Practice Guidelines

Low Back Pain: American College of Physicians Practice Guideline on Noninvasive Treatments


Key Points for Practice

• Acute and subacute low back pain often resolve spontaneously, but superficial heat, massage, acupuncture, and spinal manipulation are initial treatment options.

• If an NSAID or skeletal muscle relaxant is used, the decision between the two should be based on patient preference and the risks associated with each.

• If first-line nonpharmacologic options for chronic low back pain are ineffective, NSAIDs followed by tramadol and duloxetine can be considered.

From the AFP Editors

Low back pain occurs in most persons living in the United States and has been shown to have high costs, health care–related and indirect (e.g., missed work days, reduced efficiency at work and home), totaling about $100 billion in 2006. Often, management is based on how long symptoms have persisted, possible etiologies, occurrence of radicular symptoms, and abnormalities found on physical examination or radiography. The American College of Physicians has released a guideline, which partially updates its 2007 guideline, to provide recommendations for noninvasive treatment of acute (duration less than four weeks), subacute (duration of four to 12 weeks), and chronic (duration longer than 12 weeks) low back pain. It does not address topical or epidural therapies.


It should be noted that any improvements in pain or function with medication or other nonpharmacologic options have been found to be minimal based on the literature, and did not show well-defined differences vs. control treatments; therefore, treatment decisions should be based on patient preference, availability, possible harms, and cost. Persons with any type of low back pain should be encouraged to remain as active as pain allows.


Because acute and subacute low back pain often resolve spontaneously with time, superficial heat, massage, acupuncture, and spinal manipulation are all appropriate treatment options to try initially. Harms that have been reported with these

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.

A collection of Practice Guidelines published in AFP is available at



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Aug 15, 2018

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