For low-back pain patients and their doctors, a new, evidence-based, clinical practice guideline, published today in the Annals of Internal Medicine, recommends less reliance on expensive diagnostic imaging and reports there is strong evidence supporting the benefits of several therapies, with and without medication.

Low-back pain is the fifth most common reason for doctor's office visits and one in four adults report having it last a least once a day. Annually, low-back pain is estimated to account for more than $26 billion in direct health care costs in the U.S.

Sponsored by the American Pain Society (APS), www.ampainsoc.org, in collaboration with the American College of Physicians (ACP), the guideline is based on a multidisciplinary panel's review and analysis of volumes of evidence related to diagnosis and treatment of low-back pain in the primary care setting, according to Roger Chou, MD, director of the American Pain Society's Clinical Practice Guideline Program and associate professor, Oregon Health and Science University.

"The evidence is much better than even five or 10 years ago and will help physicians be more confident when suggesting therapies for low back pain," said Chou. "There are a number of medication and non-pharmacologic therapies supported by high-quality studies. Physicians and patients should discuss possible options proven by the evidence and choose the ones that make sense for their situation," he added.

For diagnosis, the APS guideline advises clinicians to minimize routine use of x-rays or other diagnostic tests. "There is good evidence that physicians should not order x-rays or other imaging tests for patients with non-specific low back pain. They are not helpful and could result in excessive radiation exposure or lead to unnecessary procedures," said Chou. He added that the recommendations do instruct physicians to perform diagnostic imaging tests for patients known or believed to have underlying neurological or spinal disorders.

In addressing treatment options, the guideline recommends that medications used should be appropriate for the severity of baseline pain and functional impairment, and clinicians should weigh carefully potential benefits and risks of any drug and explain them. "Several medications offer some benefits for low-back pain but they have risks," said Chou. "For example, acetaminophen is safe but not that effective, NSAIDS provide more relief but have gastrointestinal and cardiovascular side effects, and opioids can treat severe pain but pose risks for sedation and dependence over time."

There are numerous non-pharmacological treatments for low-back pain ranging from chiropractic care to massage therapy, and the guideline panel recommended they be considered for patients who do not improve with self-care options and prefer not to take pain medications. "Above all," noted Chou, "the panel strongly recommends that low-back pain patients stay active and talk honestly with their physicians about self care and other interventions that may or may not involve drugs."

A landmark APS-ACP Collaboration

The low-back-pain guideline is the first such collaboration between APS and ACP, which represents about 100,000 internists in the US. It is the fifth evidenced-based, pain management clinical practice guideline published by APS. Others have covered pain from sickle-cell disease, arthritis, cancer and fibromyalgia.

"This is a milestone collaboration in which organizations representing pain management and primary care have developed the first comprehensive, evidence-based clinical practice guideline to assist clinicians in managing low-back pain," said APS President Judith Paice, PhD, RN. "We are grateful to the American College of Physicians for joining forces with APS in developing this long-awaited publication."

The Annals article covers low-back-pain treatment in primary care settings only, and does not make recommendations regarding specialized, invasive procedures to treat the condition. Chou said APS will release the complete guideline in 2008 covering both the primary-care recommendations as well as invasive treatments for low-back pain.

Chou said the guideline panel, composed of 25 members representing more than 15 different areas of expertise, unanimously approved all seven recommendations published in the Annals article. They are:

Clinicians should conduct a focused history and physical examination to help place patients with low back pain into one of three broad categories: non-specific low back pain, back pain potentially associated with radiculopathy (nerve disorders) or spinal stenosis (narrowing), or back pain associated with another specific cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain.

Clinicians should not routinely obtain imaging or other diagnostic tests in patients with non-specific low-back pain.

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.

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 potential candidates for surgery or epidural steroid injection (for suspected radiculopathy).

Clinicians should provide patients with low-back pain evidence-based information about their expected course, advise patients to remain active, and provide information about effective self-care options.

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 the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy.

For patients who do not improve with self-care options, clinicians should consider the addition of non-pharmacologic therapy with proven benefits for low back pain. They are spinal manipulation for acute low back pain; and for chronic or sub-acute low-back pain options include: intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation.

About the American Pain Society

Based in Glenview, Ill., the American Pain Society (APS) is a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering.

APS was founded in 1978 with 510 charter members. From the outset, the group was conceived as a multidisciplinary organization. APS has enjoyed solid growth since its early days and today has approximately 3,200 members. The Board of Directors includes physicians, nurses, psychologists, basic scientists, pharmacists, policy analysts and more.

American Pain Society