Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD;
Donald Casey, MD, MPH, MBA; J. Thomas Cross, Jr, MD, MPH;
Paul Shekelle, MD, PhD; Douglas K. Owens, MD, MS
Clinical Efficacy Assessment Subcommittee of the American College of Physicians
and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel*
Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).
Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).
Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).
Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).
Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).
Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
Figure 1. Initial Evaluation of Low Back Pain
Do not use this algorithm for back pain associated with major trauma, nonspinal back pain, or back pain due to systemic illness. CRP = C-reactive protein; EMG = electromyography; ESR = erythrocyte sedimentation rate; MRI = magnetic resonance imaging; NCV = nerve conduction velocity.Figure 2. Management of Low Back Pain
MRI = magnetic resonance imaging; NSAIDs = nonsteroidal anti-inflammatory drugs; TCA = tricyclic antidepressants.
Recommendations: Treatment of Low Back Pain
Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).
Clinicians should inform all patients of the generally favorable prognosis of acute low back pain with or without sciatica, including a high likelihood for substantial improvement in the first month [6, 40]. Clinicians should explain that early, routine imaging and other tests usually cannot identify a precise cause, do not improve patient outcomes, and incur additional expenses. Clinicians should also review indications for reassessment and diagnostic testing (see recommendations 1 and 4). General advice on self-management for nonspecific low back pain should include recommendations to remain active, which is more effective than resting in bed for patients with acute or subacute low back pain [65, 66]. If patients require periods of bed rest to relieve severe symptoms, they should be encouraged to return to normal activities as soon as possible. Self-care education books (see Glossary) based on evidence-based guidelines, such as The Back Book [67], are recommended because they are an inexpensive and efficient method for supplementing clinician-provided back information and advice and are similar or only slightly inferior in effectiveness to such costlier interventions as supervised exercise therapy, acupuncture (see Glossary), massage (see Glossary), and spinal manipulation (see Glossary) [65, 66, 68–70]. Other methods for providing self-care education, such as e-mail discussion groups, layperson-led groups, videos, and group classes, are not as well studied.
Factors to consider when giving advice about activity limitations to workers with low back pain are the patient’s age and general health and the physical demands of required job tasks. However, evidence is insufficient to guide specific recommendations about the utility of modified work for facilitating return to work [71]. For worker’s compensation claims, clinicians should refer to specific regulations for their area of practice, as rules vary substantially from state to state. Brief individualized educational interventions (defined as a detailed clinical examination and advice, typically lasting several hours over 1 to 2 sessions) (see Glossary) can reduce sick leave in workers with subacute low back pain [72–74].
Application of heat by heating pads or heated blankets is a self-care option (see Glossary) for short-term relief of acute low back pain [75]. In patients with chronic low back pain, firm mattresses are less likely than a medium-firm mattress to lead to improvement [76]. There is insufficient evidence to recommend lumbar supports [77] or the application of cold packs [75] as self-care options.
Although evidence is insufficient to guide specific self-management recommendations for patients with acute radiculopathy or spinal stenosis, some trials enrolled mixed populations of patients with and without sciatica, suggesting that applying principles similar to those used for nonspecific low back pain is a reasonable approach (see also recommendation 4).
Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs).
Medications in several classes have been shown to have moderate, primarily short-term benefits for patients with low back pain. Each class of medication is associated with unique trade-offs involving benefits, risks, and costs. For example, acetaminophen is a slightly weaker analgesic than NSAIDs (<10 points on a 100-point visual analogue pain scale) [78–82] but is a reasonable first-line option for treatment of acute or chronic low back pain because of a more favorable safety profile and low cost [79, 82–84]. However, acetaminophen is associated with asymptomatic elevations of aminotransferase levels at dosages of 4 g/d (the upper limit of U.S. Food and Drug Administration–[FDA] approved dosing) even in healthy adults, although the clinical significance of these findings are uncertain [85]. Nonselective NSAIDs are more effective for pain relief than is acetaminophen [80], but they are associated with well-known gastrointestinal and renovascular risks [83]. In addition, there is an association between exposure to cyclooxygenase-2–selective or most nonselective NSAIDs and increased risk for myocardial infarction [86]. Clinicians should therefore assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs and recommend the lowest effective doses for the shortest periods necessary. Clinicians should also remain alert for new evidence about which NSAIDs are safest and consider strategies for minimizing adverse events in higher-risk patients who are prescribed NSAIDs (such as co-administration with a proton-pump inhibitor) [87]. There is insufficient evidence to recommend for or against analgesic doses of aspirin in patients with low back pain [88].
