Diagnosis and Treatment of Low Back Pain: Recommendations from the American College of Physicians/American Pain Society

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The summary below is from the full reports titled "Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society," "Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline," and "Medications for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline." They are in the 2 October 2007 issue of Annals of Internal Medicine (volume 147, pages 478-491, 492-504 , and 505-514). The authors of the first report are R. Chou, A. Qaseem, V. Snow, D. Casey, J.T. Cross Jr., P. Shekelle, and D.K. Owens, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/ American Pain Society Low Back Pain Guidelines Panel, and the authors of the second and third reports are R. Chou and L.H. Huffman.

Who developed these guidelines?

The American College of Physicians (ACP) developed these recommendations with the American Pain Society (APS). Members of the ACP are internists (that is, specialists in the care of adults).

What is the problem and what is known about it so far?

Low back pain is a common problem that often goes away after several days or weeks (acute low back pain), but in some persons may persist for longer (chronic low back pain). Low back pain is usually musculoskeletal, meaning that the cause is strain on the bones, muscles, and ligaments of the spine. However, low back pain can sometimes be due to serious conditions, such as cancer or spine problems, that cause nerve damage.

When diagnosing musculoskeletal low back pain, doctors need to rule out these serious causes. However, it is not clear that x-rays, computed tomography (CT) (or "CAT scans"), magnetic resonance imaging (MRI), or other tests are necessary in most cases.

The main goal in treating low back pain is to decrease the pain and allow patients to resume their normal activities. Treatment options for low back pain include drugs (painkillers, anti-inflammatory drugs, and muscle relaxants), physical therapy, back exercises, education about ways to prevent back injury and to deal with back pain (sometimes called "back school"), and nontraditional therapies (acupuncture, massage, spinal manipulation). It can be difficult for doctors and patients to choose from among the many treatments for low back pain.

How did the ACP and the APS develop these recommendations?

The authors reviewed published studies about the benefits and harms of tests and treatments used in low back pain.

What did the authors find?

Moderate-quality studies show that testing is helpful only when nerve damage or a serious condition is likely. Moderate-quality studies also show that self-care helps. Acetaminophen or nonsteroidal anti-inflammatory drugs are the preferred drugs for low back pain. Variable-quality studies show that spinal manipulation, massage, exercise therapy, acupuncture, yoga, cognitive-behavioral therapy, and progressive relaxation are nondrug therapies that may be helpful for low back pain.

What do the ACP and the APS suggest that patients and doctors do?

Doctors should use a patient's history and the results of a physical examination to determine whether that patient's low back pain is musculoskeletal, associated with nerve damage, or potentially related to another serious condition.

Doctors should not order x-rays, CT scans, MRIs, or other tests unless they suspect nerve damage or a specific cause of the low back pain that would show up on the test.

When patients have signs of nerve damage that might be treated with surgery or spinal injections, an MRI is the best test and a CT scan is the next best.

Doctors and patients should discuss the expected course of low back pain; the importance of remaining active; and self-care options, such as heating pads, special mattresses, and exercise. They should also consider acetaminophen or nonsteroidal anti-inflammatory drugs along with self-care.

Doctors and patients should consider the following nondrug treatments for patients who do not respond to self-care: rehabilitation, spinal manipulation, exercise therapy, massage, acupuncture, yoga, progressive relaxation, or cognitive-behavioral therapy.

What are the cautions related to these recommendations?

Recommendations may change as new studies become available.

Read all Rapid Responses

Failing evidence behind first-line medication recommendations

Jan M Bjordal, et al.

Annals Online, 7 Nov 2007 [Full text]

In Response

Roger Chou, et al.

Annals Online, 5 Dec 2007 [Full text]

Correction

Roger Chou, et al.

Annals Online, 5 Dec 2007 [Full text]

Middle cluneal neuropathy: a neglected cause of low back pain.

Stanley J Antolak

Annals Online, 5 Dec 2007 [Full text]

Early Physical Therapy intervention necessary for low back pain.

Philip P Tygiel, et al.

Annals Online, 12 May 2008 [Full text]

Re: Early Physical Therapy intervention necessary for low back pain

Amir Qaseem, et al.

Annals Online, 28 Aug 2008 [Full text]