Study Points

Low Back Pain

Course #94101 - $75 • 15 Hours/Credits

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  1. The prevalence of low back pain (LBP) is greater in

    EPIDEMIOLOGY

    In 2017, 28% of adults reported LBP in the past three months. The prevalence was slightly greater for women (30.2%) than men (25.7%) and among those with lower educational attainment (33.3%), defined as non-high school graduates, compared with those with a Bachelor's degree or higher (23.5%) [8]. Persons older than 75 years of age were more likely to report past-three-month LBP (33.5%), though there is almost identical reporting among adults 65 to 74 years of age and 45 to 64 years of age (32.7% and 32.6%, respectively). This is followed by adults 18 to 44 years of age, of whom 23.8%reported LBP. Lower family income (33.7% in ≤$35,000, 24.1% in ≥$100,000) and poverty status (35.6% in poor, 26.3% in non-poor) also appear to be factors, likely related (at least in part) to the type of work typical of the group [8].

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  2. What percentage of annual healthcare provider visits in the United States are related to LBP?

    EPIDEMIOLOGY

    An estimated 12% to 15% of annual healthcare provider visits in the United States are related to LBP [14]. The estimated 8% of patients whose LBP is chronic and debilitating account for 50% of direct medical expenditures for back pain, estimated at $85 billion [11,15]. Together with costs from decreased wages and lost productivity, the total is $100 to $200 billion [16].

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  3. All of the following are modifiable risk factors for developing LBP, EXCEPT:

    RISK AND PROGNOSTIC FACTORS

    Risk factors for developing LBP can be generally categorized as nonmodifiable, such as old age, female sex, poverty, and lower education level, and modifiable, including higher body mass index (BMI), smoking, lower perceived general health status, physical activity (e.g., bending, lifting, twisting), repetitive tasks, job dissatisfaction, and depression. The greatest contributors to LBP episodes are single-event or repetitive exposures to mechanical stress and age-related degenerative spinal changes. With chronic LBP, mechanical and biophysiologic factors play a minimal secondary role to the primary contribution from psychosocial factors [21].

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  4. Which of the following statements concerning the relationship between obesity and LBP is TRUE?

    RISK AND PROGNOSTIC FACTORS

    Obesity contributes to factors that promote the development of some pain states, including LBP. Persons with LBP exhibit abnormal movement patterns that include gait and postural dysfunction, increased thoracolumbar stiffness, decreased proprioception, and alteration in abdominal and extensor muscle activation. Pain can result from joint or structural damage due to aberrant or increased biomechanical forces over time. These processes are accelerated by obesity, and regardless of age, obesity contributes to chronic LBP, mobility impairment, and ultimately physical disability. The relationship between obesity-related LBP and functional decline is mediated by skeletal muscle strength deterioration, systemic inflammation, and psychosocial characteristics, such as pain catastrophizing, kinesiophobia, and depression. Morbid obesity greatly alters biomechanical forces on lower back tissues to accelerate the development of chronic back pain syndromes [23].

    Overweight and obesity are risk factors for both lumbar radicular pain and sciatica, and a direct relationship exists between BMI and low back pathology and pain in men and women. A meta-analysis of 28 studies found overweight and obesity were associated with lumbar radicular pain, increased the risk of hospitalization for sciatica, and increased the risk of lumbar disk herniation surgery. These associations were similar for men and women [24]. Clarification of whether or not LBP precedes obesity was addressed by an 11-year longitudinal study of 25,450 individuals. Among those without LBP at baseline, a significant positive association was found between BMI ≥30 and risk of LBP in men and women, and risk of chronic LBP recurrence in women, but not men. In contrast, LBP at baseline had little effect on later changes in BMI [25].

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  5. A study of primary care patients with persistent, nonspecific treatment-refractory musculoskeletal pain found highly prevalent deficiencies in

    RISK AND PROGNOSTIC FACTORS

    Interest in the role of vitamin D deficiency in pain was spurred by findings of highly prevalent vitamin D deficiency among primary care patients with persistent, nonspecific musculoskeletal pain refractory to pharmacotherapy [30]. Pain patients with vitamin D deficiency also require twice the opioid dosing for substantially greater duration versus non-deficient patients [31].

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  6. Which of the following is a psychosocial factor for developing LBP chronicity?

