Low Back Pain Guideline

Embargoed for release until 5:00 p.m. Eastern Time on Monday February 13th 2017

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Embargoed for release until 5:00 p.m. Eastern Time on Monday February 13th 2017

Slate 2:

American College of Physicians issues guideline for

treating nonradicular low back pain

Treatment recommendations include massage, acupuncture, spinal manipulation, tai chi, and yoga

Video News Story from American College of Physicians

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Courtesy the American College of Physicians,

publisher of Annals of Internal Medicine.

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Table of Contents:

Story Description

Interview ID

Full Video Package

Additional Soundbites

Slate 5:

Story Description:

The American College of Physicians (ACP) recommends in an evidence-based clinical practice guideline published in Annals of Internal Medicine that physicians and patients should treat acute or subacute low back pain with non-drug therapies such as superficial heat, massage, acupuncture, or spinal manipulation. If drug therapy is desired, physicians and patients should select nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants.

Low back pain is one of the most common reasons for all physician visits in the U.S. Most Americans have experienced low back pain. Approximately one quarter of U.S. adults reported having low back pain lasting at least one day in the past three months. Pain is categorized as acute (lasting less than four weeks), subacute (lasting four to 12 weeks, and chronic (lasting more than 12 weeks).

ACP says physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment, and that physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients.

The evidence showed that acetaminophen was not effective at improving pain outcomes versus placebo. Low-quality evidence showed that systemic steroids were not effective in treating acute or subacute low back pain.

For patients with chronic low back pain, ACP recommends that physicians and patients initially select non-drug therapy with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (MCE), progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.

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.

For patients with chronic low back pain who have had an inadequate response to non-drug therapy, ACP recommends that physicians and patients consider treatment with NSAIDs as first line therapy; or tramadol or duloxetine as second line therapy. Physicians 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.

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Interview ID

Nitin S. Damle, MD, MS, MACP, president,

American College of Physicians

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Full video package:

(1) Announcer: Low back pain is one of the most common reasons for all physician visits in the United States, and approximately one quarter of all adults in the U.S. have reported pain lasting at least one day in the past three months. New recommendations from the American College of Physicians say you shouldn't turn to medications first for treatment.
Nitin S. Damle,
MD, MS, MACP, president, ACP / (2) Dr. Nitin S. Damle: Acute and subacute low back pain is primarily treated with non-pharmacologic therapy, such as a massage and heat and spinal manipulation. If needed, anti-inflammatories or muscle relaxants can be used.
Paper then read on graphic
Acute –Less than 4 weeks
Subacute—4 to 12 weeks
Chronic-- More than 12 weeks / (3) Announcer: ACP’s new clinical guideline published in Annals of Internal Medicine categorizes back pain as acute--lasting less than four weeks, subacute-- lasting four to 12 weeks, and chronic--lasting more than 12 weeks.
(4) Dr. Nitin S. Damle: Most low back pain is self-limited. It will resolve within a matter of a few days or even maybe up to a week or two.
(5) Announcer: The guideline is an update of ACP’s 2007 guideline as some evidence has changed.
(6) Dr. Nitin S. Damle: The guideline found that acetaminophen is not very effective in treating low back pain.
(7) Announcer: For patients with chronic low back pain, ACP recommends that physicians and patients initially select non-drug therapy such as exercise, acupuncture, tai chi, yoga, or spinal manipulation.
(8) Dr. Nitin S. Damle: Physicians and patients should really seek the treatment that causes the least harm and is least costly. Because comparatively all treatments are comparable to each other.
(9) Announcer: ACP says physicians should remind their patients that any of the recommended physical therapies should be administered by providers with appropriate training and should only look toward drug treatment if they don't respond to non-drug therapy.
(10) Dr. Nitin S. Damle: For patients with chronic low back pain who are not responsive to non-drug therapy, second line therapy would be anti-inflammatories or duloxetine.
(11) Announcer: ACP advises physicians to consider opiods only 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. For more information go to, acponline.org.

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Additional soundbites

Nitin S. Damle, MD, MS, MACP, president, American College of Physicians

Low back pain is categorized as acute when it lasts for less than four weeks, subacute when it lasts between four and twelve weeks and chronic if it lasts for more than twelve weeks.

Physicians should avoid testing for acute and subacute low back pain because it’s mostly self-limited. And there is no real value to added tests and they can be associated with some harm and increased costs.

The evidence did not show any benefit to using steroids in acute or subacute low back pain.

For patients with chronic low back pain, opioids should only be used as a last resort therapy. There are significant harms associated with them, including addiction and potential for overdose.

ACP’s recommendation is for treating non-radicular back pain. There is insufficient evidence for treatment of radicular back pain.

Radicular back pain is when there’s actually nerve involvement and it actually goes down the leg and there might be even some weakness, and some numbness and some insensitivity. It’s a little different than non-radicular, which is just kind of low back pain without any radiation.

ACP’s guideline does not address topical therapy or epidural therapy.

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Courtesy the American College of Physicians, publisher of Annals of Internal Medicine

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