BY SARAH OWENS
Non-pharmacologic approaches should be used as first-line treatment for patients with low back pain, according to a new clinical practice guideline by the American College of Physicians (ACP) published in the February 13 online edition of Annals of Internal Medicine.
The current guideline – which updates the ACP's 2007 guideline for low back pain– offers treatment guidance based on the efficacy, effectiveness, and safety of both pharmacologic and nonpharmacologic approaches for acute (lasting less than four weeks), subacute (lasting between four and 12 weeks), and chronic low back pain (lasting more than 12 weeks).
"Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies, as they are associated with substantial harms, including the risk of addiction or accidental overdose," said Nitin S. Damle, MD, MS, MACP, president of the ACP, in a press release accompanying the guideline.
To develop the evidence-based guideline, researchers for the Agency for Healthcare Research and Quality's Pacific-Northwest Evidence-Based Practice Center conducted a systematic review of randomized, controlled trials and reviews of studies published between January 2008 and November 2016.
Non-pharmacologic treatments reviewed included psychological therapies, acupuncture, massage, exercise, and multidisciplinary rehabilitation. Pharmacologic treatments reviewed included nonsteroidal anti-inflammatory drugs (NSAIDS), opioids, and skeletal muscle relaxants. The researchers evaluated a wide range of outcome measures, including reduction or elimination of pain, improvement in health-related quality of life, reduction in work disability, return to work, and adverse effects.
Based on the current literature, the researchers concluded that non-pharmacologic treatment should be first-line therapy for all patients with low back pain. For patients with acute or subacute back pain, treatment with superficial heat is supported by moderate-quality evidence, while massage, acupuncture, and spinal manipulation are supported by low-quality evidence. For those with chronic back pain, moderate-quality evidence supported a wide variety of treatments, including exercise, acupuncture, yoga, tai chi, mindfulness-based stress reduction, and cognitive behavioral therapy.
If patients with chronic low back pain have not responded to non-pharmacologic therapy, the researchers noted, then clinicians may consider pharmacologic treatment, but should first try NSAIDS or muscle relaxants. Only after these, too, have failed should doctors prescribe opioids, and only then if the benefits outweigh the potential risks, and they must first have a thorough conversation with the patient about those benefits and risks.
The researchers noted several limitations to their review. Among them, insufficient evidence exists to assess certain treatments, such as those for radicular low back pain; and most of the randomized, controlled trials reviewed enrolled a mixture of patients with acute, subacute, and chronic back pain, which makes it "difficult to extrapolate the benefits of treatment compared with its duration."
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