    RISK AND PROGNOSTIC FACTORS

    Psychosocial factors for developing chronicity include [35,36,37,38]:

    • Negative belief that pain is harmful or potentially severely disabling

    • High levels of "fear avoidance" behaviors

    • Poor or maladaptive coping strategies

    • Expectation that passive, rather than active, treatment is beneficial

    • Excessive focus on pain

    • High emotional distress levels

    • Depressed mood, low morale, and social withdrawal

    • Resistance to change

    • Low self-efficacy

    • Family reinforcement of illness behavior

    • Concurrent social or financial problems

    • Troubled childhood (e.g., abuse, parental death, addiction)

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  7. With implantable neuromodulation devices and spinal cord stimulators, psychologic screening of potential candidates has resulted in

    RISK AND PROGNOSTIC FACTORS

    Psychosocial factors of poor outcomes in lumbar surgery include mood disorders, unresolved litigation or claims, history of child abuse, and maladaptive pain coping or beliefs [50]. The predictive power of these variables on surgical outcomes surpasses radiographic findings, neurologic signs, and other medical indices. Psychologic screening of implantable neuromodulation device candidates increased successful outcomes from 33% to 70% and is now standard protocol. In outcome studies of spinal cord stimulation in patients with failed back surgery syndrome, inadequate psychologic screening was associated with 50% short-term and 35% long-term benefit, while adequate psychologic screening led to 85% short-term and 60% long-term success rates [50].

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  8. Which of the following descriptions of the clinical course of patients with acute LBP presenting to primary care is FALSE?

    CLINICAL COURSE

    The most commonly cited short-term prognosis data state that most patients with acute LBP recover in a matter of weeks with limited or no therapy; specifically, 60% to 70% of patients recover by 6 weeks and 80% to 90% by 12 weeks [21,53]. These early prognosis projections are at variance with data derived from a study of patients presenting to primary care providers with nonspecific acute LBP [54]. This study found that 33% of patients experienced spontaneous resolution by 3 months, 57% still had problematic pain at 6 months, and 65% reported some degree of pain at 12 months after onset. Of patients with persistent pain at 3 months, only 1% to 7% experienced recovery 3 to 12 months from onset [54].

    This study confirmed the impression of experienced clinicians that the clinical course of most patients with acute LBP in a primary care practice does not conform to the conventional notion that nonspecific acute LBP has a favorable natural history and resolves within several weeks [55]. The reason for this discrepancy may be that most patients who develop acute LBP with favorable prognosis do not seek medical care [383]. In those seeking care, pain and disability can be ongoing and recurrent pain episodes may be common. Up to 70% of patients who initially improve following medical care experience recurring pain episodes [55].

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  9. Chronic LBP

    PATHOPHYSIOLOGY

    Chronic LBP reflects the uncoupling of pain from its original peripheral origin; it is a distinct disease process rather than a symptom [56]. Likewise, the extent of peripheral tissue damage is no longer viewed as the sole determinant of pain presence, severity, and duration. Chronic LBP is now understood as a multifactorial entity determined by inputs from numerous and complex electrochemical, biocellular, cognitive, and emotional factors. The broad range of individual pain responses to stimuli reflects the highly individualistic phenomenon of pain [58,59].

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  10. Nociceptive pain is

    PATHOPHYSIOLOGY

    Pain is broadly categorized as nociceptive, inflammatory, neuropathic, or centralized. Nociceptive and inflammatory pain overlap and result from peripheral tissue injury, damage, or disease. Both are protective and adaptive for survival when acute but are considered pathologic when pain continues after peripheral tissue healing. Neuropathic pain results from injury, damage, or disease to peripheral nervous structures or sensory pathways in the spinal cord or brain, and regardless of duration, it is pathologic. Centralized pain reflects aberrant function in various CNS pathways and is now thought to account for fibromyalgia, irritable bowel syndrome, and other chronic conditions [60,61]. Centralized pain is not associated with any common back pain condition or peripheral tissue injury and therefore is not discussed further in this course. These pain subcategories are not distinct and do not account for individual variations. Many cases of chronic LBP represent a mixture of pain subcategories [60].

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  11. Which of the following statements regarding the pathophysiology of pain is TRUE?

    PATHOPHYSIOLOGY

    Neuroscience findings have refuted previous assumptions of back pain pathophysiology. Healthcare providers should understand these changes in how pain is conceptualized, because the management of LBP can hinge on proper matching of pain pathophysiology and treatment mechanism. Effective chronic LBP management requires replacement of several entrenched paradigms with the following [62]:

    • Pain is not an accurate measure of tissue state.

    • Pain is modulated by multiple factors across somatic, psychologic, and social domains.

    • The relationship between pain and tissue state further weakens as pain persists.

    • Pain represents a conscious correlate of the implicit perception that tissue is in danger, not the actual tissue state and not the actual threat to tissue.

