a b s t r a c t

Objectives: Low back pain leads to more than 4.3 million emergency department (ED) visits annually. De- spite the number of ED visits for LBP, emergency medicine societies have not established clear guidelines for the evaluation and care of these patients. This study aims to describe patterns in the evaluation, treatment, and out- comes of patients presenting to an urban, academic ED for atraumatic LBP. Methods: We prospectively identified a convenience sample of patients presenting with LBP to the University of Utah Hospital ED between January 2017 and June 2018. We collected baseline demographic information and cal- culated the patient-reported outcomes Measurement Information System Physical Function Short Form 12a (PROMIS PFSF-12a) score to assess patient function and mobility (50 = average PROMIS PFSF-12a score, with higher scores indicating better function). We contacted patients 6 weeks after the ED visit to assess outpatient follow-up and functional outcomes.

Results: Over the 18-month study period, 103 patients presented with a chief complaint of LBP and agreed to par- ticipate in the study. Average age of the cohort was 48.5 years (SD = 18.3) and 55 (53.4%) were female. Notably, 61 patients (59.2%) had been seen previously in the ED for LBP and 32 (31.1%) had received an opioid for LBP in the preceding 3 months. In the ED, 35.9% of patient received an opioid while 18.5% had an Opioid prescription at discharge. While in the ED, 37 (35.9%) had an x-ray and 47 (45.6%) underwent computed tomography or mag- netic resonance imaging. At 6-week follow-up, 22 of 68 (32.4%) patients reported having missed work due to pain. PROMIS PFSF-12a score improved from 32.2 (“low” range) at time of ED visit to 42.0 (“low-average” range) at the 6-week follow up. Regarding outpatient follow-up after the ED visit, 22 patients (21.4%) saw a pri- mary care provider, 12 patients (17.8%) saw orthopedics or neurosurgery, and 8 patients (11.8%) attended phys- ical therapy.

Conclusions: Patients receiving ED care for LBP had a significant improvement in PROMIS PFSF-12a scores 6 weeks after the ED but return to function continued to lag despite interventions. Imaging patterns, medication prescrip- tions, and outpatient follow-up varied widely, emphasizing the needs for clear guidelines and treatment path- ways for ED patients with LBP.

(C) 2022

1. Introduction

low back pain has been the leading cause of years lived with disability for over 3 decades [1]. Estimates vary widely but lifetime prev- alence of low back pain is between 49 and 90% with a very high recur- rence rate [2-4]. Given this, it is not surprising that the US spent an estimated $100 billion in 2006 between direct health care costs and lost productivity [2]. The emergency department (ED) is a common first point of healthcare contact for LBP sufferers with more than 4.3 mil- lion ED visits annually [5].

* Corresponding author at: Department of Emergency Medicine, University of Utah School of Medicine, 30 N. 1900 E. 1C26, Salt Lake City, UT 84132, United States of America.

E-mail address: [email protected] (T. Madsen).

Despite the number of ED visits for and the societal costs of LBP, emergency medicine societies have not established clear guidelines for the evaluation and care of these patients. American College of Emer- gency Physicians’ choosing wisely initiative recommends against imag- ing atraumatic low back pain without the typical highly concerning features but does not offer suggestions for acute symptomatic manage- ment [6]. The guidelines that exist for primary care providers are diffi- cult to implement in the ED given the inherent lack of follow up with the same provider and higher prevalence of surgical or traumatic pa- thology [7]. Additionally, patients may choose the ED over other settings due to expectations that their workup will include imaging and that treatment will include medications to relieve their symptoms [8]. More information is needed to characterize the patients who access the ED for non-traumatic LBP. Such information could help ED providers

https://doi.org/10.1016/j.ajem.2022.06.048

0735-6757/(C) 2022

better balance the goals of patient satisfaction with the national goals of reducing inappropriate imaging and opioid use [9-13].

This study aims to describe the existing LBP pathways with particu- lar attention to patterns in the evaluation, treatment, and Short-term outcomes of patients presenting to an urban, academic ED for atraumatic LBP.

1. Methods
   1. Study design and setting

We prospectively identified a convenience sample of patients pre- senting with musculoskeletal conditions including LBP to the University of Utah Hospital ED between January 2017 and June 2018. The Univer- sity of Utah ED is an urban, academic ED located in Salt Lake City, Utah, with approximately 55,000 patient visits per year. At baseline, we collected patient demographic information as well as self-report measures of pain and physical function. At 6 week follow up, a research associate (RA) contacted the patient by phone and again obtained mea- sures of pain and function as well as information on health care utiliza- tion since the baseline ED assessment. The study was approved by the University of Utah Institutional Review Board.

