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Updated NASS Guidelines on Multidisciplinary Low Back Pain Treatment

D. Scott Kreiner, MD, co-chair of the NASS Evidence-Based Guideline Development Committee, shares details on the updated multidisciplinary recommendations for nonspecific low back pain. Plus: Chiropractors offer their take.

Editor's Note: New clinician comments posted at end of article.

The North American Spine Society (NASS) published Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care in early 2020.1 Developed by a group of multidisciplinary spine specialists, the guidelines are the first by NASS to address low back pain as a symptom potentially due to a variety of diagnoses rather than as a specific disease.

The guidelines focus on a specific subset of patients – those with nonspecific low back pain – which excludes patients with leg pain below the knee or neurologic deficits that may indicate a specific cause of the back pain, such as disc herniation.

Recommendations were developed for diagnosis and treatment of nonspecific low back pain in patients 18 years and older. These recommendations were based on 82 clinical questions identified by guideline participants as pertinent to addressing the clinical issues of diagnosing and treating low back pain. Evidence for the recommendations came from a systematic review of the evidence up to February 2016. A total of 45,000 articles were reviewed. 

A range of evidence exists for the treatment of nonspecific low back pain – but a combination of therapies may be best. (Image iStock)

This article focuses on treatment recommendations, which the guideline breaks down into four categories:

  • Medical and Psychological Treatment
  • Physical Medicine & Rehabilitation (PM&R)
  • Interventional Treatment
  • Surgical Treatment

PPM spoke to D. Scott Kreiner, MD, co-chair of the NASS Evidence-Based Guideline Development Committee, to gain some insight into how the guidelines were developed, what they mean for clinical practice, and ongoing issues that still need addressing to better treat a condition that diminishes the quality of life for many people.

 

PPM: What was most difficult in shaping the treatment recommendations overall?

Dr. Kreiner: The biggest challenge when developing all sections of this guideline was keeping the recommendations as specific to the patient population with our pre-defined inclusion and exclusion criteria. Before starting the literature search, we spent a lot of time defining ‘low back pain.’

Ultimately, we decided to focus on non-radicular low back pain that excluded conditions such as the presence of neurological deficit or leg pain experienced below the knee, among others. We came across many studies that we could not include in our analysis because the patients had radicular pain or there was no subgroup analysis. This caused us to exclude well-known and well-designed studies that just didn’t meet our inclusion criteria. Overall, it was a strength to have recommendations that focus on this specific patient population.

 

PPM: When looking at each of the four treatment approaches, what can clinicians put into practice today based on these recommendations? In turn, what should they avoid that perhaps has been commonly used until now?

Dr. Kreiner: One of the biggest benefits of a clinical guideline is that it provides actionable information that providers can use in their daily practice.

For the medical and psychological treatment of nonspecific low back pain, there were a few high-level recommendations that can help steer a clinician’s practice. In particular, cognitive-behavioral therapy (CBT) and treatments targeting fear avoidance – when used in combination with physical therapy – are effective at reducing pain in this group of patients. There was also high-level evidence against the use of antidepressants as a treatment for low back pain.

Studies on PM&R for patients with nonspecific low back pain provide high-level evidence that aerobic exercise improves pain, disability, and mental health. As a practitioner, you can feel comfortable providing information such as this to your patients. Unfortunately, within the narrow scope of nonspecific, non-radicular low back pain, many of the questions did not have adequate evidence to provide an answer.

Interestingly, spinal manipulative therapy in this narrow scope of patients was shown to be no better than no treatment, medications, or modalities. Therefore, for this particular group of patients, this treatment is probably not indicated.

For interventional treatment, the evidence in support of most of these treatments were excluded because interventional treatments are not typically recommended for nonspecific low back pain. Grade B recommendations (ie, based on fair evidence) were given in support of medial branch radiofrequency ablation (RFA) in patients with low back pain from the zygapophyseal joints, as well as the use of intradiscal steroid injections in patients with low back pain and Modic changes on MRI scan.