Opioid analgesics or tramadol are an option when used judiciously in patients with acute or chronic low back pain who have severe, disabling pain that is not controlled (or is unlikely to be controlled) with acetaminophen and NSAIDs. Because of substantial risks, including aberrant drug-related behaviors with long-term use in patients vulnerable or potentially vulnerable to abuse or addiction, potential benefits and harms of opioid analgesics should be carefully weighed before starting therapy [89–91]. Failure to respond to a time-limited course of opioids should lead to reassessment and consideration of alternative therapies or referral for further evaluation [92–94]. Evidence is insufficient to recommend one opioid over another [95].
The Glossary term skeletal muscle relaxants refers to a diverse group of medications, some with unclear mechanisms of action, grouped together because they carry FDA-approved indications for treatment of musculoskeletal conditions or spasticity. Although the antispasticity drug tizanidine has been well studied for low back pain, there is little evidence for the efficacy of baclofen or dantrolene, the other FDA-approved drugs for the treatment of spasticity [96]. Other medications in the skeletal muscle relaxant class are an option for short-term relief of acute low back pain, but all are associated with central nervous system adverse effects (primarily sedation). There is no compelling evidence that skeletal muscle relaxants differ in efficacy or safety [96, 97]. Because skeletal muscle relaxants are not pharmacologically related, however, risk–benefit profiles could in theory vary substantially. For example, carisoprodol is metabolized to meprobamate (a medication associated with risks for abuse and overdose), dantrolene carries a black box warning for potentially fatal hepatotoxicity, and both tizanidine and chlorzoxazone are associated with hepatotoxicity that is generally reversible and usually not serious.
Tricyclic antidepressants are an option for pain relief in patients with chronic low back pain and no contraindications to this class of medications [98, 99]. Antidepressants in the selective serotonin reuptake inhibitor class and trazodone have not been shown to be effective for low back pain, and serotonin–norepineprhine reuptake inhibitors (duloxetine and venlafaxine) have not yet been evaluated for low back pain. Clinicians should bear in mind, however, that depression is common in patients with chronic low back pain and should be assessed and treated appropriately [100].
Gabapentin is associated with small, short-term benefits in patients with radiculopathy [101, 102] and has not been directly compared with other medications or treatments. There is insufficient evidence to recommend for or against other antiepileptic drugs for back pain with or without radiculopathy. For acute or chronic low back pain, benzodiazepines seem similarly effective to skeletal muscle relaxants for short-term pain relief [96] but are also associated with risks for abuse, addiction, and tolerance. Neither benzodiazepines nor gabapentin are FDA-approved for treatment of low back pain (with or without radiculopathy). If a benzodiazepine is used, a time-limited course of therapy is recommended.
Herbal therapies, such as devil’s claw, willow bark, and capsicum, seem to be safe options for acute exacerbations of chronic low back pain, but benefits range from small to moderate. In addition, many of the published trials were led by the same investigator, which could limit applicability of findings to other settings [103].
Systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, because they have not been shown to be more effective than placebo [104–107].
Most medication trials evaluated patients with nonspecific low back pain or mixed populations with and without sciatica. There is little evidence to guide specific recommendations for medications (other than gabapentin) for patients with sciatica or spinal stenosis. Evidence is also limited on the benefits and risks associated with long-term use of medications for low back pain. Therefore, extended courses of medications should generally be reserved for patients clearly showing continued benefits from therapy without major adverse events.
Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
For acute low back pain (duration <4 weeks), spinal manipulation administered by providers with appropriate training is associated with small to moderate short-term benefits [108]. Supervised exercise therapy and home exercise regimens are not effective for acute low back pain [109], and the optimal time to start exercise therapy after the onset of symptoms is unclear. Other guidelines suggest starting exercise after 2 to 6 weeks, but these recommendations seem to be based on poor-quality evidence [25, 110]. Other nonpharmacologic treatments have not been proven to be effective for acute low back pain.
For subacute (duration >4 to 8 weeks) low back pain, intensive interdisciplinary rehabilitation (defined as an intervention that includes a physician consultation coordinated with a psychological, physical therapy, social, or vocational intervention) (see Glossary) is moderately effective [111], and functional restoration (see Glossary) with a cognitive-behavioral component reduces work absenteeism due to low back pain in occupational settings [112]. There is little evidence on effectiveness of other treatments specifically for subacute low back pain [113]. However, many trials enrolled mixed populations of patients with chronic and subacute symptoms, suggesting that results may reasonably be applied to both situations.
