Updated Clinical Practice Guidelines for Noninvasive Lower Back Pain Treatments

The American College of Physicians (ACP) released updatedguidelineson noninvasive treatment of lower back pain that alter prior guidelines calling for medication as first-line therapy.

The committee used the ACP grading system to base the recommendations 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.

Since most patients with acute or subacute low back pain improve over time regardless of treatments, the ACP recommends that clinicians and patients select nonpharmacological treatment with superficial heat, massage, acupuncture, or spinal manipulation.

“If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence),” according to the guidelines.

For patients with chronic low back pain, the guidelines recommend that patients and clinicians should initially select nonpharmacological treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, low-level laser therapy, progressive relaxation, electromyography biofeedback, cognitive behavioral therapy, operant therapy, or spinal manipulation (low-quality evidence).

Third, patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. However, the ACP said prescribing opioid painkillers should be avoided.

“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).”

Dr. James Weinstein, back specialist and chief executive of Dartmouth-Hitchcock Health System, told theNew York Times, “What we need to do is to stop medicalizing symptoms; pills are not going to make people better. [As for other treatments] yoga and tai chi, all those things are wonderful, but why not just go back to normal activities.”