#368 Back Pain Update with
Dr. Austin Baraki

November 28, 2022 | By Cyrus Askin

Video

A Rational Approach: Who to Image, How to Treat, and More!

Back pain is one of the most common concerns our patients bring to us in the outpatient setting.  It’s a lot more complicated than rest, ice, and NSAIDs!  Fortunately, we have pain expert, strength coach, and academic internist Dr. Austin Baraki (Austin Baraki, MD (@AustinBaraki) / Twitter) to help us develop a comprehensive, patient centered approach to help our patients manage their pain and lead healthier lives. Take control of your patients’ back pain! 

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• Credits
• Producers: Isabel Valdez, PA-C & Cyrus Askin, MD 
• Writer, Cover Art and Infographics:  Isabel Valdez, PA-C
• Show Notes: Cyrus Askin, MD
• Hosts: Matthew Watto MD, FACP;  Isabel Valdez, PA-C
• Reviewer: Molly Heublein, MD
• Showrunner: Matthew Watto MD, FACP
• Technical Production: PodPaste
• Guest: Austin Baraki, MD

Sponsor: Grammarly 

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CME Partner: VCU Health CE

• Show Segments
• Intro, disclaimer, guest bio
• Guest one-liner, Picks of the Week
• Case from Kashlak
• Introduction to Back Pain
• Eliciting the Patient’s Story
• Risk Stratification, Intro to Red Flags,  and and the STarT Back Tool 
• The Importance of Language and Patient-Centered Outcomes
• A Deeper Dive into Red Flags
• Setting Expectations for Care
• Therapeutics for Back Pain – Does anything work?
• The Exercise Prescription
• The Beast That is Chronic Back Pain 
• Chronic Back Pain Specifics: Complementary Therapies, Traditional Treatments & Referral
• Take Home Points
• Outro

Back Pain Pearls

• Perform risk stratification for biomedical conditions requiring urgent imaging or surgical evaluation, as well as psychosocial factors that impact who will likely recover well on their own, or who may require more intensive support. The STarT Back tool is a helpful guide for this.
• Provide education and advice regarding prognosis and self-management strategies, with an emphasis on more active strategies (e.g., physical activity and exercise) over passive strategies (e.g. rest, massage, etc.).  Explicit exercise prescriptions are more effective than simply telling your patients to “move”.
• Reserve imaging for suspected serious underlying pathology that would require an immediate change in management, such as severe neurological deficits/weakness, spinal infections, malignancies, or fractures. Radicular pain in the absence of neurological deficits does not require immediate imaging, and is managed similarly to non-specific back pain.
• Be VERY mindful of the language you use when you discuss back pain with your patients, as the specific diagnostic labels you assign, or the way you explain imaging studies and prognosis can have a significant impact on your patients’ perception of their back pain, their expectations, and their long-term outcomes.
• The Pain-Calculator can guide evidence-based shared decision making regarding the use of medications for back pain.
• Many patients believe any degree of pain reflects damage or injury, and must therefore be avoided. Instead, it is important to emphasize that it is not necessary to be “pain-free” before returning to movement and activities the person enjoys.

Back Pain Update – Show notes

Approaching Acute Back Pain

You WILL see this in the clinic – back pain is the leading cause of disability in the U.S., and treatment for back pain and related spine disorders now constitutes the most expensive medical problem (Hartvigsen 2018, Stevans 2021).  Although it is so common, back pain is quite complicated. Instead of viewing back pain solely through a structural/mechanical paradigm, Dr. Baraki urges us to view it using a biopsychosocial framework, which accounts for non-mechanical factors that can influence pain, function, and recovery outcomes such as social determinants or psychological stressors (Yang 2016).

The first step in evaluating patients with acute low back pain is to risk stratify patients that may have a serious process that necessitates urgent action or may progress and cause serious disability.  This evaluation, commonly framed through the lens of “red flags”, is aimed at determining whether urgent imaging or surgical evaluation is warranted.  When evaluating the patient, Dr. Baraki emphasizes the importance of pre-test probability and environment (for example, a patient with persistent low back in the clinic is different from a patient in the ED following a high-speed motor vehicle collision).   A significant proportion of patients presenting with back pain may have one or more “red flag” features, even though they do not have a serious underlying cause for their back pain.

