American College of Physicians Develops New Guidelines for Low Back Pain

The American College of Physicians (ACP) recently developed evidence-based clinical practice guidelines for the treatment of patients with nonradicular low back pain. These guidelines were published by Annals of Internal Medicine.

ACP now recommends that patients and physicians should treat acute of subacute low back pain without drug therapy. Alternative therapies, such as heat, massage, acupuncture, or spinal manipulation, should be the first line of treatment for patients with acute or subacute pain.

If drug therapy is deemed necessary, a nonsteroidal anti-inflammatory drug (NSAID) or skeletal muscle relaxant should be chosen, according to the ACP. They do not recommend opioids for acute or subacute low back pain.

Low back pain is a common reason for a physician visit, with a majority of Americans having experienced the condition. Approximately one-fourth of US adults have experienced low back pain lasting from 1 day to 3 months.

ACP classifies acute pain as lasting less than 4 weeks, subacute pain as lasting 4 to 12 weeks, and chronic pain as lasting more than 12 weeks.

“Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment,” said Nitin S. Damle, MD, MS, MACP, president of ACP. “Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients.”

Clinical evidence revealed that acetaminophen did not improve pain outcomes compared with placebo, and there was low-quality evidence suggesting systemic steroids did not effectively treat low back pain.

For patients with chronic low back pain, ACP recommends treatment with: exercise, multidisciplinary rehabilitation, acupuncture, mindfulness, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.

“For the treatment of chronic low back pain, physicians should select therapies that have the fewest harms and costs, since there were no clear comparative advantages for most treatments compared to one another,” Dr Damle said. “Physicians should remind their patients that any of the recommended physical therapies should be administered by providers with appropriate training.”

For patients with chronic low back pain who have not responded to non-drug therapy, ACP recommends NSAIDs as the first line of treatment and tramadol or duloxetine as a second line treatment.

Opioids should only be considered for patients who have failed to respond to all mentioned treatments if the treatment benefits outweigh the risks. If opioid treatment is initiated, patients must be aware of the potential risks, according to ACP.

“Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies, as they are associated with substantial harms, including the risk of addiction or accidental overdose,” Dr Damle said.

The new guidelines were created based on a systematic review of published studies regarding noninvasive pharmacological and non-pharmacological treatments of nonradicular low back pain.

Clinical outcomes, such as reduction or elimination of low back pain, improvement in function, improvement in quality of life, reduction in work disability, global improvement, number of back pain episodes, patient satisfaction, and adverse events, according to ACP.

The clinical evidence was not sufficient enough to determine standard treatments for low back pain, and which patients would benefit the most from certain treatments was also not able to be determined. The new guidelines do not discuss any other topical or epidural injection treatments.

These guidelines are meant to guide healthcare professionals who may be unsure of how to treat patients with lower back pain. ACP also has identified gaps in evidence, which can lead to studies that will address these gaps through the guideline development process, according to ACP.