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  12. The greatest contribution to the initiation of central sensitization comes from activation of which receptor network?

    PATHOPHYSIOLOGY

    The process of central sensitization begins when post-synaptic terminals of ascending neurons in the dorsal horn become altered by nociceptive barrage. The surge of excitatory signaling transmitters and modulators (e.g., glutamate, substance P, CGRP, BDNF) bind to receptors on spinal cord neurons and activate intracellular signaling pathways, which phosphorylate membrane channels of the glutamate receptors N-methyl-D-aspartate receptor (NMDA) and AMPA. This lowers the threshold and opening characteristics of the channels and results is increased CNS neuron excitation, substantial increase in pain transmission, and the development of central sensitization. The greatest contribution to initiation of central sensitization comes from post-synaptic NMDA receptor activation in the spinal cord and, subsequently, in the thalamus, limbic system, and cerebral cortex [82,83,84,85].

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  13. Pain catastrophizing refers to

    PATHOPHYSIOLOGY

    The contribution of psychologic factors to chronic LBP is essential to consider, as discussed. Depressive symptoms, pain catastrophizing, and fear avoidance in LBP are thought to enhance pain facilitatory pathways in the CNS, resulting in sensitization of dorsal horn spinal cord neurons and the development of exaggerated pain perception [81]. Pain catastrophizing refers to exaggerated negative thoughts and emotions surrounding pain, and this pain coping style significantly contributes to variability in pain perception. Catastrophizing adversely impacts pain by inducing an aroused, negative emotional state that worsens pain and fosters helplessness that decreases adaptive pain responding. This promotes the alteration of neural processes related to pain attention and response. People with trauma histories are more likely to catastrophize, suggesting that catastrophizing may mediate the effects of earlier psychologic stress on pain [57].

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  14. Narrowing of the central or lateral recesses of the spinal canal and/or the neural foramina is

    PATHOPHYSIOLOGY

    Lumbar spinal stenosis: Narrowing of the central or lateral recesses of the spinal canal and/or the neural foramina [119].

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  15. All of the following potentially contribute to failed back surgery syndrome, EXCEPT:

    PATHOPHYSIOLOGY

    Failed back surgery syndrome: Failed back surgery syndrome is not a single entity, but a complex syndrome with multiple potential causalities, including structural pathogenesis, improper surgical technique, altered biomechanics, and/or central sensitization [52,115].

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  16. Which of the following statements regarding the etiology of LBP is TRUE?

    ASSESSMENT AND DIAGNOSIS

    Roughly 85% of LBP lacks apparent etiology and is termed nonspecific. Clinical practice guidelines for LBP recommend assessment of new patients by triage, with LBP grouped as nonspecific, potentially serious, associated with radiculopathy or spinal stenosis. Several LBP syndromes and conditions have been studied with radiographic imaging (usually MRI) in an effort to establish causality. These include lumbago, myofascial syndrome, muscle spasm, mechanical LBP, lumbar strain, facet joint dysfunction, and bulging lumbar disk. No specific, defining radiographic abnormality has been identified. These conditions, often presenting as acute LBP, are considered vague and nonspecific, and imaging studies are of limited value in establishing the cause, directing therapy, or predicting the clinical course. As an example, many persons with lumbar spine degenerative change or disk protrusion evident on MRI are not experiencing LBP. Thus, some abnormalities detected by MRI are nonspecific and of uncertain relevance to the patient's complaint. A diagnostic imaging workup does not improve clinical outcomes in most patients with acute LBP [42].

    While most LBP cases lack serious pathology, each case is deserving of a careful clinical assessment for symptoms and signs (termed "red flags") associated with serious pathology. Patients with red flags are redirected to urgent diagnostic workup and intervention. Patients without red flags should be assessed for the possibility of radiculopathy and lumbar spinal stenosis, which, with diagnostic confirmation, may require early specialist referral. LBP may be classified as nonspecific when there are no red-flag indicators, radiculopathy, or suspicion of lumbar spinal stenosis. Once red flag indicators are excluded, all patients should be evaluated for risk factors of poor prognosis and chronicity ("yellow flags"). Patients with yellow flags should receive psychosocial intervention to minimize chronification and disability. Patients with painful recurrence following LBP remission require assessment of new-onset LBP [37,47,115,116,129].

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  17. Which of the following is considered a "red flag" for possible malignancy when assessing the patient with LBP?

