This is the current release of the guideline.

Acute and chronic low back pain not associated with major trauma

Diagnosis
Management
Treatment

Chiropractic
Family Practice
Internal Medicine
Neurological Surgery
Neurology
Orthopedic Surgery
Pediatrics
Physical Medicine and Rehabilitation
Radiology

Physicians

To present the available evidence for evaluation and management of acute and chronic low back pain in primary care settings

Adults with acute and chronic low back pain not associated with major trauma

Note: Children or adolescents with low back pain; pregnant women; patients with low back pain from sources outside the back (nonspinal low back pain); fibromyalgia or other myofascial pain syndromes; and thoracic or cervical back pain are not included.

Evaluation

1. History, including assessment psychological risk factors
2. Physical examination
3. Diagnostic imaging and testing, including magnetic resonance imaging or computed tomography

Treatment/Management

1. Patient education on back care and self care
2. Acetaminophen or nonsteroidal anti-inflammatory drugs
3. Intensive interdisciplinary rehabilitation
4. Spinal manipulation
5. Exercise therapy
6. Acupuncture
7. Massage therapy
8. Yoga
9. Cognitive behavioral therapy
10. Progressive relaxation

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.

• Sensitivity and specificity of diagnostic tests
• Pain reduction
• Frequency of side effects from medication
• Cost

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

The literature search for this guideline included studies from MEDLINE (1966 through November 2006), the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and EMBASE. The literature search included all English-language articles reporting on randomized, controlled trials of nonpregnant adults (age >18 years) with low back pain (alone or with leg pain) of any duration that evaluated a target medication and reported at least 1 of the following outcomes: back-specific function, generic health status, pain, work disability, or patient satisfaction.

Nonpharmacologic

Searches for systematic reviews of low back pain identified 1292 abstracts. Of these, 96 reviews seemed potentially relevant and were retrieved. A total of 40 nonpharmacologic systematic reviews met inclusion criteria; 59 systematic reviews were excluded, most frequently because they met the criteria for outdated reviews or did not report results for patients with low back pain. Five recent, large (>200 patients) trials of acupuncture and spinal manipulation or exercise supplemented the systematic reviews. No systematic reviews were identified for interferential therapy, low-level laser therapy, shortwave diathermy, ultrasonography, or yoga for low back pain. Five (5) searches for randomized trials of these interventions identified 532 citations. Three (3) trials of interferential therapy, 7 trials of low-level laser therapy, 3 trials of shortwave diathermy, 3 trials of ultrasonography, and 3 trials of yoga met inclusion criteria.

Pharmacologic

Searches for systematic reviews of low back pain identified 1292 abstracts for review. An additional 1586 citations were identified through 8 searches for randomized trials of acetaminophen, celecoxib, aspirin, the serotonin-norepinephrine reuptake inhibitors duloxetine and venlafaxine, antiepileptic drugs, opioids, tramadol, and systemic corticosteroids.

In all, 21 reviews appeared potentially relevant and were retrieved. Seven outdated reviews of nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, and multiple drugs were excluded. Also excluded were 3 reviews that did not clearly use systematic methods and 4 systematic reviews that evaluated target medications but did not report results specifically for patients with low back pain. Seven systematic reviews of NSAIDs, antidepressants, skeletal muscle relaxants, and benzodiazepines, or multiple medications were included.

Weighting According to a Rating Scheme (Scheme Given)

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.

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Information about study design, population characteristics, interventions, outcomes, and adverse events was abstracted. The Oxman criteria for systematic reviews and the Cochrane Back Review Group criteria for individual trials were used to grade methodological quality.

The primary source of data was systematic reviews. Non–English-language trials were included only if they were included in English-language systematic reviews.

The evidence in this guideline was first evaluated by the American College of Physicians (ACP)/American Pain Society (APS) panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence, estimating magnitude of benefits, and assigning summary ratings (see Appendix Tables 2, 3, and 4 of the original guideline document). The evidence was independently reviewed by the ACP's Clinical Efficacy Assessment Subcommittee. The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 of the original guideline document for acute low back pain (<4 weeks' duration) and in Appendix Table 6 of the original guideline document for chronic/subacute low back pain (>4 weeks' duration). This guideline considered interventions to have "proven" benefits only when they were supported by at least fair-quality evidence and were associated with at least moderate benefits (or small benefits but no significant harms, costs, or burdens).

See the background papers by Chou & Hoyt Huffman for more details of the methods to analyze the evidence (see "Availability of Companion Documents" field).

Expert Consensus

The American College of Physicians (ACP) and the American Pain Society (APS) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report, review its results, and formulate recommendations.

