The Quiz: Low Back Pain

Low back pain is one of the most common health complaints. Fortunately, in most patients, it is a transient problem that will resolve on its own regardless of treatment.

Unfortunately, many people-including many medical professionals-believe that there is virtually always identifiable underlying pathology that accounts for the pain. Because of this belief, many patients with low back pain undergo needless tests that provide little useful information about etiology and may lead to additional invasive treatments, such as surgery, that often do not resolve the pain and can potentially exacerbate it.

1. Which of the following is considered a “red flag” that indicates low back pain may be related to a serious underlying problem that requires further workup?

A. Unexplained weight loss

B. Change in bowel or bladder control

C. Recent trauma to the back

D. Fever

E. All of the above

2. If no “red flags” are present, what would best describe the usefulness of MRI for patients with low back pain?

A. For most patients, MRI scans have been useful in identifying the etiology of the low back pain and in providing information on treatment options

B. For many patients with low back pain, MRI scans offer little if any useful information on etiology or treatment options

C. No patient should be treated for low back pain until an MRI scan has been performed

D. A and C

The following questions are based on the newest American College of Physicians Clinical Practice Guideline on low back pain and the literature reviews that provide supporting evidence for it.^1-3

3. For acute (of less than 4 weeks’ duration) and subacute (of 4 to 12 weeks’ duration) pain, the recommendation is treatment with all but which of the following?

A. Superficial heat

B. Massage

C. Epidural corticosteroid injection

D. Acupuncture

4. If pharmacological treatment of acute or subacute back pain is desired, which medication is suggested?

A. An opioid analgesic

B. An NSAID

C. Acetaminophen

D. A tricyclic antidepressant

E. An oral corticosteroid

5. For chronic low back pain (pain that lasts for more than 12 weeks), treatment is started with an analgesic medication.

A. True

B. False

6. A number of psychological treatment modalities are beneficial for the management of chronic low back pain.

A. True

B. False

7. Tai chi and yoga can be beneficial for chronic low back pain.

A. True

B. False

8. If nonpharmacological therapies do not provide sufficient relief of chronic low back pain, treatment is initiated with:

A. An opioid analgesic

B. An NSAID

C. A benzodiazepine

D. A skeletal muscle relaxant

9. Which of these drugs is recommended as second-line treatment for the management of chronic low back pain?

A. Duloxetine

B. Pregabalin

C. Tramadol

D. A and C

E. All of the above

10. With the use of opioids other than tramadol for chronic low back pain, caution must be exercised because of which of the following problems?

A. There are no long-term studies on the use of these drugs

B. At best, the use of these drugs yielded only modest benefits

C. Identification of serious problems associated with their use (eg, abuse, addiction) was not a goal of any of the studies

D. All of the above

11. Which of the following is correct?

A. Two analgesics are more likely to provide relief for low back pain than a single analgesic

B. There is limited information as to whether two analgesics provide more relief than one alone

C. There is extensive research comparing the various analgesics with each other

D. There is little research comparing the various analgesics with each other

E. A and C

F. B and D

12. There is sufficient evidence to differentiate between treatment of low back pain with and without a radicular component.

A. True

B. False

13. Which would best describe the quality of the current evidence on the treatment of low back pain?

A. Virtually all evidence is of high quality

B. It is a mixture of high and moderate quality

C. Virtually all evidence is of moderate quality

D. It is a mixture of low and moderate quality

14. There is sufficient information to guide practitioners as to which of the recommended treatment modalities is most likely to help an individual patient and should be tried first.

A. True

B. False

15. Treatment choices for chronic low back pain should be made based on which of the following criteria?

A. Those that have the best safety and tolerability profile

B. Those that are likely to provide the quickest relief

C. Those that are least expensive

D. A and C

THE QUIZ/Low Back Pain 

1. Answer: E. All of the above

Unexplained weight loss may indicate cancer.⁴

2. Answer: B. For many patients with low back pain, MRI scans offer little if any useful information on etiology or treatment options

It is well established that for many patients, there is little correlation between MRI findings and the presence or severity of the pain.⁵

3. Answer: C. Epidural corticosteroid injection

The guideline found evidence to support the use of superficial heat, massage, and acupuncture for the treatment of acute and subacute low back pain but not epidural corticosteroid injections.

4. Answer: B. An NSAID

Despite the widespread use of acetaminophen, the guideline found little evidence that it was beneficial for acute or subacute low back pain.

5. Answer: B. False

The guideline recommends that nonpharmacological treatments be tried first before starting an analgesic medication.

6. Answer: A. True

The guideline recommends the use of a number of psychological treatment modalities, including mindfulness-based stress reduction, progressive relaxation, biofeedback, and cognitive behavioral therapy.

7. Answer: A. True

Recent evidence supports the use of tai chi for chronic low back pain. The evidence also strengthens previous findings regarding the effectiveness of yoga.

8. Answer: B. An NSAID

However, it is worth noting that the review found that NSAIDs provided fewer benefits for chronic low back pain than previously thought.

9. Answer: D. A and C (duloxetine and tramadol)

It is worth noting that duloxetine is an SNRI and that tramadol is an SNRI combined with a weak opioid.

10. Answer: D. All of the above

Although opioids are often prescribed for chronic low back pain, there is limited evidence for their effectiveness. There is a dearth of studies on their use for chronic pain of any type; many studies do not identify potentially significant adverse effects associated with their use, most notably the risk of abuse and addiction. Although tramadol contains an opioid, it is a combination drug that also contains an SNRI, and most of the analgesia it provides appears to be related to the action of the latter.

11. Answer: F. B and D

An area about which we have limited information is whether two analgesics provide more relief than one alone. Moreover, there is insufficient head-to-head research comparing the various analgesics with each other.

12. Answer: B. False

Most of the studies did not identify whether patients suffered from a radicular component.

13. Answer: D. It is a mixture of low and moderate quality

The guideline highlighted that the evidence provided by most of the studies on the management of low back pain is of limited quality, which indicates how much we still don’t know about the best treatments for low back pain.

14. Answer: B. False

The guideline found there was little information to provide guidance as to which modality was most likely to work for an individual patient.

15. Answer: A and C

Because there is little research that compares the efficacy of the various treatments, the best course for physicians is to base treatment choice on the therapies they believe are least likely to be harmful to the patient at the lowest cost.

References:

1. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med. 2017;166:493-505.

2. Chou R, Deyo R, Friedly J, et al. Systemic pharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med. 2017;166:480-492.

3. Qassem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514-530.

4. Choosing Wisely. Back Pain Tests and Treatments. 2016. http://www.choosingwisely.org/patient-resources/back-pain-tests-and-treatments/. Accessed April 11, 2017.

5. Chou R, Qassem A, Owens DK, et al. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154:181-190.