    ASSESSMENT AND DIAGNOSIS

    RED FLAG ASSESSMENT IN PATIENTS WITH LOW BACK PAIN

    Possible EtiologyRed Flags
    Malignancy
    History of or current cancer diagnosis
    Systemically unwell
    Unexplained weight loss in the past six months
    Constant, progressive, nonmechanical pain
    Altered sensation from trunk down
    Vertebral fracture
    Age older than 70 years
    Significant age-relative trauma
    Long-term corticosteroid use
    Altered sensation from trunk down
    Pain worse with flexion, pulling up from supine to sitting position, and from sitting to standing
    Cauda equina syndrome
    Acute-onset urinary retention
    Loss of anal sphincter tone or fecal incontinence
    Saddle anesthesia
    Widespread (more than one nerve root) or progressive motor weakness in legs
    Gait disturbances
    Vertebral infection
    Systemically unwell
    Constant, progressive, nonmechanical pain
    Recent bacterial infection or spinal region wound
    Intravenous drug abuse
    Immunosuppression from steroids, transplant drugs, or HIV
    Altered sensation from trunk down
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  18. In patients with LBP, age older than 70 years, significant age-relative trauma, and long-term corticosteroid use are red flags for

    ASSESSMENT AND DIAGNOSIS

    RED FLAG ASSESSMENT IN PATIENTS WITH LOW BACK PAIN

    Possible EtiologyRed Flags
    Malignancy
    History of or current cancer diagnosis
    Systemically unwell
    Unexplained weight loss in the past six months
    Constant, progressive, nonmechanical pain
    Altered sensation from trunk down
    Vertebral fracture
    Age older than 70 years
    Significant age-relative trauma
    Long-term corticosteroid use
    Altered sensation from trunk down
    Pain worse with flexion, pulling up from supine to sitting position, and from sitting to standing
    Cauda equina syndrome
    Acute-onset urinary retention
    Loss of anal sphincter tone or fecal incontinence
    Saddle anesthesia
    Widespread (more than one nerve root) or progressive motor weakness in legs
    Gait disturbances
    Vertebral infection
    Systemically unwell
    Constant, progressive, nonmechanical pain
    Recent bacterial infection or spinal region wound
    Intravenous drug abuse
    Immunosuppression from steroids, transplant drugs, or HIV
    Altered sensation from trunk down
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  19. All of the following are physical signs that may indicate an underlying non-organic or psychologic basis for LBP, EXCEPT:

    ASSESSMENT AND DIAGNOSIS

    In addition, there is a group of physical signs that may indicate an underlying non-organic or psychologic basis for LBP. This group of signs, termed Waddell signs, includes [37]:

    • Non-anatomic superficial tenderness

    • Positive simulation tests (i.e., pain from axial loading and en bloc rotation)

    • Non-positive tests with distraction (e.g., no pain with full knee extension while seated, but supine straight leg raise is markedly positive)

    • Non-anatomic motor or sensory loss

    • Verbal over-reaction or exaggerated body language

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  20. Why might grouping patients with chronic LBP into nonspecific, specific, and radicular subgroups be problematic?

    ASSESSMENT AND DIAGNOSIS

    Most guidelines for chronic LBP recommend a diagnostic triage to group patients by nonspecific, specific, and radicular LBP. This differentiation is not straightforward; patients with disk herniation are either grouped as specific with radicular pain or nonspecific with degenerative disk disease without radicular pain. Also, the definition of radicular pain is inconsistent.

    To address these and other limitations with the triage approach, an alternative classification system for chronic LBP was developed to differentiate patients with pain of nociceptive, peripheral neuropathic, or central sensitization origin using a mechanism-based classification of LBP signs and symptoms [147]. The system was developed and validated using data from 464 patients with a range of back and leg symptoms; the majority had pain duration longer than three months (chronic). Factors with the greatest predictive ability for each of the three back pain mechanisms include [147,148,149]:

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  21. Which of the following factors is predictive of peripheral neuropathic pain?

    ASSESSMENT AND DIAGNOSIS

    To address these and other limitations with the triage approach, an alternative classification system for chronic LBP was developed to differentiate patients with pain of nociceptive, peripheral neuropathic, or central sensitization origin using a mechanism-based classification of LBP signs and symptoms [147]. The system was developed and validated using data from 464 patients with a range of back and leg symptoms; the majority had pain duration longer than three months (chronic). Factors with the greatest predictive ability for each of the three back pain mechanisms include [147,148,149]:

    Nociceptive Pain

    • Clear and proportionate mechanical/anatomical nature to aggravating and easing factors

    • Usually intermittent and sharp with movement or mechanical provocation

    • At rest, tends to be a constant dull ache or throbbing pain

    • The absence of dysesthesia, disturbed sleep, antalgic postures, and pain of a burning, shooting, or electric shock-like quality

