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New evidence-based treatment guidelines for lower back pain

The American College of Physicians (ACP) recommends in an evidence-based clinical practice guideline that physicians and patients should treat acute or subacute low back pain with non-drug therapies such as superficial heat, massage, acupuncture, or spinal manipulation. If drug therapy is desired, physicians and patients should select non-steroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants.

Low back pain is one of the most common reasons for all physician visits in the US. Most Americans have experienced low back pain. Approximately one quarter of US adults reported having low back pain lasting at least one day in the past three months. Pain is categorised as acute (lasting less than four weeks), subacute (lasting four to 12 weeks, and chronic (lasting more than 12 weeks).

“Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment,” said Dr Nitin S Damle, president, ACP. “Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients.”

The evidence showed that paracetamol was not effective at improving pain outcomes versus placebo. Low-quality evidence showed that systemic steroids were not effective in treating acute or sub-acute low back pain.

For patients with chronic low back pain, ACP recommends that physicians and patients initially select non-drug therapy with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (MCE), progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioural therapy, or spinal manipulation.

“For the treatment of chronic low back pain, physicians should select therapies that have the fewest harms and costs, since there were no clear comparative advantages for most treatments compared to one another,” Damle said. “Physicians should remind their patients that any of the recommended physical therapies should be administered by providers with appropriate training.”

For patients with chronic low back pain who have had an inadequate response to non-drug therapy, ACP recommends that physicians and patients consider treatment with NSAIDs as first line therapy; or tramadol or duloxetine as second line therapy. Physicians 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.

“Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies, as they are associated with substantial harms, including the risk of addiction or accidental overdose,” said Damle.

“Non-invasive Treatments for Acute, Subacute, and Chronic Low Back Pain” is based on a systematic review of randomized controlled trials and systematic reviews published on non-invasive pharmacological and non-pharmacological treatments of non-radicular low back pain. Clinical outcomes evaluated included 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/return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.

The evidence was insufficient or lacking to determine treatments for radicular low back pain. The evidence also was insufficient for most physical modalities and for which patients are likely to benefit from which specific therapy. The guideline does not address topical therapies or epidural injection therapies.

ACP’s clinical practice guidelines are developed through a rigorous process based on an extensive review of the highest quality evidence available, including randomised control trials and data from observational studies. ACP also identifies gaps in evidence and direction for future research through its guidelines development process.

ACP’s previous recommendations for treating low back pain were published in 2007. Some evidence has changed since the 2007 guideline and supporting evidence reviews. The 2007 guideline did not assess mindfulness-based stress reduction, MCE, taping, or tai chi.

Abstract
Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.
Methods: Using the ACP grading system, the committee based these 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. Updated searches were performed through November 2016. Clinical outcomes evaluated included 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.
Target Audience and Patient Population: The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.
Recommendation 1:
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:
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:
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)

Authors
Amir Qaseem; Timothy J Wilt; Robert M McLean; Mary Ann Forciea

Abstract 2007
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 specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).
Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).
Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).
Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).
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 about effective self-care options (strong recommendation, moderate-quality evidence).
Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic 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 (weak recommendation, moderate-quality evidence).

Authors
Roger Chou; Amir Qaseem; Vincenza Snow; Donald Casey; J Thomas Cross Jr; Paul Shekelle; Douglas K Owens

[link url="https://www.acponline.org/acp-newsroom/american-college-of-physicians-issues-guideline-for-treating-nonradicular-low-back-pain"]American College of Physicians[/link]
[link url="http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice"]Guidelines 2017[/link]
[link url="http://annals.org/aim/article/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-from"]Guidelines 2007[/link]

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