Commonly cited red flags include: 

• Recent trauma (especially major, such as a serious motor vehicle crash)
• Older age 
• Urinary/bowel incontinence
• History of malignancy or unexplained weight loss
• Chronic corticosteroid use
• Bilateral “sciatica”
• Recent infections 
• Injection drug use (Will 2018)

In Dr. Baraki’s opinion, motor weakness is a significant finding that should raise alarm, as opposed to paresthesias or radicular pain which are not necessarily as concerning.

In the clinic, 90-95% of patients will not have a single, nociceptive source for their pain.  For the primary care clinician, these can be initially classified under the category of non-specific low-back pain (Bardin et al, 2017).

The next step, and arguably equally important for most patients, is a psychosocial evaluation aimed at finding  “yellow flags”.  Dr. Baraki tries to let the patient tell their story in an open-ended manner in order to fully elicit their beliefs, concerns, and expectations about their condition.  Focus on the whole patient, rather than viewing them as “just a spine.”  This means looking for clues from other organ systems that may indicate the patient’s back pain is a symptom of a bigger or different issue.  He also inquires about things like sleep, stress, and other general health factors to help identify other contributors or barriers to recovery (for example, impaired sleep can contribute to increased pain intensity).  Dr. Baraki recommends the STarT Back tool as a guide to risk stratification of those patients with back pain who might need more support, such as earlier referral for physical therapy, pain psychology, or other interventions (Hill et al, 2010; Beneciuk et al, 2013).

Physical Exam

The goal of a physical exam is primarily to determine if the patient’s presentation is consistent with serious systemic disease and/or requires surgical intervention. In Dr. Baraki’s opinion, using the physical exam to come to a specific diagnostic label is less important for patients without a serious underlying cause of their pain (i.e.., those who would typically be classified as “non-specific low back pain”).  There are many exam maneuvers which purport to differentiate one structural cause from another, but if all are non-urgent / non-surgical and can be managed similarly up-front, differentiating one from another is not a good use of time for the primary care clinician.  However, the physical exam and physical touch can help establish a strong clinician-patient relationship, which we know is incredibly important!

A common finding of “paraspinal tenderness” is actually far LESS diagnostically useful than we think (Simel DL & Rennie D, 2009)!  Exam maneuvers that can be helpful include gait/strength testing, reflex assessment, and to an extent, sensory testing – although there again, sensory abnormalities do not immediately portend badness (as opposed to motor deficits which are much more worrisome)!  Assessment of other organ systems – cardiovascular, GI, renal, etc. – should be informed by the patient’s history (such as pyelonephritis causing back pain – which would be expected to have associated GU or systemic symptoms).  Range of motion testing and soft tissue tenderness that are commonly assessed, although these are not diagnostically informative, per Dr. Baraki.

Overall the goal is to facilitate symptom relief and independent daily function. It may make us feel better as clinicians to use a specific diagnostic label and patients may want this – but in actuality, much of back pain is multifactorial and difficult to attribute to a single nociceptive source. Using more benign terms to describe non-specific low back pain such as an “episode of back pain” or “lumbar sprain”, as opposed more pathologic terms such as “degeneration” or “disc bulge” has been shown to reduce patients’ perception of the “seriousness” of their condition, improves expectations of recovery, and reduces their need for imaging and second opinions (O’Keefe 2022). Clinicians are susceptible to similar labeling biases! Simply changing the phrasing of a radiology report can prime a clinician to either view the same finding as more benign, with a better prognosis, versus a more serious finding prompting further workup and aggressive management (Rajasekaran 2021, Fried 2018).

A Rational Approach to Imaging

When a patient presentation warrants imaging, there are several options.  X-Ray can be helpful to identify basic bony abnormalities such as a compression fracture, but lack diagnostic sensitivity for many conditions.  In the majority of cases where serious underlying pathology is suspected (e.g. new-onset motor weakness, concern for spinal infection, or cancer) MRI is recommended (Will 2018).  If MRI is not an option, CT may be a suitable substitute in certain situations, but this should be determined in concert with a radiologist.  Dr. Baraki reminds us that ordering and interpreting imaging requires a suspected pathology to inform it.  In other words, it is inappropriate to ask an imaging question of a radiologist without a specific differential diagnosis, particularly given how common it is to observe various spinal structural abnormalities in asymptomatic patients (Brinjiki 2015).

