Lumbago: revised and improved treatment algorithm for doctors

Doctors in Quebec now have at their disposal a revised and improved tool to guide them in the optimal management of their patients’ back pain.

The Institut national d’excellence en santé et en services sociaux (INESSS) recently put online an algorithm for the management of low back pain with or without radicular pain that incorporates the latest scientific knowledge and best practices in the field.

“Depending on the case, we can look for information that is different and relevant,” explained the head of the chronic pain department at the CHU de Québec-Université Laval, Dr. Anne Marie Pinard, who was part of the multidisciplinary group responsible for updating the algorithm.

“For example, when should we do imaging? When should we refer for rehabilitation? What medication should be given?”

The algorithm for low back pain is one of a number proposed to doctors to guide them in the management of problems such as fibromyalgia or complex regional pain syndrome. It has not been updated for several years.

It is a “practice guide” that primary care physicians can interact with depending on the patient in their presence, said Dr. Pinard.

Unlike the previous version, she pointed out, the algorithm now places more emphasis on acute low back pain, helping doctors to identify possible chronicisation factors, since we now have the knowledge needed to identify those patients in whom acute back pain is likely to develop into a chronic problem. “This is probably the area where the most research has been done,” said Dr. Pinard.

Faced with “acute” low back pain, there are certainly classic things to do right from the start,” she stressed. But we quickly have to ask ourselves some questions: are we moving towards the right treatment to avoid (the patient) ending up on our waiting lists a few years later?

At the forefront of these factors is the whole “psychosocial” aspect of pain, the importance of which is increasingly recognised after having long been neglected.

The algorithm also enables doctors to determine a little more clearly whether their patient’s pain is nociceptive (such as a sprain), neuropathic (such as sciatic nerve pain) or nociplastic (more centralised pain, such as fibromyalgia).

“The algorithm asks us to think about what type of pain is predominant in our patient so that we can apply the best treatment methods from the outset,” explained Dr. Pinard.

The algorithm will also help doctors suggest “valid and free” resources to help patients learn how to manage their pain, such as the gerermadouleur.ca website and the Association québécoise de la douleur chronique. “There really are resources available to help patients understand what’s going on, and what they can do to help themselves,” says Dr. Pinard.

The tool will also support doctors in the decision-making process with their patients, she pointed out, citing as examples the use of painkillers such as opioids and the use of imaging.

It is known, for example, that almost two-thirds of magnetic resonance scans performed on a patient in his sixties will show what she calls a ‘significant anomaly’.

“You have to be careful not to do imaging and discover things that are not clinically significant and then start treating them thinking that they are a problem,” explained Dr. Pinard. The algorithm tells us at what point (imaging becomes relevant), and that can very well support the discussion between the doctor and the families.”

It goes without saying that a patient in pain will always ask for ‘more tests and more medication’ to get better, she said, but the algorithm should make it possible to avoid ‘things that are not useful’.

“It’s becoming easier for doctors to say, ‘Look, I think this is it, but even (the INESSS) has drawn up an algorithm with experts, and that’s their conclusion too,'” said Dr. Pinard.

Avoiding unnecessary care will also ensure that the resources available – which we know are very limited in the current context – are more easily accessible to those who really need them.

Despite the best care, she added, there will always be patients whose pain will eventually become chronic and who will need superspecialised clinics.

“But by ensuring that we take the best possible action supported by the literature in different cases, by recognising the risk factors for chronicity and all that, I think that in the long term we will succeed in improving the condition of many patients, and avoid (them) ending up on our waiting lists or in our waiting rooms for problems of low back pain that could have been managed a little earlier,” she concluded.

–This report by La Presse Canadienne was translated by CityNews