The American College of Physicians (ACP) has issued new practice guidelines on the noninvasive treatment of low back pain as a partial update to the 2007 ACP guideline.

The recommendations are intended for all clinicians treating adult patients with acute, suabcute, or chronic low back pain with the purpose of providing treatment guidance based on the efficacy, comparative efficacy, and safety of noninvasive pharmacologic and nonpharmacologic treatments in primary care.

The guideline was developed based on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. 

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For the update, the Committee evaluated the following clinical outcomes: reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.  

For adults with acute (<4 weeks), subacute (4–12 weeks), or chronic (>12 weeks) low back pain, the authors recommend the following:

  • For patients with acute or subacute low back pain, select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, select NSAIDs or skeletal muscle relaxants (moderate-quality evidence). Strong recommendation 
  • For patients with chronic low back pain, initially select nonpharmacologic treatments 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). Strong recommendation 
  • For patients with chronic low back pain with inadequate response to nonpharmacologic therapy, consider pharmacologic treatment with NSAIDs as first-line therapy, or tramadol or duloxetine as second-line therapy. Only consider opioids in patients who have failed aforementioned treatments and only if the potential benefits outweigh the risks (moderate-quality evidence). Weak recommendation

With regards to harms associated with pharmacologic therapy, the guidelines note the following:

  • Increased adverse effects seen with NSAIDs vs. placebo; COX-2 selective NSAIDs associated with lower risk for adverse effects vs. traditional NSAIDs; acetaminophen associated with lower risk of adverse effects than NSAIDs (moderate-quality evidence).
  • Short-term use of opioids increased nausea, dizziness, constipation, vomiting, somnolence, and dry mouth compared with placebo (moderate-quality evidence).
  • Increased risk of any adverse event and CNS events with skeletal muscle relaxants  vs. placebo (moderate-quality evidence).
  • Antidepressant use was shown to increase the risk for any adverse event vs. placebo though rates of specific events did not differ (moderate-quality evidence). 
  • Increased somnolence, fatigue, lightheadedness with benzodiazepines vs. placebo (low-quality evidence). 

The guidelines state that clinicians should reassure patients that acute or subacute low back pain will usually improve over time, regardless of treatment. In these cases, clinicians should not prescribe potentially harmful treatments such as narcotics. Systemic corticosteroids should also not be prescribed for these patients as they were not shown to provide benefit. 

For patients with chronic low back pain, low cost therapies with the fewest harms should be considered as there were “no clear comparative advantages for most treatments compared with one another.” Medications with substantial potential harms and those shown to be ineffective (eg, long-term opioids, tricyclic antidepressants, selective serotonin reuptake inhibitors) should be avoided. 

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Qaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians [published online February 14, 2017]. Ann Intern Med. doi:10.7326/M16-2367

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This article originally appeared on MPR