    Peripheral Neuropathic Pain

    • Pain referred in a dermatomal or cutaneous distribution

    • History of nerve injury, pathology, or mechanical compromise

    • Pain or symptom provocation with mechanical or movement tests that move, load, or compress neural tissue

    Central Sensitization

    • Disproportionate, nonmechanical, unpredictable pattern of pain provocation by multiple nonspecific aggravating or easing factors

    • Pain disproportionate to the extent of injury or pathology

    • Strongly associated with maladaptive psychosocial factors, such as negative emotions, poor self-efficacy, and maladaptive pain beliefs and behaviors

    • Diffuse non-anatomic areas of pain tenderness on palpation

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  22. Which of the following is a self-care recommendation for patients with nonspecific acute LBP?

    TREATMENT OPTIONS

    When a patient presents with LBP of less than four to six weeks, the mainstays of management are patient education, reassurance, and advice on self-management. Patients should be assured that prognosis is generally good, often resolving with little intervention. Self-care recommendations include [1,36,37,47,129,131]:

    • Stay active, avoid bed rest, and return to normal activities as tolerated.

    • Avoid twisting and bending.

    • Use heat or ice packs, whichever provides the most comfort.

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  23. The pharmacotherapy with the strongest evidence for myofascial pain is

    TREATMENT OPTIONS

    The pharmacotherapy with the strongest evidence for myofascial pain is benzodiazepines combined with ibuprofen or amitriptyline (not as monotherapy) [122,161,162]. Second-line options include topical methyl salicylate, menthol, and diclofenac patch. Although antiepileptics, antidepressants, muscle relaxants, NSAIDs, and tramadol are widely used, they are largely lacking evaluation.

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  24. Which of the following is recommended as pharmacotherapy for elderly patients with chronic LBP?

    TREATMENT OPTIONS

    Acetaminophen is recommended for initial and ongoing treatment of persistent musculoskeletal back pain in older patients [165]. There is a strong recommendation against the use of NSAIDs, amitriptyline, and imipramine due to the possible adverse effects. Systemic corticosteroids should only be used in pain from systemic inflammatory disease or metastatic bone pain.

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  25. Which of the following is true of therapeutic pain neuroscience education?

    TREATMENT OPTIONS

    With central sensitization present in chronic LBP, the brain produces pain, fatigue, and other "warning signs" of tissue harm without actual tissue damage or nociception. Explaining the mechanism of central sensitization with evidence from neuroscience to patients with chronic LBP is a therapeutic strategy known as therapeutic pain neuroscience education or TPNE [93,94].

    TPNE helps patients with chronic pain understand their pain and make sense of the lack of objective biomarkers or imaging findings. A main goal is changing pain beliefs through the reconceptualization pain. This involves patient knowledge that pain persists without tissue damage, is disproportionate to tissue damage and/or that tissue damage (and nociception) does not by itself result in pain. The distinction between "hurting versus harming" is addressed [93,94].

    To reconceptualize pain and convince patients that CNS hypersensitivity, rather than tissue damage, is the likely cause of pain symptoms, TPNE is delivered in two to three sessions over two to three weeks. Potential patient misunderstanding of being told the pain is "all in their head" can be prevented by front-end coverage of pain neurophysiology and chronic pain, before discussing potential sustaining factors such as emotions, stress, illness perceptions, pain cognitions, and pain behavior [170].

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  26. What is the goal of cognitive-behavioral therapy in the treatment of chronic LBP?

    TREATMENT OPTIONS

    Interventions that use CBT include creative visualization, imagery, progressive muscle relaxation techniques, and problem-solving techniques. The goal of CBT is to promote patient understanding, acceptance, and self-management of chronic LBP through the development of adaptive coping behaviors and strategies, which eventually empowers the patient. CBT is effective for subacute and chronic LBP, and there is moderate-to-strong evidence for CBT use early in recovery in patients with specific biopsychosocial issues. Strong evidence indicates that CBT should be used in most patients with nonspecific LBP lasting longer than 12 weeks. Comparable outcomes have been found between fear-avoidance training and spinal fusion in chronic LBP. CBT is cost effective, adds 20% efficacy to usual rehabilitation, and reduces the duration of recurrence [42,189,190].

    Studies have identified core brain regions that mediate effective cognitive interventions. These include increased rostral anterior cingulate cortex activation and decreased dorsal anterior cingulate cortex activation with cognitive distraction; involvement of the ventral lateral prefrontal cortex, mid-cingulate cortex, thalamus, amygdala, and post-central gyrus with cognitive reappraisal; and correlation of right anterolateral prefrontal cortex and the dorsal anterior cingulate cortex activation with increased self-control over pain [191,192,193].

