Aime201704040 M162367

CLINICAL GUIDELINE
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back

Pain: A Clinical Practice Guideline From the American College of
Physicians
Amir Qaseem, MD, PhD, MHA; Timothy J. Wilt, MD, MPH; Robert M. McLean, MD; and Mary Ann Forciea, MD; for the Clinical
Guidelines Committee of the American College of Physicians*
Description: The American College of Physicians (ACP) devel- muscle relaxants (moderate-quality evidence). (Grade: strong
oped this guideline to present the evidence and provide clinical recommendation)
recommendations on noninvasive treatment of low back pain.
Recommendation 2: For patients with chronic low back pain,
Methods: Using the ACP grading system, the committee based clinicians and patients should initially select nonpharmacologic
these recommendations on a systematic review of randomized, treatment with exercise, multidisciplinary rehabilitation, acupunc-
controlled trials and systematic reviews published through April ture, mindfulness-based stress reduction (moderate-quality evi-
2015 on noninvasive pharmacologic and nonpharmacologic dence), tai chi, yoga, motor control exercise, progressive
treatments for low back pain. Updated searches were performed relaxation, electromyography biofeedback, low-level laser
through November 2016. Clinical outcomes evaluated included therapy, operant therapy, cognitive behavioral therapy, or
reduction or elimination of low back pain, improvement in back- spinal manipulation (low-quality evidence). (Grade: strong
specic and overall function, improvement in health-related recommendation)
quality of life, reduction in work disability and return to work,
global improvement, number of back pain episodes or time be- Recommendation 3: In patients with chronic low back pain who
tween episodes, patient satisfaction, and adverse effects. have had an inadequate response to nonpharmacologic therapy,
clinicians and patients should consider pharmacologic treatment
Target Audience and Patient Population: The target audi- with nonsteroidal anti-inammatory drugs as rst-line therapy, or
ence for this guideline includes all clinicians, and the target pa- tramadol or duloxetine as second-line therapy. Clinicians should
tient population includes adults with acute, subacute, or chronic only consider opioids as an option in patients who have failed the
low back pain. aforementioned treatments and only if the potential benets out-
weigh the risks for individual patients and after a discussion of
Recommendation 1: Given that most patients with acute or known risks and realistic benets with patients. (Grade: weak rec-
subacute low back pain improve over time regardless of treat- ommendation, moderate-quality evidence)
ment, clinicians and patients should select nonpharmacologic
treatment with supercial heat (moderate-quality evidence), mas-
sage, acupuncture, or spinal manipulation (low-quality evidence). Ann Intern Med. 2017;166:514-530. doi:10.7326/M16-2367 Annals.org
If pharmacologic treatment is desired, clinicians and patients For author afliations, see end of text.
should select nonsteroidal anti-inammatory drugs or skeletal This article was published at Annals.org on 14 February 2017.
L ow back pain is one of the most common reasons

for physician visits in the United States. Most Amer-
icans have experienced low back pain, and approxi-
Low back pain is associated with high costs, including
those related to health care and indirect costs from
missed work or reduced productivity (2). The total costs
mately one quarter of U.S. adults reported having low attributable to low back pain in the United States were
back pain lasting at least 1 day in the past 3 months (1). estimated at $100 billion in 2006, two thirds of which
were indirect costs of lost wages and productivity (3).
Low back pain is frequently classied and treated
See also: on the basis of symptom duration, potential cause,
Related articles. . . . . . . . . . . . . . . . . . . . . . . . 480, 493 presence or absence of radicular symptoms, and corre-
Editorial comment . . . . . . . . . . . . . . . . . . . . . . . . . 533 sponding anatomical or radiographic abnormalities.
Acute back pain is dened as lasting less than 4 weeks,
Summary for Patients . . . . . . . . . . . . . . . . . . . . . . . I-20
subacute back pain lasts 4 to 12 weeks, and chronic
Web-Only back pain lasts more than 12 weeks. Radicular low back
CME quiz pain results in lower extremity pain, paresthesia, and/or
* This paper, written by Amir Qaseem, MD, PhD, MHA; Timothy J. Wilt, MD, MPH; Robert M. McLean, MD; and Mary Ann Forciea, MD, was developed for the
Clinical Guidelines Committee of the American College of Physicians. Individuals who served on the Clinical Guidelines Committee from initiation of the
project until its approval were Mary Ann Forciea, MD (Chair); Thomas D. Denberg, MD, PhD (Immediate Past Chair); Michael J. Barry, MD; Cynthia Boyd,
MD, MPH; R. Dobbin Chow, MD, MBA; Nick Fitterman, MD; Russell P. Harris, MD, MPH; Linda L. Humphrey, MD, MPH; Devan Kansagara, MD, MCR;
Scott Manaker, MD, PhD; Robert M. McLean, MD; Sandeep Vijan, MD, MS; and Timothy J. Wilt, MD, MPH. Approved by the ACP Board of Regents on 2
May 2016.
Author (participated in discussion and voting).
Nonauthor contributor (participated in discussion but excluded from voting).
514 2017 American College of Physicians
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/936156/ on 07/09/2017

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain CLINICAL GUIDELINE
weakness and is a result of nerve root impingement. Table. The American College of Physicians Guideline
Most patients with acute back pain have self-limited ep- Grading System*
isodes that resolve on their own; many do not seek
medical care (4). For patients who do seek medical Quality of Strength of Recommendation
Evidence
care, pain, disability, and return to work typically im-
Benets Clearly Outweigh Risks Benets Finely Balanced
prove rapidly in the rst month (5). However, up to one and Burden or Risks and Burden With Risks and Burden
third of patients report persistent back pain of at least Clearly Outweigh Benets
moderate intensity 1 year after an acute episode, and 1 High Strong Weak
in 5 report substantial limitations in activity (6). Many Moderate Strong Weak
noninvasive treatment options are available for radicu- Low Strong Weak
lar and nonradicular low back pain, including pharma- Insufcient evidence to determine net benets or risks
cologic and nonpharmacologic interventions.
* Adopted from the classication developed by the GRADE (Grading
of Recommendations Assessment, Development and Evaluation)
workgroup.
GUIDELINE FOCUS AND TARGET POPULATION
The purpose of this American College of Physicians
(ACP) guideline is to provide treatment guidance
cluded reduction or elimination of low back pain,
based on the efcacy, comparative effectiveness, and
improvement in back-specic and overall function,
safety of noninvasive pharmacologic and nonpharma-
improvement in health-related quality of life,
cologic treatments for acute (<4 weeks), subacute (4 to
reduction in work disability, return to work, global
12 weeks), and chronic (>12 weeks) low back pain in
primary care. This guideline does not address topical improvement, number of back pain episodes or time
pharmacologic therapies or epidural injection thera- between episodes, patient satisfaction, and adverse
pies. It serves as a partial update of the 2007 ACP effects.
guideline (it excludes evidence on diagnosis). These The magnitude of effect (small, moderate, or large)
recommendations are based on 2 background evi- was determined as previously described (10, 11). A
dence reviews (7, 8) and a systematic review sponsored small effect on pain was dened as a mean between-
by the Agency for Healthcare Research and Quality group difference after treatment of 5 to 10 points on a
(AHRQ) (9). The target audience for this guideline in- visual analogue scale of 0 to 100 or equivalent, a mean
cludes all clinicians, and the target patient population between-group difference of 0.5 to 1.0 point on a nu-
includes adults with acute, subacute, or chronic low merical rating scale of 0 to 10, or a standardized mean
back pain. difference of 0.2 to 0.5. A moderate effect was dened
as a mean between-group difference of greater than 10
to no more than 20 points on a visual analogue scale of
METHODS 0 to 100 or equivalent, a mean between-group differ-
Systematic Review of the Evidence ence of greater than 1.0 to no more than 2.0 points on
The evidence review was conducted by the a numerical rating scale of 0 to 10 or equivalent, or a
AHRQ's Pacic Northwest Evidence-based Practice standardized mean difference greater than 0.5 but no
Center. Additional methodological details can be more than 0.8. For function, a small effect was dened
found in the Appendix (available at Annals.org) as well as a mean between-group difference of 5 to 10 points
as in the accompanying articles (7, 8) and full report (9). on the Oswestry Disability Index (ODI), a mean
Reviewers searched several databases for studies pub- between-group difference of 1 to 2 points on the Ro-
lished in English from January 2008 through April 2015 land Morris Disability Questionnaire (RDQ), or a stan-
and updated the search through November 2016. dardized mean difference of 0.2 to 0.5. A moderate
Studies published before 2007 were identied using effect on function was dened as a mean between-
the 2007 ACP/American Pain Society (APS) systematic group difference of greater than 10 to no more than 20
reviews (10, 11). Reviewers combined data when pos- points on the ODI, a mean between-group difference
sible using meta-analysis and assessed risk of bias and of greater than 2 to no more than 5 points on the RDQ,
study quality according to established methods. The or a standardized mean difference greater than 0.5 but
study population included adults (aged 18 years) with no more than 0.8. No large effects were found with any
acute, subacute, or chronic nonradicular low back pain, intervention.
radicular low back pain, or symptomatic spinal stenosis.
The review evaluated pharmacologic (acetamino-
phen, nonsteroidal anti-inammatory drugs [NSAIDs], Grading the Evidence and Developing
opioids, skeletal muscle relaxants [SMRs], benzodiaz- Recommendations
epines, antidepressants, antiseizure medications, and This guideline was developed by ACP's Clinical
systemic corticosteroids) and nonpharmacologic (psy- Guidelines Committee (CGC) according to ACP's
chological therapies, multidisciplinary rehabilitation, guideline development process, details of which can
spinal manipulation, acupuncture, massage, exercise be found in the methods paper (12). The CGC used the
and related therapies, and various physical modalities) evidence tables in the accompanying evidence reviews
treatments for low back pain. Evaluated outcomes in- (7, 8) and full report (9) when reporting the evidence
Annals.org Annals of Internal Medicine Vol. 166 No. 7 4 April 2017 515

