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ACP Issues Recommendations on Chronic Back Pain
Ann Intern Med; ePub 2017 Feb 14; Qaseem, et al
The American College of Physicians (ACP) has issued a clinical practice guideline for noninvasive treatment of acute, subacute, and chronic low back pain in adults. The ACP makes the following clinical recommendations:
- Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence) (Grade: strong recommendation).
- For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence) (Grade: strong recommendation).
- In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).
Qaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. [Published online ahead of print February 14, 2017]. Ann Intern Med. doi:10.7326/M16-2367.
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This ACP guideline is a welcome addition to the literature on the treatment of low back pain (LBP). LBP with a duration of a day or more is experienced by up to a quarter of adults over any 3-month period and often presents to our offices with strong expectations for quick relief of pain. We now make treatment decisions in the context of an increasing epidemic of opioid abuse; it is clear that we need to curtail the use of opioids for acute pain if we are going to have impact on long-term abuse and diversion. The reminder that non-pharmacologic approaches such as heat and massage have efficacy in acute LBP is helpful in giving legitimacy to those recommendations. The next step up remains simple— NSAIDs and muscle relaxers—which help get people through the initial few days until the body begins to heal itself. Over the long-term, back stretching and abdominal strengthening are helpful, with NSAIDs still having a place and adjuvant pain medications such as duloxetine also useful in the treatment of chronic LBP. —Neil Skolnik, MD