Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society
2 October 2007
Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross, Jr, MD, MPH; Paul Shekelle, MD, PhD; Douglas K. Owens, MD, MS, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel*
Annals of Internal Medicine

Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).

Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).

Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).

Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).

Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).

Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.

Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefitsÛfor acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

* This paper, written by Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS, was developed for the American College of Physicians' Clinical Efficacy Assessment Subcommittee and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel. For members of these groups, see end of text. Approved by the American College of Physicians Board of Regents on 14 July 2007. Approved by the American Pain Society Board Executive Committee on 18 July 2007.

--------------------------------------------------------------------------------
Low back pain is the fifth most common reason for all physician visits in the United States (1, 2). Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months (2), and 7.6% reported at least 1 episode of severe acute low back pain (see Glossary) within a 1-year period (3). Low back pain is also very costly: Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $26.3 billion in 1998 (4). In addition, indirect costs related to days lost from work are substantial, with approximately 2% of the U.S. work force compensated for back injuries each year (5).
Many patients have self-limited episodes of acute low back pain and do not seek medical care (3). Among those who do seek medical care, pain, disability, and return to work typically improve rapidly in the first month (6). However, up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode, and 1 in 5 report substantial limitations in activity (7). Approximately 5% of the people with back pain disability account for 75% of the costs associated with low back pain (8).

Many options are available for evaluation and management of low back pain. However, there has been little consensus, either within or between specialties, on appropriate clinical evaluation (9) and management (10) of low back pain. Numerous studies show unexplained, large variations in use of diagnostic tests and treatments (11, 12). Despite wide variations in practice, patients seem to experience broadly similar outcomes, although costs of care can differ substantially among and within specialties (13, 14).

The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain (see Glossary) in primary care settings. The target audience for this guideline is all clinicians caring for patients with low (lumbar) back pain of any duration, either with or without leg pain. The target patient population is adults with acute and chronic low back pain not associated with major trauma. Children or adolescents with low back pain; pregnant women; and patients with low back pain from sources outside the back (nonspinal low back pain), fibromyalgia or other myofascial pain syndromes, and thoracic or cervical back pain are not included. These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue (15, 16) from an evidence report by the American Pain Society (17). The evidence report (17) discusses the evidence for the evaluation, and the 2 background papers (15, 16) summarize the evidence for management.

Complete article may be viewed online.