American College of Physicians Releases New Guidelines for Low Back Pain

The ACP’s new guidelines support the use of nonpharmacologic therapies, such as chiropractic and acupuncture, as first-line options for treating nonspecific low back pain.

By Thomas G. Ciccone

Interviews with Nitin S. Damle, MD, MS, MACP, John Garzione, PT, DPT, William Lauretti, DC

The American College of Physicians (ACP) is making a strong push for the use of nonpharmacological treatments for low back pain.

In a new set of guidelines,¹ the ACP has outlined a number of nondrug treatments to be used as first-line options for acute, sub-acute, and chronic forms of low back pain. These include:

• Superficial heat
• Massage therapy
• Spinal manipulation
• Acupuncture

According to the ACP, in cases where patients do not respond to nondrug treatments, doctors also may consider the use of nonsteroidal anti-inflammatory drugs (NSAIDs) as an alternative first-line therapy or the use duloxetine (Cymbalta) as a second-line therapy. Tramadol, an opioid approved for moderate to severe pain, can also been used as a second-line therapy in properly selected patients. All other opioids should be considered a last-resort option, in the event a patient has been unresponsive to other treatments.

“The guidelines did want to highlight the importance of avoiding opioid prescription due to their high risk for dependency and overdose,” ACP president Nitin S. Damle, MD, MS, MACP, told Practical Pain Management. Opioids “are of limited therapeutic value [in this setting] and should only be prescribed in rare circumstances at the lowest possible dose and shortest frequency after a full discussion with the patient about the pros and cons.”

ACP Recommendations

The ACP guidelines make strong recommendations for the use of nonpharmacological treatments as first-line options for treating nonspecific low back pain, whether it be acute or sub-acute. As noted, these treatments can include superficial heat, massage therapy, spinal manipulation, and acupuncture.

For patients with chronic back pain, the ACP also recommends additional therapies, including

• Exercise
• Multidisciplinary rehabilitation
• Mindfulness-based stress reduction
• Tai Chi
• Yoga
• Motor Control Exercise
• Progressive Relaxation
• Electromyography biofeedback
• Low-level laser therapy
• Operant therapy, a form of behavioral therapy that focuses on positive or negative reinforcement
• Cognitive behavioral therapy

Practical Challenges of Incorporating Nondrug Therapies

The ACP’s focus on first using nondrug therapies to treat low back pain is not entirely new. Indeed, many of the recommendations mirror past positions taken by the ACP since their last guideline in 2007.² A notable exception would be acetaminophen, which research has shown to be ineffective in treating low back pain.^3-4

Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) also have been found ineffective for nonspecific low back pain.⁵  Most recently, a study comparing diazepam and naproxen to placebo and naproxen, found no difference between the two groups—showing that the muscle relaxant did not improve acute low back pain in the emergency department.⁶ In addition, some doctors are finding that providing more immediate access to physical therapy services could facilitate even better clinical results and prevent unnecessary medical interventions down the line.

But according to some doctors, the ACP’s new guidelines may not be practical enough for health care providers, considering many of the recommended nondrug therapies simply are not covered by patients’ insurance policies.

The ACP’s recommendations “all make sense until everyone realizes the fact that many of these treatments are either not paid for by insurance companies or there is a high co-payment on physical therapy and chiropractic. This makes it very difficult for people in this country to get the care they need,” John Garzione, PT, DPT, told Practical Pain Management.

Dr. Damle recognized that the guidelines do not address the payment issue. It also was not the intention of the ACP or its guideline committee to lobby for these treatments to be more accepted by insurance policies, “but they should be used as part of the evidence base in making coverage decisions,” Dr. Damle said.

Unfortunately, the evidence base behind many nonpharmacological options still is considered weak. Every nonpharmacological treatment recommended by the ACP for treating acute and subacute forms of low back pain comes with low-quality evidence, with the exception of superficial heat, which had moderate-quality evidence.

“I think a typical primary care doctor that may be reading this might be left a little confused of what they should do at this point,” said William Lauretti, DC, an associate professor at New York Chiropractic College in Seneca Falls, New York.

Dr. Lauretti, who is a media spokesperson for the American Chiropractic Association (ACA), recognized the ACP guidelines could be a great recommendation for multidisciplinary practitioners able to provide many of the nonpharmacological treatments recommended in the guidelines.

However, much of the ACP’s membership is comprised of primary care physicians, who may be unqualified to provide these treatments or simply be unaware of how to get their patients access to them. “That’s certainly not part of their training at all. You may find a handful of primary care doctors who may have a yoga class on the side, but it is not conventional medicine by any means,” Dr. Lauretti explained.

“I like that they recommend all of these different therapies based on the scientific basis for them…but they also kind of leave their members dangling in the wind in not making it clear where to go with this,” said Dr. Lauretti.

The guidelines were supported financially by the ACP. All guideline authors have submitted any relevant conflict of interest information, which can be access by reading the full guideline document.

View Sources

1. Qaseem A, Wilt TJ, 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. February 14, 2017. [Epub ahead of print.]
2. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.Ann Intern Med. 2007;147(7):478-491.
3. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial.Lancet. 2014;384:1586-1596.
4. Roelofs PD, Deyo RA, Koes BW, et al. Nonsteroidal anti-inflammatory drugs for low back pain.Cochrane Database Syst Rev. 2008:CD000396.
5. Urquhart DM, Hoving JL, Assendelft WW, et al. Antidepressants for non-specific low back pain.Cochrane Database Syst Rev. 2008:CD001703.
6. Friedman BW, Irizarry E, Solorzano C, et al. Diazepam is no better than placebo when added to naproxen for acute low back pain.Ann Emerg Med. February 20, 2017. [Epub ahead of print.]