NUR 7072 Module 4 Low Back Pain Case Paper: Red Flags, Risk Stratification and Nonpharmacologic First-Line Care Example

Keep Moving: Treating Acute Low Back Pain Without Imaging or Opioids

Student Name

M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University

NUR-7072: Adult Primary Care Part II

Mentor Name

Month Day, Year

Keep Moving: Treating Acute Low Back Pain Without Imaging or Opioids

The Patient

Marcus Hill, an invented 42-year-old package delivery driver, lifted a 60-pound box from a truck five days ago and felt a sharp pain across his lower back. The pain is worst when bending or getting out of the truck and eases when he lies on his side. It does not travel below his knees, and he has no numbness, weakness, bladder or bowel changes or numbness in the groin. He has no fever, history of cancer, weight loss, injection drug use, steroid use or recent major trauma. He has been resting in bed for most of three days and is anxious about losing income. He asked for an X-ray "to see what's broken" and for "something stronger than ibuprofen." His examination showed paraspinal muscle tenderness and limited bending, with normal strength, reflexes and sensation and a negative straight leg raise.

Ruling Out Serious Causes

Foster et al. (2018) note that fewer than 1 percent of people presenting to primary care with low back pain have a serious specific cause such as fracture, infection, cancer or cauda equina syndrome. Clinicians should screen for features that suggest these conditions, such as new bladder or bowel dysfunction or saddle numbness, progressive neurologic deficit, fever, a history of cancer, unexplained weight loss, significant trauma or long-term steroid use. Mr. Hill has none. The review notes that guidelines discourage routine imaging for nonspecific low back pain because it seldom changes recovery, often shows findings common in people without pain and may set off procedures that are not needed.

What the Guideline Recommends

Qaseem et al. (2017) reviewed randomized trials of noninvasive treatments. Because most acute and subacute low back pain improves over time regardless of treatment, they recommend that clinicians and patients first choose nonpharmacologic treatment: superficial heat, which had moderate-quality evidence, or massage, acupuncture or spinal manipulation. When the patient wants medicine, the guideline suggests an NSAID or a skeletal muscle relaxant. The guideline found that acetaminophen did not improve acute low back pain and that systemic corticosteroids were ineffective. For chronic pain, exercise and several mind-body therapies come first, with opioids considered only after other treatments fail and after discussing risks.

Matching Care to Risk

Hill et al. (2011) tested whether sorting patients by their risk of a poor outcome improved results. In 851 primary care patients, the STarT Back tool, a nine-item questionnaire covering pain spread, function and psychological factors such as fear and catastrophizing, assigned people to low, medium or high risk. Low-risk patients received a single clinic session with advice and reassurance; medium-risk patients received physical therapy; high-risk patients received physical therapy informed by psychological approaches. Compared with usual best care, the stratified approach produced greater improvement in disability at 4 and 12 months, saved costs and used fewer resources for low-risk patients.

Stratifying Mr. Hill

His STarT Back score was 3, placing him at low risk of a poor outcome. He agreed with the item about pain spreading only partly and did not endorse the psychological items strongly, although his worry about income was real. Low risk means he is likely to recover with advice, reassurance and simple measures, without referral to physical therapy at this stage.

Plan

I explained that his pain came from muscles and ligaments, that nothing appeared broken and that an X-ray would not change the treatment or speed recovery. We agreed on heat wraps several times a day, naproxen, 500 mg with food twice a day for no more than two weeks, gentle walking several times a day and returning to normal movement as pain allows. He has no kidney disease, ulcer history or heart disease that would make an NSAID unsafe. Opioids were not prescribed; I explained that they do not work better than NSAIDs for acute back pain and carry risks, including dependence. A muscle relaxant was offered for nighttime use but he declined because of drowsiness concerns while driving.

Getting Back to Work

Bed rest slows recovery. Foster and colleagues emphasize staying active and returning to work early, with modifications if needed. I wrote a note for five days of modified duty, limiting lifting to 20 pounds, and taught him to lift with his legs and hold loads close to his body. His employer offers light duty, which protected his income.

Return Precautions

He was told to come back at once if he notices saddle numbness, difficulty passing urine, loss of bowel control, weakness in a leg or fever, and to return in two weeks if he was not improving. Pain persisting beyond four to six weeks would prompt reassessment and referral to physical therapy.

If Pain Persists

Most people with acute low back pain improve substantially within six weeks. If Mr. Hill's pain lasts beyond that, the plan shifts toward exercise therapy and physical therapy, and his STarT Back score will be repeated, since rising worry or fear of movement would move him toward psychologically informed care. Imaging would be reconsidered only if new neurologic findings or red flags appear.

Limits

Most trials in the ACP review were small, and the quality of evidence for many treatments was low. The STarT Back trial was conducted in the United Kingdom's health system. The patient is invented.

Conclusion

Qaseem and colleagues placed heat and other nonpharmacologic care first for acute low back pain, Foster and colleagues showed that serious causes are rare and that imaging, rest and opioids do more harm than good and Hill and colleagues showed that matching care to risk improves outcomes. Reassurance, heat, a short course of naproxen, staying active and modified duty give Mr. Hill the care the evidence supports rather than the care he expected.

References

Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Ferreira, P. H., Fritz, J. M., Koes, B. W., Peul, W., Turner, J. A., & Maher, C. G. (2018). Prevention and treatment of low back pain: Evidence, challenges, and promising directions. The Lancet, 391(10137), 2368-2383. https://doi.org/10.1016/S0140-6736(18)30489-6

Hill, J. C., Whitehurst, D. G. T., Lewis, M., Bryan, S., Dunn, K. M., Foster, N. E., Konstantinou, K., Main, C. J., Mason, E., Somerville, S., Sowden, G., Vohora, K., & Hay, E. M. (2011). Comparison of stratified primary care management for low back pain with current best practice (STarT Back): A randomised controlled trial. The Lancet, 378(9802), 1560-1571. https://doi.org/10.1016/S0140-6736(11)60937-9

Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514-530. https://doi.org/10.7326/M16-2367