chiropractic’s and

appropriate imaging studies

make decisions in regard to

To assist in helping physicians

Prepared by an expert advisory

EMBASE

appropriate use of diagnostic

Not stated

provided by clinicians,

decision making for the imaging for spinal disorders

emergency physicians.

references and reference

primary care providers in

consensus)

2012 Guideline

primary care but not

register, Google, cross

chiropractors and other

expert

separately to paper. 2. Hand-searched from web.

(Delphi)

Cochrane, National research

guidelines to assist

review and

1. Protocol published

assessment, expert consensus

Literature review, quality

MEDLINE (1966-),

diagnostic imaging practice

To develop evidence-based

care settings

report.

‘Summary’ via NGC

2. Only able to access

recommendation.



website, and Methodology

n = 385+

Not stated

included.

2. Small number of studies

documentation.

1. Nil supporting

and considerations

n=2

Methodological observations

Studies selected

disorders seen in primary

√

√

?

assessment

bias

Risk and

work-related low back

Searched in 2003–2006 –

group technique), pilot

expert consensus (nominal

CINAHL, EMBASE, PEDro

occupational medical care and disability management,

extraction, critical appraisal,

Online, Cochrane, TRIP,

practices for key areas of

To describe evidence-based best 1966–2010 – MEDLINE, EBM Literature review, data

requesting in EDs

appropriate pathology test

To provide guidance on

Objectives

(systematic

2008 Guideline

2011 Guideline

60

ACOEM

2013 Guideline

ACEM and RCPA53

Design

Year

Guideline characteristics

Reference

TABLE 4.



2012 Guideline

DeLitto et al.59

Daffner et al.

2012 Guideline

secondary sources

Colorado Workers’

consensus)

58

searched for primary and

are enforceable under the

expert

© 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine throughout

by two independent authors with consensus by third author if required, expert group review

treatment matched to LBP subgroup responder categories, treatments that

evidence to influence the

treatments that have

recurrence of LBP and

have evidence to prevent

stated, referenced

critical appraisal performed


Not specifically

CINAHL, Cochrane, hand-

√

n = 87

recommendations related to

Literature review including

√

literature and make

1966–2010 – MEDLINE,

(Delphi)

To describe peer-reviewed

of suspected spine trauma


Literature review with data appraisal, expert consensus

MEDLINE

consensus

the diagnosis and evaluation

of radiologic procedures in

To evaluate the appropriateness Date range not stated,

Procedure

Compensation Rules of

reference lists, hand-

Science, Cochrane, BMJ,

the treatment of LBP that

educational guidelines for

review and

n = 103

evidence and at least

1. Used own grading system.

recommendation.

2. Used own strengths of

Guideline Clearinghouse.

1. Published in National

throughout.

recommendations

3. Does not give strength of

System, not Australian.

Workers’ Compensation

2. Based on Colorado

injury.

not all relevant to acute

1. Very extensive guideline but

harms, costs or burdens).

benefits but no significant

moderate benefits (or small

by at least fair-quality throughout

recommended if supported

1. Interventions only

referenced

Not specifically

and considerations


peer review

√

Studies selected

stated,

√

assessment

bias

Risk and

consensus, multiple levels of

Literature review, expert panel


2006–2012 – PubMed, Web of Literature review, expert panel

(systematic

To provide advisory and

Cochrane and EMBASE

Inception – 2006, MEDLINE,

sources


Compensation57

2014 Guideline

settings

chronic LBP in primary care

management of acute and

evidence for evaluation and

To present the available

prescribed opioid analgesics

abuse and overdose of

frequency of adverse events,

to address the increasing

Objectives

Workers’

Colorado Division of

algorithm

2007 Guideline and

Chou et al.56

Design

Year

Continued

Reference

TABLE 4.


27

integration of acute and

pathway to improve the

To report on the development

pathway

2010 Guideline

Staiger et al.68

trauma patients

spinal injuries in blunt

screening for thoracolumbar

recommendations on the

To provide evidence-based

of a multidisciplinary care

2013 Guideline

Sixta et al.67

management in the ED

care and optimise pain

To implement evidence-based

practice guidelines

and care

2011 Guideline

NICS

64

evidence-based clinical

implementation of common

development and

LBP through the

the management of acute

To achieve significant,

behalf of their patients

appraisal, expert consensus

Not described



consensus

Literature review, expert panel



2005–2011 – PubMed, hand-

development process

Specific methodology not stated NHMRC guideline

Inception – 2011, PubMed

?

