Low Back Pain CPG (2021 Update)

We're back! This is the first time we have had to revisit a topic due to a CPG update, and the relationship between the 2012 and 2021 LBP CPG is complicated. To make things worse, the 2021 CPG was pretty controversial when it was released. How should you use these two documents to prepare for the OCS?  We cover it here.

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Transcript

Hey, everybody! We’re back, and today we are kicking off the 2023 OCS cycle with an oft-requested topic: the new 2021 low back pain CPG. Before we dive in, a couple quick updates:

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Now let’s turn our attention to the 2021 LBP CPG. At the time of its publication, this new LBP CPG received a lot of criticism, which I think is mostly due to the guideline being misunderstood. In this particular case, it’s important to read the introduction to the guideline to understand what’s going on. Specifically, it’s important for you to know that this guideline does not replace the entire 2012 CPG. The new guideline is only focused on treatments. The “rationale” section of the introduction reads, “A decision to focus the 2021 update on treatments was made because diagnosis, differential diagnosis, and examination recommendations are well covered in other guidelines.”

The rationale section of this CPG argues that these other guidelines offer essentially the same guidance as the diagnosis and examination recommendations that were made in the 2012 CPG. So the 2012 CPG is still going to be very important for you to review. Specifically, the authors here note that most recently published CPGs emphasize 11 key recommendations: “(1) ensure care is patient centered, (2) screen for red flag conditions, (3) assess psychosocial factors, (4) use imaging selectively, (5) undertake a physical examination to assess impairments, (6) monitor patient progress, (7) provide education and evidence-based information as a treatment supplement, (8) incorporate physical activity/exercise, (9) use manual therapy only as an adjunct to other active treatments, (10) offer high-quality, nonsurgical care prior to surgery, and (11) try to keep patients at work.”

You can see how this reemphasizes many of the same themes we focused on in the 2012 guideline. Now pay special attention to a few of these recommendations: the seventh item on this list was to provide patient education as a treatment supplement. This is an important recommendation that we’re going to come back to later in this episode, as this CPG makes some specific education recommendations. The eighth and ninth recommendations are to incorporate physical activity and exercise and to use manual therapy only as an adjunct to other active treatments. One of the claims that was made by critics of this CPG was that this guideline seemed to de-emphasize exercise and over-emphasize manual therapy; but you can see right here at the beginning that we are instructed to use manual therapy only as an adjunct to other active treatments. So if you’re given a LBP case on the exam, and you are given a choice between manual therapy only, manual therapy plus passive treatments, or manual therapy plus an active treatment, there’s a very good chance you should choose manual therapy plus the active treatment. Lastly, note that the final recommendation in this list is to try to keep patients at work. This is consistent with past guidelines that encourage active rest instead of complete physical rest. So just remember that it’s going to be best if you can keep individuals with LBP working as much as possible.

That’s enough reading the introduction. Let’s look at the evidence updates for low back pain treatments.

This new CPG divides most treatment recommendations into acute or chronic back pain groups. When appropriate, it further subgroups back pain as with or without leg pain (in other words, with or without suspected radiculopathy). It also adds a postoperative category. This is all new compared to the 2012 version.

I’m going to skip ahead in the CPG to the section on LBP classification systems first. For acute LBP, the new CPG gives the same B-level recommendation for Fritz’s Treatment-Based Classification system. In addition, it gives a C-level recommendation for MDT, Mechanical Diagnosis and Therapy, which is the fancy name for the McKenzie approach. For chronic LBP, we get a B-level recommendation for MDT (or McKenzie), prognostic risk stratification, and pathoanatomic-based classification; and we get a C-level recommendation for Treatment-Based Classification, Cognitive Functional Therapy, and Movement System Impairment methods.

So what does all this mean, and how does it affect how you prepare for the OCS? If you’ve listened to our other episodes, you know that we recommend that you know and use the Treatment-Based Classification approach—both the 2007 Fritz model as a foundation, and then the newest Alrwaily model that was published in 2016. So does the new CPG suggest you should forget about the Treatment-Based Classification approach and learn McKenzie, prognostic risk stratification, and these other approaches?

In short, I don’t think so. The authors here are very clear that there is just not enough evidence to make strong recommendations, and there are no studies that directly compare these classification methods to one another, so we can’t say one particular method is a better choice than the others.

We still think the updated Alrwaily Treatment-Based Classification approach is your best resource for learning how to choose specific interventions for a given patient case. That’s because it’s the direct descendent of the Fritz model, which got a B recommendation for acute LBP above, and it incorporates more evidence (that was not available during the development of the Fritz model) as well as the 2012 CPG in its recommendations. Additionally, unlike some other classification systems, the Treatment-Based approach does not require extensive continuing education and paid certification. Guidelines for OCS item writers state that OCS exam questions should test issues that are universal, and, “Information required to answer items correctly must be used frequently by physical therapists in the normal course of their work.” Because the Treatment-Based approach is easily accessible in published format and requires no esoteric additional training or certification, we think it is the most likely to be used on the exam. And even though the Fritz model only gets a C recommendation in the chronic LBP group, you’ll see in a minute that the Alrwaily update is pretty consistent with the new CPG’s chronic LBP recommendations.

