The strength of evidence (High, Moderate, Low) and the strength of the recommendations (Strong or Weak) are defined at the end of the "Major Recommendations" field.
Evaluation of Low Back Pain
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).
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).
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).
Note: See appendix tables 5 and 6 in the original guideline document for levels of evidence and summary grades for other noninvasive interventions in patients with acute or chronic/subacute low back pain.
Grading of Quality of Evidence
High Quality Evidence
Evidence obtained from one or more well-designed and well-executed randomized control trials (RCTs) yielding consistent directly applicable results.
Moderate Quality Evidence
Evidence obtained from RCTs with important limitations. For example, biased assessment of the treatment effect, large loss of follow-up, unblended study, unexplained heterogeneity (even if it is generated from rigorous RCTs), indirect evidence originating from similar (but not identical) populations of interest, and RCTs with a very small N or observed very few events. Evidence from well designed controlled trials without randomization, well-designed cohort or case control analytic studies, multiple time series with or without intervention also fall in this category.
Low Quality Evidence
Evidence obtained from observational studies. However, on very rare occasions, it can be classified as moderate or even high. For example, when they yield extremely large and consistent estimates of the magnitude of a treatment effect or when all plausible biases from observational studies may be working to underestimate an apparent treatment effect.
Grading of Guideline Recommendations*
Benefits clearly outweigh risks and burden OR risks and burden clearly outweigh benefits.
Benefits are finely balanced with risks and burden or appreciable uncertainty exists about magnitude of benefits and risks.
I or Insufficient Recommendation
The evidence is insufficient to recommend for or against routinely providing the service. Evidence is conflicting, of poor quality, or lacking and the balance of benefits and harms cannot be determined.
|Quality of Evidence
||Strength of Recommendation
||Benefits clearly outweigh risks and burden
OR risks and burden clearly outweigh benefits
|Benefits finely balanced with risks and burden
|Insufficient evidence to determine net benefits or risks
Note: Adopted from the classification developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Workshop.