For chronic low back pain, moderately effective nonpharmacologic therapies include acupuncture [114, 115], exercise therapy [109], massage therapy [116], Viniyoga-style yoga (see Glossary) [70], cognitive-behavioral therapy or progressive relaxation (see Glossary) [117, 118], spinal manipulation [108], and intensive interdisciplinary rehabilitation [119], although the level of supporting evidence for different therapies varies from fair to good (Appendix Table 6). In meta-regression analyses, exercise programs that incorporate individual tailoring, supervision, stretching, and strengthening are associated with the best outcomes [109]. The evidence is insufficient to conclude that benefits of manipulation vary according to the profession of the manipulator (chiropractor vs. other clinician trained in manipulation) or according to presence or absence of radiating pain [108]. With the exception of continuous or intermittent traction (see Glossary), which has not been shown to be effective in patients with sciatica [120–122], few trials have evaluated the effectiveness of treatments specifically in patients with radicular pain [122] or symptoms of spinal stenosis. In addition, there is insufficient evidence to recommend any specific treatment as first-line therapy. Patient expectations of benefit from a treatment should be considered in choosing interventions because they seem to influence outcomes [123]. Some interventions (such as intensive interdisciplinary rehabilitation) may not be available in all settings, and costs for similarly effective interventions can vary substantially. There is insufficient evidence to recommend the use of decision tools or other methods for tailoring therapy in primary care, although initial data are promising [124–126].
Transcutaneous electrical nerve stimulation (see Glossary) and intermittent or continuous traction (in patients with or without sciatica) have not been proven effective for chronic low back pain (Appendix Table 6). Acupressure (see Glossary), neuroreflexotherapy (see Glossary), and spa therapy (see Glossary) have not been studied in the United States, and percutaneous electrical nerve stimulation (see Glossary) is not widely available. There is insufficient evidence to recommend interferential therapy (see Glossary), low-level laser therapy (see Glossary), shortwave diathermy (see Glossary), or ultrasonography. Evidence is inconsistent on back schools (see Glossary), which have primarily been evaluated in occupational settings, with some trials showing small, short-term benefits [127].
It may be appropriate to consider consultation with a back specialist when patients with nonspecific low back pain do not respond to standard noninvasive therapies. However, there is insufficient evidence to guide specific recommendations on the timing of or indications for referral, and expertise in management of low back pain varies substantially among clinicians from different disciplines (including primary care providers). In general, decisions about consultation should be individualized and based on assessments of patient symptoms and response to interventions, the experience and training of the primary care clinician, and the availability of specialists with relevant expertise. In considering referral for possible surgery or other invasive interventions, other published guidelines suggest referring patients with nonspecific low back pain after a minimum of 3 months [25] to 2 years [128] of failed nonsurgical interventions. Although specific suggestions about timing of referral are somewhat arbitrary, one factor to consider is that trials of surgery for nonspecific low back pain included only patients with at least 1 year of symptoms [129–131]. Other recommendations for invasive interventions are addressed in a separate guideline from the APS [17].
Glossary
Acute low back pain: Low back pain present for fewer than 4 weeks, sometimes grouped with subacute low back pain as symptoms present for fewer than 3 months.
Cauda equina syndrome: Compression on nerve roots from the lower cord segments, usually due to a massive, centrally herniated disc, which can result in urinary retention or incontinence from loss of sphincter function, bilateral motor weakness of the lower extremities, and saddle anesthesia.
Chronic low back pain: Low back pain present for more than 3 months.
Herniated disc: Herniation of the nucleus pulposus of an intervertebral disc through its fibrous outer covering, which can result in compression of adjacent nerve roots or other structures.
Neurogenic claudication: Symptoms of leg pain (and occasionally weakness) on walking or standing, relieved by sitting or spinal flexion, associated with spinal stenosis.
Nonspecific low back pain: Pain occurring primarily in the back with no signs of a serious underlying condition (such as cancer, infection, or cauda equina syndrome), spinal stenosis or radiculopathy, or another specific spinal cause (such as vertebral compression fracture or ankylosing spondylitis). Degenerative changes on lumbar imaging are usually considered nonspecific, as they correlate poorly with symptoms.
Radiculopathy: Dysfunction of a nerve root associated with pain, sensory impairment, weakness, or diminished deep tendon reflexes in a nerve root distribution.
Sciatica: Pain radiating down the leg below the knee in the distribution of the sciatic nerve, suggesting nerve root compromise due to mechanical pressure or inflammation. Sciatica is the most common symptom of lumbar radiculopathy.
Spinal stenosis: Narrowing of the spinal canal that may result in bony constriction of the cauda equina and the emerging nerve roots.
