Evidence-based recommendations for evaluation and management in the primary care setting
The American College of Physicians and the American Pain Society have published a clinical practice guideline on the diagnosis and treatment of low back pain. The seven guideline recommendations are:
1. Physical exam and focused history, including assessment of psychosocial risk factors for chronic disabling back pain, to categorize patients as having nonspecific back pain, radiculopathy or spinal stenosis, or pain with another specific spinal cause
2. No routine imaging or other diagnostic tests for patients with nonspecific back pain
3. Imaging and other relevant diagnostic testing for patients with severe or progressive neurologic deficits or when serious underlying conditions are suspected
4. Imaging (preferably magnetic resonance) for evaluation of persistent pain, radiculopathy, or spinal stenosis only when patients are being considered for surgery or epidural steroid injection
5. Providing patients with prognostic information and self-care options (written information, remain active, superficial heat)
6. Use of acetaminophen or nonsteroidal anti-inflammatory drugs as first-line medication, depending on pain severity and physical dysfunction while considering lack of long-term efficacy
7. Nonpharmacologic therapy for patients who do not improve with self-care alone: spinal manipulation for acute pain; intensive interdisciplinary rehabilitation, exercise therapy, yoga, cognitive behavioral therapy, or progressive relaxation for chronic pain
These recommendations are based on systematic evidence reviews. These reviews also cite evidence for efficacy of skeletal muscle relaxants for acute pain and tricyclic antidepressants for chronic pain.
Comment: These guidelines do not address surgical management. They do, however, provide a rational evidence-based approach. The full guideline and evidence reviews contain extensive detail supporting the general recommendations.
— Richard Saitz, MD, MPH, FACP, FASAM
Published in Journal Watch General Medicine October 25, 2007
Chou R et al. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007 Oct 2; 147:478.