• 1. Selection of participants

We performed this study in the context of a Physical therapy (PT) in the ED clinical pilot program in which a physical therapist (PT) was available to evaluate patients with primary musculoskeletal complaints in the ED. A PT was present in the ED approximately 25 h per week dur- ing the study period and was available to evaluate and treat ED patients if consulted by the treating ED provider. The PT was not part of the study but was present as part of a clinical program in cooperation between the ED and the PT department. When consulted by the treating provider, the PT would perform patient assessment and intervention as deemed appropriate. The PT would then provide outpatient resources and refer- rals in consultation with the treating provider. We make note of the PT’s presence in the ED given the unique nature of this clinical resource, but our study did not aim to assess outcomes related to the ED PT pilot pro- gram.

Trained undergraduate RAs were present in the ED approximately 80 h per week during the study period and identified patients with a musculoskeletal complaint based on the triage chief complaint. RAs screened all ED patients age 18 and older who met enrollment criteria regardless of whether they participated in a PT assessment during the ED visit.

We performed a subgroup analysis of patients specifically present- ing for LBP. A study investigator (JM) reviewed all patients with LBP and excluded those who had an underlying condition which clearly ex- plained the LBP (e.g., Cauda equina syndrome, fracture, urinary tract in- fection). For those patients who were not excluded based on the initial review, a second investigator (TM) reviewed the medical record to con- firm that the patient did not have an underlying condition to explain the patient’s LBP.

• 1. Demographic variables

The RA recorded the patient’s self-reported age in years, gender, and race/ethnicity. We noted whether the patient was working their regular duty job and whether the reason for the ED visit was due to a work- related injury. RAs also recorded whether the patient had used an opioid prescription for any reason in the 3 months before the ED visit and whether the patient had a previous visit to the ED for the same reason as the current visit.

• 1. Outcome variables

We utilized the Patient Reported Outcomes Measurement Informa- tion System (PROMIS) Patient-Specific Functional Scale (PSFS) 12a to assess patient functional status. The primary study outcome was the change in the PROMIS PFSF-12a scores between the initial visit and 6-week follow-up. A validated tool, the PROMIS PFSF-12a is composed of 12 items, with higher scores indicating better physical function. PROMIS asks patients to rate their well-being in terms of physical func- tion, pain, quality of life and perception of treatment efficacy. This mea- sure augments objective data by assessing the patient’s perceived clinical benefit from treatment. Raw scores are rescaled into a T-score for each individual with a standardized mean score of 50 and a standard deviation (SD) of 10. A person with a T-score of 40, therefore, is one SD below the population mean of 50. An individual’s change of 10 points on the PROMIS scale would represent a significant clinical change equal to one SD of the population [14].

To measure the patient’s current level of pain, the patient completed an 11-point numeric pain rating (NPR) scale [15]. We recorded pain medications (opioid, NSAID, Muscle relaxant, oral steroid, acetamino- phen and any mental health drug) provided during the ED visit and pre- scribed upon discharge. We noted imaging performed during the ED visit, including x-ray, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound. We recorded LBP-relatED referrals pro- vided at discharge, including referrals for PT, primary care, physiatry, or- thopedic surgery, neurosurgery and mental health.

Study RAs contacted patients at least 6 weeks after the ED visit and noted whether the patient had undergone any LBP-related imaging or received additional prescriptions after the ED visit. We also recorded whether the patient had returned to the ED or had attended any LBP- related follow-up visits to an orthopedic or neurosurgeon, physical ther- apist, chiropractor or physiatrist, urgent care provider, or massage ther- apist. The patient also completed the NPR and PROMIS PFSF-12a.

• 1. Statistical analysis

We utilized means with standard deviations (SD) and frequency counts with percentages to characterize continuous variables and cate- gorical variables, respectively, at baseline and 6-week follow-up. We utilized paired t-tests to assess the change in PROMIS PFSF-12a and the NPR from baseline to 6-week follow-up. We conducted all statistical analyses using Stata statistical software (version 16, StataCorp LLC, Col- lege Station, Texas).

1. Results

Over the 18-month study period, 103 patients presented to the ED with a chief complaint of LBP and agreed to participate in the study (Fig. 1). The mean age of the cohort was 48.5 years (SD 18.3) and 55 (53.4%) were female. Sixteen patients (15.5%) self-identified as Hispanic and 75 (72.8%) self-identified as White non-Hispanic. Notably, 61 pa- tients (59.2%) reported that they had been seen previously by a healthcare provider for LBP, 38 (36.9%) had been seen in the ED for the same chief complaint and 32 (31.1%) had received an opioid for LBP in the preceding 3 months. 51 (49.5%) reported working regular duty at the time of the ED visit. (Table 1).

