• Amir Qaseem, Timothy J Wilt, Robert M McLean, Mary Ann Forciea, Clinical Guidelines Committee of the American College of Physicians, Thomas D Denberg, Michael J Barry, Cynthia Boyd, R Dobbin Chow, Nick Fitterman, Russell P Harris, Linda L Humphrey, and Sandeep Vijan.
• From the American College of Physicians and Penn Health System, Philadelphia, Pennsylvania; Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota; and Yale School of Medicine, New Haven, Connecticut.
• Ann. Intern. Med. 2017 Apr 4; 166 (7): 514-530.

DescriptionThe American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.MethodsUsing the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. Updated searches were performed through November 2016. Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.Target Audience And Patient PopulationThe target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.Recommendation 1Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).Recommendation 2For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).Recommendation 3In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).

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