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 All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.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.
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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.
Qaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee of 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. Ann Intern Med. [Epub ahead of print 14 February 2017]:. doi: 10.7326/M16-2367
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Published: Ann Intern Med. 2017.
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)
Table. The American College of Physicians Guideline Grading System*
Appendix Table 1. Pharmacologic and Nonpharmacologic Treatments for Acute or Subacute Low Back Pain
Appendix Table 2. Pharmacologic and Nonpharmacologic Treatments for Chronic Low Back Pain
Appendix Table 3. Pharmacologic and Nonpharmacologic Treatments for Radicular Low Back Pain
Appendix Table 4. Adverse Events for Treatments for Acute, Chronic, and Radicular Low Back Pain
Summary of the American College of Physicians guideline on noninvasive treatments for acute, subacute, or chronic low back pain.
COX-2 = cyclooxygenase-2; LLLT = low-level laser therapy; NSAID = nonsteroidal anti-inflammatory drug; SMR = skeletal muscle relaxant.
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Alain Braillon M.D., Ph.D
University Hospital, CEDEX
February 16, 2017
Acupuncture and low-back pain: an international bazar
The American College of Physicians (ACP) guideline on non-invasive treatments for low back pain recommending “complementary and alternative medicine therapies” (massage, acupuncture, or spinal manipulation)” while mentioning the “low-quality evidence” deserves comment.(1)First, the correct term is “Complementary and Alternative Practices” (CAP): medicine should be based on evidence. Adding “therapies” to practices which enduringly failed to show evidence of relevant effects creates an oxymoron.(2) For low back pain, endpoints are a decrease in pharmacological treatment, an increase in the odds of being at work, improved functional limitations or quality of life …Second, the recommendation ignored several old robust trials published in core clinical journals showing effectiveness of Cognitive Behavioral Therapies.(e.g. 3,4) The trial cited as reference 121 was prolonged, confirming improvements in pain and functional limitations at 26 weeks.(5)Third, in England, the National Institute for Health and Care Excellence specifically recommended acupuncture NOT be used for managing low back pain as evidence is lacking.(https://www.nice.org.uk/guidance/ng59) In Australia, Friends of Science in Medicine warned “There is already enough evidence to confidently conclude that acupuncture doesn’t work. It is merely a theatrical placebo based on pre-scientific myths”(www.scienceinmedicine.org.au/images/pdf/acupuncturereview.pdf) and showed advertising claims are grossly misleading lay people.(http://www.scienceinmedicine.org.au/images/pdf/ukasaletter.pdf)Patients need explanations and reassurance to promote autonomy, not to be given faith in weird practices. Several skills in the doctor-patient encounter are pivotal (take time, remove barriers, let the patient explain…), CAP cannot replace them, they only strengthen medical arrogance. Voltaire at his time (1694-1778) stated "The art of medicine consists in amusing the patient while nature cures the disease." In 2017 AD, why amusing patients with weird practices from BC and non-existing meridians? Last, acupuncture was excluded from the Imperial Medical Institute by a decree of the Emperor of China in 1822, being regarded as superstitious and irrational.1 Qaseem A, Wilt TJ1, McLean RM et al. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2017. Online Feb 14. doi: 10.7326/M16-2367.2 Braillon A. Placebo and chronic low back pain: Too much in way of expectations, too little in terms of data. Pain 2017;158:535-536. 3 Cherkin DC, Sherman KJ, Balderson BH et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial. JAMA 2016;315:1240-9. 4 Lamb SE, Mistry D, Lall R et al. Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet 2010;375:916-235 Cherkin DC, Sherman KJ, Balderson BH et al. Two-year follow-up of a randomized clinical trialof mindfulness-based stress reduction vs cognitive behavioral therapy or usual care for chronic low back pain. JAMA 2017:317:642-3.
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