Clinical Practice Guideline

Low Back Pain

Diagnosis and Treatment of Low Back Pain

(Endorsed, February 2011)

The guideline, Diagnosis and Treatment of Low Back Pain, was developed by the American College of Physicians and the American Pain Society, and endorsed by the American Academy of Family Physicians.

Key Recommendations

  • A focused history and physical examination should be conducted to help place patients with low back pain into one of three 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.
  • Imaging or other diagnostic tests should not be routinely obtained in patients with nonspecific low back pain.
  • Diagnostic imaging and testing should be performed 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.
  • Patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis should be evaluated with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection.
  • Patients should be provided with evidence-based information on low back pain with regard to their expected course, advised to remain active, and provided information about effective self-care options.
  • For patients with low back pain, the use of medications with proven benefits in conjunction with back care information and self-care should be considered. Severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data should be assessed before initiating therapy. For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
  • For patients who do not improve with self-care options, addition of nonpharmacologic therapy with proven benefits should be considered. For acute low back pain, consider 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 could be added.

See full recommendation for further details.


These guidelines are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These guidelines are only one element in the complex process of improving the health of America. To be effective, the guidelines must be implemented.