Appropriate communication is key in relaying imaging findings.  It is incumbent upon the clinician to avoid unnecessary biomedical jargon that may falsely bias the patient into thinking something that is age-related or benign is actually much more worrisome, or that it is unsafe for them to move (Rajasekaran 2021, Fried 2018).

Pharmacotherapy – Overview

In Dr. Baraki’s expert opinion, the majority of patients seen in the clinic do not routinely need pharmacotherapy for their back pain (Traeger 2019). In more severe cases, a multi-modal pain regimen should be considered.  This can include acetaminophen, NSAIDs, topical therapies, “muscle relaxants”, and rare use of opioids. Corticosteroid injections can be used for acute radicular back pain, but in Dr. Baraki’s expert opinion, systemic steroids should be avoided given their lack of evidence for benefit and increased risk for complications like infection, venous thromboembolism, and hyperglycemia.  The goal of these therapies should be to facilitate movement, physical activity, and sleep, as this will in turn facilitate functional recovery and reduce the risk of persistent disability.

Relevant psychosocial factors should be elucidated and addressed. Given the favorable natural history of most episodes of back pain, tincture of time and reassurance may be the most effective “medicine” for many patients. Even intervertebral disc herniations – which carry a significant amount of psychological baggage with them – have a favorable natural history, with evidence of objective reabsorption/healing on their own (Chiu 2015). This reality can equip clinicians with tools to assuage patient fears in the absence of concern for a serious underlying cause of back pain.

In summary, Dr. Baraki recommends using shared-decision making with patients regarding the use of medications to facilitate specific goals and specific endpoints; stressing the use of medications to facilitate movement and sleep. He also recommends that clinicians who treat back pain review a few resources to help reach patient-centered decisions on management. The PEER simplified chronic pain guideline is an excellent resource from the College of Family Physicians of Canada that discusses management of chronic low back, osteoarthritic, and neuropathic pain in primary care.  They have a visual tool for shared-decision making that can be reviewed during a consultation and is found at: Low Back Pain – PEER Pain Calculator (pain-calculator.com).  

Pharmacotherapy – The Nitty Gritty 

Acetaminophen and NSAIDs

Acetaminophen is often a first line therapy for back pain (or any pain for that matter) despite a lack of good evidence for efficacy.  NSAIDs, such as ibuprofen or naproxen, can be helpful medications in the setting of acute back pain, assuming no strong contraindications (Traeger et al, 2018).

Muscle Relaxants

Dr. Baraki reminds us that “muscle relaxers” tend to be centrally-acting medications with sedative effects, and do not have specific effects on “relaxing muscles”.  While these medicines may help reduce pain intensity in the short term, they often have a lot of side effects including significant sedation, orthostasis, cardiovascular depression and even profound hypotension (Will 2018, Chou 2017). Overall, Dr. Baraki views the role of analgesics and “muscle relaxants” as tools to facilitate movement AND sleep, which are both very important when it comes to recovery.  These drugs do not, in and of themselves, “fix” back pain!

SNRIs and Gabapentinoids 

SNRIs – specifically duloxetine – have data showing duloxetine may help with back pain in the chronic phase, although this is a small effect (Chou 2017).  Medications like gabapentin and pregabalin have been used by many clinicians for radicular back pain, however, the evidence here is very poor and these also have many potential adverse effects (Chou 2017). 

Opioids

 Dr. Baraki recommends STRONGLY against the use of opioids in most patients due to their adverse effect profile, potential for dependence, and potential for opioid-induced hyperalgesia (Kum et al, 2020). 

Topical Treatment Options 

Other interventions which commonly come up include, cold packs, hot packs, topical NSAIDs /capsaicin/lidocaine and CBD products. All of these interventions have minimal, low-quality evidence per Dr. Baraki.  CBD specifically has some studies related to back pain (Xantus et al, 2021) but the generalizability is suspect.  His general understanding of the literature is that these topical treatments are generally not harmful, there may be some minor signal for pain-relief and they are certainly going to be safer than chronic opioids.  He has no strong objection to any of these in the context of using them to facilitate movement.

Steroid Injections

Epidural corticosteroid injections appear to provide a small, short-term effect on pain intensity for radicular pain (Rivera 2018).  In non-radicular pain, epidural and facet joint steroid injections perform similarly to placebo injections (Chou 2015, Stout 2010).

