Noninvasive treatments for acute, subacute and chronic low back pain

Correction: This article originally stated that the American College of Physicians had released 2024 guidelines on the topic below, however, the most recent guidelines from that organization were released in 2017. We apologize for the error. Low back pain is one of the most common reasons for physician visits. About one-quarter of U.S. adults report having low back pain lasting at least one day in the past three months. By definition, acute back pain lasts less than four weeks, subacute back pain lasts four to 12 weeks, and chronic back pain lasts more than 12 weeks. Radicular low back pain results in lower extremity pain, paresthesia and/or weakness and is caused by nerve root impingement.Most patients with acute back pain have self-limited episodes that resolve on their own. For patients who do seek medical care, back pain and disability (and return to work) usually improve rapidly in the first month. However, up to one-third of patients have persistent back pain of at least moderate intensity one year after an acute episode, and 20% report substantial limitations in activity. Several noninvasive treatment options are available for radicular and nonradicular low back pain, including pharmacologic and nonpharmacologic interventions.To assist healthcare providers in managing adults with low back pain, the American College of Physicians (ACP) developed treatment guidance based on the efficacy, comparative effectiveness and safety of noninvasive pharmacologic and nonpharmacologic treatments for acute ( 12 weeks) low back pain in primary care. The guideline does not address topical pharmacologic therapies or epidural injection therapies. The 2017 document partially updates the 2007 ACP low back pain guideline, but excludes evidence on diagnosis.The 2017 guideline discusses the following:The benefits and comparative benefits of pharmacologic therapies in acute or subacute low back pain, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), skeletal muscle relaxants and systemic corticosteroids.The benefits and comparative benefits of pharmacologic therapies in chronic low back pain, including NSAIDs, opioids, skeletal muscle relaxants, benzodiazepines and antidepressants.The benefits and comparative benefits of pharmacologic therapies in radicular low back pain, including benzodiazepines and systemic corticosteroids.Harms of pharmacologic therapies.The comparative benefits of nonpharmacologic therapies in acute or subacute low back pain, including exercise, acupuncture, massage, spinal manipulation, superficial heat, low-level laser therapy and lumbar supports.The comparative benefits of nonpharmacologic therapies in chronic low back pain, including exercise, motor control exercise, pilates, tai chi, yoga and several others.The comparative benefits of nonpharmacologic therapies in radicular low back pain.Harms of nonpharmacologic therapies.Summary of changes from the 2007 ACP back pain guideline:The 2007 guideline concluded that acetaminophen was effective for acute low back pain, based on indirect evidence from trials of acetaminophen for other conditions and trials of acetaminophen versus other analgesics. However, the 2017 update includes a placebo-controlled randomized controlled trial in patients with low back pain that showed no difference in effectiveness between acetaminophen and placebo (low-quality evidence).Contrary to the 2007 guideline, current moderate-quality evidence shows that tricyclic antidepressants are not effective for chronic low back pain compared with placebo.Duloxetine and pregabalin are additional pharmacologic treatments addressed in the 2017 guideline.Many conclusions about nonpharmacologic interventions are similar between the 2007 and 2017 guidelines. Additional modalities assessed (with at least low-quality evidence) include mindfulness-based stress reduction, motor control exercise, taping and tai chi.Additional evidence or changes in the 2017 guideline include that superficial heat is more effective for acute or subacute low back pain (moderate-quality evidence) and neither ultrasound nor transcutaneous electrical nerve stimulation is effective compared with controls (low-quality evidence).Recommendations in the 2017 ACP back pain guideline:Acute or subacute low back pain Given that most patients with 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 NSAIDs or skeletal muscle relaxants (moderate-quality evidence). (Strong recommendation)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 behavioural therapy or spinal manipulation (low-quality evidence). (Strong recommendation)Chronic low back pain In patients who have an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with NSAIDs 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 previously mentioned treatments and only if the potential benefits outweigh the risks for individual patients, and after a discussion of known risks and realistic benefits with each patient. (Weak recommendation, moderate-quality evidence) The guideline authors point out that evidence is currently insufficient or lacking to determine treatments for radicular low back pain.Reference:Qaseem A, Wilt TJ, McLean RM, et al; 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. Ann Intern Med 2017;166(7). (accessed December 30, 2024).

Noninvasive treatments for acute, subacute and chronic low back pain

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