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After a thorough analysis of published research by investigators at the Oregon Evidence-Based Practice Center at Oregon Health & Science University, the American Pain Society and the American College of Physicians are set to issue new treatment guidelines for lower back treatment.

With about 1 in 4 Americans experiencing lower back pain at least once a day–and the 5th most common reason for a patient to see a doctor–the new guidelines weigh the benefits and risks of any drug and explain that they be used based on the severity of baseline pain and functional impairment.

There are a number of treatments for low-back pain that don’t include medication, such as supervised exercise therapy, chiropractic care, and massage therapy. The guideline suggests these options for patients who do not improve with self-care or pain medication.

The report suggest that medications offer some benefits for low-back pain, but not without risks. For example, acetaminophen is safe, but not that effective. Nonsteroidal anti-inflammatory drugs, like ibuprofen, provide more relief but have gastrointestinal and cardiovascular side effects. Opioids can treat severe pain, but pose risks for sedation and dependence over time. It is recommended that physicians and patients discuss the options and select the one(s) that best suit their specific needs.

This is a brief summary of the new guidelines:

  • Clinicians should conduct a focused history and physical examination to help place patients with low-back pain into one of three broad categories: nonspecific low-back pain, back pain potentially associated with radiculopathy (nerve disorders) or spinal stenosis (narrowing), or back pain associated with another specific cause.  The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain.
  • Clinicians should not routinely obtain imaging or other diagnostic tests in patients with non-specific low-back pain.
  • Clinicians should perform diagnostic imaging and testing for patients with low-back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.
  • Clinicians should evaluate patients with persistent low-back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they potential candidates for surgery or epidural steroid injection (for suspected radiculopathy).
  • Clinicians should provide patients with low-back pain evidence-based information about their expected course, advise patients to remain active, and provide information about effective self-care options.
  • For patients with low-back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self care.  Clinicians should assess the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy.
  • For patients who do not improve with self-care options, clinicians should consider the addition of non-pharmacologic therapy with proven benefits for low-back pain.  They are spinal manipulation for acute low-back pain; and for chronic or sub-acute low-back pain options include:  intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation.

Currently only guidelines for low-back-pain treatment in a primary care setting is available. The complete guideline covering both the primary care recommendations, as well as invasive treatments, will be released in 2008.