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In the Clinic |

Low Back Pain

Roger Chou, MD
[+] Article, Author, and Disclosure Information

CME Objective: To review current evidence for prevention, diagnosis, treatment, and practice improvement of low back pain.

Funding Source: American College of Physicians.

Disclosures: Dr. Chou, ACP Contributing Author, has disclosed the following conflicts of interest: Payment for manuscript preparation: American College of Physicians. Consultancy: Palladian. Grants/grants pending: Agency for Healthcare Research and Quality. Royalties: UptoDate. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1032.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

With the assistance of additional physician writers, Annals of Internal Medicine editors develop In the Clinic using resources of the American College of Physicians, including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program).

Ann Intern Med. 2014;160(11):ITC6-1. doi:10.7326/0003-4819-160-11-201406030-01006
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Low back pain has a lifetime prevalence of nearly 80%, and spinal disorders are the fourth most common primary diagnosis for office visits in the United States (1). Low back pain is also costly, accounting for a large and increasing proportion of health care expenditures without evidence of corresponding improvements in outcomes (2). In most patients, the specific cause of low back pain cannot be identified, and episodes generally resolve within days to a few weeks with self-care. Up to one third of patients, however, report persistent back pain of at least moderate intensity 1 year after an acute episode, and 1 in 5 report substantial limitations in activity (3). Because low back pain is common, can lead to substantial disability, and can become chronic, proficiency in evaluation and management is important.

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Inflammatory Back Pain as a Screening Tool
Posted on June 25, 2014
Paramvir Sidhu MD, Mandeep Brar MD
Franciscan Medical Group, Tacoma WA
Conflict of Interest: None Declared
We read Dr Chou’s review (1) on back pain published in your journal with great interest. This article made some excellent points about management of back pain. However, we feel that it did not sufficiently stress the need for differentiating inflammatory from mechanical back pain and contained some inaccuracies with regards to prevalence of ankylosing spondylitis (AS) in patients with back pain in general and inflammatory back pain (IBP) in particular.
Most studies have shown that prevalence of axial spondyloarthritis including AS in patients with chronic back pain is around five percent rather than the much lower prevalence suggested in this article. In this article Dr Chou states that positive predictive value of inflammatory back pain criteria is low in patients with back pain due to low prevalence of ankylosing spondylitis, implying that inflammatory back pain criteria of limited utility. However, studies have shown that prevalence of axial spondyloarthritis including AS in patients referred for further evaluation due to IBP alone is around 15% and even higher in groups with IBP and other risk factors. For example, prevalence of axial spondyloarthritis has been found to be around 1in3 in patients referred for IBP and positive HLA B27 (2,3,4). Therefore, IBP is a very useful clinical screening too for axial spondyloarthritis.
This article also fails to provide the reader a clear algorithm with regards to back pain patients that need referral to a rheumatologist further evaluation for possible axial spondyloarthritis like AS. We recommend that patients with chronic back pain meeting criteria for IBP should be considered for a referral to a rheumatologist for a comprehensive evaluation for inflammatory spondyloarthritis, especially if they have additional risk factors like positive HLA B27, inflammatory bowel disease, uveitis or psoriasis.

1.Chou R. Low Back Pain. Ann Intern Med. 2014;160:ITC6-1.
2.Rudwaleit, M., Metter, A., Listing, J., Sieper, J. & Braun, J. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum. 54, 569–578 (2006).
3.Hermann, J., Giessauf, H., Schaffler, G., Ofner, P. & Graninger, W. Early spondyloarthritis: usefulness of clinical screening. Rheumatology (Oxford) 48, 812–81
4.Weisman, M. H. et al. Development and validation of a case ascertainment tool for ankylosing spondylitis. Arthritis Care Res. (Hoboken) 62, 19–27 (2010).
In response
Posted on July 21, 2014
Roger Chou, MD
Oregon Health & Science University
Conflict of Interest: Funding from the Agency for Healthcare Research and Quality on low back pain topics; royalties from UpToDate; consultant for Palladian Health
Estimates for the prevalence of ankylosing spondylitis in patients with low back pain vary depending on the population studied and the criteria used to define this condition. The estimate of 0.3% is based on estimates from primary care patients with low back pain and unequivocal radiologic changes.1 Using wider diagnostic criteria for axial spondylarthropathy, the prevalence may be as high as 5%,2 but the clinical manifestations and severity of symptoms varies substantially for this group of conditions. Although risk assessment instruments may be useful for identifying persons at higher risk for ankylosing spondylitis, more research is needed to understand their performance in clinical practice. However, based on a sensitivity of 0.67 and specificity of 0.95, resulting in a calculated positive likelihood ratio of about 13.4, the estimated positive predictive value in a population with 1% prevalence of ankylosing spondylitis would only be about 12%. Even in a population with a prevalence of 5%, the majority of patients with positive results on the screening instrument would not have ankylosing spondylitis. As noted, the presence of multiple risk factors for ankylosing spondylitis in persons with chronic back pain may warrant additional evaluation, though the purpose of the article was not to provide detailed diagnostic algorithms for all conditions potentially associated with low back pain.

1Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992;268:760-5.
2Underwood MR, Dawes P. Inflammatory back pain in primary care. Br J Rheumatol 1995;34:1074-7.
3Weisman MH, Chen L, Clegg DO, Davis JC, Dubois RW et al. Development and validation of a case ascertainment tool for ankylosing spondylitis. Arthritis Care Res 2010;62:19-27.
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