ACP: Try Nondrug Therapies First for Nonradicular Low Back Pain

Treatment Recommendations Include Massage, Acupuncture, Yoga

February 14, 2017 04:50 pm Chris Crawford

In the past three months, about one in four U.S. adults has reported having low back pain lasting at least one day. This complaint is one of the most common reasons patients visit their physicians.  

That's according to the American College of Physicians (ACP), which released an evidence-based clinical practice guideline(annals.org) on Feb. 14 that recommends physicians treat patients' nonradicular acute or subacute low back pain with nonpharmacologic therapies such as superficial heat, massage, acupuncture and spinal manipulation.

If drug therapy is desired, the ACP guideline recommends that physicians and patients select nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants.

"Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment," said ACP President Nitin Damle, M.D., M.S., in a news release(www.acponline.org). "Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients."  

Story highlights
  • The American College of Physicians released a clinical practice guideline on Feb. 14 that recommends physicians treat patients' nonradicular acute or subacute low back pain with nonpharmacologic therapies.
  • For patients with chronic low back pain, the ACP recommends that physicians help patients initially select non-drug therapy.
  • For patients with chronic low back pain who have had an inadequate response to non-drug therapy, the ACP recommends considering treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, and with tramadol or duloxetine as second-line therapy.  

Researchers found that evidence did not support use of acetaminophen, which didn't improve pain outcomes versus a placebo. Low-quality evidence showed systemic steroids also weren't effective in treating acute or subacute low back pain.

Previously, the ACP and the American Pain Society had released a joint guideline(annals.org) on evaluating and managing acute and chronic low back pain that addressed pharmacologic options as well as nondrug therapies, which the AAFP endorsed. However, the authors of the current guideline said new evidence had emerged since the development of that 2007 guideline, which didn't assess mindfulness-based stress reduction, motor control exercise, taping or tai chi.

Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News the recommendation to preferentially use nonpharmacologic treatment and/or NSAIDs for chronic pain is consistent with the CDC's guideline on opioid prescribing for chronic pain(www.cdc.gov), which the AAFP supports.

Also, in 2004, the AAFP issued a clinical recommendation on the prevention of low-back pain, which concluded evidence was insufficient to recommend for or against routine use of interventions to prevent low back pain in adults in primary care settings.

Chronic Low Back Pain Recommendations

For patients with chronic low back pain, the new ACP guidance recommends that physicians help patients initially select nondrug therapy 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.

"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," said Damle in the release. "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, the ACP recommends physicians assist patients in considering treatment with NSAIDs as first-line therapy, and with tramadol (Ultram, ConZip, Ryzolt) or duloxetine (Cymbalta) as second-line therapy.

The guideline group said physicians should consider opioids as a therapeutic option only in patients who have failed the aforementioned treatments -- and then only if the potential benefits outweigh the risks for individual patients -- 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," Damle said.

Recommendation Review, Methodology

For this guideline, researchers with the Agency for Healthcare Research and Quality's (AHRQ's) Pacific Northwest Evidence-based Practice Center produced two systematic reviews covering studies published through April 2015 on noninvasive pharmacologic(annals.org) and nonpharmacologic treatments(annals.org) 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.

The evidence reviews were sent to invited peer reviewers and posted on the AHRQ website for public comment. They and the guideline itself also underwent a peer review process through the journal.

Radicular Low Back Pain Treatments

Researchers noted in this guideline that evidence was insufficient to determine treatments for radicular low-back pain. The evidence also was insufficient to recommend most physical modalities and to identify which patients might benefit from specific therapies.

Furthermore, the guideline doesn't address topical or epidural injection therapies.

According to Frost, the takeaway for family physicians is that in the majority of patients, acute back pain will resolve regardless of treatment.

"When treating something that will likely resolve on its own, we need to be mindful about not inadvertently causing harm to the patient," she said. "Nonpharmacologic interventions can provide some short-term relief, with a low likelihood of causing any harm. Pharmacological treatments are easy to prescribe, but they all carry varying risks of harm."

Related AAFP News Coverage
Annals of Family Medicine Research
Discussing Opioid Risks May Reduce Likelihood of Misuse, Abuse
(12/9/2016)

Search and Rescue Campaign Aims to Educate Opioid Prescribers
(10/13/2016)

CDC Releases Final Guideline for Prescribing Opioids for Chronic Pain
More Research Still Needed to Support the Guidance
(3/16/2016)

More From AAFP
American Family Physician: Diagnosis and Treatment of Acute Low Back Pain