An updated clinical practice guideline from the American College of Physicians (ACP) recommends spinal manipulation and other non-invasive, non-drug therapies as first options for acute, subacute and chronic low back pain, rather than pain medications, as stipulated in the original 2007 guideline.
Based on two background evidence reviews and a systematic review sponsored by the Agency for Healthcare Research and Quality (AHRQ), the guideline partially updates the 2007 joint ACP / American Pain Society guideline and features three recommendations for all clinicians treating adult patients presenting with LBP:1
Recommendation #1: Acute or Subacute LBP
"Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)"
Recommendation #2: Chronic LBP
"For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)"
Recommendation #3: Try Drugs Only If Non-Drug Therapies Prove Ineffective
"In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)"
The 2007 ACP / APS guideline featured seven recommendations focusing on history / exam, diagnostic testing and other considerations for clinical management of LBP, but only suggested patient education regarding staying active and self-care options. "Use of medications with proven benefits [acetaminophen or nonsteroidal anti-inflammatory drugs] in conjunction with back care information and self-care" (Recommendation #6) was suggested as the first-line treatment option.
Reference
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