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Evidence-Based Physiatry

Evidence-Based Physiatry

Clinical Practice Guideline: Noninvasive Treatments for Low Back Pain

Paganoni, Sabrina MD, PhD

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American Journal of Physical Medicine & Rehabilitation: October 2018 - Volume 97 - Issue 10 - p 763
doi: 10.1097/PHM.0000000000001003
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Low back pain (LBP) is one of the most common reasons for physiatric evaluation and is associated with high healthcare costs. Variability in the diagnosis and management of LBP may lead to suboptimal outcomes and may result in unnecessary spending. To guide the care of this common complaint, the American College of Physicians conducted a rigorous review of the scientific literature and published evidence-based clinical practice guidelines.1 The goal of these guidelines is to present the evidence and provide clinical recommendations on noninvasive treatment of LBP.


What are the comparative benefits and harms of different noninvasive interventions for LBP, including both pharmacologic and nonpharmacologic treatments?


The guidelines are applicable to adults with acute (<4 wks), subacute (4–12 wks), or chronic (>12 wks) LBP including axial LBP, radicular LBP, or symptomatic lumbar spinal stenosis.


The Clinical Guidelines Committee of the American College of Physicians developed the recommendations based on a systematic review of randomized controlled trials and systematic reviews published in English between January 2008 and April 2015. Database searches were updated through November 2016, and the final recommendations were published in February 2017 in Annals of Internal Medicine.1

The interventions that were evaluated included both pharmacologic and nonpharmacologic treatments for LBP. Pharmacological treatments included acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), skeletal muscle relaxants, antidepressants, benzodiazepines, corticosteroids, opioids, antiepileptic medications, capsaicin, and lidocaine. Nonpharmacological treatments included physical therapy, psychological therapy, exercise (including yoga and tai chi), spinal manipulation, acupuncture, massage, passive physical modalities (such as heat, cold, ultrasounds, transcutaneous electrical nerve stimulation), lumbar support braces, and taping. Clinical outcomes included both pain and function, as well as adverse events. These guidelines did not address the role of surgery or injection therapies.


Physiatrists should be familiar with evidence-based practices for the noninvasive treatment of LBP and should advise patients to remain active as tolerated. There is good evidence to support the use of specific noninvasive treatments for LBP, although improvements in pain and function were often small. When selected therapies were compared head-to-head, few differences were found. Therefore, treatment choices among recommended therapies should be based on patient preference, potential for harm, and costs.

Acute and subacute axial low back pain usually improves over time regardless of treatment, and physicians should avoid prescribing costly and potentially harmful treatments. If treatment is desired, physicians should recommend nonpharmacological options first, such as superficial heat (moderate-quality evidence) or massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacological treatment is pursued, NSAIDs or skeletal muscle relaxants are recommended (moderate-quality evidence). Acetaminophen and systemic steroids were not shown to provide benefit to patients with acute or subacute LBP.

For chronic LBP, physicians should select therapies that have the fewest harms and lowest costs. Priority should be given to select nonpharmacologic treatments including exercise, physical therapy, acupuncture and mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, biofeedback, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). For patients with chronic LBP who did not respond to nonpharmacological therapy, physicians should consider treatment with NSAIDs as first-line therapy or tramadol or duloxetine as second line therapy. The use of opioids should be limited to patients who have failed multiple other treatments and only if the potential benefits outweigh the risks for individual patients. Physicians should avoid prescribing agents that have high potential for adverse effects, such as long-term opioids, or that have not shown benefit for the treatment of chronic LBP, such as tricyclic antidepressants or selective serotonin uptake inhibitors.


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 2017;166:514–30
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