CLINICAL GUIDELINE Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain
and graded the recommendations using the ACP's methylprednisolone or a 5-day course of prednisolone
guideline grading system (Table). compared with placebo in patients with acute low back
pain (24, 25).
Peer Review
The AHRQ systematic review was sent to invited
peer reviewers and posted on the AHRQ Web site for Other Therapies
public comments. The accompanying evidence reviews Evidence was insufcient to determine effective-
(7, 8) also underwent a peer review process through ness of antidepressants, benzodiazepines (26, 27), an-
the journal. The guideline underwent a peer review tiseizure medications, or opioids versus placebo in pa-
process through the journal and was posted online for tients with acute or subacute low back pain.
comments from ACP Regents and ACP Governors, who
represent ACP members at the regional level. Chronic Low Back Pain
Appendix Table 2 (available at Annals.org) summa-
rizes the ndings for all therapies for chronic low back
BENEFITS AND COMPARATIVE BENEFITS OF pain.
PHARMACOLOGIC THERAPIES
Acute or Subacute Low Back Pain
NSAIDs
Appendix Table 1 (available at Annals.org) summa-
rizes the ndings for all therapies for acute or subacute Moderate-quality evidence showed that NSAIDs
low back pain. were associated with small to moderate pain improve-
ment compared with placebo (14, 28, 29). Low-quality
evidence showed that NSAIDs were associated with no
Acetaminophen to small improvement in function (28 31). Moderate-
Low-quality evidence showed no difference be- quality evidence showed that most head-to-head trials
tween acetaminophen and placebo for pain intensity or of one NSAID versus another showed no differences
function through 4 weeks or between acetaminophen in pain relief in patients with chronic low back
and NSAIDs for pain intensity or likelihood of experi- pain (14). There were no data on COX-2selective
encing global improvement at 3 weeks or earlier (13, NSAIDs.
14).
Opioids
NSAIDs Moderate-quality evidence showed that strong opi-
Moderate-quality evidence showed that NSAIDs oids (tapentadol, morphine, hydromorphone, and oxy-
were associated with a small improvement in pain in- morphone) were associated with a small short-term im-
tensity compared with placebo (14, 15), although sev- provement in pain scores (about 1 point on a pain scale
eral randomized, controlled trials (RCTs) showed no dif- of 0 to 10) and function compared with placebo (32
ference in likelihood of achieving pain relief with 36). Low-quality evidence showed that buprenorphine
NSAIDs compared with placebo (16 18). Low-quality patches improved short-term pain more than placebo
evidence showed a small increase in function with in patients with chronic low back pain; however, the
NSAIDs compared with placebo (19). Moderate-quality improvement corresponded to less than 1 point on a
evidence showed that most head-to-head trials of one pain scale of 0 to 10 (37 40). Moderate-quality evi-
NSAID versus another showed no differences in pain dence showed no differences among different long-
relief in patients with acute low back pain (14). Low- acting opioids for pain or function (33, 41 44), and low-
quality evidence showed no differences in pain be- quality evidence showed no clear differences in pain
tween cyclooxygenase (COX)-2selective NSAIDs ver- relief between long- and short-acting opioids (4550).
sus traditional NSAIDs (14). Moderate-quality evidence showed that tramadol
achieved moderate short-term pain relief and a small
SMRs
improvement in function compared with placebo (32,
51, 52).
Moderate-quality evidence showed that SMRs im-
proved short-term pain relief compared with placebo
after 2 to 4 and 5 to 7 days (20, 21). Low-quality evi-
SMRs
dence showed no differences between different SMRs
for any outcomes in patients with acute pain (20). Low- Evidence comparing SMRs versus placebo was in-
quality evidence showed inconsistent ndings for the sufcient (5355). Low-quality evidence showed no dif-
effect on pain intensity with a combination of SMRs ferences in any outcome between different SMRs for
plus NSAIDs compared with NSAIDs alone (20, 22, 23). treatment of chronic low back pain (20).
Systemic Corticosteroids Benzodiazepines

Low-quality evidence showed no difference in pain Low-quality evidence showed that tetrazepam im-
or function between a single intramuscular injection of proved pain relief at 5 to 7 days and resulted in overall
516 Annals of Internal Medicine Vol. 166 No. 7 4 April 2017 Annals.org

improvement at 10 to 14 days compared with placebo NSAIDs, and acetaminophen was associated with a
(20). lower risk for adverse effects than NSAIDs (14).
Moderate-quality evidence showed that short-term use
of opioids increased nausea, dizziness, constipation,
Antidepressants
vomiting, somnolence, and dry mouth compared with
Moderate-quality evidence showed no difference
placebo, and SMRs increased risk for any adverse event
in pain between tricyclic antidepressants (TCAs) or se-
and central nervous system adverse events (mostly se-
lective serotonin reuptake inhibitors (SSRIs) versus pla-
dation) compared with placebo (20). Moderate-quality
cebo, and low-quality evidence showed no differences
evidence showed that antidepressants increased risk
in function for antidepressants (56). Moderate-quality
for any adverse event compared with placebo, al-
evidence showed that duloxetine was associated with a
though rates of specic adverse events did not differ
small improvement in pain intensity and function com-
(72). The risk for serious adverse events did not differ
pared with placebo (5759).
between duloxetine and placebo, although duloxetine
was associated with increased risk for withdrawal due
Other Therapies to adverse events (5759). Low-quality evidence
Evidence was insufcient to determine the effect of showed no clear differences in adverse effects for ga-
acetaminophen, systemic corticosteroids, or antiseizure bapentin versus placebo (67, 68). Low-quality evidence
medications on chronic low back pain. showed that benzodiazepines caused more frequent
somnolence, fatigue, and lightheadedness than pla-
Radicular Low Back Pain
cebo (20). Harms were not well-reported, and no RCTs
Appendix Table 3 (available at Annals.org) summa- assessed long-term use of benzodiazepines or risks for
rizes the ndings for all treatments for radicular low addiction, abuse, or overdose. Adverse events for sys-
back pain. temic corticosteroids were not well-reported in RCTs,
but the largest trial found that oral prednisone was as-
Benzodiazepines sociated with increased risk for any adverse event,
Low-quality evidence showed no difference be- insomnia, nervousness, and increased appetite (66).
tween diazepam and placebo for function at 1 week However, low-quality evidence showed no cases of hy-
through 1 year and analgesic use, return to work, or perglycemia that required medical attention (24, 61,
likelihood of surgery through 1 year of follow-up in pa- 64).
tients with acute or subacute radicular pain (60). Diaze-
pam resulted in a lower likelihood of pain improvement
at 1 week compared with placebo.
COMPARATIVE BENEFITS OF
NONPHARMACOLOGIC THERAPIES
Acute or Subacute Low Back Pain
Systemic Corticosteroids Exercise
Moderate-quality evidence showed no differences Low-quality evidence showed no difference be-
in pain between systemic corticosteroids and placebo tween exercise therapy and usual care for pain or func-
and no to small effect on function in patients with radic- tion in patients with acute or subacute pain (11); addi-
ular low back pain (61 66). tional trials reported inconsistent results (7375).
Moderate-quality evidence showed no clear differ-
Other Therapies ences between different exercise regimens in more
No RCTs evaluated acetaminophen, SMRs, antide- than 20 head-to-head RCTs in patients with acute low
pressants, or opioids for radicular low back pain. Re- back pain.
sults for NSAIDs were inconsistent for pain, and
evidence was therefore insufcient (22). There was in- Acupuncture
sufcient evidence to determine the effect of antisei- Low-quality evidence showed that acupuncture re-
zure medications on radicular low back pain (6771). sulted in a small decrease in pain intensity compared
with sham acupuncture with nonpenetrating needles,
HARMS OF PHARMACOLOGIC THERAPIES but there were no clear effects on function (76 78).
Low-quality evidence showed that acupuncture slightly
Harms were derived from the identied systematic
increased the likelihood of overall improvement com-
reviews. Adverse effects generally associated with the
pared with NSAIDs (76, 79 83).
drugs can be found in Appendix Table 4 (available at
Annals.org).
Moderate-quality evidence showed no difference Massage
among scheduled acetaminophen, acetaminophen Low-quality evidence showed that massage mod-
taken as needed, or placebo for serious adverse events erately improved short-term (1 week) pain and function
(13). Moderate-quality evidence showed that more ad- compared with sham therapy for subacute low back
verse effects occurred with NSAIDs than placebo, COX- pain (84), although 1 trial (85) showed no difference in
2selective NSAIDs were associated with a decreased pain or function at 5 weeks. Moderate-quality evidence
risk for adverse effects compared with traditional showed that massage improved short-term pain relief

and function compared with other interventions (ma- Lumbar Supports

nipulation, exercise therapy, relaxation therapy, acu- Low-quality evidence showed no difference in pain
puncture, or physiotherapy) for patients with subacute or function between lumbar supports added to an ed-
to chronic low back pain, but effects were small (84, ucational program compared with an educational pro-
86). Low-quality evidence showed that a combination gram alone or other active interventions in patients with
of massage plus another intervention (exercise, exer- acute or subacute low back pain (95).
cise and education, or usual care) was superior to the
other intervention alone for short-term pain in patients
with subacute to chronic low back pain (84). Other Therapies
Evidence was insufcient to determine the effec-
tiveness of transcutaneous electrical nerve stimulation
(TENS), electrical muscle stimulation, inferential ther-
Spinal Manipulation apy, short-wave diathermy, traction, supercial cold,
Low-quality evidence showed that spinal manipula- motor control exercise (MCE), Pilates, tai chi, yoga, psy-
tion was associated with a small effect on function chological therapies, multidisciplinary rehabilitation, ul-
compared with sham manipulation; evidence was insuf- trasound, and taping.
cient to determine the effect on pain (87, 88). Low-
quality evidence showed no difference in pain relief at Chronic Low Back Pain
1 week between spinal manipulation and inert treat- Exercise
ment (educational booklet, detuned ultrasound, de- Moderate-quality evidence showed that exercise
tuned or actual short-wave diathermy, antiedema gel, resulted in a small improvement in pain relief and func-
or bed rest), although 1 trial showed better longer-term tion compared with no exercise (11, 96). Moderate-
pain relief (3 months) with spinal manipulation (89). quality evidence showed that compared with usual
Function did not differ between spinal manipulation care, exercise resulted in small improvements in pain
and inert treatment at 1 week or 3 months (89). intensity and function at the end of treatment, although
Moderate-quality evidence showed no difference be- effects were smaller at long-term follow-up (96).
tween spinal manipulation and other active interven- Moderate-quality evidence showed no clear differ-
tions for pain relief at 1 week through 1 year or function ences between different exercise regimens in more
(analyses included exercise, physical therapy, or back than 20 head-to-head RCTs in patients with chronic low
school as the comparator) (89, 90). Low-quality evi- back pain.
dence showed that a combination of spinal manipula-
tion plus exercise or advice slightly improved function
MCE
at 1 week compared with exercise or advice alone, but
Motor control exercise focuses on restoring coordi-
these differences were not present at 1 or 3 months
nation, control, and strength of the muscles that control
(89).
and support the spine. Low-quality evidence showed
that MCE moderately decreased pain scores and
slightly improved function in short- to long-term
Supercial Heat follow-up compared with a minimal intervention (97).
Moderate-quality evidence showed that a heat Low-quality evidence showed that MCE resulted in
wrap moderately improved pain relief (at 5 days) and small improvements in pain intensity at short-term (6
disability (at 4 days) compared with placebo (91). Low- weeks to <4 months) and intermediate-term (4 to <8
quality evidence showed that a combination of heat months) follow-up compared with general exercise, al-
plus exercise provided greater pain relief and im- though improvements were small and no longer signif-
proved RDQ scores at 7 days compared with exercise icant at long-term follow-up (97). Motor control exer-
alone in patients with acute pain (92). Low-quality evi- cise also resulted in small improvements in function in
dence showed that a heat wrap provided more effec- the short and long term (97). Low-quality evidence
tive pain relief and improved RDQ scores compared showed that MCE resulted in a moderate improvement
with acetaminophen or ibuprofen after 1 to 2 days (93). in pain intensity and function compared with multi-
Low-quality evidence showed no clear differences be- modal physical therapy at intermediate follow-up (97).
tween a heat wrap and exercise in pain relief or func- Low-quality evidence showed no clear differences in
tion (92). pain with a combination of MCE plus exercise versus
exercise alone (98, 99).
Low-Level Laser Therapy Pilates

Low-quality evidence showed that a combination Low-quality evidence showed that Pilates resulted
of low-level laser therapy (LLLT) and NSAIDs largely de- in small or no clear effects on pain and no clear effects
creased pain intensity and resulted in a moderate im- on function compared with usual care plus physical ac-
provement in function (as measured by the ODI) com- tivity (100 107). Low-quality evidence showed no clear
pared with sham laser therapy plus NSAIDs in patients differences between Pilates and other types of exercise
with acute or subacute pain (94). for pain or function (108 110).