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  27. A patient with chronic LBP who scores 3 on the Primary Care-PTSD Screen should be referred to

    TREATMENT OPTIONS

    BIOPSYCHOSOCIAL ASSESSMENT AND REFERRAL OF PATIENTS WITH CHRONIC LOW BACK PAIN

    DomainInstrumentMeasurement-Based ScoreStep Care Referral
    Pain intensityIntensity numerical rating scale (1–10)Score ≥7 without diagnosis/planPain specialist
    Pain interferenceInterference numerical rating scale (1–10)Score >4Physiatry, occupational therapy, and/or physical therapy or vocational rehabilitation
    MoodPHQ-4, PHQ-9, or PC-PTSDPHQ-4 score ≥6 or PC-PTSD score ≥3aBehavioral health specialist
    Sleep qualitySTOP-BANGSTOP-BANG score ≥3, high morphine equivalent dose, or the use of opioids and sedativesSleep specialist
    Risk of opioid misuseORTORT score ≥8, more than four minor urinary drug test aberrancies, or any serious aberranciesAddiction specialist
    ORT = Opioid Risk Tool, PC-PTSD = Primary Care-PTSD Screen, PHQ = Patient Health Questionnaire, STOP-BANG = sleep apnea questionnaire.
    aBased on DSM-V diagnostic criteria for PTSD. If using DSM-5 criteria, >3 is considered optimally sensitive and >4 is considered optimally efficient.
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  28. Which of the following is a core component of multidisciplinary pain programs?

    TREATMENT OPTIONS

    Multidisciplinary pain programs are used for chronic LBP with the goal of restoring and improving physical and emotional functioning and quality of life. In contrast to other pain programs, multidisciplinary pain programs provide interdisciplinary care, with collaboration by providers from different program components to develop and implement patient care. Core components of multidisciplinary pain programs are medical and behavioral therapy, physical reconditioning, and education; adjunctive modalities can be added. Multidisciplinary pain programs are often viewed as the last resort for intractable pain, and many enrolled patients have exhausted most other non-invasive options. However, they may be considered earlier in the disease course. Multidisciplinary pain programs may improve chronic LBP outcomes by simultaneously addressing multiple contributing factors to chronic pain [201]. These programs cause few if any adverse effects, in contrast to surgery or long-term opioid therapy [202]. The biopsychosocial model of chronic pain (the theoretical basis of multidisciplinary pain programs) describes psychosocial factors as part of a complex system with dynamic and reciprocal inter-relationships between biologic, psychologic, and sociocultural factors that shape patient pain experience and therapeutic response [203].

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  29. Research suggests that acupuncture benefit in chronic LBP is mediated, at least in part, by

    TREATMENT OPTIONS

    Acupuncture is a Chinese medicine technique whereby needles are slightly inserted in particular points on the body to stimulate energy fields and meridians. There is now greater understanding of the mechanisms that mediate successful acupuncture therapy, specifically stimulation of the fascia, a web of connective tissue that envelops muscle fiber and surrounds, separates, and connects organs and allows them to slide past one another when necessary [220]. Thoracolumbar fascia mediates force transfer, and disruption of its self-regulatory features may contribute to LBP. Stimulation by acupuncture needles inserted into muscle fascia induces the realignment of fibroblasts [221,222,223].

    Reviews and clinical practice guidelines have broadly concluded acupuncture in acute LBP lacks evidence. However, a randomized controlled trial of 58 patients with severely disabling acute LBP compared diclofenac injection to motion-style acupuncture treatment, an approach whereby part of the body moves passively or actively while retaining acupuncture needles. Following a single session of both treatments, motion-style acupuncture treatment led to a 3.12 greater mean pain reduction (on a 0–10 scale) and a 33% greater reduction in disability than diclofenac. These differences remained significant two and four weeks post-treatment. Motion-style acupuncture treatment showed immediate pain relief and functional recovery in disabling acute LBP [55]. A Mayo Clinic review stated that acupuncture efficacy is difficult to evaluate under controlled conditions because of the individualized and tailored approach of acupuncture to specific patient needs [226]. Bias has also been identified in Cochrane reviews of acupuncture [227]. Positive response to acupuncture and other CAM therapies has long been attributed to placebo response from high patient expectations, but this has been generally disproven [228]. Due to ongoing interest in acupuncture as a therapy for LBP, a proposal was announced in July 2019 in which Medicare will cover acupuncture as an alternative to opioids for LBP research. If the proposal is accepted, participants must be enrolled in an approved study and agree to have outcomes data collected [408].

