Qaseem, Ann Intern Med 2017 - Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians - Article Summary

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians

Qaseem, Vijan, et al.·Ann Intern Med·2017·3,311 citations·Spine

This is the 2017 ACP clinical practice guideline on noninvasive treatment of low back pain. It asks which pharmacologic and nonpharmacologic therapies actually improve pain and function in adults with acute, subacute, and chronic low back pain. Recommendations are graded from a systematic review of RCTs and prior systematic reviews.

Key Findings

For acute or subacute low back pain, nonpharmacologic therapy comes first because most episodes are self-limited. Recommended options are superficial heat (moderate-quality evidence), massage, acupuncture, and spinal manipulation. If a drug is wanted, choose NSAIDs or skeletal muscle relaxants.
Acetaminophen is not effective for acute low back pain. A placebo-controlled RCT showed no difference from placebo for pain or function through 4 weeks. This reverses the 2007 ACP guideline, which had called acetaminophen effective based on indirect evidence.
For chronic low back pain, nonpharmacologic therapy is first-line because it carries fewer harms. Options with moderate-quality evidence include exercise, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction. Tai chi, yoga, motor control exercise, and CBT are also recommended on low-quality evidence.
When drugs are needed for chronic pain, the sequence is clear:
- First-line: NSAIDs
- Second-line: tramadol or duloxetine
- Last resort: opioids, only after other therapies fail and after a risk discussion.
Opioids gave only about 1 point of pain relief on a 0-to-10 scale short-term, with substantial harms. This small benefit against real addiction and overdose risk is why they are pushed to last-line.
TCAs and SSRIs did not improve pain in chronic low back pain (moderate-quality evidence). This also reverses the 2007 guideline, which had listed TCAs as effective.
No treatment produced a large effect on pain or function. All effects were small to moderate, and head-to-head trials showed few differences, so treatment should follow patient preference, harms, and cost.
Systemic steroids showed no benefit for acute or subacute pain, even with radicular symptoms, and are recommended against.

Board PearlTreat acute low back pain with nonpharmacologic options first; acetaminophen is ineffective and opioids are a last resort even for chronic pain.

Qaseem, Ann Intern Med 2017 - Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from 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

Key Findings

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