Tai Chi Multidisciplinary Rehabilitation
Low-quality evidence showed that tai chi resulted Moderate-quality evidence showed that multidisci-
in moderate pain improvement compared with wait-list plinary rehabilitation moderately reduced short-term
controls or no tai chi (111, 112), and 1 study showed a (<3 months) and slightly reduced long-term pain inten-
small increase in function (111). Moderate-quality evi- sity and disability compared with usual care, although
dence showed that tai chi moderately decreased pain there was no difference in return to work (124). Low-
intensity at 3 and 6 months compared with backward quality evidence showed that multidisciplinary rehabil-
walking or jogging but not versus swimming (112). itation was associated with moderately lower short-
term pain intensity and slightly lower disability than no
rehabilitation (124). Moderate-quality evidence showed
Yoga that multidisciplinary rehabilitation was associated with
Low-quality evidence showed that Iyengar yoga re- slightly lower short-term pain intensity and disability,
sulted in moderately lower pain scores and improved moderately lower long-term pain intensity, and im-
function compared with usual care at 24 weeks (113). proved function compared with physical therapy and a
Low-quality evidence showed that yoga resulted in a greater likelihood of returning to work compared with
small decrease in pain intensity compared with exercise nonmultidisciplinary rehabilitation (124).
(114 118). Low-quality evidence showed that, com-
pared with education, yoga resulted in a small de-
crease in short-term (12 weeks) but not long-term Acupuncture
(about 1 year) pain intensity and a small increase in Low-quality evidence showed that acupuncture
short- and long-term function (119). was associated with moderate improvement in pain re-
lief immediately after treatment and up to 12 weeks
later compared with sham acupuncture, but there was
Psychological Therapies no improvement in function (125130). Moderate-
Low-quality evidence showed that progressive re- quality evidence showed that acupuncture was associ-
laxation therapy moderately improved pain intensity ated with moderately lower pain intensity and im-
and functional status compared with wait-list controls proved function compared with no acupuncture at the
(120). Low-quality evidence showed that electromyog- end of treatment (125). Low-quality evidence showed a
raphy biofeedback training moderately decreased pain small improvement in pain relief and function com-
intensity (reduction of 5 to 13 points on a 100-point pared with medications (NSAIDs, muscle relaxants, or
pain scale) compared with wait-list controls, but there analgesics) (125).
was no effect on function (120). Low-quality evidence
showed that operant therapy (behavioral therapy in-
volving reinforcement) slightly improved pain intensity Massage
compared with wait-list control, although there was no Low-quality evidence showed no difference in pain
difference for function (120). Low-quality evidence between foot reexology and usual care for patients
showed that cognitive behavioral therapy (CBT) and with chronic low back pain (131133). Moderate-quality
other combined psychological therapies (involving ed- evidence showed that massage improved short-term
ucation, problem-solving training, coping techniques, pain relief and function compared with other interven-
imagery, relaxation, goal setting, cognitive pain control, tions (manipulation, exercise therapy, relaxation ther-
and exercises) were associated with moderately im- apy, acupuncture, physiotherapy, or TENS) for patients
proved pain intensity compared with wait-list controls, with subacute to chronic low back pain, although ef-
but there was no difference in function (120). fects were small (84, 86). Low-quality evidence showed
Moderate-quality evidence showed that mindfulness- that a combination of massage plus another interven-
based stress reduction is an effective treatment for tion (exercise, exercise and education, or usual care)
chronic low back pain. One study showed a small im- was superior to the other intervention alone for short-
provement in pain at 26 and 52 weeks and in function term pain in patients with subacute to chronic low back
at 26 weeks compared with usual care (121). The same pain (84).
study showed no difference between mindfulness-
based stress reduction and CBT for improvements in
pain or function. Two other studies showed improve- Spinal Manipulation
ment in pain and function compared with education Low-quality evidence showed no difference in pain
(122, 123). Low-quality evidence showed no difference with spinal manipulation versus sham manipulation at 1
between psychological therapies and exercise or phys- month (134, 135). Low-quality evidence showed that
ical therapy for pain intensity (120). Low-quality evi- spinal manipulation slightly improved pain compared
dence showed no differences in pain or function be- with an inert treatment (136 142). Moderate-quality ev-
tween a combination of psychological therapy plus idence showed no clear differences in pain or function
exercise or physiotherapy compared with exercise or compared with another active intervention. Low-quality
physiotherapy alone (120). Moderate-quality evidence evidence showed that a combination of spinal manipu-
showed no differences between different psychological lation with another active treatment resulted in greater
therapies for pain or function outcomes (120). pain relief and improved function at 1, 3, and 12

months compared with the other treatment alone (134, traction plus physiotherapy versus physiotherapy
143147). alone, or between different types of traction in patients
with low back pain with or without radiculopathy (169).
Ultrasound
Low-quality evidence showed no difference be- Other Therapies
tween ultrasound and sham ultrasound for pain at the Evidence was insufcient for ultrasound, MCE,
end of treatment or 4 weeks after treatment (148 150). Pilates, tai chi, yoga, psychological therapies, multidis-
Low-quality evidence showed no difference between ciplinary rehabilitation, acupuncture, massage, spinal
ultrasound and no ultrasound for pain or function (151, manipulation, LLLT, electrical muscle stimulation, short-
152). wave diathermy, TENS, interferential therapy, super-
cial heat or cold, lumbar support, and taping.
TENS
Low-quality evidence showed no difference be-
tween TENS and sham TENS for pain intensity or func- HARMS OF NONPHARMACOLOGIC THERAPIES
tion at short-term follow-up (153). Low-quality evidence Evidence on adverse events from the included
showed no difference between TENS and acupuncture RCTs and systematic reviews was limited, and the qual-
in short- or long-term pain (154). ity of evidence for all available harms data is low. Harms
were poorly reported (if they were reported at all) for
most of the interventions.
LLLT Low-quality evidence showed no reported harms
Low-quality evidence showed that LLLT slightly im- or serious adverse events associated with tai chi, psy-
proved pain compared with sham laser (155157), and chological interventions, multidisciplinary rehabilita-
1 RCT (155) showed that LLLT slightly improved function, ultrasound, acupuncture, lumbar support, or trac-
tion compared with sham laser. tion (9, 95, 150, 170 174). Low-quality evidence
showed that when harms were reported for exercise,
Lumbar Support they were often related to muscle soreness and in-
Evidence was insufcient to compare lumbar sup- creased pain, and no serious harms were reported. All
port versus no lumbar support. Low-quality evidence reported harms associated with yoga were mild to
showed no difference between a lumbar support plus moderate (119). Low-quality evidence showed that
exercise (muscle strengthening) versus exercise alone none of the RCTs reported any serious adverse events
for pain or function at 8 weeks or 6 months (158). Low- with massage, although 2 RCTs reported soreness dur-
quality evidence showed no clear differences between ing or after massage therapy (175, 176). Adverse
lumbar supports and other active treatments (traction, events associated with spinal manipulation included
spinal manipulation, exercise, physiotherapy, or TENS) muscle soreness or transient increases in pain (134).
for pain or function (159 161). There were few adverse events reported and no clear
differences between MCE and controls. Transcutane-
ous electrical nerve stimulation was associated with an
Taping increased risk for skin site reaction but not serious ad-
Low-quality evidence showed no differences be- verse events (177). Two RCTs (178, 179) showed an
tween Kinesio taping and sham taping for back-specic increased risk for skin ushing with heat compared with
function after 5 or 12 weeks, although effects on pain no heat or placebo, and no serious adverse events
were inconsistent between the 2 trials (162, 163). Low- were reported. There were no data on cold therapy.
quality evidence showed no differences between Kine- Evidence was insufcient to determine harms of electri-
sio taping and exercise for pain or function (164, 165). cal muscle stimulation, LLLT, percutaneous electrical
nerve stimulation, interferential therapy, short-wave
Other Therapies diathermy, and taping.
Evidence was insufcient to determine the effec-
tiveness of electrical muscle stimulation, interferential
therapy, short-wave diathermy, traction, or supercial COMPARISON OF CONCLUSIONS WITH THOSE
heat or cold. OF THE 2007 GUIDELINE
Radicular Low Back Pain Some evidence has changed since the 2007 ACP
guideline and supporting evidence review. The 2007
Exercise
review concluded that acetaminophen was effective for
Low-quality evidence showed that exercise re-
acute low back pain, based on indirect evidence from
sulted in small improvements in pain and function com-
trials of acetaminophen for other conditions and trials
pared with usual care or no exercise (166 168).
of acetaminophen versus other analgesics. However,
this update included a placebo-controlled RCT in pa-
Traction tients with low back pain that showed no difference in
Low-quality evidence showed no clear differences effectiveness between acetaminophen and placebo
between traction and other active treatments, between (low-quality evidence). In addition, contrary to the 2007