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  30. A review of randomized controlled trails in LBP found that yoga

    TREATMENT OPTIONS

    Yoga is an ancient discipline, originating in the Indian subcontinent, designed to restore balance and health to the physical, mental, emotional, and spiritual dimensions of the practitioner. Yoga has gained popularity in the United States, and proponents claim benefits from yoga that include reduced inflammation and decreased heart rate and blood pressure [229]. Yoga has also become increasingly used in patients with chronic musculoskeletal pain, including back pain, and has been investigated in several trials [230]. A review of randomized controlled trials in chronic LBP found that yoga showed a medium-to-large effect size in reducing disability and pain. The same benefits remained at follow-up, with somewhat smaller effect sizes. Despite differences in yoga style and duration in the reviewed trials, treatment outcomes were consistent [231]. Little is known of the mechanisms in yoga benefit [232]. Generalizability to diverse populations was assessed in 95 low-income urban minorities with moderate-to-severe chronic LBP. Following 12 weeks of once- or twice-weekly yoga classes, both groups showed significant reductions in pain (30% and 36%, respectively) and disability (36% for both) [233].

    Yoga is not free of potential injury. A survey of 1,336 yoga instructors found the most frequent and severe injuries involved the neck, lower back, shoulder, wrists, and knees. Risk factors for yoga injury include poor technique or alignment, previous injury, excessive effort, and improper instruction. Specific yoga forms were associated with specific injuries, including neck injuries from headstand and shoulder stand, and low back injuries from forward bends, twists, and backbends. Recommendations to reduce yoga injuries include population-specific instructor training, appropriate placement of new students, improved understanding of appropriate effort levels, improved teacher detection of overzealous students and improper alignment, and the use of assistants to watch for overzealous and poorly aligned students in large classes [234].

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  31. Ozone therapy for LBP involves

    TREATMENT OPTIONS

    Ozone (O3) is an allotropic form of oxygen primarily used in Europe as an alternative treatment option for patients with LBP from disk herniation. Ozone is administered percutaneously as an oxygen-ozone gas mixture at nontoxic concentrations of 1–40 mcg ozone per mL of oxygen. Proposed mechanisms of analgesia include anti-inflammatory and antioxidant action on the nucleus pulposus. The safety and efficacy of percutaneous ozone injection in LBP secondary to disk herniation was reviewed using four randomized controlled trials and eight observational studies. Based on pain reduction at six-month follow-up, the authors strongly recommended intradiscal and paravertebral ozone therapy [384].

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  32. In regard to complementary and alternative medicine outcomes, higher pre-treatment expectation is

    TREATMENT OPTIONS

    Likewise, in acupuncture-naïve patients with chronic LBP, higher pre-treatment expectations for success did not predict pain or functional improvement. An association did develop with ongoing treatments, but positive pre-treatment attitude toward acupuncture was not associated with superior outcomes [248].

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  33. Which of the following statements regarding the efficacy of NSAIDs in the treatment of LBP is TRUE?

    TREATMENT OPTIONS

    NSAIDs are effective in reducing acute LBP and pain associated with several chronic LBP conditions, though no benefit has been found in LBP with radiating symptoms [261]. The data on acute LBP are less convincing than with non-radicular chronic LBP, but, given the toxicity potential with acetaminophen, NSAIDs seem preferable in acute LBP [251]. NSAIDs have a ceiling effect, where further dose escalation increases side effects but not analgesia [263]. Analgesic efficacy between coxibs and non-selective NSAIDs is comparable, and consistent differences in pain reduction for specific NSAIDs have not been found [261]. For unknown reasons, up to 70% to 80% of patients preferentially respond to a specific NSAID. Response cannot be predicted, but some patients lacking response to one NSAID will achieve full benefit from another [262].

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  34. Which of the following tricyclic antidepressants is preferred for the treatment of chronic LBP?

    TREATMENT OPTIONS

    In chronic LBP, nortriptyline and desipramine are preferred over amitriptyline and imipramine as they show fewer side effects with comparable efficacy. TCA advantages include once-daily dosing and low cost [266]. However, TCAs exhibit a wide range of adverse effects, which differ among the various agents. Common adverse effects include anticholinergic effects, antihistaminergic effects, and orthostatic hypotension (α-1 adrenergic receptor blockade). Anticholinergic side effects include urinary retention, dry mouth, and constipation. Cardiac complications are described as a possible TCA side effect in patients with a history of coronary artery disease, more likely with doses greater than 100 mg/day. Potential side effects and overdose risks should be considered when prescribing antidepressants for chronic LBP; in TCAs, risks include weight gain, driving impairment, falls, and greater overdose lethality potential than other analgesic antidepressants [263,268].

