Table 2 Results of initial seed statement review

Patients seeking initial care from Duke Health for LBP may be evaluated by different provider disciplines and points of entry such as the emergency room, primary care, orthopedics, physiatry, chiropractic, physical therapy, and neurology. Regardless of provider discipline or point of entry, clinical evaluation of patients initiating care with any of these first access clinicians should include: (The pretext header was attached to the following two seed statements)

A detailed clinical history Including prior treatments and response, prior related symptoms or concerns, general health history, and review of systems

30/30 (100%)

Assessment/screening for serious or systemic disease, such as progressive neurological deficit, infection, abdominal aortic aneurysm, renal disease, primary tumors or metastatic disease

29/30 (96.7%)

For patients seeking initial care from Duke Health, imaging studies should be performed only when clinical history or symptoms suggest possible serious disease wherein imaging offers key information to rule in / out clinical suspicions or inform urgent/emergent care or other specialty management

28/30 (93.3%)

After screening for serious or systemic disease, the first access clinician should make a clinical decision based on the patient’s presenting condition regarding whether the patient should be 1) treated by the first access clinician, 2) referred to specialty care for further evaluation, surgical consult or pain management with a physiatrist, or 3) referred to a primary spine practitioner (chiropractic or physical therapy) for conservative non-pharmacological treatment

28/30 (93.3%)

Regardless of provider discipline, clinicians treating patients with LBP should incorporate: (The pretext header was attached to the following three seed statements)

Psychological, social, assessment/screening for factors that may influence prognosis and/or contribute to the problem is also appropriate

28/30 (93.3%)

Screening for relevant environmental factors is appropriate

27/20 (90.0%)

Education to inform patients about their condition with the purpose of fostering health literacy, providing reassurance, helping patients make more informed decisions about healthcare, and encouraging self-monitoring and self-management capacity

30/30 (100.0%)

Evidence of mild or moderate radiculopathy is not a stand-alone indication for advanced imaging

24/30 (80.0%)

Evidence of severe radiculopathy is an indication for advanced imaging and consultation with a spine surgeon

27/30 (90.0%)

Psychological factors can increase risk for developing chronic LBP or reduce a prognosis for recovery

29/29 (100.0%)

When psychological factors are present, providers caring for patients with LBP should employ education and consider co-management with others skilled in therapies designed to directly address them, such as cognitive behavioral therapy, and acceptance and commitment therapy

28/29 (96.6%)

The American College of Physicians recommend nonpharmacological treatment for the initial course of care for patients with acute LBP that is not associated with pathology. Evidence-based, initial nonpharmacological care for acute LBP may include:

• Superficial heat

• Manual therapies such as therapeutic massage

• Acupuncture

• Spinal manipulation (thrust and non-thrust passive joint mobilization procedures)

• Exercise (e.g., tai chi and yoga)

30/32 (93.8%)

Patients with LBP that does not respond favorably to nonpharmacological therapies should initially be referred for evaluation and management for guideline-concordant conservative pharmacotherapy by a primary care provider

26/29 (89.7%)

Initial pharmacological management should consist of nonsteroidal anti-inflammatory drugs, or tramadol or duloxetine as second-line therapy

27/29 (93.1%)

Secondary pharmacological management should include tramadol or duloxetine

20/29 (69.0%)*

Patients with LBP that does not respond favorably to conservative pharmacotherapies should be referred for evaluation by an interventional spine specialist or pain management specialist

26/29 (89.7%)

Patients with LBP that does not respond favorably to interventional spine or pain management approaches should be referred for evaluation or an e-consult by a spine surgeon to determine if evidence-based criteria for surgical intervention are met

26/29 (89.7%)

There may be circumstances when specific factors warrant a deviation from the general referral pathway model, such as when progressive neurological deficit is present, indicating urgent spine surgical consult rather than first referring for a trial of care in pain management

29/29 (100.0%)

Step 1: Conduct a screening evaluation for serious or systemic disease. If serious or systemic disease is identified, refer for appropriate specialty care. If not, proceed to step 2

29/29 (100.0%)

Step 2: For patients without serious of systemic disease, treat with guideline recommended nonpharmacological therapies incorporating biopsychosocial components or refer to a provider who offers this approach and comanage with other providers as clinically indicated

27/29 (93.1%)

Step 3: For patients unresponsive to treatment, consider whether additional co-management or an alternate treatment is viable. If an additional trial of care is appropriate, initiate additional trial. If not, refer to a provider with the next most conservative approach unless otherwise indicated

28/29 (96.6%)