review, current moderate-quality evidence showed that erences and likely individual medication risk prole.
TCAs were not effective for chronic low back pain com- Treatment with NSAIDs resulted in a small improve-
pared with placebo. Additional pharmacologic treatment in both pain intensity (moderate-quality evidence)
ments addressed in the current review included dulox- and function (low-quality evidence), and treatment with
etine and the antiseizure medication pregabalin. Many SMRs resulted in a small improvement in pain relief
conclusions about nonpharmacologic interventions are (moderate-quality evidence). There was no evidence
similar between the 2007 review and the update. Addi- for the effect of SMRs on function. Nonsteroidal anti-
tional modalities assessed (with at least low-quality ev- inammatory drugs are associated with gastrointestinal
idence) include mindfulness-based stress reduction, and renal risks. Clinicians should therefore assess reno-
MCE, taping, and tai chi. Additional evidence or vascular and gastrointestinal risk factors before pre-
changes from the updated review include that super- scribing NSAIDs and recommend the lowest effective
cial heat was found to be more effective for acute or doses for the shortest periods necessary. Although they
subacute low back pain (moderate-quality evidence)
are associated with lower risk for adverse effects than
and neither ultrasound nor TENS was shown to be ef-
nonselective NSAIDs, COX-2selective NSAIDs were
fective compared with controls (low-quality evidence).
not assessed for improvement in pain or function. Skel-
The Figure summarizes the recommendations and
etal muscle relaxants are associated with central ner-
clinical considerations. Additional details on the evi-
dence are available in Appendix Tables 1 to 4 and the vous system adverse effects, especially sedation.
accompanying evidence reviews (7, 8). The updated evidence showed that acetamino-
phen was not effective at improving pain outcomes ver-
sus placebo. However, this study assessed pain at 3
RECOMMENDATIONS weeks after the intervention, and evidence from head-
Recommendation 1: Given that most patients with to-head trials showed no difference between acetamin-
acute or subacute low back pain improve over time re- ophen and NSAIDs. Low-quality evidence showed that
gardless of treatment, clinicians and patients should se- systemic steroids were not effective in treating acute or
lect nonpharmacologic treatment with supercial heat subacute low back pain, and we recommend against
(moderate-quality evidence), massage, acupuncture, or these drugs for treatment of acute low back pain.
spinal manipulation (low-quality evidence). If pharmaco- Recommendation 2: For patients with chronic low
logic treatment is desired, clinicians and patients should back pain, clinicians and patients should initially select
select nonsteroidal anti-inammatory drugs or skeletal nonpharmacologic treatment with exercise, multidisci-
muscle relaxants (moderate-quality evidence). (Grade: plinary rehabilitation, acupuncture, mindfulness-based
strong recommendation) stress reduction (moderate-quality evidence), tai chi,
Clinicians should inform all patients of the gener- yoga, motor control exercise, progressive relaxation,
ally favorable prognosis of acute low back pain with or electromyography biofeedback, low-level laser therapy,
without sciatica, including a high likelihood for substan- operant therapy, cognitive behavioral therapy, or spinal
tial improvement in the rst month (5, 180). Clinicians manipulation (low-quality evidence). (Grade: strong
should also provide patients with evidence-based infor- recommendation)
mation with regard to their expected course, advise Nonpharmacologic interventions are considered as
them to remain active as tolerated, and provide infor- rst-line options in patients with chronic low back pain
mation about effective self-care options. Clinicians and because fewer harms are associated with these types of
patients should use a shared decision-making ap- therapies than with pharmacologic options. It is impor-
proach to select the most appropriate treatment based tant that physical therapies be administered by provid-
on patient preferences, availability, harms, and costs of ers with appropriate training. Moderate-quality evi-
the interventions. Nonpharmacologic interventions dence showed that exercise therapy resulted in small
shown to be effective for improving pain and function
improvements in pain and function. Specic compo-
in patients with acute or subacute low back pain in-
nents associated with greater effects on pain included
clude supercial heat (moderate-quality evidence and
individually designed programs, supervised home ex-
moderate improvement in pain and function) and mas-
sage (low-quality evidence and small to moderate im- ercise, and group exercise; regimens that included
provement in pain and function). Low-quality evidence stretching and strength training were most effective.
showed that acupuncture had a small effect on improv- Moderate-quality evidence showed that, compared
ing pain and spinal manipulation had a small effect on with usual care, multidisciplinary rehabilitation resulted
improving function compared with sham manipulation in moderate pain improvement in the short term (<3
but not inert treatment. Harms of nonpharmacologic months), small pain improvement in the long term, and
interventions were sparsely reported, and no serious small improvement in function in both the short and
adverse events were reported. Supercial heat was as- long term. Low-quality evidence showed that multidis-
sociated with increased risk for skin ushing, and mas- ciplinary rehabilitation resulted in a moderate improve-
sage and spinal manipulation were associated with ment in pain and a small improvement in function
muscle soreness. compared with no multidisciplinary rehabilitation. Acu-
We recommend that the choice between NSAIDs puncture had a moderate effect on pain and function
and SMRs be individualized on the basis of patient pref- compared with no acupuncture (moderate-quality evi-

Figure. Summary of the American College of Physicians guideline on noninvasive treatments for acute, subacute, or chronic
low back pain.
Summary of the American College of Physicians Guideline on Noninvasive Treatments for Acute, Subacute, or Chronic Low Back Pain
Disease/Condition Low back pain
Target Audience All clinicians
Target Patient Population Adults with acute, subacute, or chronic low back pain
Interventions Evaluated Pharmacologic interventions: NSAIDs, nonopioid analgesics, opioid analgesics, tramadol and tapentadol, antidepressants, SMRs,
benzodiazepines, corticosteroids, antiepileptic drugs
Nonpharmacologic interventions: interdisciplinary or multicomponent rehabilitation; psychological therapies; exercise and

related interventions, such as yoga or tai chi; complementary and alternative medicine therapies, including spinal manipulation,
acupuncture, and massage; passive physical modalities, such as heat, cold, ultrasound, transcutaneous electrical nerve
stimulation, electrical muscle stimulation, interferential therapy, short-wave diathermy, traction, LLLT, lumbar supports/braces
Outcomes Evaluated Pain, function, health-related quality of life, work disability/return to work, global improvement, number of back pain episodes
or time between episodes, patient satisfaction, adverse effects
Benefits Acute low back pain

Pharmacologic
NSAIDs: improved pain and function (small effect)
SMRs: improved pain (small effect)
Nonpharmacologic
Heat wrap: improved pain and function (moderate effect)
Massage: improved pain and function (at 1 but not 5 wk) (small to moderate effect)
Acupuncture: improved pain (small effect)
Spinal manipulation: improved function (small effect)
Chronic low back pain

Pharmacologic
NSAIDs: improved pain (small to moderate effect) and function (no to small effect)
Opioids: improved pain and function (small effect)
Tramadol: improved pain (moderate effect) and function (small effect)
Buprenorphine (patch or sublingual): improved pain (small effect)
Duloxetine: improved pain and function (small effect)
Nonpharmacologic
Exercise: improved pain and function (small effect)
Motor control exercise: improved pain (moderate effect) and function (small effect)
Tai chi: improved pain (moderate effect) and function (small effect)
Mindfulness-based stress reduction: improved pain and function (small effect)
Yoga: improved pain and function (small to moderate effect, depending on comparator)
Progressive relaxation: improved pain and function (moderate effect)
Multidisciplinary rehabilitation: improved pain (moderate effect) and function (no to small effect)
Acupuncture: improved pain (moderate effect) and function (no to moderate effect, depending on comparator)
LLLT: improved pain and function (small effect)
Electromyography biofeedback: improved pain (moderate effect)
Operant therapy: improved pain (small effect)
Cognitive behavioral therapy: improved pain (moderate effect)
Spinal manipulation: improved pain (small effect)
Radicular low back pain

Exercise: improved pain or function (small effect)
Harms Generally poorly reported
Pharmacologic
NSAIDs: increased adverse effects compared with placebo and acetaminophen (COX-2selective NSAIDs decreased risk for
adverse effects compared with traditional NSAIDs)
Opioids: nausea, dizziness, constipation, vomiting, somnolence, and dry mouth
SMRs: increased risk for any adverse event and central nervous system adverse events (mostly sedation)
Benzodiazepines: somnolence, fatigue, lightheadedness
Antidepressants: increased risk for any adverse event
Nonpharmacologic
Poorly reported, but no increase in serious adverse effects
Continued on following page

FigureContinued
Recommendations Recommendation 1: Given 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 2: For 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 3: In 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)
High-Value Care Clinicians should reassure patients that acute or subacute low back pain usually improves over time regardless of treatment and
should avoid prescribing costly and potentially harmful treatments. Systemic steroids were not shown to provide benefit and
should not be prescribed for patients with acute or subacute low back pain, even with radicular symptoms. For treatment of
chronic low back pain, clinicians should select therapies that have the fewest harms and lowest costs. Clinicians should avoid
prescribing costly therapies and those with substantial potential harms, such as long-term opioids, and pharmacologic therapies
that were not shown to be effective, such as tricyclic antidepressants and selective serotonin reuptake inhibitors.
Clinical Considerations Clinicians should inform patients with acute or subacute low back pain of the generally very favorable outcome. Thus, patients can
avoid potentially harmful and costly tests and treatments.
Clinicians should advise patients with acute, subacute, or chronic low back pain to remain active as tolerated.
Improvements in pain and function due to pharmacologic and nonpharmacologic interventions were small and often showed no
clear differences compared with controls.
Few differences in recommended therapies were found when they were studied in head-to-head trials. Therefore, clinicians should
base treatment recommendations on patient preferences that also minimize harms and costs.
COX-2 = cyclooxygenase-2; LLLT = low-level laser therapy; NSAID = nonsteroidal anti-inammatory drug; SMR = skeletal muscle relaxant.
dence) and a moderate effect on pain with no clear were no clear differences between spinal manipulation
effect on function compared with sham acupuncture and other active interventions (moderate-quality
(low-quality evidence). Moderate-quality evidence evidence).
showed that mindfulness-based stress reduction re- Harms were poorly reported for nonpharmacologic
sulted in small improvements in pain and function therapies, although no serious harms were reported for
(small effect), and 1 study showed that it was equivalent any of the recommended interventions. Muscle sore-
to CBT for improving back pain and function. ness was reported for exercise, massage, and spinal
Low-quality evidence showed that tai chi had a manipulation.
moderate effect on pain and a small effect on function. Ultrasound, TENS, and Kinesio taping had no effect
Tai chi sessions in included studies lasted 40 to 45 min- on pain or function compared with control treatments
utes and were done 2 to 5 times per week for 10 to 24 (low-quality evidence).
weeks. Low-quality evidence showed that yoga im- Recommendation 3: In patients with chronic low
proved pain and function by a moderate amount com- back pain who have had an inadequate response to
pared with usual care and by a small amount compared nonpharmacologic therapy, clinicians and patients
with education. Low-quality evidence showed that MCE should consider pharmacologic treatment with non-
had a moderate effect on pain and a small effect on steroidal anti-inammatory drugs as rst-line therapy, or
function. Motor control exercise, tai chi, and yoga were tramadol or duloxetine as second-line therapy. Clini-
favored over general exercise (low-quality evidence). cians should only consider opioids as an option in pa-
Low-quality evidence showed that progressive re- tients who have failed the aforementioned treatments
laxation had a moderate effect on pain and function, and only if the potential benets outweigh the risks for
electromyography biofeedback and CBT each had a individual patients and after a discussion of known risks
moderate effect on pain and no effect on function, and and realistic benets with patients. (Grade: weak recom-
operant therapy had a small effect on pain and no ef- mendation, moderate-quality evidence)
fect on function. Low-quality evidence showed that Pharmacologic therapy should be considered for
LLLT had a small effect on pain and function. Low- patients with chronic low back pain who do not im-
quality evidence showed that spinal manipulation had a prove with nonpharmacologic interventions. Nonsteroi-
small effect on pain compared with inert treatment but dal anti-inammatory drugs had a small to moderate
no effect compared with sham manipulation. There effect on pain (moderate-quality evidence) and no to