Surgical treatments tend to be directed at a specific cause of pain and therefore, by definition, not treatments for nonspecific low back pain. While the workgroup attempted to identify how patients with back pain respond to various fusion techniques, nearly all studies evaluated included patients with leg pain or spondylolisthesis, excluding them from evaluation.

 

PPM: How do these recommendations change approaches to back pain?

Dr. Kreiner: The recommendations in all sections of this guideline are specific to the defined patient population (that is, patients without leg pain, neurological deficits, and other exclusion criteria defined in the guideline). The recommendations may not be the same as other guidelines for low back pain in general, demonstrating that these patients should not necessarily be treated the same way as patients who do experience those conditions.

These multidisciplinary recommendations may change approaches to low back pain care for this specific subset of patients instead of being grouped together with all patients with low back pain.

 

PPM: Some have noted that there are some limitations with the final recommendations given that the data period used to shape the guidelines culminated in February 2016. What’s your take?

Dr. Kreiner: Yes, the evidence surrounding spine care is constantly evolving. It is definitely possible that, if this guideline were updated with a revised literature search date, evidence that is more recent could alter the existing recommendations. The only way that would be possible is if a systematic review was completed again and the new evidence met the pre-defined inclusion criteria. For example, even if the recently published studies provide good evidence, if they involve a patient population excluded in our guideline (such as patients with radiculopathy) without a subgroup analysis, they would not be included in our analysis and would not have any impact on the existing recommendations.

Further, we could not rely on a single article that may potentially change a recommendation, because there may be conflicting evidence that we are not aware of until a complete search is done…. Updating guideline recommendations is a complex process. This specific guideline took significantly more time than a typical guideline due to the volume of literature and multiple participants, among other factors.

 

PPM: What is still needed in the different treatment approaches to improve back pain care?

Dr. Kreiner: The workgroup provided future recommendations for research for each question.

For medical and psychological treatment, for example, recommendations include the need for high-quality prospective studies that clearly identify what types of psychosocial intervention in what frequency, timing, duration, and combination that is most effective for the treatment of low back pain and the development of registries that collect information regarding psychological factors that can influence low back pain and quantitative analysis of this information.

For PM&R, recommendations include the need for higher quality studies to show the benefits of the addition of cognitive-behavioral therapy in this patient population and the effectiveness of rehab programs before and after surgery for low back pain as we defined it.

For interventional treatment, we included the need for RCTs of radiofrequency denervation of the lateral branch nerves following lateral branch blocks, and randomized controlled trials comparing the various nerve ablation techniques of the lateral branch nerves for sacroiliac joint (SIJ) pain.

For surgical treatment, we recommended undertaking additional randomized controlled trials comparing surgical treatment to medical/interventional treatment in patients with low back pain only without a history of prior lumbar surgery.

 

PPM: Given the current evidence supported in this guideline, do you think there is now a consensus on how to treat low back pain?

Dr. Kreiner: First, it is important to emphasize again that this guideline focuses on a very specific patient population. Even within this subset of patients, low back pain is a symptom rather than a diagnosis, and treatment should be individualized. The main consensus on the treatment of low back pain throughout all treatment sections in the guideline is that it needs to continue to be individualized.

The NASS Low Back Pain Guideline is not intended to be a fixed treatment protocol and the ultimate judgment regarding any specific procedure or treatment is to be made by the provider and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.

......................

Editor's Note

The following Letters to the Editor were submitted to PPM after publication of the above Q&A.

 

Submitted by David M. Glick, DC, DAAPM, CP, FASPE:
This was one subject I could not ignore.  Maybe I am missing something, but the NASS guidelines on multidisciplinary low back pain treatment are highly flawed and are more likely to result in a disservice, or at best, to maintain the status quo when it comes to treating low back pain. At least that was my take when reading this interview with Dr. Kreiner about the guideline.

