When self-care options do not result in improvement, clinicians should consider adding nonpharmacologic modalities shown to be of benefit. For acute low back pain, the only modality in this category is spinal manipulation. For chronic or subacute low back pain, modalities shown to be of benefit are intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation; moderate-quality evidence).
"Opioids and muscle relaxers can provide relief for those with severe pain, but their potential benefits and risks should be weighed carefully," Dr. Chou said. "Patients who prefer not to take medication can benefit from non-drug treatments, such as acupuncture, spinal manipulations, and massage therapy. None, however, are proven to be more effective than others to warrant recommendation as first-line therapy."
Dr. Chou has disclosed receiving an honorium from Bayer Healthcare Pharmaceuticals. One of the authors has disclosed financial relationships with Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Novo Nordisk, Pfizer, Merck, Bristol-Myers Squibb, Atlantic Philanthropics, and Sanofi-Pasteur.
Ann Intern Med. 2007;147:478-491.
Clinical Context
Low back pain is a widespread and often chronic and debilitating problem, with about 25% of US adults reporting having had low back pain in the past 3 months, whereas 7.6% report at least 1 episode of severe acute low back pain within the previous year. Because most low back pain improves within 1 month even without treatment, it is important for clinicians to have a rational basis for recommending diagnostic tests and for prescribing various treatment options.
A multidisciplinary panel of experts convened in 2006 by the ACP and APS has issued a comprehensive, evidence-based joint clinical practice guideline for diagnosis and treatment of low back pain. These guidelines target primary care clinicians and address only conservative pharmacologic treatment options. Future guidelines being planned by the APS will address use of invasive procedures for low back pain.
Study Highlights
Target populations for these guidelines are adults (including pregnant women), children, and adolescents with chronic or acute low back, cervical, or thoracic pain not related to major trauma, including patients with nonspinal pain and myofascial pain syndromes.
Specific recommendations in the guidelines are as follows:
Focused history and physical examination should help categorize patients into 1 of 3 broad groups: nonspecific low back pain; back pain potentially associated with radiculopathy or spinal stenosis; or back pain potentially associated with another specific spinal cause, such as cancer or infection.
Evaluation of psychosocial risk factors is essential during history taking because these predict the risk for chronic, disabling back pain (strong recommendation; moderate-quality evidence). History should also include location, duration, quality and frequency of pain, as well as previous response to treatment. History and examination should look for evidence of cancer, infection, or other systemic cause of pain, as well as evidence of neurologic deficit suggesting radiculopathy or cauda equina syndrome.
Nonspecific low back pain should not routinely be evaluated with imaging studies, such as radiographs, CT scans, and MRI, or other diagnostic tests (strong recommendation; moderate-quality evidence).
Imaging studies and other appropriate diagnostic tests are indicated for patients with severe or progressive neurologic deficits, or in whom a history and physical examination suggest cancer, infection, or other underlying condition as the cause of the back pain (strong recommendation; moderate-quality evidence).
Patients with persistent back pain and signs or symptoms of radiculopathy or spinal stenosis should undergo MRI or CT only if surgery or epidural steroid injection for suspected radiculopathy is being considered. MRI is preferred to CT (strong recommendation; moderate-quality evidence).
Clinicians should educate patients by providing evidence-based information on the expected course of low back pain and effective self-care options. Clinicians should also recommend that their patients be physically active (strong recommendation; moderate-quality evidence).
When pharmacotherapy is considered, drugs of choice should be those with proven benefits, and they should be used together with self-care and back care education. Before starting pharmacotherapy, clinicians should evaluate baseline pain and functional deficits, as well as the risks and benefits of specific medications. Clinicians should be aware of the relative lack of long-term efficacy and safety data (strong recommendation; moderate-quality evidence). For most patients, acetaminophen or NSAIDs are preferred first-line drugs.
For acute pain, superficial heat, muscle relaxants, benzodiazepines, or opioids may be considered. For chronic pain, opioids or antidepressants may be indicated.
For patients who do not improve with self-care, clinicians should consider adding nonpharmacologic modalities of demonstrated benefit. For acute low back pain, the only such modality is spinal manipulation. For chronic or subacute low back pain, modalities shown to be of benefit are intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation; moderate-quality evidence).
Pearls for Practice
Focused history and physical examination should help categorize patients into 1 of 3 broad groups: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. Evaluation of psychosocial risk factors is essential to predict the risk for chronic, disabling low back pain.
Clinicians should provide patients with evidence-based information on the expected course of low back pain and effective self-care options and should also recommend that their patients be physically active.