New LBP Guidelines Encourage Conservative Approach, Spinal Manipulation

Practice guidelines published in the October 2007 issue of the Annals of Internal Medicine¹ and targeted toward "all clinicians caring for patients with low (lumbar) back pain of any duration, either with or without leg pain" recommend spinal manipulation for patients whose pain does not improve with self-care.

The stated purpose of the guidelines, co-authored by the American College of Physicians (ACP) and the American Pain Society (APS), was "to present the available evidence for evaluation and management of acute and chronic low back pain ... in primary care settings." Data gathered to formulate the guidelines were derived from MEDLINE studies (1966-2006), the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and EMBASE. The literature search included randomized, controlled trials of nonpregnant adults with low back pain (alone or in connection with leg pain) of any duration and reporting on back-specific function, generic health status, pain, work disability and/or patient satisfaction as an outcome.

A multidisciplinary panel guided the evidence-gathering process, reviewed its results and formulated seven recommendations based on the evidence. Recommendations of particular interest to the chiropractic profession are reprinted verbatim as follows:

• Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic, disabling back pain.
• Recommendation 2: Clinicians should not routinely obtain imaging and other diagnostic tests in patients with nonspecific low back pain.
• Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurological deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination.
• Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information abouteffective self-care options.
• Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacological therapy with proven benefits - for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy or progressive relaxation.

As might be expected, the guidelines also recommend that clinicians "consider the use of medications with proven benefits [acetaminophen or nonsteroidal anti-inflammatory drugs] in conjunction with back care information and self-care" (Recommendation 6). However, they emphasize that before initiating such therapy, clinicians "should assess severity of baseline pain and functional deficits, potential benefits, risks and relative lack of long-term efficacy and safety data."

Reference

1. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, October 2007;147:478-91.