Family Practice Physicians take on Acute LBP

A narrative review published in February’s edition of American Family Practice gave some insight on recommendations for the treatment of LBP for Family Practice physicians.  The author made “key recommendations for practice” based off of a review of the literature and graded each recommendation based off of the available evidence.
A rating: consistent, good-quality, patient-oriented evidence
B rating: inconsistent or limited-quality, patient-oriented evidence
C rating: consensus, disease-oriented evidence, usual ractice, expert opinion, or case series.
A Rating Clinical Recommendations:

  • Nonsteroidal anti-inflammatories, acetominophen, and muscle relaxants
  • Bed rest is not helpful
B Rating Clinical Recommendations:
  • Patient education that includes advice to stay active, avoid aggravating movements and return to normal activity as soon as possible
  • Physical therapy (McKenzie method and spinal stabilization) may lesson risk of recurrence
  • Spinal manipulation and chiropractic technique are no more beneficial than established treatments for nonspecific low back pain
C Rating Clinical Recommendations:
  • Red flags are common in patients with acute low back pain and do not indicate serious pathology
  • Without findings of serious pathology, imaging is not indicated in patients with acute low back pain

While I appreciate the effort, this article was nothing more than a narrative review with integrated expert opinion.   He did say he searched PubMed for the key term: acute low back pain with multiple variations (ie. acute low back pain mckenzie), but this article only included 46 citations.
What I find interesting is that he believes spinal manipulation is no more beneficial than established treatments for nonspecific acute LBP.  Doesn’t this contradict the CPR which we hold so dearly?  I also find it fascinating that Physical Therapy treatments were identified as the McKenzie method and spinal stabilization. While there is clinical utility for these (and I have nothing against these), I am familiar with alot of evidence that also demonstrates effectiveness using other methods.
What do you think?
Casazza BA. Diagnosis and Treatment of Acute Low Back Pain. American Family Physician 2012; 85: 343-350.

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All Comments

  • Joe,
    Thanks for sharing this. I do agree it is interesting the article specifically says McKenzie. I am not McKenzie trained but have worked under clinicians who are. I think it is a great approach but not necessarily for everyone, from a patient perspective but also a therapist perspective. I doubt, but hope this doesn’t lead to PCPs just referring to certified therapists. This could get out of control considering the amount of certifications out there. And isn’t general exercise just as effective as stabilizing program under high level research?
    I do like the idea of different classifications and ranks. I can imagine LBP patients are almost a worse nighymare to PCPs. This is a good start. Also, maybe it’s the percentage of pts who come in my office, but I find patients try to stay away from muscle relaxers. Interesting this is still class A.

    Harrison Vaughan April 10, 2012 9:47 am Reply
  • Harrison,
    I have seen patients recovering completely after following McKenzie exercises. Actually its a graded protocol and classification of syndromes is very good or can be easily applied to patients. General exercises are not sequential and every therapist follows according to their knowledge.

    NEELIMA April 11, 2012 12:57 am Reply
  • I also can’t believe the class A vs B. This is no different than what many PCPs already do, oh wait, except there is only class A. Class B may be if the patient begs for PT and it they and we are lucky it won’t be 6-12 months after onset.
    Honestly this makes as much sense clinically as to us managing high cholesterol and blood pressure within the scope of our practice.

    Erson Religioso III, DPT April 11, 2012 12:57 pm Reply
  • Joe,
    When I looked at the references in this article, I found a bunch of systematic reviews that were either several years old or compared a heterogeneous population of acute and chronic patients. It completely ignored the excellent research put out in the last 8-10 years that subgroups low back pain patients. If the latest research demonstrating how effective PT can be was published in PT journals, I’d be a little more forgiving, but since much of it has appeared in the Annals of Internal Medicine, Spine, etc., I have to think leaving it out was either ignorance, or a blatant omission.
    I’m working on a presentation for some local family practice docs using this article…and refuting some of it’s findings.

    Sean Weatherston, PT, OCS April 11, 2012 8:59 pm Reply

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