Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

2 October 2007 | Volume 147 Issue 7 | Pages 478-491

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).

* This paper, written by Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS, was developed for the American College of Physicians' Clinical Efficacy Assessment Subcommittee and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel. For members of these groups, see end of text. Approved by the American College of Physicians Board of Regents on 14 July 2007. Approved by the American Pain Society Board Executive Committee on 18 July 2007.

Author and Article Information

From Oregon Health & Science University, Portland, Oregon; the American College of Physicians, Philadelphia, Pennsylvania; Atlantic Health, Morristown, New Jersey; Medstudy, Colorado Springs, Colorado; and Veterans Affairs Health Care System and RAND, Santa Monica, Veterans Affairs Palo Alto Health Care System, Palo Alto, and Stanford University, Stanford, California.

Clinical Efficacy Assessment Subcommittee of the American College of Physicians: Douglas K. Owens, MD, MS (Chair); Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Dallas, MD; Nancy C. Dolan, MD; Mary Ann Forciea, MD; Lakshmi Halasyamani, MD; Robert H. Hopkins Jr., MD; and Paul Shekelle, MD, PhD. Co-chairs and members of the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel: John D. Loeser, MD (Co-chair); Douglas K. Owens, MD, MS (Co-chair); Richard W. Rosenquist, MD (Co-chair); Paul M. Arnstein, RN, PhD, APRN-BC; Steven Julius Atlas, MD, MPH; Jamie Baisden, MD; Claire Bombardier, MD; Eugene J. Carragee, MD; John Anthony Carrino, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA; Daniel Cherkin, PhD; Penney Cowan; J. Thomas Cross Jr., MD, MPH; Anthony Delitto, PhD, MHS; Robert J. Gatchel, Ph.D, ABPP; Lee Steven Glass, MD, JD; Martin Grabois, MD; Timothy R. Lubenow, MD; Kathryn Mueller, MD, MPH; Donald R. Murphy, DC, DACAN; Marco Pappagallo, MD; Kenneth G. Saag, MD, MSc; Paul G. Shekelle, MD, PhD; Steven P. Stanos, DO; and Eric Martin Wall, MD, MPH. Participants from the Veterans Affairs/Department of Defense Evidence-Based Practice Workgroup: Carla L. Cassidy, ANP, MSN; COL Leo L. Bennett, MC, MD, MPH; John Dooley, MD; LCDR Leslie Rassner, MD; Robert Ruff, MD, PhD; and Suzanne Ruff, MHCC. Also a co-chair of the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel. Also members of the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel.

Note: Clinical practice guidelines are "guides" only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. The views and opinions expressed are those of Veterans Affairs/Department of Defense Evidence-Based Practice Workgroup members and do not necessarily reflect official Veterans Health Affairs or Department of Defense positions.

Acknowledgments: The authors thank Laurie Hoyt Huffman for reviewing the manuscript and providing helpful suggestions, Jayne Schablaske and Michelle Pappas for administrative assistance in preparing the manuscript, Andrew Hamilton for conducting the literature searches, and Oded Susskind for assistance in developing the algorithm.

Grant Support: Financial support for the development of this guideline comes exclusively from the ACP and APS operating budgets.

Potential Financial Conflicts of Interest: Honoraria: R. Chou (Bayer Healthcare Pharmaceuticals). Grants received: V. Snow (Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, Novo Nordisk, Pfizer Inc., Merck & Co. Inc., Bristol-Myers Squibb, Atlantic Philanthropics, Sanofi-Pasteur).

Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, aqaseem{at}acponline.org.

Current Author Addresses: Dr. Chou: 3181 SW Sam Jackson Park Road, Mailcode BICC, Portland, OR 97239.

Drs. Qaseem and Snow: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Dr. Casey: 475 South Street, PO Box 1905, Morristown, NJ 07962.

Dr. Cross: 1761 South 8th Street, Suite H, Colorado Springs, CO 80906.

Dr. Shekelle: 1776 Main Street, Santa Monica, CA 90401.

Dr. Owens: 117 Encina Commons, Stanford, CA 94305

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