Amir Qaseem, MD, PhD, MHA; Timothy J. Wilt, MD, MPH; Robert M. McLean, MD; Mary Ann Forciea, MD; for the Clinical Guidelines Committee of the American College of Physicians (*)
Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Dr. McLean reports personal fees from Takeda Pharmaceuticals outside the submitted work and membership in the American College of Physicians Clinical Guidelines Committee and the American College of Rheumatology Quality of Care Committee. Dr. Barry reports grants, personal fees, and nonfinancial support from Healthwise outside the submitted work. Dr. Boyd reports other support from UpToDate outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2367. All financial and intellectual disclosures of interest were declared and potential conflicts were discussed and managed. Dr. Manaker participated in the discussion for this guideline but was recused from voting on the recommendations because of an active indirect financial conflict. Dr. Kansagara participated in the discussion for this guideline but was recused from voting on the recommendations because of an inactive direct financial conflict. A record of disclosures of interest and management of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Dr. Qaseem: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Wilt: Minneapolis VA Medical Center, VA Medical Center 111-0, Minneapolis, MN 55417.
Dr. McLean: Yale School of Medicine, 46 Prince Street, Suite 302, New Haven, CT 06519.
Dr. Forciea: Penn Health System, 3615 Chestnut Street, Philadelphia, PA 19104.
Author Contributions: Conception and design: A. Qaseem, R. McLean, M.J. Barry.
Analysis and interpretation of the data: A. Qaseem, T. Wilt, R. McLean, M.A. Forciea, C. Boyd, R.P. Harris, L.L. Humphrey, S. Vijan.
Drafting of the article: A. Qaseem, R. McLean, M.A. Forciea, T.D. Denberg.
Critical revision of the article for important intellectual content: A. Qaseem, T. Wilt, R. McLean, M.A. Forciea, T.D. Denberg, M.J. Barry, C. Boyd, R.D. Chow, R.P. Harris, L.L. Humphrey, S. Vijan.
Final approval of the article: A. Qaseem, T. Wilt, R. McLean, M.A. Forciea, T.D. Denberg, M.J. Barry, C. Boyd, R.D. Chow, N. Fitterman, R.P. Harris, L.L. Humphrey, S. Vijan.
Statistical expertise: A. Qaseem, T. Wilt.
Administrative, technical, or logistic support: A. Qaseem, T.D. Denberg.
Collection and assembly of data: R.P. Harris.
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.
Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. Updated searches were performed through November 2016. Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.
The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.
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)
Amir Qaseem, Timothy J. Wilt, Robert M. McLean, Mary Ann Forciea, . Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166:514–530. doi: 10.7326/M16-2367
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Published: Ann Intern Med. 2017;166(7):514-530.
Published at www.annals.org on 14 February 2017
Back Pain, Guidelines, High Value Care, Neurology, Neuropathy.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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