VA/DoD Clinical Practice Guideline: Diagnosis and Treatment of Low Back Pain
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VA/DoD Clinical Practice Guideline: Diagnosis and Treatment of Low Back Pain Sanjog S. Pangarkar, MD1,2, Daniel G. Kang, MAJ, MD3, Friedhelm Sandbrink, MD1, Adam Bevevino, MAJ, MD3, Kirsten Tillisch, MD1, Lisa Konitzer, LTC, PT, DSc, OCS, FAAOMPT3, and James Sall, PhD, FNP-BC3 1
United States Department of Veterans Affairs, Washington, DC, USA; 2VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; 3United States Department of Defense, Washington, DC, USA.
DESCRIPTION: In September 2017, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved the joint Clinical Practice Guideline (CPG) for Diagnosis and Management of Low Back Pain. This CPG was intended to provide healthcare providers a framework by which to evaluate, treat, and manage patients with low back pain (LBP). METHODS: The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine’s tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through September 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. A patient focus group was also convened to ensure patient values and perspectives were considered when formulating preferences and shared decision making in the guideline. RECOMMENDATIONS: The VA/DOD LBP CPG provides evidence-based recommendations for the diagnostic approach, education and self-care, non-pharmacologic and non-invasive therapy, pharmacologic therapy, dietary supplements, non-surgical invasive therapy, and team approach to treatment of low back pain. KEY WORDS: acute low back pain; chronic back pain; sciatica; radiculopathy; Veteran; military; lumbago. J Gen Intern Med DOI: 10.1007/s11606-019-05086-4 © Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019
some point in their lives.1 In 2010, of all diseases and injuries contributing to disability-adjusted life years in the U.S., LBP was ranked third.2 In 2012, approximately 27.5% of adults 18 years and older in the U.S. reported experiencing LBP in the last 3 months.3 More than two-thirds of pregnant women experience LBP and symptoms typically increase with advancing pregnancy4; however, pregnancy-related LBP often resolves itself in the post-partum period and may require specialist care when LBP persists or red flags are present. In a study of U.S. healthcare costs from 1996 through 2013, spending related to LBP and neck pain was the third highest out of 155 conditions. In 2013, the estimated spending related to LBP and neck pain was $87.6 billion, an increase of $57.2 billion over the past 18 years.5 The National Institutes of Health 2014 Natio
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