Public health

Back pain ‘red flags’ need to go: Maher

Research challenging the efficacy of existing recommendations for the treatment of lower back pain has prompted a call for a re-evaluation of the guidelines.

Speaking at the 57th ARA and RHPA Annual Scientific Meeting, in Darwin, Northern Territory today, Professor Chris Maher said the current protocol of involving red flag conditions, the use of pain medication and prevention of LBP needed revising.

“New research challenges many of the key recommendations for the management of low back pain and will force a rethink of how we go about managing low back pain,” he said.

Professor Maher is a professor of physiotherapy at the Sydney University Medical School and also Director of the Musculoskeletal Division at the George Institute for Global Health.

He told the limbic that the recommendations associated with red flagging were of particular concern, as they had resulted in diagnostic imaging that was often both unnecessary and unhelpful.

The presence of a single red flag such as unexplained weight loss, fever or recent infection was likely to be common, and some patients are referred for imaging or other diagnostic tests on that basis alone.

While a cluster of red flags may be a better indicator of serious pathology, Professor Maher said research showed that serious disease was uncommon in patients with lower back pain presenting to primary care.

“That is a lot of exposure to radiation and cost,” he said. “And if you take an image of anyone’s back it can return incidental findings (sometimes unrelated to the pain) and unfortunately some people can get on a roller coaster,” he said the limbic.

Professor Maher said he believed there was growing support for abandoning the red flagging altogether.

“The simplistic approach with red flags hasn’t worked particularly well,” he said.

“People should be taking history and making a judgement on the whole history, not just red flags.”

Professor Maher said the majority of patients with a short duration of symptoms would recover with minimal intervention, and this could not justify the millions of dollars spent on unnecessary imaging.

“We’re going to have to go through and cull some of these red flags,” he said.

What about pain relief?

On the subject of pain medication, he said the traditional approach of paracetamol as the initial treatment, followed by a NSAID or combination analgesic, such as paracetamol with a therapeutic dose of codeine, also needed a rework.

“For back pain it was recently established that paracetamol doesn’t work at all,” he said. “NSAIDs work to some extent. Opioids don’t seem to have a large effect – a bit better than NSAIDs, but they have a huge potential for harm.”

And in some patients, those who build up tolerance to drugs or have a condition such as hyperalgesia, medication can actually make the pain worse.

“Some people thing medicines are the only answer,” Professor Maher said.

He said of all the medications, it appeared NSAIDs were the most effective and carried the least potential for harm. But while opioids are subsidised through the PBS, simple NSAIDs were not, a fact he is critical of, especially when they are not proved for acute low back pain relief.

“In some ways a person with chronic pain is forced down the path,” he said. “We’re probably using too many opioids.”

He said the stepped approach to pain portrayed in the WHO analgesic ladder had already lost one rung (the use of paracetamol), and while NSAIDs have confirmed efficacy there was a problem further up the ladder with opioids.

“The problem is that there are no trials for opioids for acute low back pain,” he said. “The trials that do exist evaluate short-term use for chronic low back pain and reveal a modest effect. The recent Friedman trial found that adding an opioid or muscle relaxant to a NSAID did not improve outcomes for acute low back pain.”

So what is the answer?

“You might find there’s enough money to go around if we stop spending money on unnecessary things and direct it to other things that we know work,” he said.

Referral to pain clinics, education, exercise and non-pharmacological approaches such as physiotherapy have an important role to play but are underutilised in the treatment of LBP.

“There are many traditional approaches to prevention of low back pain, including options like back belts, lifting devices and redesign of the workplace,” Professor Maher said.

“A recent systematic review reported that exercise alone or in combination with education is effective for preventing LBP. Other interventions, including education alone, back belts and show insoles, do not appear to prevent LBP.”

Professor Maher said there was a need for more research – and more funding for research – into prevention, even though there is strong anecdotal evidence that education and exercise can lead to significantly reduce the risk of a patient having recurrent LBP.

“Strangely, we haven’t studied prevention very well or very often,” he said.


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