Passive Therapies

Dr. Baraki’s professional opinion is that spine manipulation, dry needling and acupuncture can be relatively benign, and if the patient feels they are helping, he doesn’t strongly recommend against their use as part of a more comprehensive, active management plan. However, he says there simply is a paucity of quality data for the efficacy of these interventions, and that many practitioners offering them predicate their interventions on a narrative that conflicts with the available evidence (for example, a spine being “out of alignment” requiring manipulation in order to “restore alignment”).

Braces, Belts, and Insoles

Unfortunately, there is no data to support the use of braces, belts and insoles in all-comers for chronic back pain (Sowah et al, 2018). If a patient is using something and they feel it helps and allows them to move with less pain, that’s excellent!  However, Dr. Baraki doesn’t broadly recommend these interventions.  Similarly, posture trainers/ practitioners that put intense focus on posture are not supported by evidence.

Back Pain & Movement

Only about 20% of patients who present to clinics with low back pain are given education related to self-management strategies (Williams et al, 2010).  This is a huge issue!

There are no exercises that are uniquely beneficial, or that are critical to avoid, for routine back pain management (Owen et al, 2019). This means that we have near-infinite options to employ to get patients moving. So, Dr. Baraki recommends tailoring your recommendation to the patient’s interests, current fitness level, limitations, and what resources, exercise equipment, etc. they have access to.  The key is that the clinician and patient must forge a partnership with the goal of determining a physical activity / exercise prescription that is compelling, feasible and has a good chance of adherence.  An explicit “Physical Activity Prescription” can be helpful to deliver this recommendation to patients. Finally, it is important that patients know it is safe for them to move, and that they do not need to wait until they are pain-free to resume movement and valued activities.

Chronic Back Pain – Where Things Get Tricky

When seeing a patient with chronic back pain, try to determine why they are presenting “today” – i.e. what has changed – and what are their pre-visit beliefs, what have they heard/been told, and what are their expectations moving forward.  For example, many patients believe any degree of pain reflects ongoing tissue damage and thus, movements that cause any degree of pain must be avoided. Dr. Baraki reminds us that this leans on the antiquated biomedical model for pain rather than a more modern biopsychosocial perspective, which is more in line with current evidence.  A pearl he leaves us with is that absolutely pain-free movement may not always be a realistic goal, so it is important to facilitate patients’ confidence in the belief that they are safe to move, even if it is associated with discomfort.

Time to Refer

Once you are at the end of your tether, Dr. Baraki agrees with the team that referral to PM&R may be reasonable to get another opinion/perspective.  They can also be helpful in bridging the discussion between medical and surgical management.  It’s important to recognize that in carefully selected patients there MAY be a place for surgery, however, it’s an option that should generally be reserved for patients who have undergone evidence-based, non-invasive management with an emphasis on active rehabilitation strategies.

Take Home Points:

This great clinical resource from the Aussies provides a comprehensive, evidence-based guide for the assessment and management of back pain!

Links

1. How Minds Change (book)
2. You Are Note So Smart (podcast)
3. Six the Musical(musical)
4. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis (website)

Goal

Listeners will develop a framework to approach low back pain in the acute and chronic setting, to include strategies for risk stratification, setting expectations, and providing therapy – namely an exercise prescription – in order to combat low back pain.

Learning objectives

After listening to this episode listeners will…  

1. Appreciate the impact of low back pain the the primary care setting
2. Recognize red flag findings concerning for more serious illness
3. Integrate validated risk stratification with treatment tools to help work with patients that have back pain
4. Develop a patient-centered approach to discussing back pain, with emphasis on expectation management and understanding that patients relationship with their back pain and the impact of pain on their day-to-day life
5. Realize that many of the therapeutic options available for low back pain are not particularly effective
6. Master the use of analgesia as a primary means to facilitate movement and allow for quality sleep, recognizing that these are the two greatest determinants of recovery
7. Be introduced to chronic back pain as a somewhat distinct entity from acute back pain, including how to approach chronic back pain and what referral options may exist

Disclosures

Dr. Baraki reports working for Barbell Medicine LLC. as a potential conflict of interest.  The Curbsiders report no relevant financial disclosures. 

Citation

Valdez I, Askin C, Baraki A, Williams PN, Watto MF. “#368 Back Pain Update. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list November 28, 2022.