In the ED, the most common medications administered included NSAIDS (40.8%), opioids (35.9%) and acetaminophen (19.4%). The most common prescriptions at discharge from the ED included muscle relaxants (25.2%), opioids (18.5%), and NSAIDs (18.5%). While in the ED, 37 (35.9%) had an x-ray, 47 (45.6%) underwent CT or MRI, and 16 (15.3%) had an ultrasound. PT evaluated 17 (16.5%) patients during the ED visit. (Table 2).

We were able to contact 68 patients (66%) to obtain follow-up data at least 6 weeks after the ED visit. Over the 6 weeks following the ED visit, 22 (32.4%) patients reported having missed work due to pain. An

Fig. 1. Enrollment Diagram.

additional 15 patients (20.6%) had an x-ray and 14 (20.6%) had an MRI. Fifteen (22.6%) patients had received an opioid prescription since their ED visit and 5 (87.6%) went on to have a steroid injection.

The mean change from baseline to 6-week follow-up for the PROMIS PFSF-12a scores was 10.8 points (95% CI = 7.7 to 14.0, p < .001) indicat- ing a statistically significant improvement in physical function. The mean change in the NPR was 3.2 (95% CI = 2.3 to 4.0, p < .001) indicat- ing a statistically significant improvement in pain.

Table 1

Baseline characteristics of patients presenting to the emergency department with a primary complaint of low back pain

Characteristic	n = 103
Age (y) mean (SD)	48.5	(18.3)
Sex (Female)	55	(53.4%)
Race
White non-Hispanic	76	(73.9%)
Hispanic ethnicity	15	(14.6%)
Black or African American	3	(2.9%)
Native Hawaiian or Pacific Islander	3	(2.9%)
Asian	2	(2%)
American Indian or Alaska Native	1	(1%)
Other/not reported	3	(2.9%)
living situation Lives alone	23	(22.3%)
Spouse/partner	52	(50.5%)
Other family member	15	(14.6%)
Non family	13	(12.6%)
Education
Highschool or less	31	(30.1%)
Some college	37	(35.9%)
College graduate or more	35	(34.0%)
Work status
Works regular duty	51	(49.5%)
Previous health care for same problem	61	(59.2%)
ED visit for same problem	38	(36.9%)
Work injury	20	(19.4%)
Opioid for any reason past 3 months	32	(31.1%)

Table 2

ED interventions for patients presenting to the emergency department for a primary complaint of low back pain

Medications in ED
NSAID	42	(40.8%)
Muscle relaxant	7	(6.8%)
Opioid	37	(35.9%)
Steroid	9	(8.7%)
Acetaminophen	20	(19.4%)
Mental health medication	28	(27.2%)
None	9	(8.8%)
More than one medication	49	(47.6%)
Medications prescribed NSAID	19	(18.5%)
Muscle relaxant	26	(25.2%)
Opioid	19	(18.5%)
Steroid	11	(10.7%)
Acetaminophen	10	(9.7%)
Mental health medication	8	(7.8%)
None	35	(34%)
More than one medication	25	(24.3%)
ED imaging
X-ray	37	(35.9%)
CT/MRI	47	(45.6%)
Ultrasound	16	(15.3%)
None	34	(33%)
More than one imaging modality	31	(30.1%)
Referral Physical therapy	14	(13.5%)
Primary care	22	(21.4%)
Physiatry	0	(0%)
Orthopedic surgery	12	(11.7%)
Neurosurgery	9	(8.7%)
Mental health	1	(1%)
None	68	(66%)
More than one referral	23	(22.3%)

Abbreviations: MRI = magnetic resonance imaging; CT = computed tomography; ED = emergency department; NSAID = non-steroidal anti-inflammatory drug.

In the 6 weeks since the ED visit, 16 patients (23.5%) saw a primary care provider, 12 patients (17.7%) visited an Orthopedic surgeon or neu- rosurgeon, and 8 (11.8%) visited a physical therapist. Finally, 8 (11.8%) patients had a visit with a chiropractor and 1 (1.5%) reported visiting a massage therapist. (Table 3).