It would be my argument that there is perceived clinical incompetence with the concept involving an actual diagnosis of “nonspecific back pain” or idiopathic back pain as one can question whether the mindset is valid to begin with. Virtually all back pain has an underlying cause. It is the skilled physician or clinician that is responsible for identifying the underlying cause(s) of a patient’s low back pain (technically any musculoskeletal pain pathology) and to deliver an effective treatment targeted to mitigate or resolve such, in a highly patient-centered manner. That is the art of delivering the science of healthcare in general and how back pain, or any pain, should be best managed.

Glancing through the guideline, there appears to be a clear deficiency in the authors’ ability to understand basic pathophysiology when it comes to underlying causes, nor the skill set required to help identify how such pathologies impact the patient manifestation of pain. In the absence of such knowledge, it would seem clinicians are “spinning the wheel of misfortune” to help deliver patient treatment. In this regard, NASS is contributing to the problem rather than to the solution, which is what I find most frustrating about clinical practice.

In 30 years of practice, I cannot recall ever having a patient where a more specific patient-centered diagnosis could not be rendered. I may not have been able to effectively treat all patients but having an understanding as to why they have pain is half the battle, and accounts for a track record of better outcomes with long-term management for those patients in which a resolution is not possible, and a treatment resolution for many, even those with long-standing histories of back pain.

Do I appreciate a multidisciplinary approach, of course? Combining disciplines or individual treatments in a highly patient-centered manner has been the hallmark of what I and many others do best in a true multidisciplinary mindset. Technically, there is a patient for every treatment.  The key to clinical success is to determine what treatment(s) would best for each patient at a particular time. In a sense, this is the concept of triaging patient care for pain.

In an earlier article for PPM, we identified a major concern for treating back pain that centered around contradictions relative to guidelines for back pain treatment. NASS has exemplified this problem once again. In contrast, I thought the Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline, offered a much more positive approach to LBP and well as MSK pain.  

Of note, I personally identify as a musculoskeletal pain physician, whose practice is more akin to PM&R/neurology pain management even though I have training in chiropractic medicine.  In practice, I find it quite valuable to leverage rational pharmacology, interventions, CBT, and conservative treatments, including manipulation. My bias is more toward favoring the individual needs of the patient, regardless of the discipline.  Remember, back pain is nothing more than a symptom, not a diagnosis. Do we treat chest pain, or do we seek to determine the underlying cause and treat the underlying pathology?

 

Submitted by Ryan Kain, DC: 
After reading this guideline update Q&A, I felt transported back to the ‘80s, when we didn’t have decades of research showing chiropractic – spinal manipulation (SMT) in particular – to be the most cost-effective and clinically effective treatment with one of the highest patient satisfaction rates for treating not only low back pain but also neck pain and headaches, with millions of patient visits attesting to these facts. Transported back to the ‘80s before the AMA lost a federal racketeering lawsuit for smearing chiropractic practice and pressuring state medical boards against cooperation with chiropractic physicians.

For decades, we as a profession were told we needed more research. Now, after 40 years of federally and privately funded research overwhelmingly proving our points, we are still making the same arguments about the effectiveness of chiropractic care, still dealing with professional bias, misinformation, counter-studies using cherry-picked references and criteria, and just plain ignorance. We have done the research and we have the patient satisfaction to back it up. It boggles my mind that I can attend integrative pain management meetings and there will only be one or two, if any, mention of chiropractic – it’s all about the outdated care approaches and “if it works” instead of talking about how it works and, more importantly, how to incorporate chiropractic with your patient’s care. (If you need a short education on the science behind chiropractic and what it actually does, might I suggest the book “Reality Check” by neuroscientist Dr. Heidi Haavik.)

When is it going to penetrate that “nonspecific low back pain” is only nonspecific to some medical researchers and others who have not bothered to learn anything new? I realize that, according to research, it takes the medical community an average of 15 years to accept clinical research and change their practices to fit now-old research. However, I just shake my head when I read about “new” guidelines like this one. Let’s move forward!

Last updated on: October 26, 2020
Continue Reading:
Experts Roundtable: Finding a Bottom Line in Back Pain Care
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