To summarize: many classification systems seem to be good, but no studies show the superiority of one vs. the other. So we don’t think the OCS could ask you a question that makes you choose one particular classification approach. But because of its accessibility and conformity to other published recommendations, we think the 2016 Treatment-Based Classification approach by Alrwaily et al. is still your best resource for choosing a treatment for a given patient case.

Okay, let’s talk about exercise next.

For acute low back pain without leg pain, we have a C recommendation to use exercise, including specific trunk muscle activation training. The authors clarify that this recommendation is only weak because nearly all studies on acute low back pain include individuals with leg pain. We suspect it’s good for those without leg pain too; we just don’t have the number of studies to show it yet. For the group with acute low back pain and leg pain, we have a B recommendation for exercise, including trunk muscle strengthening and endurance and specific trunk muscle activation to reduce both pain and disability.

For chronic low back pain without leg pain, we have an A recommendation for trunk muscle strengthening, endurance, multimodal exercise, specific trunk muscle activation exercise, aerobic exercise, aquatic exercise, and general exercise. We also have a B level recommendation for movement control or trunk mobility exercise.

For chronic low back pain with movement control impairment, we have an A-level recommendation to use specific trunk muscle activation and movement control exercise. No surprise there.

For chronic low back pain in older adults, we have an A-level recommendation to use general exercise training (including aquatic training) to reduce pain and disability. The authors note that the effects seem to be more related to appropriate exercise prescription than exercise type, so appropriate volume, intensity, and progression are important here.

Finally, for postoperative LBP, there are few studies with conflicting results, so we get a C recommendation that PTs can use general exercise training postoperatively.

To recap, you will notice that recommendations are generally in line with what we’ve discussed about low back pain before. Exercise is recommended for acute and chronic LBP. There’s no evidence to say one type of exercise is superior to another as long as the prescription is appropriate. When there are movement control impairments (think: the “movement control” subgroup in the Alrwaily Treatment-Based Classification), treatments should include muscle activation and movement control exercises. Chronic LBP benefits from all kinds of exercise, including aquatic exercise, which is new in this CPG.

Now let’s talk about “manual and other directed therapies.”

In acute LBP, we have an A-level recommendation for thrust and non thrust joint mobilization to reduce pain and disability, and a B-level recommendation for massage or soft tissue mobilization for short-term pain relief. This is consistent with previous recommendations. We will note that studies examining thrust and non thrust joint mobilization generally follow the mobilization with exercise, and the authors of the CPG note that there is no evidence investigating the prolonged use of manual therapy; studies are generally shorter than three weeks. So this is all recommended for short-term relief, to be followed by exercise, as we noted before.

If you recall from our discussion of lumbar manipulation, researchers in our clinical prediction rule derivation and validation studies followed the lumbar manipulation with pelvic tilts, so that would be a good exercise to choose to do first after manipulation if you’re asked to pick one.

Chronic LBP is where we see some new recommendations. In chronic LBP, we have a A-level recommendation for thrust or non thrust mobilization in those without leg pain and a B-level recommendation for those with leg pain. This seems to run counter to previous recommendations that said spinal manipulation is best indicated for acute low back pain. But I don’t think you should let this throw you off much. I would recommend you continue to use the lumbar manipulation clinical prediction rule to decide if manipulation is appropriate for a particular case, and just don’t let the timeframe scare you away from manipulation if the individual meets the other criteria. Remember that you need 3/5 findings for a positive cluster. So if you have a case where the LBP has been going on for a few months, the pain goes down to the ankle, they have a hypomobile segment, at least one hip has greater than 35 degrees of IR, and the FAB-Q Work is less than 19, still go ahead and manipulate. Even though the original rule says pain should be less than 16 days and the pain should be above the knee, having the other 3 positive findings still gives you a 68% chance of success. And now that our CPG gives an A-level recommendation for chronic LBP and a B-level recommendation for back pain with leg pain, we shouldn’t let those two findings scare us away from an otherwise positive clinical prediction rule. Just be sure you follow it up with exercise.

Moving on in the chronic LBP group, we have a B-level recommendation for soft tissue mobilization or massage “in conjunction with other treatments to reduce pain and disability in the short term.” The two keys here are “in conjunction with other treatments” and “short term” relief.

Also new in this CPG is a C-level recommendation to consider using dry needling “in conjunction with other treatments to reduce pain and disability in the short term.” We don’t have an overwhelming amount of evidence for dry needling yet, but the studies listed here are promising. Note that dry needling needs to be paired with other effective treatments; we do not have evidence for its use as a standalone or à la carte treatment. The recommendation is for “short term” relief primarily because all the studies had only short term follow up.