small effect on function (low-quality evidence) and and available evidence showed no clear connection
should be the rst option considered. Moderate-quality with improvements in pain.
evidence showed no difference in pain improvement
when different NSAIDs were compared with one an-
other. Nonsteroidal anti-inammatory drugs are associ- HIGH-VALUE CARE
ated with gastrointestinal and renal risks. Clinicians Clinicians should reassure patients that acute or
should therefore assess renovascular and gastrointesti- subacute low back pain usually improves over time, re-
nal risk factors before prescribing NSAIDs and should gardless of treatment. Thus, clinicians should avoid pre-
recommend the lowest effective doses for the shortest scribing costly and potentially harmful treatments for
periods necessary. COX-2selective NSAIDs were not these patients, especially narcotics. In addition, sys-
assessed for improvement in pain or function, although temic steroids were not shown to provide benet and
they are associated with lower risk for adverse effects should not be prescribed for patients with acute or sub-
than nonselective NSAIDs. acute low back pain, even with radicular symptoms. For
For second-line therapies, moderate-quality evi- treatment of chronic low back pain, clinicians should
dence showed that tramadol had a moderate effect on select therapies that have the fewest harms and lowest
pain and a small effect on function in the short term. Of costs because there were no clear comparative advan-
note, tramadol is a narcotic and, like other opioids, is tages for most treatments compared with one another.
associated with the risk for abuse (181). Moderate- Clinicians should avoid prescribing costly therapies;
quality evidence showed that duloxetine had a small those with substantial potential harms, such as long-
effect on pain and function. term opioids (which can be associated with addiction
Moderate-quality evidence showed that opioids and accidental overdose); and pharmacologic thera-
(morphine, oxymorphone, hydromorphone, and tapen- pies that were not shown to be effective, such as TCAs
tadol) had a small effect on short-term pain and func- and SSRIs.
tion. Low-quality evidence showed that buprenorphine
(patch or sublingual) resulted in a small improvement in From the American College of Physicians and Penn Health
pain. Opioids should be the last treatment option con- System, Philadelphia, Pennsylvania; Minneapolis Veterans Af-
sidered and should be considered only in patients for fairs Medical Center, Minneapolis, Minnesota; and Yale
whom other therapies have failed because they are as- School of Medicine, New Haven, Connecticut.
sociated with substantial harms. Moderate-quality evi-
dence showed no difference in pain or function when Note: Clinical practice guidelines are guides only and may
different long-acting opioids were compared with one not apply to all patients and all clinical situations. Thus, they
another. Harms of short-term use of opioids include in- are not intended to override clinicians' judgment. All ACP
creased nausea, dizziness, constipation, vomiting, som- clinical practice guidelines are considered automatically with-
nolence, and dry mouth compared with placebo. Stud- drawn or invalid 5 years after publication or once an update
ies assessing opioids for the treatment of chronic low has been issued.
back pain did not address the risk for addiction, abuse,
or overdose, although observational studies have Disclaimer: The authors of this article are responsible for
shown a dose-dependent relationship between opioid its contents, including any clinical or treatment
use for chronic pain and serious harms (182). recommendations.
Moderate-quality evidence showed that TCAs did
not effectively improve pain or function (low-quality ev- Financial Support: Financial support for the development
idence) in patients with chronic low back pain, which is of this guideline comes exclusively from the ACP operating
contrary to the 2007 guideline. In addition, moderate- budget.
quality evidence showed that SSRIs did not improve
pain. Disclosures: Dr. McLean reports personal fees from Takeda
Pharmaceuticals outside the submitted work and membership
in the American College of Physicians Clinical Guidelines
Committee and the American College of Rheumatology Qual-
AREAS OF INCONCLUSIVE EVIDENCE ity of Care Committee. Dr. Barry reports grants, personal fees,
and nonnancial support from Healthwise outside the submit-
Evidence is insufcient or lacking to determine
ted work. Dr. Boyd reports other support from UpToDate out-
treatments for radicular low back pain. Most RCTs en-
side the submitted work. Authors not named here have dis-
rolled a mixture of patients with acute, subacute, and
closed no conicts of interest. Disclosures can also be viewed
chronic low back pain, so it is difcult to extrapolate the at www.acponline.org/authors/icmje/ConictOfInterestForms
benets of treatment compared with its duration. Use .do?msNum=M16-2367. All nancial and intellectual disclo-
of opioids for chronic pain is an important area that sures of interest were declared and potential conicts were
requires further research to compare benets and discussed and managed. Dr. Manaker participated in the dis-
harms of therapy. The evidence is also insufcient for cussion for this guideline but was recused from voting on the
most physical modalities. Evidence is insufcient on recommendations because of an active indirect nancial con-
which patients are likely to benet from which specic ict. Dr. Kansagara participated in the discussion for this
therapy. Evidence on patient-important outcomes, such guideline but was recused from voting on the recommenda-
as disability or return to work, was largely unavailable, tions because of an inactive direct nancial conict. A record

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Current Author Addresses: Dr. Qaseem: American College of Search Strategy
Physicians, 190 N. Independence Mall West, Philadelphia, PA Reviewers searched MEDLINE, the Cochrane Cen-
19106. tral Register of Controlled Trials, and the Cochrane Da-
Dr. Wilt: Minneapolis VA Medical Center, VA Medical Center
tabase of Systematic Reviews for trials published from
111-0, Minneapolis, MN 55417.
Dr. McLean: Yale School of Medicine, 46 Prince Street, Suite
January 2008 through April 2015. Searches were up-
302, New Haven, CT 06519. dated through November 2016. Studies published be-
Dr. Forciea: Penn Health System, 3615 Chestnut Street, Phila- fore 2008 were identied using the 2007 ACP/APS sys-
delphia, PA 19104. tematic reviews (10, 11).
Quality Assessment
Author Contributions: Conception and design: A. Qaseem, R. Randomized trials were evaluated using methods
McLean, M.J. Barry. developed by the Cochrane Back Review Group and
Analysis and interpretation of the data: A. Qaseem, T. Wilt, R.
the AHRQ (183), and systematic reviews were assessed
McLean, M.A. Forciea, C. Boyd, R.P. Harris, L.L. Humphrey, S.
Vijan. using AMSTAR (A Measurement Tool to Assess System-
Drafting of the article: A. Qaseem, R. McLean, M.A. Forciea, atic Reviews) (184).
T.D. Denberg.
Population Studied
Critical revision of the article for important intellectual con-
tent: A. Qaseem, T. Wilt, R. McLean, M.A. Forciea, T.D. Den- Adults with acute, subacute, or chronic nonradicu-
berg, M.J. Barry, C. Boyd, R.D. Chow, R.P. Harris, L.L. Hum- lar low back pain, radicular low back pain, or symptom-
phrey, S. Vijan. atic spinal stenosis.
Final approval of the article: A. Qaseem, T. Wilt, R. McLean,
M.A. Forciea, T.D. Denberg, M.J. Barry, C. Boyd, R.D. Chow, Interventions Evaluated
N. Fitterman, R.P. Harris, L.L. Humphrey, S. Vijan. Oral or topical pharmacologic therapies included
Statistical expertise: A. Qaseem, T. Wilt. NSAIDs, acetaminophen, opioids, tramadol and tapen-
Administrative, technical, or logistic support: A. Qaseem, T.D. tadol, antidepressants, SMRs, benzodiazepines, corti-
Denberg. costeroids, antiepileptic medications, capsaicin, and
Collection and assembly of data: R.P. Harris. lidocaine.
Noninvasive, nonpharmacologic therapies in-
cluded interdisciplinary or multicomponent rehabilita-
tion (physical therapy plus psychological therapy with
APPENDIX: DETAILED METHODS some coordination), psychological therapies, exercise
The evidence review was conducted by the and related interventions (such as yoga or tai chi), com-
AHRQ's Pacic Northwest Evidence-based Practice plementary and alternative medicine therapies (spinal
Center. Details of the ACP guideline development pro- manipulation, acupuncture, and massage), passive
cess can be found in ACP's methods paper (12). Disclo- physical modalities (such as heat, cold, ultrasound,
sures of interests and management of any conicts can TENS, electrical muscle stimulation, interferential ther-
be found at www.acponline.org/clinical_information apy, short-wave diathermy, traction, LLLT, and lumbar
/guidelines/guidelines/conicts_cgc.htm. supports/braces), and taping.
Key Questions Addressed Comparators

1. What are the comparative benets and harms of Interventions were compared with each other or
different pharmacologic therapies for acute or chronic with placebo (drug trials), sham (functionally inert)
nonradicular low back pain, radicular low back pain, or treatments, or no treatment.
spinal stenosis, including NSAIDs, acetaminophen, opi- Outcomes
oids, muscle relaxants, antiseizure medications, antide- Outcomes included reduction or elimination of low
pressants, corticosteroids, and topical or patch- back pain (including related leg symptoms), improve-
delivered medications? ment in back-specic and overall function, improve-
2. What are the comparative benets and harms of ment in health-related quality of life, reduction in work
different nonpharmacologic, noninvasive therapies for disability and return to work, global improvement,
acute or chronic nonradicular low back pain, radicular number of back pain episodes or time between epi-
low back pain, or spinal stenosis, including but not lim- sodes, patient satisfaction, and adverse effects of
ited to interdisciplinary rehabilitation, exercise (various interventions.
types), physical modalities (ultrasound, TENS, electrical
Timing
muscle stimulation, interferential therapy, heat [various
Timing of outcomes was stratied as long-term (1
forms], and ice), traction tables/devices, back supports/
year) and short-term (6 months).
bracing, spinal manipulation, various psychological
therapies, acupuncture, massage therapy (various Setting
types), yoga, magnets, and low-level lasers? Settings included inpatient and outpatient.
Annals.org Annals of Internal Medicine Vol. 166 No. 7 4 April 2017

Target Audience public comments. The accompanying evidence reviews
The target audience includes all clinicians. (7, 8) also underwent a peer review process through
Target Patient Population the journal. The guideline underwent a peer review
The target patient population includes adults with process through the journal and was posted online for
acute (<4 weeks), subacute (4 to 12 weeks), or chronic comments from ACP Regents and ACP Governors, who
(>12 weeks) nonradicular low back pain, radicular low represent ACP members at the regional level.
back pain, or symptomatic spinal stenosis. Children or
adolescents with low back pain; pregnant women; and Web-Only References
patients with low back pain from sources outside the 183. Agency for Healthcare Research and Quality. Methods Guide
for Effectiveness and Comparative Effectiveness Reviews. AHRQ
back (nonspinal low back pain), bromyalgia or other
publication no. 10(13)-EHC063-EF. Rockville: Agency for Healthcare
myofascial pain syndromes, and thoracic or cervical Research and Quality; 2014.
back pain are not included. 184. Shea BJ, Hamel C, Wells GA, Bouter LM, Kristjansson E, Grim-
shaw J, et al. AMSTAR is a reliable and valid measurement tool to
Peer Review assess the methodological quality of systematic reviews. J Clin
The AHRQ systematic review was sent to invited Epidemiol. 2009;62:1013-20. [PMID: 19230606] doi:10.1016/j
peer reviewers and posted on the AHRQ Web site for .jclinepi.2008.10.009
Annals of Internal Medicine Vol. 166 No. 7 4 April 2017 Annals.org

