Management of Low Back Pain:
Getting From Evidence-Based Recommendations to High-Value Care

This section is compiled by Frank M. Painter, D.C.
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FROM:   Annals of Internal Medicine 2017 (Apr 4); 166 (7): 533-534 ~ FULL TEXT

Steven J. Atlas, MD, MPH

Massachusetts General Hospital,
Boston, Massachusetts.

This issue of Annals includes updated systematic reviews of noninvasive pharmacologic and nonpharmacologic therapies for low back pain and accompanying practice recommendations from the American College of Physicians (ACP). [1–3] Low back pain is common, and its management may be a good example of low-value health care—expensive tests and therapies that deliver limited benefits in terms of reduced pain and increased function. [4] Greater use of effective treatments, whether for acute symptoms managed in the primary care setting or chronic, disabling pain that typically involves a range of specialists, might help patients who are suffering, clinicians who are frustrated with providing treatments that often do not help, and insurers who pay the bills.

Turning first to the systematic reviews, Chou and colleagues [1, 2] updated their previous work by focusing on new randomized trials and systematic reviews published since 2007. They identified 46 pharmacologic and 114 new nonpharmacologic reviews and trials. Importantly, the authors conducted their current work by using qualitative synthesis without performing new quantitative meta-analyses. Instead, they examined whether findings from new studies were consistent with previous pooled results or qualitative findings from their 2007 reviews. [5, 6] They used standard methods to evaluate and report findings for many therapies, most of which are widely available. Their goal was to examine outcomes, including pain and function, on the basis of symptom duration: acute (<1 month), subacute (1 to 3 months), and chronic (>3 months). The authors examined studies of patients with nonradicular or radicular (for example, sciatica or spinal stenosis) low back pain separately.

Regarding pharmacologic therapies, major new findings are the lack of benefit of acetaminophen for acute low back pain — largely on the basis of data from a large, good-quality study — and evidence supporting duloxetine for patients with chronic low back pain. For acute low back pain, the authors found unchanged evidence of short-term pain relief for nonsteroidal antiinflammatory drugs and skeletal muscle relaxants, sparse evidence for benzodiazepines, and a lack of benefit for oral steroids. For chronic low back pain, opiates and tramadol continue to show modest, short-term benefit, whereas tricyclic antidepressants and antiseizure medications are no more effective than placebo. Key limitations include the funding of most studies by drug manufacturers, few studies involving older patients or those with radicular symptoms, and few studies reporting longer-term follow-up in patients with chronic symptoms or those likely to have clinically significant improvement.

Regarding nonpharmacologic therapies, new evidence supports the use of mindfulness-based stress reduction and tai chi for chronic low back pain, and other studies suggest that acupuncture may be effective for acute low back pain. Evidence continues to support exercise, psychological therapies, multidisciplinary rehabilitation, massage, spinal manipulation, and acupuncture for chronic low back pain. Although not reported in the current review by Chou and colleagues, most passive physical modalities, such as ultrasound, supports, and electrical stimulation, continue to have little evidence to support their use. [7] Similar to pharmacologic therapies, outcomes generally were assessed over short-term follow-up, the magnitude of benefit seen for most therapies was small to moderate, and few therapies stood out compared with other active treatments.

For both pharmacologic and nonpharmacologic approaches, few therapies were assessed as they are applied in routine practice — either bundled, such as a medication started along with a physical therapy referral, or sequential, in which a new intervention is added after previous treatments have failed. The need for pragmatic trials to evaluate these common therapies in real-world settings is a major deficiency that is not immediately evident in these reports but directly affects how these findings may be used to provide clinicians with practice recommendations.

So, how should clinicians use this information to guide treatments for patients with low back pain? The ACP addresses this question with simplified recommendations. The new guidelines are based on the clinical presentation — pain of acute, subacute, or chronic duration. For acute or subacute low back pain, the ACP recommends an initial focus on nonpharmacologic therapies rather than medications. Although reasonable, this strategy may represent a major change for primary care clinicians, and little direct evidence exists to support it. This change in emphasis partly reflects the limited pharmacologic choices—nonsteroidal antiinflammatory drugs and skeletal muscle relaxants, with acetaminophen no longer being recommended. It also may represent a shift toward efforts to prevent progression to chronic low back pain by identifying patients at increased risk for persistent pain. A randomized trial from the United Kingdom suggests that stratified care with earlier referral for physical therapy decreases disability. [8] This study represents the kind of pragmatic trials needed to evaluate whether applying the ACP recommendations in the United States would result in reduced disability and lower costs.

Regarding chronic low back pain, the ACP's recommendations represent a continued emphasis on nonpharmacologic therapies, with stronger cautions regarding the use of opiates. Although de-emphasizing opiate medications makes sense, this approach is based more on the lack of evidence for long-term benefits and the growing perception about the risks of opioid use than on new evidence. The new recommendations do not address how to compare these treatments with invasive procedures that often are considered for patients with chronic low back pain. Finally, regarding some of the nonpharmacologic therapies, such as multidisciplinary rehabilitation and psychological or mind– body treatments, the problem lies in their limited availability and affordability for patients, often reflecting insurance coverage decisions.

Despite the considerable effort invested in these systematic reviews and in providing clinicians with rational recommendations for care, doubts exist as to whether simply publishing this work will be sufficient to drive guideline-concordant care. Systematic reviews and recommendations from governmental organizations and professional societies are not new and predate large increases in diagnostic and therapeutic services. [9] For example, the lack of evidence supporting opiates for low back pain did not prevent their dramatic increase in use. [10] Moreover, these updated reviews and recommendations do not focus on diagnostic tests, such as magnetic resonance imaging, and invasive therapies, such as injections and surgery, which are major drivers of health care spending for low back pain. [4]

If clinicians and their professional societies cannot demonstrate that their recommendations are improving the delivery of high-value services, what are the alternatives? Likely what is needed is an “all of the above” approach: more pragmatic trials to evaluate proven therapies and their combinations in real-world settings; efforts to reduce the use of low-value services, such as payer coverage policies based on guideline recommendations; patient engagement through shared decision making; and pressure on insurers to cover nonpharmacologic, noninvasive therapies that have shown benefit. Nevertheless, rigorous reviews of existing evidence and their application in practice guidelines remain an underpinning that should drive efforts not only to decrease the use of therapies without demonstrated benefit but also to show that the therapies being used improve real-world outcomes for patients with low back pain.


Dr. Atlas reports royalty payments from UpTo- Date and personal fees from Healthwise. Disclosures can be viewed at


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