The American College of Physicians (ACP) has released 3 recommendations regarding the noninvasive treatment of acute, subacute, and chronic low back pain in a clinical practice guideline published in the Annals of Internal Medicine.

The ACP developed the guideline from randomized, controlled trials and systematic reviews published through April 2015 that focused on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. The agency evaluated outcomes including reduction or elimination of back pain, improvement in back-specific function, improvement in health-related quality of life, reduction in work disability, number of back pain episodes, patient satisfaction, and adverse events.

Recommendation 1

The ACP recommends that clinicians and patients should select nonpharmacologic treatment with superficial heat to treat acute or subacute low back pain, given that this pain usually improves over time. Clinicians can also treat acute or subacute pain with massage, acupuncture, or spinal manipulation. Nonsteroidal anti-inflammatory drugs or muscle relaxants should be selected if pharmacologic treatment is required (Grade: strong recommendation).

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“Clinicians should reassure patients that acute or subacute low back pain usually improves over time, regardless of treatment,” the study authors wrote. “Thus, clinicians should avoid prescribing costly and potentially harmful treatments for these patients, especially narcotics. In addition, 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.”

Recommendation 2

For patients with chronic low back pain, the ACP recommends that patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction. Other treatments include tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (Grade: strong recommendation).

Recommendation 3

The ACP states that clinicians should consider pharmacologic treatment in patients with chronic low back pain who have an inadequate response to nonpharmacologic therapy, using nonsteroidal anti-inflammatory drugs as a first-line therapy or tramadol or duloxetine as a second-line therapy.

The agency notes that opioids should only be considered as an option in patients who have failed the other treatments, and only if the potential benefits outweigh the risks. Clinicians should discuss the known risks and realistic benefits of opioid use with their patients (Grade: weak recommendation, moderate-quality evidence).

“Clinicians should avoid prescribing costly therapies; those with substantial potential harms, such as long-term opioids (which can be associated with addiction and accidental overdose); and pharmacologic therapies that were not shown to be effective, such as TCAs [tricyclic antidepressants] and SSRIs [selective serotonin reuptake inhibitors],” the authors concluded.


  1. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017. doi:10.7326/M16-2367