Appendix Table 1. Pharmacologic and Nonpharmacologic Treatments for Acute or Subacute Low Back Pain
Annals.org
Intervention Outcome Magnitude of Effect Strength of Data
Evidence (Studies)
Pharmacologic treatments vs. placebo (acute only)
Acetaminophen
Pain No effect Low (1 RCT) 0 to 10 scale: Score differences, 0.20 point
Function No effect Low (1 RCT) RDQ: Score differences, 0.60 point
NSAIDs
Pain Small (pain intensity) Moderate (5 RCTs) 0 to 100 scale: WMD, 8.39 (95% CI, 12.68 to 4.10;
No effect (pain relief) chi-square, 3.47; P > 0.10)
Function Small Low (2 RCTs) 0 to 24 RDQ: Score differences, 2.4 to 2.9 points; P < 0.001
SMRs
Pain Small Moderate (5 RCTs) 0- to 10-point visual analogue scale
2 to 4 d: RR, 1.25 (CI, 1.12 to 1.41)
5 to 7 d: RR, 1.72 (CI, 1.32 to 2.22)
Systemic corticosteroids
Pain No effect Low (2 RCTs) No clear difference (single intramuscular injection or a 5-d
Function No effect Low (2 RCTs) course of systemic corticosteroids)
Nonpharmacologic treatments vs. sham, no treatment,

or usual care (acute or subacute)
Exercise vs. usual care
Pain No effect Low (6 RCTs) 0 to 100 scale
Acute, intermediate-term: WMD, 0.59 (CI, 11.51 to 12.69)
Subacute: WMD, 1.89 (CI, 1.13 to 4.91)
Function No effect Low (6 RCTs) Acute, short-term: WMD, 2.82 (CI, 15.35 to 9.71)
Acute, intermediate-term: WMD, 2.47 (CI, 0.26 to 5.21)
Subacute: WMD, 1.07 (CI, 3.18 to 5.32)
Acupuncture vs. sham acupuncture
Pain Small Low (2 RCTs) 0 to 100 scale

MD, 9.38 (CI, 1.76 to 17.0; I2 = 27%)
3 other trials reported effects consistent with these ndings
Function No effect Low (5 RCTs) No clear effect
Massage vs. sham massage
Pain 1 wk: Moderate Low (2 RCTs) 1 wk: SMD, 0.92 (CI, 1.35 to 0.48)
5 wk: No effect There was no signicant difference in pain at 5 wk in 1 trial
Function 1 wk: Moderate Low (2 RCTs) 1 wk: SMD, 1.76 (CI, 3.19 to 0.32)
5 wk: No effect There was no signicant difference in function at 5 wk in 1 trial
Spinal manipulation vs. inert treatment
Pain No effect Low (3 RCTs) 0 to 10 scale at 1 wk: WMD, 0.14 (CI, 0.69 to 0.96; I2 = 27%),
although 1 trial found spinal manipulation to be associated
with better pain relief at 3 mo; MD, 1.20 (CI, 2.11 to 0.29)
Function No effect Low (2 RCTs) 1 wk: SMD, 0.08 (CI, 0.37 to 0.21; I2 = 0%)
3 mo: SMD, 0.28 (CI, 0.59 to 0.02)
Spinal manipulation vs. sham treatment
Function Small Low (2 RCTs) Statistically signicant in 1 trial
Heat wrap vs. placebo
Pain Moderate Moderate (4 RCTs) 0 to 5 scale, 5 d: MD, 1.06 (CI, 0.68 to 1.45)
0 to 100 scale, 3 to 4 d: score differences, 16 to 20 points
Function Moderate Moderate (2 RCTs) RDQ, 4 d: MD, 2.10 (CI, 3.19 to 1.01)
(Continued on following page)
Annals of Internal Medicine Vol. 166 No. 7 4 April 2017

Appendix Table 1Continued

Evidence (Studies)
Comparative benets of pharmacologic and
nonpharmacologic treatments
NSAID vs. NSAID
Pain No difference Moderate (21 RCTs) No reported differences in 15 of 21 trials
Acetaminophen vs. NSAID
Pain No difference Low (4 RCTs) Pooled SMD, 0.21 (CI, 0.02 to 0.43)
Function No difference Low (4 RCTs) RR, 0.81 (CI, 0.58 to 1.14)
COX-2selective NSAID vs. traditional NSAID
Pain No difference Low (3 RCTs) No clear differences
SMR vs. another SMR
Pain No difference Low (2 RCTs) No differences for carisoprodol vs. cyclobenzaprine or
Function No difference Low (2 RCTs) tizanidine vs. chlorzoxazone
Exercise vs. exercise
Pain No difference Moderate (>20 RCTs) No clear differences in >20 head-to-head trials of patients

Function No difference Moderate (>20 RCTs)
Lumbar support vs. other active treatments
Pain No difference Low (3 RCTs) 3 trials found no clear differences between lumbar supports
vs. other active treatments in pain or function
Function No difference Low (3 RCTs)
Acupuncture vs. NSAIDs
Overall improvement Small Low (5 RCTs) RR, 1.11 (CI, 1.06 to 1.16; I2 = 0%)
Spinal manipulation vs. other active treatments (exercise, physical
therapy, or back school)
Pain No difference Moderate (3 RCTs) 0 to 10 scale
1 wk: WMD (CI, 0.53 to 0.65; I2 = 0%)
1 mo: WMD, 0.15 (CI, 0.49 to 0.18; I2 = 0%)

3 to 6 mo: WMD, 0.20 (CI, 1.13 to 0.73; I2 = 81%)
1 y: mean difference, 0.40 (CI, 0.08 to 0.88)
Function No difference Moderate (3 RCTs) Findings were similar for function, with no differences
observed at any time point
Heat vs. simple analgesics
Pain Small Low (1 RCT) 0 to 10 scale
1 to 2 d, acetaminophen: MD, 0.90 (CI, 0.50 to 1.30)
1 to 2 d, ibuprofen: MD, 0.65 (CI, 0.25 to 1.05)
Function Small Low (1 RCT) RDQ
1 to 2 d, acetaminophen: MD, 2.00 (CI, 0.86 to 3.14)
1 to 2 d, ibuprofen: MD, 2.20 (CI, 1.11 to 3.29)
Heat vs. exercise
Pain No difference Low (1 RCT) 0 to 10 scale
Days 1 to 2: MD, 0.40 (CI, 0.15 to 0.95)
Day 7: MD, 0.30 (CI, 0.68 to 1.28)
Function No difference Low (1 RCT) RDQ
Day 4: MD, 0.70 (CI, 2.09 to 0.69)
Day 7: MD, 0.90 (CI, 2.84 to 1.04)
Annals.org
Annals.org

Evidence (Studies)
Combination therapy treatments vs. monotherapy
treatments or no treatment (acute or subacute)
SMR + NSAID vs. NSAID alone
Pain Inconsistent benet Low (3 RCTs) Estimate from 3 trials favored combination therapy: RR, 1.56
(CI, 0.92 to 2.70; I2 = 84%), but another trial found no effect
Massage vs. other treatments (manipulation, exercise therapy,
relaxation therapy, acupuncture, or physiotherapy) vs. other
treatment alone (subacute to chronic)
Pain Small Moderate (9 RCTs) 0 to 10 scale, short-term: Better effects in 7 of 9 trials (MDs,
0.6 to 0.94 points)
Function Small Moderate (4 RCTs) Short-term: Better effects on short-term function in 3 of 4 trials
Massage plus another active treatment (exercise, exercise and
education, or usual care) vs. the other treatment alone (subacute to
chronic)
Pain Improved Low (5 RCTs) Short-term: Superior to other intervention without massage;
effects stronger when massage combined with exercise
Function Improved Low (5 RCTs) Long-term: Few differences
Spinal manipulation plus exercise or advice vs. exercise or advice alone
Function 1 wk: Small Low (4 RCTs) 1 wk: SMD, 0.41 (CI, 0.73 to 0.10; I2 = 18%)

1 or 3 mo: No 1 mo: SMD, 0.09 (CI, 0.39 to 0.21; I2 = 37%)
difference 3 mo: SMD, 0.22 (CI, 0.61 to 0.16; I2 = 41%)
Heat plus exercise vs. exercise alone
Pain Small Low (1 RCT) 0 to 10 scale: MD, 1.40 (CI, 0.69 to 2.11)
Function Small Low (1 RCT) RDQ at 7 d: MD, 3.20 (CI, 5.42 to 0)
LLLT + NSAID vs. sham + NSAID
Pain Large Low (1 RCT) 0 to 100 scale at 3 wk: Mean change, 30.0 vs. 15.7 vs. 20.8
Function Moderate Low (1 RCT) ODI at 3 wk: Mean change, 12.0 vs. 6.5 vs. 10.0
Lumbar support plus education vs. education
Pain No difference Low (1 RCT) No reported differences after 1 y
Function No difference Low (1 RCT)
COX-2 = cyclooxygenase-2; LLLT = low-level laser therapy; MD = mean difference; NSAID = nonsteroidal anti-inammatory drug; ODI = Oswestry Disability Index; RCT = randomized, controlled
trial; RDQ = Roland Morris Disability Questionnaire; RR = relative risk; SMD = standardized mean difference; SMR = skeletal muscle relaxant; WMD = weighted mean difference.