√

√

Not stated

n = 21

n=2

published.

2. Evaluation of pathway not

documentation.

1. No supporting

recommendation.




articles.

2. Small number of included

now rescinded).

NHMRC, 2003 (which is

musculoskeletal pain’ by

management of acute

‘Evidence-based

1. Key messages guided by

is not stated.


recommendation.




Radiologists accessed.

New Zealand College of

LBP imaging referrals on

Royal Australian and

World of Science

judicious decisions regarding

Not stated

development report by

PubMed, TRIP database,

disciplines on how to make

Literature review with critical

abstract. Module

1. Taken from conference

groups, piloted

n = 19

and considerations


MEDLINE, PreMedline,

√

Studies selected

practitioners from all

√

assessment

bias

Risk and

appraisal, expert writing

Literature review, critical


CINAHL, EMBASE,

Inception – 2012, All EBM,

sources


undergraduates and medical

To educate medical

chronic LBP and disability

progression from acute to

Objectives

Consortium63

2014 Guideline

2014 Guideline

Design

measurable improvements in

61

Year

Improvement

Michigan Quality

Goergen and Grimm

Reference

TABLE 4. Continued




√, yes; LBP, low back pain.

Institute69

recommendation.

CINAHL, hand-searched

compensation conditions reference lists


MD Consult, eMedicine,

treatment of workers’

is not stated.


report.

website, and Methodology

‘Summary’ via NGC

3. Only able to access


expert panel



Guideline Clearinghouse,

Not stated

recommendation.




for the assessment and

√

n = 11




Literature review with critical

Cochrane Library, National

1993–2014 – MEDLINE,

2009–2014 – PubMed

to recommendations.

by-step decision protocols

To offer evidence-based step-

quality

Industries62

2013 Guideline

syndrome is of the highest

Labor and

To help ensure diagnosis and

Science

CINAHL, EMBASE, Web of

CRD Databases, AMED,

articles

development group

Google, Chartered Society of

non-specific LBP Physiotherapy, Cochrane,

other included 2. Lists level of evidence next

consensus by guideline

group.

1. Generated from Canadian

International Network,

n = 8 ‘seed’

is not stated.


and considerations


about care of patients with

treatment of cauda equina

Work Loss Data

Studies selected

guidelines +

√

√

assessment

bias

Risk and




Infobase, NGC Guidelines

1996–2010 – PubMed, CMA

sources


evidence-informed decisions

To help clinicians make

continuity of care

patients and to ensure

community care for LBP

Objectives

Department of

Washington State

2014 Guideline

2011 Guideline

Practice65

Toward Optimized

Design

Year

Reference

TABLE 4. Continued


29

30

Imaging & Diagnostic Tests (n = 16)

Initial Assessment (n = 21)

K STRUDWICK ET AL.

Screen and assess for ‘red flags’35, 38, 40, 41, 43-45, 49, 52, 54, 56, 57, 60, 62-65, 69 • Neurological signs: • loss of bladder/bowel function (urinary retention, incontinence, absent anal sphincter tone, patulous anus, reduced/absent bulbocavernosus reflex), sexual dysfunction, saddle anaesthesia. • bilateral numbness or weakness in the lower limbs, gait disturbance or ataxia. • unilateral multiple nerve root distribution of numbness and weakness. • Risk factors or signs of infection, systemic disease or malignancy: persistent fever, night sweats, rash, abnormal laboratory exams, intravenous drug use, recent bacterial infection, immunocompromised, history of malignancy or unexplained weight loss, nocturnal pain, 50 years of age, non-mechanical pain. • History of trauma with any focal spinal tenderness on palpation, contusion or abrasion, altered consciousness or distracting injury. • Medication effects (i.e. corticosteroid or anticoagulant use). • Persistent or intractable pain not responding to appropriate treatment.

Cauda equina and cord injury Fracture Cancer Infection Systemic disease AAA Failed surgical fusion

Identify ‘yellow flags’46, 49, 56, 57, 59, 63, 65, 68 • E.g. past history of LBP, fear of re-injury, depression / history of mental health issues, social and emotional stresses, low job satisfaction.

