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Guidelines for Lower Back Pain Treatment Strategies

The American College of Physicians (ACP) issued an updated set of recommendations for the non-invasive treatment of lower back pain.

Pharmacological vs non-pharmacological treatments for back pain

Lower back pain is one of the most common complaints heard at the doctor’s office. Most adults experience lower back pain at least once in their lifetime, and approximately a quarter of adults in the United States report having lower back pain within the last three months. Lower back pain can be a debilitating condition associated with a high cost, which includes expenses for treatment and time missed from work.

The ACP reviewed randomized controlled trials published through November 2016, which focused on non-invasive pharmacologic, as well as non-pharmacologic treatments for lower back pain. The treatment guidance was issued for acute (lasting less than four weeks), subacute (4 to 12 weeks) and chronic (lasting more than 12 weeks) lower back pain, targeting adults as a patient population. The major clinical outcomes included:

  • a reduction or elimination of low back pain,
  • improvement in function,
  • quality of life,
  • quicker return to work,
  • a reduction of disability,
  • a decrease in back pain episodes and the intervals between them,
  • diminished patient satisfaction,
  • and adverse events.

The assessment of all available data led to the following conclusions.

  1. Acetaminophen is not effective for the treatment of acute or subacute lower back pain. Acetaminophen was found to be not more effective than placebo for the reduction of pain intensity and improvement in function for acute or subacute lower back pain.

2. Non-pharmacologic treatments are recommended for acute and subacute lower back pain. Since patients with acute and subacute back pain tend to improve over time without any intervention, the ACP advises non-pharmacologic treatments for this group of patients. These could include superficial heat, spinal manipulation, acupuncture and massage. If these treatments are not effective and/or the pharmacologic intervention is preferred, the first treatment choice should be non-steroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants. The patients should be informed about a favourable prognosis and the likelihood of improvement of their acute pain within the first month even without any treatment.

3. Non-pharmacologic treatments should be the first choice for chronic lower back pain. Patients suffering from chronic back pain should initially be advised to try non-pharmacologic treatments, including exercise, acupuncture, mindfulness-based techniques, tai chi, yoga, electromyography biofeedback, multidisciplinary rehabilitation and cognitive behavioural therapy. These treatments are associated with fewer adverse events than pharmacologic strategies. Factors that improve the likelihood of success include individualizing treatment, group exercises, supervised exercise in the home setting, as well as treatment protocols that involve stretching and strength training.

4. Opioids should be considered as a last treatment choice for chronic lower back pain. If non-pharmacologic treatments for lower back pain fail, the first pharmacologic treatment option should be NSAIDs. The second line of treatment should be tramadol and duloxetine. Tramadol is a narcotic medication and should be considered cautiously, considering the potential for addiction. Physicians are advised to consider opioids only as a last resort when all of the above-mentioned treatments have failed. Due to the well-known serious adverse effects associated with opioid use, the risks should be carefully weighed against the potential benefits on a case-by-case basis. If opioids are chosen as a part of the treatment plan, the patients should be counselled on the potential side effects of such treatment.

Personalized treatments are best

The treatment strategy of choice should be based on the classification of pain into acute, subacute, or chronic categories and should involve interventions associated with the smallest potential for adverse events. Physicians should advise their patients of a likely improvement in acute and subacute back pain, regardless of treatment. Considering this, costly treatments or pharmacologic treatments associated with significant adverse events, such as opioids, should be avoided.

Moreover, systemic steroids were found to be ineffective in the treatment of this group of patients, therefore they should not be prescribed. The treatment of chronic lower back pain should mostly focus on non-pharmacologic strategies that are associated with fewer adverse events. The treatments with a high potential for severe side effects, such as opioids, should be reserved for cases where all other options fail.


  1. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2017;166(7):514. doi:10.7326/m16-2367


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