Appendix Table 2. Pharmacologic and Nonpharmacologic Treatments for Chronic Low Back Pain
Evidence (Studies)
Pharmacologic treatments vs. placebo
NSAIDs
Pain Small to moderate Moderate (6 RCTs) 0 to 100 scale, 12 wk: WMD, 12.40 (95% CI, 15.53 to 9.26;
chi-square, 1.82; P > 0.5)
0 to 10 scale, 12 to 16 wk: Score changes, 0.41 to 0.59
30% pain relief: 56.8% vs. 31.7% and 37% vs. 27%
Function Small to no effect Low (4 RCTs) RDQ: MDs, 0.02 to 2.00 points
Strong opioids
Pain Small Moderate (10 RCTs) 0 to 10 scale: SMD, 0.43 (CI, 0.52 to 0.33; I2 = 0%; MD, 1 point)
Function Small Moderate (8 RCTs) RDQ: SMD, 0.26 (CI, 0.37 to 0.15; I2 = 0%; MD, 1 point)
Tramadol
Pain Moderate Moderate (7 RCTs) 0 to 10 scale: SMD, 0.55 (CI, 0.66 to 0.44; I2 = 86%; MD, 1 point)
Function Small Moderate (7 RCTs) RDQ: SMD, 0.18 (CI, 0.29 to 0.07; I2 = 0%); MD, 1 point)
Opioids: buprenorphine patch or sublingual (subacute or
chronic)
Pain Small Low (3 RCTs) 0 to 10 scale: Score difference, 1 point
Tetrazepam
Pain Lower likelihood of failure Low (2 RCTs) 5 to 7 d: RR, 0.82 (CI, 0.72 to 0.94)

to improve 10 to 14 d: RR, 0.71 (CI, 0.54 to 0.93)
Overall improvement Lower likelihood of failure Low (2 RCTs) 10 to 14 d: RR, 0.63 (CI, 0.42 to 0.97)
to improve
TCAs
Pain No effect Moderate (4 RCTs) SMD, 0.10 (CI, 0.51 to 0.31; I2 = 32%)
Antidepressants
Function No effect Low (2 RCTs) SMD, 0.06 (CI, 0.40 to 0.29; I2 = 0%)
SSRI
Pain No effect Moderate (3 RCTs) SMD, 0.11 (CI, 0.17 to 0.39; I2 = 0%)
Duloxetine
Pain Small Moderate (3 RCTs) 0 to 10 scale: Mean between-group difference, 0.58 to 0.74
Function Small Moderate (3 RCTs) RDQ: Mean change from baseline, 2.69 vs. 2.22; P = 0.26

Nonpharmacologic treatments vs. sham,
no treatment, or usual care
Exercise vs. no exercise
Pain Small Moderate (19 RCTs) 0 to 100 scale: WMD, 10.0 (CI, 1.31 to 19.09)
Function Small Moderate (18 RCTs) 0 to 100 scale: Not statistically signicant; WMD, 3.0 (CI, 0.53 to 6.48)
Pain Small Moderate (3 RCTs) 0 to 100 scale
Treatment end: WMD, 9.23 (CI, 16.02 to 2.43)
Long-term: MD, 4.94 (CI, 10.45 to 0.58)
Function Small Moderate (18 RCTs) 0 to 100 scale
Treatment end: WMD, 12.35 (CI, 23.0 to 1.69)
Long-term: MD, 3.17 (CI, 5.96 to 0.38)
MCE vs. minimal intervention
Pain Moderate Low (2 RCTs) 0 to 100 scale
Short-term: WMD, 12.48 (CI, 19.04 to 5.93)
Intermediate-term: WMD, 10.18 (CI, 16.64 to 3.72)
Long-term: WMD, 13.32 (CI, 19.75 to 6.90)
Function Small Low (3 RCTs) 0 to 100 scale
Tai chi vs. wait list or no tai chi
Pain Moderate Low (2 RCTs) 0 to 10 scale: MDs, 0.9 and 1.3
Function Small Low (1 RCT) RDQ: MD, 2.6 (CI, 1.1 to 3.7)
Annals.org
Annals.org
Evidence (Studies)
Yoga vs. usual care
Pain Moderate Low (1 RCT) 0 to 100 VAS, 24 wk: Mean scores, 24 vs. 37 (P < 0.001)
Function Moderate Low (1 RCT) 0 to 100 ODI, 24 wk: Mean scores, 18 vs. 21 (P < 0.01)
Yoga vs. education
Pain Short-term: Small Low (5 RCTs) Short-term; SMD, 0.45 (CI, 0.63 to 0.26; I2 = 0%)
Long-term: No difference Long-term: Not statistically signicant; SMD, 0.28 (CI, 0.58 to 0.02;
I2 = 47%)
Function Small Low (5 RCTs) Short-term: SMD, 0.45 (CI, 0.65 to 0.25; I2 = 8%)
Long-term: SMD, 0.39 (CI, 0.66 to 0.11; I2 = 40%)
Mindfulness-based stress reduction vs. usual care
Pain Improved Moderate (3 RCTs) 0 to 10 scale, 26 wk: Score difference, 0.64
30% improvement: RR, 1.64 (CI, 1.15 to 2.34)
Function Improved Moderate (3 RCTs) RDQ, 26 wk: score difference, 1.37
30% improvement: RR, 1.37 (CI, 1.06 to 1.77)
Progressive relaxation vs. wait-list control
Pain Moderate Low (3 RCTs) 0 to 100 VAS: MD, 19.77 (CI, 34.0 to 5.20; I2 = 57%)
Function Moderate Low (3 RCTs) SMD, 0.88 (CI, 1.36 to 0.39; I2 = 0%)
Electromyography biofeedback vs. wait-list control or
placebo
Pain Moderate Low (3 RCTs) SMD, 0.80 (CI, 1.32 to 0.28; I2 = 0%)
Function No effect Low (3 RCTs) No clear effect
Operant therapy vs. wait-list control
Pain Small Low (3 RCTs) 0 to 100 VAS or 0 to 78 McGill: SMD, 0.43 (CI, 0.75 to 0.1; I2 = 0%)
Function No effect Low (2 RCTs) 0 to 100 Sickness Impact Prole: MD, 1.18 (CI, 3.53 to 1.18)
CBT vs. wait-list control
Pain Moderate Low (5 RCTs) 0 to 100 VAS or 0 to 78 McGill: SMD, 0.60 (CI, 0.97 to 0.22; I2 =
40%)
Function No effect Low (4 RCTs) Sickness Impact Prole: Not statistically signicant; SMD, 0.37 (CI,
0.87 to 0.13; I2 = 50%)

Multidisciplinary rehabilitation vs. usual care
Pain Short-term: Moderate Moderate (9 RCTs) 0 to 10 scale
Long-term: Small <3 mo: SMD, 0.55 (CI, 0.83 to 0.28) or 1.4-point MD
Long-term: SMD, 0.21 (CI, 0.37 to 0.04) or 0.5-point MD
Disability Small Moderate (9 RCTs) RDQ
<3 mo: SMD, 0.41 (CI, 0.62 to 0.19) or 2.5-point MD
Return to work No effect Moderate (7 RCTs) Short-term: OR, 1.07 (CI, 0.60 to 1.90)
Long-term: OR, 1.04 (CI, 0.73 to 1.47)
Multidisciplinary rehabilitation vs. no multidisciplinary
rehabilitation
Pain Moderate Low (3 RCTs) 0 to 10 scale: SMD, 0.73 (CI, 1.22 to 0.24; I2 = 64%) or 1.7-point
MD
Disability Small Low (3 RCTs) RDQ: Pooled SMD, 0.49 (CI, 0.76 to 0.22; I2 = 0%) or 2.9-point MD
Acupuncture vs. sham acupuncture
Pain Moderate Low (9 RCTs) Immediately at the end of treatment: WMD, 16.76 (CI, 33.3 to 0.19;
I2 = 90%)
12 wk: WMD, 9.55 (CI, 16.5 to 2.58; I2 = 40%)
Function No effect Low (9 RCTs) No reported differences
Acupuncture vs. no acupuncture
Pain Moderate Moderate (4 RCTs) Immediately: SMD, 0.72 (CI, 0.94 to 0.49; I2 = 51%)
Function Moderate Moderate (3 RCTs) Immediately: SMD, 0.94 (CI, 1.41 to 0.47; I2 = 78%)

Evidence (Studies)
Massage vs. usual care
Pain No effect Low (1 RCT) 1 trial found no difference between foot reexology vs. usual care in
pain or function, and 1 trial found structural or relaxation massage to
be associated with better function (mean, 2.5 to 2.9 points on the
RDQ) vs. usual care at 10 wk; effects were less pronounced at 52 wk
Spinal manipulation vs. sham treatment
Pain No effect Low (4 RCTs) 0 to 100 scale, 1 mo: WMD, 3.24 (CI, 13.62 to 7.15)
Spinal manipulation vs. inert treatment
Pain Small Low (7 RCTs) 0 to 10 scale: MD, 0.9 (CI, 0.1 to 1.7)
Ultrasound vs. sham ultrasound
Pain No effect Low (5 RCTs) 0 to 100 scale
Immediately: MD, 7.12 (CI, 18.0 to 3.75; I2 = 77%)
4 wk: No reported differences in 2 trials
Ultrasound vs. no ultrasound
Pain No effect Low (5 RCTs) 0 to 100 scale: MD, 2.16 (CI, 4.66 to 0.34; I2 = 0%)
Function No effect Low (5 RCTs) 0 to 100 scale: MD, 0.41 (CI, 3.14 to 2.32)

TENS vs. sham treatment
Pain No effect Low (4 RCTs) 0 to 100 scale: WMD, 4.47 (CI, 12.84 to 3.89)
Disability No effect Low (2 RCTs) 0 to 100 scale: WMD, 1.36 (CI, 4.38 to 1.66)
LLLT vs. sham laser
Pain Small Low (3 RCTs) 3 of 4 trials showed improvement
Function Small Low (1 RCT) 1 trial showed improvement
Kinesio taping vs. sham taping
Function No effect Low (2 RCTs) No effect on back-specic function at 5 or 12 wk
Comparative benets of pharmacologic and

NSAID vs. NSAID
Pain No difference Moderate (6 RCTs) No reported differences in 6 of 6 trials

Long-acting opioids vs. long-acting opioids
Pain No difference Moderate (4 RCTs) No clear differences (oral morphine vs. transdermal fentanyl or
oxymorphone vs. oxycodone or morphine vs. oxycodone)
Function No difference Moderate (4 RCTs)
Long-acting opioids vs. short-acting opioids*
SMR vs. another SMR
Pain No difference Low (2 RCTs) No reported differences (pridinol vs. thiocolchicoside)
Diazepam vs. cyclobenzaprine
Muscle spasms No difference Low (2 RCTs) No clear difference
MCE vs. general exercise
Long-term: Not statistically signicant; WMD, 3.10 (CI, 7.03 to 0.83)
Function Small Low (6 RCTs) 0 to 100 scale
MCE vs. multimodal physical therapy
Pain Moderate Low (4 RCTs) 0 to 100 scale, intermediate-term: WMD, 14.20 (CI, 21.23 to 7.16)
Function Moderate Low (2 RCTs) 0 to 100 scale, intermediate-term: WMD, 12.98 (CI, 19.49 to 6.47)
Annals.org
Annals.org
Evidence (Studies)
Exercise vs. exercise
Pain No difference Moderate (>20 No clear differences in >20 head-to-head trials of patients
RCTs)
Function No difference Moderate (>20
RCTs)
Pilates vs. usual care + physical activity
Pain Small to no effect Low (7 RCTs) Small (MD, 1.6 to 4.1 points) to no effect on pain
Function No effect Low (7 RCTs) No clear effects
Pilates vs. other exercise
Tai chi vs. other exercise
Pain Moderate Low (1 RCT) Backward walking or jogging through 6 mo: MDs, 0.7 and 0.8
Swimming: No reported differences (MD, 0.1 at 3 and 6 mo)
Yoga vs. exercise
Pain Small Low (5 RCTs) Lower pain intensity vs. exercise in most trials, although effects were
small and differences were not always statistically signicant
Psychological therapies vs. exercise or physical therapy
Psychological therapies vs. other psychological therapies
Pain No difference Moderate (10 RCTs) No clear differences
Function No difference Moderate (10 RCTs)
Multidisciplinary rehabilitation vs. physical therapy
Pain Short-term: Small Moderate (13 RCTs) 0 to 10 NRS
Long-term: Moderate Short-term: SMD, 0.30 (CI, 0.54 to 0.06) or 0.6-point MD
Function Short-term: Small Moderate (13 RCTs) 0 to 10 NRS, short-term: SMD, 0.39 (CI, 0.68 to 0.10) or 1.2 point
Long-term: Moderate MD
RDQ, long-term function: SMD, 0.68 (CI, 1.19 to 0.16) or 4.0-point
MD