1. Discussion

In this assessment of LBP treatment and referral pathways, we found that ED interventions and follow-up varied widely within a single aca- demic ED. Of particular note, the majority of ED patients with LBP had been seen previously by a healthcare provider for LBP. A significant pro- portion of LBP patients had received an opioid prescription in the pre- ceding 3 months, had an opioid administered in the ED, and/or received an opioid prescription at discharge. It was encouraging to find that LBP sufferers managed in the ED overall had significant im- provement in their pain and disability at 6-week follow-up. However, less than half of LBP patients saw an outpatient provider after the ED visit and only 11.8% of patients saw a PT. ED imaging patterns, medica- tion administration, and outpatient prescriptions varied widely, empha- sizing the needs for clear guidelines and treatment pathways for ED patients with LBP.

No specific LBP Guideline recommendations currently exist for the emergency medicine community. The closest applicable guideline is the Joint Clinical Practice Guideline from the American College of Physi- cians and the American Pain Society, which provides guidance for pri- mary care providers. These guidelines recommend avoiding imaging without a history of trauma, radiculopathy, or red flag symptoms. Their algorithm starts treatment with NSAIDs and acetaminophen then advocates for adding non-pharmacologic treatments such as PT, spinal manipulation, massage, acupuncture and cognitive behavioral therapy. The guidelines recommend against opioids except in the

Table 3

Pain, function, and healthcare utilization outcomes occurring between baseline and 6-week follow-up

Outcome (n = 68)

Pain medications

NSAID	1	(1.5%)
Opioid	15	(22.1%)
Muscle relaxant	1	(1.5%)
Steroid	2	(2.9%)
None	51	(75%)
More than one medication	1	(1.0%)
Imaging X-ray	14	(20.6%)
MRI	13	(19.2%)
CT	5	(7.4%)
None	48	(70.6%)
More than one imaging modality	12	(11.7%)
Procedures Surgery	4	(5.9%)
Steroid injection provider types visited	5	(7.4%)

While we observed large variation in index visit experiences, the pa- tient experience after leaving the ED varied even more widely. While we did not investigate an associated between ED treatment and follow-up patterns, a previous study noted systematic predictors of follow-up among patients who received different management strate- gies in a primary care office. Odds of a PT consult increased with pre- scriptions for NSAIDs (aOR = 1.81, CI 1.0 to 3.27) or muscle relaxants (aOR = 2.24, CI 1.03 to 4.87) but decreased for those with Tobacco use or Multiple comorbidities [(aOR = 0.52; 95% CI, 0.20 to 0.91) and 0.42 (95% CI, 0.23 to 0.78), respectively)]. Those who received a radiograph at baseline were more likely to participate in PT (OR = 2.96; 95% CI, 1.20 to 7.20). Perhaps most significantly, those who had received a PT consult or participated with PT were less likely to have received an opi- oid prescription at one-year follow-up (aOR = 0.65; 95% CI, 0.43 to 1.00 and aOR = 0.47; 95% CI, 0.24 to 0.92, respectively) [21].

Despite the poor follow up and range of management strategies, pa- tients did report significantly improved pain scores at the 6-week follow-up. Perhaps part of the improved pain score effect was from

PT	8	(11.8%)	the sense that some treatment had been initiated. Wand et al. con-
Chiropractor	8	(11.8%)	ducted a study on the outcomes associated with early intervention for
PCP	16	(23.5%)	back pain with manual therapy and exercise. They compared this to
Neurosurgery Orthopedic surgery Physiatry	5 7 0	(7.4%) (10.3%) (0.0%)	an assess/advise/wait model in which patients were advised that most LBP improves in a month and that they would be treated if their pain
Emergency department	10	(14.7%)	had not improved in the expected time frame. While the investigators
Urgent care	2	(2.9%)	did not find a significant difference in the disability and pain scores at

Massage	1	(1.5%)
None	29	(42.6%)
More than one provider visited	18	(17.5%)
Missed days of work because of pain	22	(32.4%)

Abbreviations: NPR = numeric pain rating; PROMIS = Patient Reported Outcomes Man- agement Information System; NSAID = non-steroidal anti-inflammatory drug; MRI = magnetic resonance imaging; CT = computed tomography; PT = physical therapist; PCP = primary care provider; ED = emergency department.

most severe and refractory exacerbations and advise against long-term opioid management for those with chronic pain. They advocate for ed- ucating all patients on the expected clinical course and on staying active despite symptoms. Insufficient evidence was available to specify the op- timal follow up intervals and methods but they propose a one-month follow-up, suggesting most acute LBP will improve independently [9].

