July 1996 Bulletin

Academy to test low back pain algorithms

Consultant urges activist approach to collections

The Academy's efforts to develop clinical guidelines reached a milestone with the approval by the Board of Directors in May for limited-use field testing of Phase I and Phase II Low Back Pain algorithms.

Jointly developed by the Academy and the North American Spine Society (NASS), the algorithms offer a clinically-realistic approach to the treatment of acute low back pain, said David Wong, MD.

Dr. Wong is chairman of the multispecialty work group that developed the algorithm for the Academy's Task Force on Clinical Algorithms in cooperation with the Committee on Clinical Policies. Representatives of the Board of Councilors, American Association of Neurological Surgeons, American College of Physical Medicine and Rehabilitation, American Academy of Family Practice, and NASS also participated.

Improves in 4 weeks

Phase I focuses on the four-week period when this commonly occurring form of back pain will most likely improve spontaneously or with activity modification, and non-narcotic drugs. Phase II provides a reasonable approach to further evaluation and treatment by a musculoskeletal specialist.

The Phase I algorithms give first contact physicians a sequential program for evaluating and conservatively treating one of the most common problems encountered by the public. The algorithm does not address all possible conditions associated with low back pain, only those that account for a significant portion of initial visits to a physician.

If the initial evaluation does not indicate certain "critical exclusionary diagnoses" such as cauda equina syndrome, fracture, neoplasm or infection, the physician is advised to proceed with approximately four weeks of a combination of activity modification, medication, self-applied thermal modalities, and physical therapy.

If the exclusionary diagnoses are suspected, a workup for that specific diagnosis is indicated. The patient then would no longer follow the spine algorithm.

If exclusionary diagnoses are not suspected and the condition is not resolved with initial treatment, the physician can re-evaluate the history, physical examination, and imaging tests and modify the conservative treatment. If the condition is still unresolved, the physician has the option of continuing treatment if he or she has the necessary expertise, or refer the patients to a musculoskeletal specialist.

Phase II deals with treatment of patients referred to musculoskeletal specialists. The definition of a musculoskeletal specialist is "any licensed medical doctor who has completed a resident training program focused on the management of musculoskeletal conditions, including, but not limited to: orthopaedic surgeons, neurologists, neurosurgeons, and rheumatologists."

Review 2,000 articles

The task force developed the algorithms following an extensive literature review of more than 2,000 articles and a series of meetings in which the information from the literature was transformed into draft "decision trees." This was supplemented by consensus opinion of the work group. Multiple iterations of the algorithms were reviewed by the participating societies and individual experts. Comments were reviewed by the spine task force and changes were made in the algorithms where appropriate.

"The algorithms are not written in stone," Dr. Wong said. The algorithms will undergo limited-use field testing in a variety of settings, including managed care organizations, workers' compensation environments, clinics, and fee-for-service organizations. Currently two managed care organizations and two clinics with a workers' compensation focus have expressed interest in the program.

The field testing will begin in the fall and last about one year. The algorithms also will be published in Spine in order to solicit comment from a wider universe of clinicians.

Discussions are underway to investigate placing the algorithms on CD-ROM. The CD-ROM with appropriate case studies for each differential diagnosis,
including diagnostic visuals such as X-rays, photographs, etc., could be utilized in a variety of ways, including as a self-learning tool with CME credit.

Chronology

In July 1986, the Board of Directors charged the Coordinating Committee on Health Policy to recommend a process to establish guidelines for quality orthopaedic care. A model format and the first set of draft polices were developed.

The Board appointed the Task Force on Clinical Policies to refine the first six policies in July 1988 and adopted the policies a year later. In March 1991, the Board adopted four new clinical policies and in May 1992, approved five more clinical policies. From July 1991 to June 1992, the Committee on Clinical Policies developed disease-based clinical policies.

In July 1993, Board approved creation of a task force to develop clinical algorithms outlining musculoskeletal care for diagnoses encountered by primary care providers and appropriately managed by orthopaedic surgeons.


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