ACP Recommendations for Noninvasive Therapies for Acute, Subacute, and Chronic Low Back Pain

Authors: Atlas SJ., Ann Intern Med 2017 Feb 14;

The American College of Physicians has evaluated a broad array of treatment options.

Sponsoring Organization: American College of Physicians (ACP)

Target Audience: All clinicians

Target Population: Adults with acute (<4 weeks), subacute (4–12 weeks), or chronic (>12 weeks) back pain in primary care settings

Background

The ACP has developed a guideline that updates its 2007 recommendations on noninvasive approaches to treating patients with low back pain (NEJM JW Gen Med Nov 15 2007 and Ann Intern Med 2007; 147:478). Randomized trials and systematic reviews were included in the analysis. Reviewers evaluated outcomes including pain, function, health-related quality of life, work disability and return to work, global improvement, and patient satisfaction. The guideline does not include topical therapies or epidural injections.

Key Findings

• Pharmacologic therapies for acute or subacute low back pain:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) yielded a small improvement in pain and slightly better function, compared with placebo. No significant differences in efficacy were found between traditional NSAIDs and cyclooxygenase (COX)-2–selective NSAIDs.
  • Skeletal muscle relaxants (SMRs) improved short-term pain; inconsistent results were found on pain reduction with NSAIDs plus SMRs versus NSAIDs alone.
  • Systemic corticosteroids yielded no significant improvement in pain or function.
  • Evidence was insufficient to determine the effectiveness of antidepressants, benzodiazepines, antiseizure medications, or opioids.
• Pharmacologic therapies for chronic low back pain:
  • NSAIDs were associated with small-to-moderate improvements in pain, and no-to-small improvements in function, relative to placebo. No significant differences in efficacy were found among traditional NSAIDs; no data were available on COX-2–selective NSAIDs.
  • Strong opioids were associated with small short-term improvements in pain and function, compared with placebo. Tramadol resulted in moderate short-term pain relief and small improvements in function.
  • Evidence was insufficient to evaluate efficacy of SMRs.
  • The benzodiazepine tetrazepam improved pain at 5 to 7 days and improved function at 10 to 14 days.
  • No difference in pain was seen with tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors relative to placebo. Duloxetine was associated with small improvements in pain and function.
  • Investigators found insufficient evidence to evaluate the effects of acetaminophen, systemic corticosteroids, or antiseizure medications.
• Nonpharmacologic therapies for acute or subacute low back pain:
  • No difference was found between exercise and usual care for pain or function.
  • Acupuncture yielded a small reduction in pain and slightly increased likelihood of overall improvement relative to NSAIDs.
  • Massage moderately improved short-term pain. Spinal manipulation did not show clear improvement in pain; however, spinal manipulation slightly improved function.
  • Heat wraps moderately improved pain.
  • Lumbar supports were not beneficial.
  • Evidence was insufficient to determine the efficacy of other therapies, including transcutaneous electrical nerve stimulation (TENS), Pilates, tai chi, yoga, or multidisciplinary rehabilitation.
• Nonpharmacologic therapies for chronic low back pain:
  • Exercise resulted in small improvements in pain and function.
  • Tai chi and yoga resulted in moderate pain improvement; Pilates resulted in small or no improvement.
  • Acupuncture yielded moderate reduction in pain.
  • Rehabilitation resulted in moderate reductions in pain and disability.
  • Massage yielded small improvements in pain.
  • Spinal manipulation, ultrasound, and TENS did not yield significant benefits.

Recommendations

• For patients with acute or subacute low back pain, use superficial heat, massage, acupuncture, or spinal manipulation. Add an NSAID or SMR, if needed. (Strong recommendation)
• For chronic low back pain, select a nonpharmacologic therapy. (Strong recommendation)
• For chronic low back pain with inadequate response to nonpharmacologic therapies, NSAIDs should be first-line therapy, with tramadol or duloxetine as second-line therapy. Opioids should be considered only if first- or second-line pharmacologic therapies have failed and after discussing the benefits and harms with the patient. (Weak recommendation)

What’s Changed

A significant change from the 2007 guideline is dropping acetaminophen and TCAs from recommended medications. The deletion of acetaminophen is based on a study in which researchers evaluated pain at 3 weeks; no improvement in pain was seen relative to placebo. However, head-to-head studies failed to demonstrate a difference in efficacy between NSAIDs and acetaminophen.

Comment

Most patients do not require any specific intervention for low back pain. For those who do, many available options are not very effective — most interventions had only a small benefit on pain or function. Given how little we have to offer, one can summarize these recommendations as: Do no harm (and avoid opioids).