Unfortunately, the ED does not naturally support a step-wise ap- proach as advocated by these guidelines and patients often view their pain as an emergency requiring immediate resolution [13]. This likely contributes to the higher than desirable utilization of opioids which we observed. This pattern is consistent with data showing that back pain remains the most common diagnosis for which opioids and benzo- diazepines are prescribed [16]. While many other classes of medications including NSAIDs, acetaminophen, muscle relaxers, steroids, Selective serotonin reuptake inhibitors, and triCyclic antidepressants have also been suggested as management options, there is only low quality evi- dence for any drug class and no studies to date have specifically evalu- ated these for acute LBP pain management in the emergency setting.

Even if clear ED guidelines existed, compliance with those guidelines would likely be an issue. Primary care providers cite time as a barrier to adopting their LBP guidelines [17]. Surveyed physicians feared that pa- tients would not accept a non-structural diagnosis without radiographic proof. Our data suggest a possible similar psychology among emergency physicians given the high imaging rate. Another possible contributor is the lack of reliable strategies to exclude emergent pathology. The gen- eral medicine guidelines that exist in the United States, Canada, and Europe all fail to recommend standardized exams and history questions to avoid imaging [12]. The traditional “red flag questions” lack adequate sensitivity to effectively rule out the indications for emergent advanced imaging [18-20]. Given the emergency physician’s duty to rule out pa- thology requiring inpatient care, it is not surprising that we observed a high imaging rate.

long-term follow up, quality of life, mood and general health metrics were significantly better in the early intervention group. This led the team to conclude that “short-term intervention is more effective than advice on staying active, leading to more rapid improvement…Timing of intervention affects the development of psychosocial features.” [22].

1. Limitations

Our study is limited to a single center. As such, our findings may be unique to the clinical diagnostic evaluations and to the management strategies at this site. Additional limitations with our site may be related to the nature of the academic center, in which medical students, resi- dent physicians, advanced practice providers, and attending physicians are all making initial decisions related to evaluation and treatment of these patients. Given this unique practice setting, these results may not be generalizable to other centers.

Additionally, we selected patients as a convenience sample of those presenting for the chief complaint of LBP. Presumably, the patients en- rolled in this study represent a small proportion of the total number of patients who presented to the ED with LBP during the study period. We were limited by RA enrollment hours and patient willingness to par- ticipate in the study.

Further limitations relate to the reliance upon the electronic medical record for patient demographic, testing, and medication information. We retrieved relevant outcomes through review of the medical record. As such, this methodology is susceptible to bias through mistakes within the medical record or error in the review and transcription pro- cess.

Finally, our outcomes data are limited due to the study’s 6-week follow-up rate. 68 of the initial 103 patients had 6-week follow up data. It is possible that those patients willing to complete follow-up may have either been those with a higher level of compliance or, con- versely, those who were generally dissatisfied with their care and wish- ing to communicate their concerns. Additionally, as the long-term end point was 6 weeks, it is possible that we did not adequately capture those with delayed outpatient follow up appointments.

1. Conclusion

Despite the multitude of strategies for addressing acute LBP, no one strategy has proven to be statistically better at decreasing disability.

Practice patterns in our study varied widely, with inconsistent imaging, in-hospital pain treatment, post-visit prescriptions, and outpatient follow-up. Guidelines tailored to the emergency medicine setting may help to standardize care, ultimately improving patient outcomes as well as cost effectiveness.

Meetings

Accepted for presentation at the national meeting of the Society for Academic Emergency Medicine, New Orleans, Louisiana, May 10-13, 2022.

Grants

For author JM, the research reported in this publication was sup- ported (in part or in full) by the National Center for Advancing Transla- tional Sciences (NCATS) and National Center For Complementary & Integrative Health (NCCIH) of the National Institutes of Health under Award Number KL2TR002539. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author contributions

TM, JM, JF, and KR conceived of this study. TM oversaw patient iden- tification, recruitment and quality control. JM provided statistical advice and analyzed the data. KS, JM and TM drafted the manuscript while all contributed substantially to its revisions. TM takes responsibility for this paper as a whole.

CRediT authorship contribution statement

Jake Magel: Writing - review & editing, Writing - original draft, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Kayte Suslavich: Writing - review & editing, Writing - original draft. Keith Roper: Project adminis- tration, Methodology, Investigation, Conceptualization. Julie Fritz: Writing - review & editing, Supervision, Investigation, Conceptualiza- tion. Troy Madsen: Writing - review & editing, Writing - original draft, Supervision, Resources, Project administration, Methodology, Investigation, Data curation, Conceptualization.

Declaration of Competing Interest

none.

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