Hoping to bring clarity to an area of medicine long fraught with dissension, the American College of Physicians and the American Pain Society have issued guidelines for assessing and treating low-back pain in the primary-care setting (Ann Intern Med. 2007;147:478-491). Broadly speaking, the seven recommendations, which “are not intended to override clinicians’ judgment,” discourage expensive imaging scans, prescription medications, bed rest, and surgery.
The guidelines, written for pain “of any duration,” do not apply to major trauma patients, children or adolescents, those with fibromyalgia, or pregnant women. Here is a quick summary of what clinicians should do:
1. Conduct a focused history and physical examination to help place patients into one of three broad categories: nonspecific low-back pain, pain potentially associated with radiculopathy or spinal stenosis, or pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict likelihood of developing chronic disabling back pain.
2. Do not routinely obtain imaging or other diagnostic tests in patients with nonspecific pain.
3. Order diagnostic imaging and testing when severe or progressive neurologic deficits are present or serious underlying conditions are suspected on the basis of history and physical examination.
4. Evaluate patients with persistent pain and signs or symptoms of radiculopathy or spinal stenosis with MRI (preferred) or CT only if the patient is considered a potential candidate for surgery or epidural steroid injection (for suspected radiculopathy).
5. Advise patients to remain active, and let them know that their prognosis is favorable for substantial improvement within a month.
6. For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
7. For those patients who do not improve with self-care, consider the addition of nonpharmacologic therapy with proven benefits: for acute pain, spinal manipulation; for chronic or subacute pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, cognitive-behavioral therapy, yoga, or progressive relaxation.