Psychosocial risk factors to predict prognosis

Exclude serious conditions

Imaging only indicated in trauma or red flags 41, 46, 49, 54, 56-58, 60-63, 66, 67, 69 • X-ray indicated in suspected vertebral compression fracture. • MRI indicated in presence of neurological abnormalities or suspected malignancy. • CT indicated in known high-velocity trauma, poor visualization of vertebral fracture on x-ray, or if MRI contraindicated. Pathology tests not routinely recommended unless suspected malignancy, infection, or requiring admission.41, 53, 56, 63, 65

Referrals and Follow-up (n = 14)

Treatment (n = 19)

Diagnosis 41, 46, 48, 54, 56, 57, 59, 65 • consider grouping patients into either non-specific LBP, back pain potentially with associated radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. • do not provide a definitive cause for initial episodes of LBP. Pain relief is an important aspect of ED management of LBP • Pharmacological management 33, 34, 36, 37, 41, 50, 55-58, 60, 63-65, 69 • First-line analgesics should include paracetamol or ibuprofen (with consideration of their side-effect profiles in relation to the patient and their adequacy in relieving pain). • Avoid the use of opioids unless in some cases with severe pain; if prescribed, short-acting doses, for a limited duration, with consideration of the risk for misuse and abuse. • Non-pharmacological management 39, 41, 49, 56, 57, 59, 60, 63-65, 69 • Education and reassurance: good prognosis, avoid bed rest, advice for “self care”, stay active and continue with normal activities; return to ED if ‘red flags’ arise. • Heat and/or cold packs, according to availability and patient preference. • Exercise recommendations: increase physical activity with limited focus on specific exercise prescription.

Referrals 27, 41, 42, 50, 51, 56, 57, 59, 63-65, 68, 69 • GP: Patients should be encouraged to follow-up with their GP for non-specific LBP and non-serious conditions. • Specialist: Recommended in the presence of serious pathology or red flags. • Physiotherapy: Those patients unlikely to improve with aforementioned pain relief strategies may benefit from ongoing non-pharmacological treatments with a Physiotherapist. Patients with ‘yellow flags’ 46, 56, 57, 60, 63 • May benefit from early referral to psychology if psychosocial risk factors are present. • Also consider referral to physiotherapy or other allied health. Chronic LBP 56, 63, 65, 68 • Refer for community health involvement or referral to a multidisciplinary pain management team. Return to Work 57, 60, 63, 65, 69 • An early return to work, even if on modified duties, promotes better outcomes for patients and is associated with less disability.

Figure 2. Existing evidence for LBP across the clinical cycle of care in ED (n = 38). © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

31


following statement, ‘Don’t perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain’.17 Convincing evidence to support this recommendation includes the inconsistent correlation between findings on imaging and patientreported symptoms,70 the lack of association with improved outcomes22 and the poorer subjective sense of well-being reported by patients who receive imaging.71 Furthermore, in the absence of neurological deficits, suspected malignancy, infection or trauma, imaging is not necessary for effective management56,72 and it may increase the likelihood of unnecessary surgery and inefficacious costly interventions.73 One reviewed article recommended a number of pathology tests;53 however, it should be noted that these are only indicated to exclude red flags, and it should not be included in the routine investigation and management of LBP in ED. It is likely that the overuse of imaging and pathology testing is driven by the pressure to exclude serious pathology, to make an accurate diagnosis and to fulfil patient expectations. Although understandable, the benefits of avoiding unnecessary diagnostic testing are clear, and clinicians must be encouraged to comply with evidence-based practice.

Opioids The prescription of opioids is currently very topical due to the dramatic increase in use, the significant variation in opioid-prescribing patterns in ED, the increase in opioidrelated harms such as hospitalisations and deaths due to accidental poisoning and the corresponding costs to the Australian government.74,75 Analysis of opioid-prescribing patterns in EDs suggest an increase in the use of opioids in place of simple analgesics,20,74 an increasing trend of opioids prescribing on discharge from EDs21 and significant variations between clinicians in prescribing opioids specifically for LBP in ED.76 The evidence in this rapid review clearly supports a reduction in the use of opioids, with some articles recommending reserving opioid use for

severe pain, or recommended against opioid use due to questionable efficacy and increased adverse events.50,55–57,60,63–65 Although early prescription of opioids in this setting may reduce pain severity more rapidly, research shows that this is associated with longer term opioid use, increased costs and increased risk of adverse events.23 For this reason, opioid prescription in ED must be reserved for the most severe cases of LBP, where simple analgesics have been insufficient.

