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CLINICAL PRACTICE GUIDELINES FOR ACUTE LOW BAC K PAIN

CLINICAL PRACTICE GUIDELINES FOR ACUTE LOW BAC K PAIN. AETNA USHEALTHCARE. PATIENT GOALS. Prevent or minimize daily symptoms/recurrent exacerbations with return to baseline function. Foster optimal use of specialty and ancillary services.

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CLINICAL PRACTICE GUIDELINES FOR ACUTE LOW BAC K PAIN

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  1. CLINICAL PRACTICE GUIDELINES FOR ACUTE LOW BAC K PAIN AETNA USHEALTHCARE

  2. PATIENT GOALS • Prevent or minimize daily symptoms/recurrent exacerbations with return to baseline function. • Foster optimal use of specialty and ancillary services. • Minimize the need for acute care services (ER/urgent care visits, hospitalizations.

  3. DIAGNOSIS • Initial assessment includes a focused history, physical, and neurological exam. • Exclude “Red Flags” which include fracture, cancer, infection, and Cauda Equina Syndrome. • Cauda Equina syndrome is diagnosed when there is saddle anesthesia, loss of bladder or bowel sphincter tone and/or rapidly progressive neurological deficit.

  4. ASSESSMENT • With a symptomatic herniated disc leg pain usually outweighs back pain. • 90% of patients will recover within four weeks, regardless of treatment, unless there are “Red Flags”.

  5. ASSESSMENT • X-rays and lab tests (CBC, U/A, ESR) should be considered when there is no response to an initial four weeks of conservative therapy, to further evaluate potentially serious pathology, or when surgery is being considered. • MRI/CT should be requested on the basis of clinical findings since 1/3 of asymptomatic adults may show a bulging disc on MRI/CT

  6. THERAPY • Acetaminophen is the safest drug treatment for common acute low back pain. • Salicylates or NSAIDs can be used alone or added to acetaminophen therapy. • Muscle relaxants and narcotics should be reserved for severe cases in the first week only.

  7. THERAPY • A short course of physical therapy may be beneficial. • A short course of oral steroids may be considered after failure of initial conservative therapy. • Surgery is primarily for unrelenting sciatica with signs of nerve root compression and a concordantly abnormal imaging study.

  8. PATIENT INSTRUCTIONS • Activity as tolerated: there is no relationship between activity level, rest, and recovery. • Resume daily activities and support return to work with initial improvement. • Patient does not have to be completely pain-free before returning to work.

  9. PATIENT INSTRUCTIONS • Events and activities that “trigger” acute low back pain should be identified and avoided, and “safe lifting” techniques should be taught. • Develop a long-term daily program of flexibility and back-strengthening exercises as soon as symptoms resolve.

  10. WARNING SIGNS • Re-evaluate if symptoms do not improve after 4 weeks of initial therapy and consider imaging studies and/or referral to specialist. • Depression is a barrier that may confound the symptoms and assessment of chronic back pain.

  11. SPECIALIST INVOLVEMENT • If symptoms do not improve after 4 weeks of conservative therapy. • If new or progressive neurological deficits and/or if any “Red Flags” are recognized at any time. • Recurrent symptoms (more than two episodes in a 6-month period). • Recurrent symptoms after low back surgery.

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