ACP Clinical Guideline on Noninvasive Management of Low Back Pain Across Stages

The American College of Physicians (ACP) developed this guideline to provide evidence-based recommendations for noninvasive low back pain treatments. Low back pain is one of the most frequent reasons for medical visits in the United States. 

About one quarter of adults report at least one day of low back pain over three months, leading to high health care costs and loss of productivity. In 2006, the total cost in the United States was estimated at $100 billion, with most due to missed work.

Low back pain is classified by duration: acute (<4 weeks), subacute (4–12 weeks), and chronic (>12 weeks). Most acute cases resolve spontaneously, but up to one-third of patients continue to experience moderate pain a year later. Noninvasive management includes pharmacologic and nonpharmacologic options.

The ACP guideline is based on systematic reviews of studies published up to 2016. The evidence review, conducted by the AHRQ’s Pacific Northwest Evidence-based Practice Center, evaluated medications such as NSAIDs, muscle relaxants, antidepressants, and opioids, as well as non-drug therapies including exercise, spinal manipulation, acupuncture, massage, heat, and psychological interventions.

For acute and subacute pain, nonpharmacologic therapies such as heat, massage, acupuncture, or spinal manipulation are recommended. If medications are used, NSAIDs or skeletal muscle relaxants are preferred. First-line management should focus on exercise, multidisciplinary rehabilitation, mindfulness, yoga, tai chi, or cognitive-behavioral approaches for chronic low back pain.

Reference: 

1. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. 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(7):514-530. doi:10.7326/M16-2367; https://www.acpjournals.org/doi/10.7326/M16-2367