Practice Guidelines 2013 Adult Low Back Pain - Management
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
C LINICAL PRACTICE G UIDELINES Capital BlueCross’ Quality Studies Committee adopts or develops clinical practice guidelines based upon existing recommendations of pertinent external specialty organizations or governmental bodies. The most current version of the clinical practice guidelines is available on Capital BlueCross’ Health Plan Home Page via the NaviNet portal at: https://navinet.navimedix.com/main.aspx
The guidelines are not intended to replace the clinical judgment of our participating physicians. They are intended to improve clinical outcomes by providing medical education, reducing variations in care, and helping to guide the proper use of technology. Unless otherwise stated the guidelines are applicable to all Capital BlueCross products, including: Indemnity, PPO, HMO, POS, and SeniorBlue HMO and SeniorBlue PPO and, if applicable, Capital Cares 4 Kids, SpecialCare, FEP PPO.
NaviNet is an independent company providing this provider portal service on behalf of Capital BlueCross.
2011
Provider Manual
Practice Guidelines - 1
Adult Low Back Pain – Recommendations for Management (Revised 2013-0201) The Capital BlueCross Quality Improvement Committee recently reviewed and revised the following Clinical Practice Guideline – Recommendations for the Management of Adult Low Back Pain. The Committee decided to adopt the January 2012 edition of the “Health Care Guideline: Adult Acute and Subacute Low Back Pain” published by the Institute for Clinical Systems Improvement (ICSI). Though regional (Minnesota), ICSI is a very well known and respected non-profit consortium of medical groups and health care insurers. This is just one of over 50 guidelines that they have developed using evidence-based literature. They are independent of any pharmaceutical industry support. The ICSI low back pain document can be found at the following website: https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog _musculoskeletal_guidelines/low_back_pain/ The following are areas of the above document where further comment was recommended:
ICSI has made a significant format enhancement to their scientific documents. All online scientific documents (excluding Order Sets) now have “interactive” capability that allows a user to click on various links in the document and easily navigate from one area to another. There have been major changes since the previous (14th) edition. The title has been expanded in keeping with the larger scope of the guideline. The target population remains adult patients, age 18 and over, in primary care who have symptoms of low back pain or radiculopathy. The focus is not only on the acute (pain for up to 7 weeks) but also on the subacute (pain for between 7 and 12 weeks) phases of low back pain. It describes the ongoing management, including indications for spine specialist referral within the first 12 weeks of onset. The treatment of chronic back pain (>12 weeks in duration) continues not to be addressed in this guideline. New individual algorithms for “red flag” and radicular pain situations were developed and are included in the 15th edition.
The new ICSI guideline aims to: Improve the evaluation and re-evaluation of patients 18 years and older with acute and subacute low back pain diagnosis
Reduce or eliminate imaging for non-specific low back pain diagnosis in patients 18 years and older in the absence of “red flag” or other serious indicators
Delay imaging in patients with radicular pattern pain until after six weeks to allow for resolution that usually occurs within this period
Increase the use of a core treatment plan as first-line treatment. This includes activity, heat, education, exercise and analgesics for patients 18 years and older with low back pain diagnosis. Supplementary considerations for early acute phase treatment, late acute phase treatment and subacute phase treatment are provided.
Limit the use of opioids to the appropriate management of acute or subacute low back pain
Increase the utilization of validated pain and function scales to help differentiate treatment approaches in order to improve the patient’s ability to function
Increase the use of collaborative decision-making to allow patients to make more informed decisions about their care. Focus on shared decisions related to imaging, interventions and surgery for radicular pain diagnosis.
Clinical highlights are the following: Low back pain assessment should include a subjective pain rating, functional status, patient history including notation of presence or absence of “red flags,” psychosocial indicators, assessment of prior treatment and response, employment status, and clinician’s objective assessment
Reduce or eliminate imaging unless “red flag” or other serious indicators exist
Patients with acute or subacute low back pain should be advised to stay active and continue ordinary daily activity as tolerated
A conservative approach should be first-line treatment. Emphasize patient education and a core treatment plan, which includes encouraging activity, use of heat, no imaging, rare use of opioids, anti-inflammatory and analgesic over-the-counter medications and return to work assessment
Specific references to Minnesota’s Workers’ Compensation regulations should be ignored Specific references to other ICSI Health Care Guidelines should be ignored The section “Quality Improvement Support” (pages 34-51) should be ignored Several appendices have either been added or expanded National Imaging Associates, Inc. (NIA) currently provides preauthorization for MRI/CT requests for Keystone Health Plan Central and SeniorBlue HMO Members. Interpretation of Annotations #31 and 34 (page 29) and Appendices G and H (pages 8185) may be influenced by NIA clinical criteria for those Members.
If you do not have Internet access and desire to receive a copy of this information, please contact your Provider Relations Consultant. Periodically, Capital BlueCross reviews documentation of the care provided to our members with low back pain. When auditing medical charts for compliance with the low back pain guideline, the reviewers focus on the following aspects: Acute and Subacute
In the absence of urgent clinical “red flags,” progressing neurologic deficit or persistent disabling pain, advanced imaging studies (MRI, CT scan) are not utilized in the initial evaluation of patients with acute low back pain. If urgent clinical “red flags” do exist or in the presence of progressing neurologic deficit or persistent disabling pain, advanced imaging studies (MRI, CT scan) are ordered. In the absence of urgent clinical “red flags,” progressing neurologic deficit or persistent disabling pain, specialty consultation is not obtained