Straight-leg-raise test: A procedure in which the hip is flexed with the knee extended in order to passively stretch the sciatic nerve and elicit symptoms suggesting nerve root tension. A positive test is usually considered reproduction of the patient’s sciatica when the leg is raised between 30 and 70 degrees. Reproduction of the patient’s sciatica when the unaffected leg is lifted is referred to as a positive “crossed” straight-leg-raise test.
Interventions
Acupressure: An intervention consisting of manipulation with the fingers instead of needles at specific acupuncture points.
Acupuncture: An intervention consisting of the insertion of needles at specific acupuncture points.
Back school: An intervention consisting of education and a skills program, including exercise therapy, in which all lessons are given to groups of patients and supervised by a paramedical therapist or medical specialist.
Brief individualized educational interventions: Individualized assessment and education about low back pain problems without supervised exercise therapy or other specific interventions. As we defined them, brief educational interventions differ from back schools because they do not involve group education or supervised exercise.
Exercise: A supervised exercise program or formal home exercise regimen, ranging from programs aimed at general physical fitness or aerobic exercise to programs aimed at muscle strengthening, flexibility, stretching, or different combinations of these elements.
Functional restoration (also called physical conditioning, work hardening, or work conditioning): An intervention that involves simulated or actual work tests in a supervised environment in order to enhance job performance skills and improve strength, endurance, flexibility, and cardiovascular fitness in injured workers.
Interdisciplinary rehabilitation (also called multidisciplinary therapy): An intervention that combines and coordinates physical, vocational, and behavioral components and is provided by multiple health care professionals with different clinical backgrounds. The intensity and content of interdisciplinary therapy varies widely.
Interferential therapy: The superficial application of a medium-frequency alternating current modulated to produce low frequencies up to 150 Hz. It is thought to increase blood flow to tissues and provide pain relief and is considered more comfortable for patients than transcutaneous electrical nerve stimulation.
Low-level laser therapy: The superficial application of lasers at wavelengths between 632 and 904 nm to the skin in order to apply electromagnetic energy to soft tissue. Optimal treatment parameters (wavelength, dosage, dose-intensity, and type of laser) are uncertain.
Massage: Soft tissue manipulation using the hands or a mechanical device through a variety of specific methods. The pressure and intensity used in different massage techniques vary widely.
Neuroreflexotherapy: A technique from Spain characterized by the temporary implantation of staples superficially into the skin over trigger points in the back and referred tender points in the ear. Neuroreflexotherapy is believed to stimulate different zones of the skin than acupuncture.
Percutaneous electrical nerve stimulation (PENS): An intervention that involves inserting acupuncture-like needles and applying low-level electrical stimulation. It differs from electroacupuncture in that the insertion points target dermatomal levels for local pathology, rather than acupuncture points. However, there is some uncertainty over whether PENS should be considered a novel therapy or a form of electroacupuncture.
Progressive relaxation: A technique which involves the deliberate tensing and relaxation of muscles, in order to facilitate the recognition and release of muscle tension.
Self-care options: Interventions that can be readily implemented by patients without seeing a clinician or that can be implemented on the basis of advice provided at a routine clinic visit.
Self-care education book: Reading material (books, booklets, or leaflets) that provide education and self-care advice for patients with low back pain. Although the specific content varies, self-care books are generally based on principles from published clinical practice guidelines and encourage a return to normal activity, adoption of a fitness program, and appropriate lifestyle modification, and they provide advice on coping strategies and managing flares.
Shortwave diathermy: Therapeutic elevation of the temperature of deep tissues by application of short-wave electromagnetic radiation with a frequency range from 10-100 MHz.
Spa therapy: An intervention involving several interventions, including mineral water bathing, usually with heated water, typically while staying at a spa resort.
Spinal manipulation: Manual therapy in which loads are applied to the spine by using short- or long-lever methods and high-velocity thrusts are applied to a spinal joint beyond its restricted range of movement. Spinal mobilization, or low-velocity, passive movements within or at the limit of joint range, is often used in conjunction with spinal manipulation.
Traction: An intervention involving drawing or pulling in order to stretch the lumbar spine. Various methods are used, usually involving a harness around the lower rib cage and the iliac crest, with the pulling action done by using free weights and a pulley, motorized equipment, inversion techniques, or an overhead harness.
Transcutaneous electrical nerve stimulation (TENS): Use of a small, battery-operated device to provide continuous electrical impulses via surface electrodes, with the goal of providing symptomatic relief by modifying pain perception.
Yoga: An intervention distinguished from traditional exercise therapy by the use of specific body positions, breathing techniques, and an emphasis on mental focus. Many styles of yoga are practiced, each emphasizing different postures and techniques.