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  35. Which of the following is a common side effect of opioid use?

    TREATMENT OPTIONS

    The use of opioids to manage acute and cancer pain is established and relatively straightforward, but their appropriateness for chronic pain is sometimes disputed [202]. The most common side effects are dry mouth, constipation, and nausea. A substantial minority of subjects in randomized controlled trials of opioids for chronic noncancer pain drop out due to side effects (20% to 30% with opioids vs. 5% to 15% with placebo) [202].

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  36. Which topical NSAID has the most evidence supporting its use for LBP?

    TREATMENT OPTIONS

    Of all topical NSAIDs, diclofenac has the most evidence supporting its use and is the sole NSAID with FDA approval for topical use. Approved formulations include diclofenac sodium 1% and 3% gel, diclofenac sodium 1.5% topical solution in 45.5% dimethyl sulfoxide, diclofenac epolamine topical patch 1.3%, and diclofenac sodium topical solution 2% [298,310]. Topical diclofenac has shown efficacy in pain reduction superior to placebo; comparable to topical NSAIDs indomethacin, ketoprofen, and piroxicam; and comparable to oral NSAIDs diclofenac, ibuprofen, and naproxen. The effectiveness, safety, and tolerability of topical diclofenac support its use for a variety of inflammatory chronic back pain conditions [305,308]. Randomized controlled trials of diclofenac applied three times daily showed that benefits began at 1 week, were fully apparent by 4 weeks, and were maintained to 12 weeks [309].

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  37. The American Academy of Neurology has concluded that botulinum toxin A is

    TREATMENT OPTIONS

    A single-blind, randomized clinical trial study of 50 patients with refractory chronic LBP similarly assigned patients to receive either botulinum toxin or saline injections in the paraspinal muscles where the pain localized [334]. After four weeks, 76% of the participants receiving botulinum reported improvements in pain, compared with 20% of patients receiving saline. After eight weeks, the botulinum treatment group was significantly more likely to report improvements in functionality (68% vs. 12%) [334]. The American Academy of Neurology has concluded botulinum toxin A is possibly effective for chronic, predominantly unilateral LBP, but its role in chronic LBP treatment should be clarified by larger randomized controlled trials in homogenous populations [335,406].

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  38. Spinal surgery in acute LBP is limited to patients with

    TREATMENT OPTIONS

    Roughly 80% of patients evaluated by neurosurgeons are referred for spinal pain, but surgery is indicated in fewer than 10% [347]. In many cases, primary care providers lack an understanding of back pain amenable to surgery. Patients in pain may wait for extended periods for initial consult, only to be sent back to primary care; improved knowledge can limit inappropriate patient referral. Spinal surgery in acute LBP is limited to patients with severe or progressive motor weakness or cauda equina syndrome. Surgical options and appropriate chronic LBP indications include spinal compression surgery, fusion surgery, and disk arthroplasty [347,348].

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  39. Evidence for epidural steroid injection is strongest for

    TREATMENT OPTIONS

    Corticosteroid injection into the epidural space for LBP treatment was first reported in 1953, and despite numerous publications and exponential increases in use, its efficacy and safety remain controversial [349]. Interventional pain medicine specialists strongly believe in the efficacy of this intervention for lumbar radicular pain, reinforced by more than five decades of use and centrality in numerous pain programs [351]. The benefit of epidural steroid injection varies, with efficacy best demonstrated in short-term pain relief of persistent radiculopathy with lumbar disk herniation [47]. Evidence for epidural steroid injection in spinal stenosis is less robust than for herniated disk, but greater than with failed back surgery syndrome and axial back pain without radiating symptoms [349]. The conceptual appeal of epidural steroid injection is that subsequent pain relief allows the body time to heal while avoiding the long-term consequences of central sensitization. However, more than 70% of radiculopathies recover within six months, and a similar proportion of disk herniation undergoes resorption within one year [349].

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  40. Which of the following is an area of crisis in pain care in the United States according to the International Association for the Study of Pain?

    BARRIERS TO EFFECTIVE CARE OF CHRONIC LBP

    The International Association for the Study of Pain has identified areas of crisis in pain care in the United States: poor evidence base in most treatment approaches; inadequate primary care provider pain education; the unknown value of opioid therapy for chronic pain; pain provider reimbursement; and declining access to multidisciplinary pain programs [5].

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