Low back pain affects millions of people in the United States, and the condition is one of the most common reasons for people missing work. New guidelines from the American College of Physicians recommend noninvasive ways of treating nonradicular low back pain.
The American Chiropractic Association (ACA) report that approximately 31 million U.S. individuals experience low back pain at one point during their lives. The ACA also note that low back pain is the leading cause of disability across the world, as well as one of the most popular reasons why people miss work.
The condition accounts for a large proportion of all doctor visits in the U.S., and almost 25 percent of the entire adult population in the U.S. has experienced at least one day of low back pain in the past 3 months.
The pain is typically characterized as acute if it lasts for under 4 weeks, subacute if it lasts between 4 and 12 weeks, and chronic if it lasts for more than 12 weeks.
The American College of Physicians (ACP) have published their clinical practice guideline for treating nonradicular low back pain in the journal Annals of Internal Medicine. Nonradicular pain refers to pain that does not irradiate from, and is not caused by, damage to the spinal nerve root.
An evidence-based guideline for clinical practice
The guideline is based on a review of randomized controlled trials and observational studies conducted on noninvasive drug and non-drug treatments for low back pain.
The health outcomes evaluated by the ACP include the reduction or complete elimination of low back pain, improvement in overall motor function and quality of life, reduction or elimination of work disability, and drug side effects. The review also looked at the number of back pain episodes and duration between episodes.
The ACP have reached their conclusions through a meticulous reviewing process that consists of several stages: a systematic review of the evidence available; a deliberation based on the evidence; a summary of the recommendations; grading the quality of the evidence; and issuing the recommendations.
In 1981, the ACP first established the clinical practice guidelines program, and they have been updating their guidelines ever since. The recommendations are automatically considered invalid or withdrawn if they are not updated every 5 years.
The ACP last published their clinical practice guideline in 2007. Since then, some of the evidence has changed, and the 2017 guidelines include evaluations of mindfulness-based therapies, motor control exercise (MCE), and tai chi.
Opioids should be ‘last option’ for treatment
Clinical trials reviewed in the guidelines show that acetaminophen does not reduce pain when compared with a placebo. Systemic steroids were also shown to be ineffective in treating acute or subacute low back pain. However, the evidence supporting this was deemed “low-quality” by the ACP.
The committee recommends that patients with chronic low back pain start by undergoing non-drug therapy and exercising, as well as engaging in multidisciplinary rehabilitation, acupuncture, mindfulness-based therapies for stress reduction, tai chi, and yoga.
Other practices recommended by the ACP in the initial stages of chronic low back pain include MCE (an activity that focuses on the “activation of the deep and global trunk muscles”) and progressive muscle relaxation, including the use of electromyography biofeedback. Biofeedback-assisted relaxation uses electronic devices to measure body functions, thus helping the patient gain control of muscle tension and relaxation.
The ACP also recommend low-level laser therapy and spinal manipulation, as well as cognitive behavioral and operant therapy.
The president of the ACP comments on the newly issued recommendations:
“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. Physicians should remind their patients that any of the recommended physical therapies should be administered by providers with appropriate training.”
Dr. Nitin S. Damle
As the next clinical step for patients with chronic low back pain who did not respond well to nonpharmacological therapy, the ACP recommend nonsteroidal anti-inflammatory drugs, followed by drugs such as tramadol or duloxetine as second-line therapy.
The committee notes that physicians should only consider prescribing opioids for patients who did not respond adequately to these previous treatments. The committee recommends that physicians should consult the patients and present to them the associated risks and potential benefits of opioid treatment.
Finally, the physicians should only prescribe opioids if the possible benefits clearly outweigh the risks.
“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,” adds Dr. Damle.
Overall, Dr. Damle explains, “physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment.”
“Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients,” Dr. Damle adds.