Grading of Guideline Recommendations*

Strong Recommendation

Benefits clearly outweigh risks and burden OR risks and burden clearly outweigh benefits.

Weak Recommendation

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.

Note: Adopted from the classification developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Workshop.

Published cost analyses were reviewed.

Peer Review

This guideline was approved by the American College of Physicians Board of Regents on July 14, 2007 and American Pain Society Board Executive Committee on July 18, 2007.

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.

Definitions:

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*

Strong Recommendation

Benefits clearly outweigh risks and burden OR risks and burden clearly outweigh benefits.

Weak Recommendation

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.

Note: Adopted from the classification developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Workshop.

The original guideline document contains clinical algorithms for:

• Initial evaluation of low back pain
• Management of low back pain

The type of evidence supporting most recommendations is specifically stated (see "Major Recommendations").

Accurate diagnosis and effective treatment of low back pain

• Acetaminophen is associated with asymptomatic elevations of aminotransferase levels at dosages of 4 grams per deciliter (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. Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are more effective for pain relief than is acetaminophen, but they are associated with well-known gastrointestinal and renovascular risks. In addition, there is an association between exposure to cyclooxygenase-2–selective or most nonselective NSAIDs and increased risk for myocardial infarction. 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).
• Because of substantial risks of opioid analgesics or tramadol, 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.
• Skeletal muscle relaxants are associated with central nervous system adverse effects (primarily sedation). There is no compelling evidence that skeletal muscle relaxants differ in efficacy or safety. 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.
• Benzodiazepines seem similarly effective to skeletal muscle relaxants for short-term pain relief but are also associated with risks for abuse, addiction, and tolerance.

• The authors of this article are responsible for its contents, including any clinical or treatment recommendations. The views and opinions expressed are those of Veterans Affairs/Department of Defense Evidence-Based Practice Workgroup members and do not necessarily reflect official Veterans Health Affairs or Department of Defense positions.
• 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 American College of Physicians (ACP) clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

Not applicable: The guideline was not adapted from another source.

2007 Oct 2

American College of Physicians - Medical Specialty Society
American Pain Society - Professional Association

American College of Physicians

American Pain Society

Clinical Efficacy Assessment Subcommittee of the American College of Physicians/American Pain Society Low Back Pain Guideline Panel

Authors: 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; and Douglas K. Owens, MD, MS

Clinical Efficacy Assessment Subcommittee of the American College of Physicians: Douglas K. Owens, MD, MS (Chair)*; Donald E. Casey Jr., MD, MPH, MBA**; J. Thomas Cross Jr., MD, MPH**; Paul Dallas, MD; Nancy C. Dolan, MD; Mary Ann Forciea, MD; Lakshmi Halasyamani, MD; Robert H. Hopkins Jr., MD; and Paul Shekelle, MD, PhD**

Co-chairs and members of the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel: John D. Loeser, MD (Cochair); Douglas K. Owens, MD, MS (Co-chair); Richard W. Rosenquist, MD (Co-chair); Paul M. Arnstein, RN, PhD, APRN-BC; Steven Julius Atlas, MD, MPH; Jamie Baisden, MD; Claire Bombardier, MD; Eugene J. Carragee, MD; John Anthony Carrino, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA; Daniel Cherkin, PhD; Penney Cowan; J. Thomas Cross Jr., MD, MPH; Anthony Delitto, PhD, MHS; Robert J. Gatchel, PhD, ABPP; Lee Steven Glass, MD, JD; Martin Grabois, MD; Timothy R. Lubenow, MD; Kathryn Mueller, MD, MPH; Donald R. Murphy, DC, DACAN; Marco Pappagallo, MD; Kenneth G. Saag, MD, MSc; Paul G. Shekelle, MD, PhD; Steven P. Stanos, DO; and Eric Martin Wall, MD, MPH

Participants from the Veterans Affairs/Department of Defense Evidence-Based Practice Workgroup: Carla L. Cassidy, ANP, MSN; COL Leo L. Bennett, MC, MD, MPH; John Dooley, MD; LCDR Leslie Rassner, MD; Robert Ruff, MD, PhD; and Suzanne Ruff, MHCC

*Also a co-chair of the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel

**Also members of the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel

Honoraria: R. Chou (Bayer Healthcare Pharmaceuticals). Grants received: V. Snow (Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, Novo Nordisk, Pfizer Inc., Merck & Co. Inc., Bristol-Myers Squibb, Atlantic Philanthropics, Sanofi-Pasteur).

This is the current release of the guideline.

This NGC summary was completed by ECRI Institute on December 10, 2007. The information was verified by the guideline developer on December 13, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.