Receiving an upgrade compared to the previous CPG, neural mobilization now has a B-level recommendation—again, when used in conjunction with other treatments for short-term relief.

And lastly, traction continues to receive a D-level recommendation, indicating that PTs should not use traction.

So let’s summarize: thrust and non thrust joint mobilizations are good for acute and chronic LBP when combined with exercise. Soft tissue mobilization can be good for short-term relief when combined with other treatments. Preliminary evidence suggests that dry needling can be beneficial when combined with other treatments. Neural mobilization can be beneficial when combined with other treatments. And traction does not appear to be beneficial when combined with other treatments, so we probably shouldn’t use it.

Do you see a theme? A combination of manual therapy or directed therapies with exercise is clearly the evidence-based treatment of choice, so, when given the option, you should always choose a combination of approaches. We also think this backs up the philosophy behind the 2016 Treatment-Based Classification system, which uses things like manipulation and manual therapy to provide short-term relief so that the patient can move towards more active, exercise-oriented treatments.

Let’s wrap up with the last section: patient education. The authors largely do not change the recommendations from 2012, so we still think those are valuable. However, they do get a little more detailed.

For acute LBP, education gets a B-level recommendation, stating, “Physical therapists may use active education strategies rather than passive strategies (ie, providing access to educational materials only). Active education strategies include one-on-one education on the bio-psychosocial contributors to pain and self-management techniques, such as remaining active, pacing strategies, and back-protection techniques. Physical therapists may also incorporate counseling on the favorable natural history of acute LBP as part of the education strategy.” You will notice that several themes from 2012 are present here: encourage people to stay active, discuss the favorable natural history of back pain, etc. If I was an OCS item writer, I would pick up on the recommendation to use active strategies rather than passive strategies; handing out educational material is not enough.

Moving on to chronic LBP, general education gets a B-level recommendation, but not as a standalone treatment. In providing education, providers should include advice related to exercise and about how to stay active.

We also get an A-level recommendation to include active treatments like yoga, stretching, Pilates, and strength training in addition to education for those with chronic LBP. That’s because “education alone” is typically the control group in these studies, and education plus active treatments always outperforms education alone.

Our last recommendation for chronic LBP is an A-level recommendation to use pain neuroscience education, but it needs to be used alongside other interventions like exercise or manual therapy. Pain neuroscience education plus other treatments generally has a greater effect size than pain neuroscience education alone.

Finally, we have a recommendation for post-operative LBP. For those undergoing discectomy or decompression, we have a B-level recommendation to use general education, such as post-surgical precautions, exercise, and resuming physical activity. The authors note that this education seems to work much better preoperatively than postoperatively, so, if given the option, we would prefer for this to happen before the surgery.

So let’s summarize the whole CPG and wrap up.

For acute LBP, our strongest evidence is for thrust or non thrust joint mobilizations, but those techniques should always be combined with active techniques as well. Then we have B-level recommendations for strength and endurance exercise, specific trunk activation, soft tissue mobilization and massage, Treatment-Based Classification, and education. The education should be active and address biopsychosocial contributors to pain, self-management techniques, and the favorable natural history of LBP.

For chronic LBP, we have the strongest evidence for most forms of exercise, including aquatic and multimodal exercise, thrust and non thrust mobilization, pain neuroscience education, and patient education combined with active treatments and not as a standalone. Our recommendation with the weakest evidence is in favor of dry needling, and we have a recommendation against traction, meaning it is unlikely that you will get any OCS questions that expect you to select mechanical traction as a treatment for LBP.

I hope this has cleared up some of the confusion around this CPG and how it relates to the 2012 version, Remember to go back and review the 2012 version for a lot of important material about things like risk factors, diagnosis, imaging, and red flags.

Let’s finish with a quick practice question:

A 43-year-old man presents for initial evaluation 1 day after sudden onset of low back pain that occurred when helping transfer his 16-year-old son, who has CP. NPRS is currently 8/10. Pain is in his central low back and does not radiate. He presents with a flexed lumbar posture and is unable to extend to neutral. Which of the following educational interventions would be most appropriate?

 A. Written handout emphasizing the favorable natural course of acute LBP
 B. Verbal communication about anatomical explanations for his pain
 C. A group class on back protection techniques
 D. Verbal communication about biopsychosocial contributors to pain

Although it would be very important to emphasize the favorable natural course of acute LBP with this patient, the fact that this option only involves distributing a written handout makes it inappropriate based on our clinical practice guidelines. Communication about detailed anatomical explanations for his pain is still recommended against. A group class on back protection techniques is not one-on-one training as is recommended in this guideline. So D. verbal communication about the biopsychosocial contributors to pain, is the best option, because it involves an active education strategy that targets one of the three CPG-recommended topics: biopsychosocial contributors to pain, self-management techniques, and the favorable natural history of LBP.

It’s been good to be back with you, and we’re looking forward to getting some more episodes out to you soon. Until then, study hard.