Greater likelihood of return to work: OR, 1.87 (CI, 1.39 to 2.53)
Acupuncture vs. medications (NSAIDs, muscle relaxants,
and analgesics)
Pain Small Low (3 RCTs) 0 to 100 scale, immediately: WMD, 10.56 (CI, 20.34 to 0.78)
Function Small Low (3 RCTs) 0 to 100 scale, immediately: SMD, 0.36 (CI, 0.67 to 0.04)
Spinal manipulation vs. other treatments (exercise, usual
care, medications, or massage)
Pain No difference Moderate (6 RCTs) 0 to 100 scale
Short-term: WMD, 2.76 (CI, 5.19 to 0.32; I2 = 27%)
6 mo: WMD, 3.07 (CI, 5.42 to 0.71; I2 = 0%)
12 mo: WMD, 0.76 (CI, 3.19 to 1.66; I2 = 0%)
Function No difference Moderate (6 RCTs) 1 mo: SMD, 0.17 (CI, 0.29 to 0.06)
6 mo: SMD, 0.12 (CI, 0.23 to 0.00)
12 mo: SMD, 0.06 (CI, 0.16 to 0.05)
TENS vs. acupuncture
Pain No difference Low (4 RCTs) Short-term: SMD, 0.15 (CI, 0.33 to 0.63)
Long-term: SMD, 0.32 (CI, 0.33 to 0.96)
Lumbar supports vs. other active treatments (traction,
spinal manipulation, exercise, physiotherapy, or
TENS)

Evidence (Studies)
Kinesio taping vs. exercise therapy
Combination therapy treatments vs. monotherapy

treatments or no treatment

MCE plus exercise vs. exercise alone
Psychological therapy + exercise or physiotherapy vs.
exercise or physiotherapy alone
Spinal manipulation plus another active treatment vs. the
other treatment alone
1 mo: WMD, 5.88 (CI, 10.85 to 0.90)
3 mo: MD, 7.23 (CI, 11.72 to 2.74)
12 mo: MD, 3.31 (CI, 6.60 to 0.02)
Function Improved Low (3 RCTs) 0 to 100 scale

1 mo: SMD, 0.40 (CI, 0.73 to 0.07)
3 mo: SMD, 0.22 (CI, 0.38 to 0.06)
12 mo: SMD, 0.21 (CI, 0.34 to 0.09)
Lumbar support plus exercise vs. exercise alone (muscle
strengthening)
Pain No difference Low (1 RCT) No difference in short-term (8 wk) or long-term (6 mo)
Function No difference Low (1 RCT)
CBT = cognitive behavioral therapy; LLLT = low-level laser therapy; MCE = motor control exercise; MD = mean difference; NSAID = nonsteroidal anti-inammatory drug; NRS = numerical rating
scale; ODI = Oswestry Disability Index; OR = odds ratio; RCT = randomized, controlled trial; RDQ = Roland Morris Disability Questionnaire; RR = relative risk; SMD = standardized mean difference;
SMR = skeletal muscle relaxant; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant; TENS = transcutaneous electrical nerve stimulation; VAS = visual analogue scale;
WMD = weighted mean difference.
* Although some RCTs found that long-acting opioids were associated with greater pain relief, patients randomly assigned to long-acting opioids also received higher doses.
Annals.org
Appendix Table 3. Pharmacologic and Nonpharmacologic Treatments for Radicular Low Back Pain
Intervention Outcome Magnitude of Effect Strength of Evidence Data

(Studies)
Pharmacologic treatments vs. placebo
Diazepam (acute or subacute radicular
pain)
Pain Lower likelihood of 50% Low (1 RCT) 5 mg twice daily for 5 d: 41% vs. 79%; RR,
improvement 0.5 (95% CI, 0.30.8)
Function No effect Low (1 RCT) RDQ: No difference through 1 y of follow-up
Systemic corticosteroids
Pain No effect Moderate (6 RCTs) No clear effect
Function Small to no effect Moderate (6 RCTs)
Nonpharmacologic treatments vs.

sham, no treatment, or usual
care (acute or subacute)
Pain Small Low (3 RCTs) Favored exercise, although effects were
small
Function Small Low (3 RCTs)
Comparative benets of
pharmacologic and
Traction vs. other treatments
Traction vs. other type of traction
Combination therapy vs.

monotherapy or no treatment
Traction + physiotherapy vs.
physiotherapy alone
RCT = randomized, controlled trial; RDQ = Roland Morris Disability Questionnaire; RR = relative risk.
Annals.org Annals of Internal Medicine Vol. 166 No. 7 4 April 2017

Appendix Table 4. Adverse Events for Treatments for Acute, Chronic, and Radicular Low Back Pain
Interventions Data on Adverse Events (Quality of Evidence; Adverse Effects
Studies)
Adverse events reported for
pharmacologic treatments
Acetaminophen Versus placebo: No difference in risk for serious Thrombocytopenia, agranulocytosis,
adverse events (moderate quality; 1 RCT) pancytopenia, hemolytic anemia,
Versus NSAIDs: A systematic review found that methemoglobinemia, hypoglycemia,
acetaminophen was associated with lower risk for hypothermia, pancreatitis, nephrotoxicity,
adverse events; RR, 0.57 (95% CI, 0.360.89) hepatotoxicity (with overdose), hepatic
(moderate quality; 3 RCTs) necrosis, pneumonitis, rash, and
hypersensitivity
NSAIDs Versus placebo: NSAIDs associated with more adverse Abdominal pain or cramps, dyspepsia,
effects; RR, 1.35 (CI, 1.091.68) (moderate quality; diarrhea, gastrointestinal bleeding,
10 RCTs) gastrointestinal perforation, dizziness,
headache, edema, rash, heartburn, tinnitus,
and pruritus
COX-2selective NSAIDs Versus nonselective NSAIDs: COX-2selective NSAIDs Abdominal pain, diarrhea, dizziness, dyspepsia,
associated with lower risk for adverse effects; RR, edema, atulence, headache, nausea, rash,
0.83 (CI, 0.700.99) (moderate quality; 4 RCTs) upper respiratory tract infection,
inuenza-like illness, and musculoskeletal
and connective tissue signs and symptoms
(back pain, muscle spasms, and
musculoskeletal pain)
Opioids Versus placebo: Short-term use associated with higher Short-term use: Nausea, dizziness, constipation,
risk; risks higher in trials that did not use an enriched vomiting, somnolence, and dry mouth
enrollment and withdrawal design; trials were not Long-term use: Addiction, abuse, overdose,
designed to assess risks for overdose, abuse, and fractures, cardiovascular events, sexual
addiction or long-term harms (moderate quality; 16 dysfunction, and motor vehicle accidents
studies)
SMRs Versus placebo (any adverse event): SMRs associated Sedation, drowsiness, and dizziness
with increased risk; RR, 1.50 (CI, 1.141.98)
(moderate quality; 8 RCTs)
Versus placebo (central nervous system events): SMRs
associated with increased risk (primarily sedation);
RR, 2.04 (CI, 1.233.37) (moderate quality; 8 RCTs)
Benzodiazepines Versus placebo: Central nervous system adverse Somnolence, fatigue, lightheadedness,
events reported more frequently with addiction, abuse, overdose, and fractures
benzodiazepines, although harms were not
reported well; no trial was designed to evaluate
risks with long-term use (low quality; 9 RCTs)
Antidepressants Versus placebo: Antidepressants associated with Drowsiness, dizziness, dry mouth, constipation,
higher risk for any adverse events but no differences sexual dysfunction, and nausea
in rates of specic adverse events or serious adverse
events (moderate quality; 12 RCTs)
Duloxetine associated with nausea and increased risk
for withdrawal due to adverse event
Systemic corticosteroids Versus placebo: Trials did not report serious adverse Hyperglycemia requiring medical treatment,
events, but adverse events were not reported well in facial ushing, infection, and gastrointestinal
some trials (low quality; 12 RCTs) bleeding
Adverse events reported for nonpharmacologic treatments*

Exercise, Tai chi, massage, and spinal manipulation: Harms typically related to muscle soreness and/or small increases in pain were reported.
Yoga: Reporting was suboptimal, but almost all adverse events were classied as mild to moderate.
TENS: Evidence was limited but suggests an increased risk for skin reactions without an increased risk for serious adverse events.
Heat: Heat was not associated with increased risk for skin ushing vs. no heat or placebo in 2 trials.
COX-2 = cyclooxygenase-2; NSAID = nonsteroidal anti-inammatory drug; RCT = randomized, controlled trial; RR = relative risk; SMR = skeletal
muscle relaxant; TENS = transcutaneous electrical nerve stimulation.
* Harms were poorly reported in most trials of nonpharmacologic interventions. No serious adverse events were reported.
Annals of Internal Medicine Vol. 166 No. 7 4 April 2017 Annals.org

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CLINICAL GUIDELINE

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back

L ow back pain is one of the most common reasons

514 2017 American College of Physicians

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Systemic Corticosteroids Benzodiazepines

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and function compared with other interventions (ma- Lumbar Supports

Low-Level Laser Therapy Pilates

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Disease/Condition Low back pain

Target Audience All clinicians

Nonpharmacologic interventions: interdisciplinary or multicomponent rehabilitation; psychological therapies; exercise and

Benefits Acute low back pain

Chronic low back pain

Radicular low back pain

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Key Questions Addressed Comparators

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Nonpharmacologic treatments vs. sham, no treatment,

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Annals of Internal Medicine Vol. 166 No. 7 4 April 2017

Intervention Outcome Magnitude of Effect Strength of Data

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(Continued on following page)

Intervention Outcome Magnitude of Effect Strength of Data

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Comparative benets of pharmacologic and

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Combination therapy treatments vs. monotherapy

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Intervention Outcome Magnitude of Effect Strength of Evidence Data

Nonpharmacologic treatments vs.