Psychosocial factors In the past few decades, psychosocial factors known as ‘yellow flags’ have emerged as the most important consideration to identify those at risk of developing chronic pain.77,78 This view was supported by the reviewed articles, which promoted psychosocial screening during assessment. Disappointingly, there was little suggestion of what action should be taken when these factors are identified in the acute setting and some might argue that as these factors do not pose an immediate threat to well-being, they are not a priority for management in the ED. It is acknowledged that ED clinicians are often under significant time pressure, and psychosocial factors can be complex and can take some time to properly assess and understand. However, given the known personal, societal and economic burden of chronic LBP1 and the potential for early intervention to reduce this burden,77–79 proactive strategies should be encouraged in the ED. In the absence of clear evidence for the management of ‘yellow flags’ in the ED, the authors recommend that clinicians make use of readily available, quick, easy and reliable psychosocial screening tools, such as the Örebro Musculoskeletal Pain Screening Questionnaire80 or the STarT Back Tool,79 to identify patients at high risk for a poor recovery and to aid in the initial decision making for referrals and follow up. While in the ED, high-risk patients should be given appropriate reassurance, education on simple self-management strategies and

encouragement to resume normal activity. These patients should then be referred on for early psychological intervention and/or active physiotherapy management where possible,77,78 coordinated with their regular GP.

Early return to work Evidence from the rapid review supports that an early return to work for patients with LBP, even if on modified duties, promotes better outcomes for patients and is associated with less disability. Careful consideration should be made to the issuing of medical certificates, as there is evidence to suggest that medical certificates recommending a complete absence from work creates major challenges later in terms of return to work, labour force productivity, the viability of the compensation system and long-term social and economic development.81 Although it may not be the ED’s responsibility to ensure that systems exist in the work place to facilitate a return to work, it is the ED’s role to refer patients appropriately for early co-ordinated care in the community so that a return to work plan is enacted and extended leave is avoided.82 Evidence suggests there is significant variability in duration of work absence in people with LBP who eventually do return to work, ranging from 5–61 days, which further highlights the importance of early community follow up in order to capture the higher risk patients.83 It is also essential to commence patient education on return to work options and outline the health consequences of remaining off work, which include the adverse impacts on mental and physical health, high social and economic costs and possible permanent work disability.

Limitations As described in the corresponding methodology paper,31 there are limitations with conducting a rapid review. Strict inclusion and exclusion criteria were used in order to curtail the duration of the review process, which may have introduced the risk of bias; however, the limitations in this


32

K STRUDWICK ET AL.

instance also serve to provide the best and most recent evidence. For this rapid review on LBP, primary articles of a lower level of evidence were included when the topic was related to red flag conditions in which prospective methodology would be both unsafe and unethical. Similarly, while systematic database searches were undertaken, a systematic and exhaustive handsearch was not, which may mean that some relevant articles were not included.

aspects of the work. AB contributed to the conception and design of the work, drafting and revising, final approval of the version to be published and agreement to be accountable for all aspects of the work.

Competing interests

This rapid review serves to provide a summary of the most recent and highest quality evidence supporting best practice for the assessment, use of diagnostic testing, pharmacological and non-pharmacological management and discharge considerations and advice for patients who present to ED with LBP. There is abundant and strong evidence supporting the exclusion of serious pathology by screening for ‘red flags’, more targeted use of imaging and pharmacological management, the identification of psychosocial risk factors from ‘yellow flags’ with associated appropriate discharge planning and promoting an early return to work and functioning following the ED visit. LBP is a common presentation to all EDs and clinicians should aim to adhere to the evidence base and best practice management presented in this review in order to improve patient outcomes and utilise resources more effectively.

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Acknowledgements Funding by the Emergency Medicine Foundation assisted with the completion of these rapid reviews. The research team acknowledge the contribution of Mr Joseph Danicic.

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Author contributions KS, MM, MM-K and TR contributed to the conception and design of the work, acquisition, analysis and interpretation of data for the work, drafting and revising, final approval of the version to be published and agreement to be accountable for all

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AB is a section editor for Emergency Medicine Australasia.

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Supporting information Additional supporting information may be found in the online version of this article at the publisher’s web site: Appendix S1. Specific search terms for each database. Appendix S2. Summary of the evidence across the clinical cycle of care for LBP.
