Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians
SUMMARY:
Low back pain is a common complaint in outpatient settings, with an estimated 25% of adults reporting an episode of low back pain lasting for at least one day in the past three months. It is associated with high healthcare costs and is a leading cause of activity limitation and missed worked days globally. The diagnosis of low back pain can be clinically frustrating, with the majority of cases unattributable to a specific cause. The American College of Physicians last released guidelines to aid in diagnosis and treatment of low back pain in 2007, and updated their treatment guidelines in 2017, stressing non-pharmacological therapies for most types of back pain.
Clinical Presentation
Diagnosis
- Obtain detailed history and physical
- Pay attention for signs and symptoms of radiculopathy or spinal stenosis
- Assess for other symptoms or illnesses that may contribute to back pain (e.g., history of autoimmune disease, falls, and injuries)
- Imaging is typically not recommended for non-specific back pain, and should only be done when it will change management
Etiologies
- Mechanical: Lumbar Strain | Fracture | Osteoporosis | Herniated Disc | Degenerative disc disease
- Non-Mechanical: Malignancy | Osteomyelitis | Abscess | Inflammatory arthritis
- Visceral: Prostatitis | Endometriosis | Pancreatitis | Nephrolithiasis | Aortic aneurysm
- The vast majority of back pain will be non-specific with no obvious etiology
Definitions
- Acute: Pain lasting less than 4 weeks
- Subacute: Pain lasting 4 to 12 weeks
- Chronic: Pain lasting over 12 weeks
Treatment for Acute/Sub-Acute Low Back Pain
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.
Pharmacologic therapy
- No benefit: Tylenol | Systemic steroids
- Small benefit
- NSAIDs: Improved pain and function | Should be used at lowest effective dose for short periods of time to reduce associated risks (e.g., renal, GI risks)
- Skeletal muscle relaxants (SMR): Provided short term pain relief with studies showing no difference in outcomes between different SMRs
- Insufficient evidence to determine benefit: Antidepressants | Opioids | Benzodiazepines | Antiepileptics
Non-Pharmacologic
- No benefit: Exercise | Lumbar supports
Benefit
- Improved pain and function: Massage | Heat wrap | Low-level laser therapy (in conjunction with NSAIDs)
- Acupuncture improved pain only
- Spinal manipulation improved function only
Insufficient evidence
- Transcutaneous electrical nerve stimulation (TENS) | Electrical muscle stimulation | Inferential therapy | Short-wave diathermy | Traction | Superficial cold (ice) | Motor control exercise (MCE) | Pilates | Tai chi | Yoga | Psychological therapies | Multidisciplinary rehabilitation | Ultrasound | Taping
Note: Clinicians should reassure patients that the vast majority of acute/subacute low back pain improves with time regardless of therapies used
Treatment for Chronic Low Back Pain
For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.
Non-Pharmacologic Therapy
Should be used first line due to minimal associated risks compared to pharmacologic therapies
No benefit: Foot reflexology | Ultrasound | Transcutaneous electrical nerve stimulation (TENS) | Taping
Benefit
- Improved pain and function: Exercise | Motor control exercise (MCE) | Tai chi | Yoga | Psychologic therapies (e.g., progressive relaxation therapy) | Multidisciplinary rehabilitation | Acupuncture | Massage | Low-level laser therapy
- Improved pain only: Electromyography biofeedback | Operant therapy | Cognitive behavioral therapy | Spinal manipulation
Insufficient evidence
- Lumbar support | Electrical muscle stimulation | Interferential therapy | Short-wave diathermy | Traction | Superficial heat or cold
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 out-weigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients.
Pharmacologic Therapy
No benefit:
- TCAs | SSRIs
Benefit:
- NSAIDs: Improved pain with possible small improvement in function. No difference in outcomes between NSAID types. Should be given at lowest effective dose for short periods of time to reduce harm
- Opioids: Improved short-term pain and function. No clear difference between opioid types and formulations (e.g., long vs short acting). Tramadol also effective
- Benzodiazepines: Specifically, tetrazepam improved pain
- SNRIs: Duloxetine improved pain and function
Insufficient evidence: SMRs | Tylenol | Systemic steroids | Antiepileptics
Key Points:
- Patient should be encouraged to remain active as tolerated despite low back pain
- Improvements in pain and function with different therapies (pharmacologic and non-pharmacologic) were small and many studies reviewed had low-quality evidence
- Few differences exist between the different pharmacologic and non-pharmacologic therapies outlined above
- Providers should use shared decision-making with the patient to choose which therapy would be most likely to help, based on individual patient traits and discussion of risks and benefits
