Lower back pain is one of the most common reasons for clinic visits in the United States. It is associated with increased healthcare costs as well as lost wages and decreased work productivity.
Up to 30% of patients report persistent low back pain up to 1 year after experiencing an acute episode. One in five report substantial limitations in activity.
The American College of Physicians (ACP) has released updated guidelines for the noninvasive treatment of non-radicular (no associated leg symptoms) in subacute, acute, and chronic low back pain in primary care. The guidelines, along with updated evidence reviews, were published in February of 2017 in the Annals of Internal Medicine.
Overall, the new guidelines emphasize conservative treatment. First-line therapy should incorporate nondrug therapies. Wen nondrug therapy fails, nonsteroidal anti-inflammatories (over the counter, such as Motrin or Advil), or skeletal muscle relaxants, (available by prescription) should be considered. The guidelines strongly discourage the use of opioids.
"For treatment of chronic low back pain, clinicians should select therapies that have the fewest harms and lowest costs. Clinicians should avoid prescribing costly therapies; those with substantial potential harms, such as long-term opioids (which can be associated with addiction and accidental overdose); and pharmacologic therapies that were not shown to be effective, such as antidepressants," writes the chairman of the ACP guidelines committee.
The ACP made the following strong recommendations:
- First-line therapy should include nondrug therapy, such as superficial heat, massage, acupuncture, or spinal manipulation. When nondrug therapy fails, consider NSAIDs (over the counter, such as Motrin or Advil), or skeletal muscle relaxants, (available by prescription).
- For chronic low back pain, consider nondrug therapy, such as exercise, multidisciplinary rehabilitation, acupuncture, stress reduction, tai chi, yoga, exercise, low-level laser therapy, or spinal manipulation.
- For chronic low back pain that does not respond to nondrug therapy, consider NSAIDs as first-line therapy. For second-line, consider tramadol or duloxetine (Cymbalta). Consider opioids only in patients in whom first- and second-line therapy has failed.
Editorial note: Although the guidelines do not address topical medicinal treatments, many of my patients have very good results with rub on creams or therapeutic patches.
I am very pleased with the new recommendations, primarily because they officially recognize what I have seen in my practice for years: most people with low back pain recover rapidly when they receive Osteopathic Manipulation and acupuncture!