New guidelines for treating low-back pain

The American College of Physicians (ACP) and the American Pain Society (APS) today released joint guidelines on diagnosing and treating low back pain.

About one in four Americans reported having low back pain in the past three months and about l7.6 percent of all adults reported at least one episode of severe acute low back pain within the previous year, according to several studies. Other studies show that most people's low back pain will improve within one month, regardless of treatment. Treatments range from doing nothing to spinal surgery.

In 2006, ACP and APS convened a multidisciplinary panel of experts to develop questions and the scope of an evidence report on low back pain, to review its results and come up with recommendations for primary care physicians to diagnose and treat low back pain.

The recommendations, published in the Oct. 2, 2007, issue of Annals of Internal Medicine, include an algorithm to guide clinicians in obtaining and interpreting information during the first patient visit and place patients into one of three general categories:

- Nonspecific low back pain (85% of patients fall in this category) - Back pain potentially associated with spinal conditions, such as spinal stenosis, sciatica, vertebral compression fracture - Back pain potentially associated with another specific cause, such as cancer.

The recommendations say that clinicians should not routinely order imaging or other diagnostic tests such as X-rays, CAT scans, and MRIs, for patients with nonspecific low back pain. They should reserve these tests for patients who have severe or progressive neurologic deficits or suspected underlying conditions, such as cancer or infection.

The joint ACP-APS guidelines are designed for primary care physicians and other clinicians and do not address invasive therapies performed by specialists. The American Pain Society will publish a separate guideline covering invasive procedures for low back pain in 2008.

“There are many options for evaluation and treatment of low back pain,” said Amir Qaseem, MD, PhD, MHA, senior medical associate in the ACP Department of Clinical Programs and Quality of Care, and an author of the guidelines. “We wanted to review all the evidence and develop guidance for clinicians and to give our patients a realistic sense of what they can expect when they visit a clinician for low back pain. It is important to tell patients about their expected course based on evidence-based information and advise them to remain active.”

Roger Chou, head of the American Pain Society Clinical Practice Guidelines Program, an author of the guidelines, and the senior author of the two background papers on which the guidelines were based, reviewed evidence for both drug therapies and non-drug therapies for acute and chronic low back pain.

"Almost all medications reviewed had some benefits, but they have risks," Chou said. "Acetaminophen, for example, is very safe but might not be effective. NSAIDS have gastrointestinal and cardiovascular risks. Opioids and muscle relaxers can provide relief for those with severe pain, but their potential benefits and risks should be weighed carefully."

"Patients who prefer not to take medication can benefit from non-drug treatments, such as acupuncture, spinal manipulations and massage therapy. None, however, are proven to be more effective than others to warrant recommendation as first-line therapy."