Wisdom Wednesday: Guidelines on nonradicular low back pain by the American College of Physicians

Most patients with acute or subacute low back pain improve over time regardless of treatment and can avoid potentially harmful and costly treatments and tests. First-line therapy should include nondrug therapy, such as superficial heat, massage, acupuncture, or spinal manipulation. When nondrug therapy fails, consider NSAIDs or skeletal muscle relaxants.

For chronic low back pain, consider nondrug therapy, such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercises, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive-behavioral therapy, or spinal manipulation.

For chronic low back pain that does not respond to nondrug therapy, consider NSIADs as first-line therapy. For second-line consider tramadol or duloxetine. Consider opioids only in patients in whom first- and second-line therapy has failed, in whom risks are outweighed by benefits, and only after full discussion of the potential risks and benefits.

My Take – Nonradicular low back pain is well localized pain that does not radiate down either leg. Acute low back pain is limited to patients with an onset of 7-10 days maximum. Subacute low back pain extends from a week to six weeks and chronic low back pain is anything greater than subacute.

In general, I agree with these guidelines. For over 40 years, I have used spinal manipulation successfully in the treatment of acute, subacute and chronic low back pain.

Back Pain Patients Seek Pain Relief First, Mobility Second

When asked to choose between a treatment that would reduce back discomfort and one that would help them stand and walk, the vast majority of patients wanted to ease their pain, a new study found.

“There has long been a debate in the medical community over striking the right balance between pain relief and physical function,” said the study’s lead author, Dr. John Markman, director of the Translational Pain Research Program in the University of Rochester Department of Neurosurgery in Rochester, N.Y.

“While physicians have leaned toward the need to increase mobility, this study shows that patients have a clear preference for pain relief,” Markman said in a university news release.

The study’s authors focused on nearly 270 patients who had trouble standing and walking and suffered from chronic back pain associated with lumbar spinal stenosis. The participants were asked to choose between a therapy that reduced their pain and one that would enable them to stand and walk. Nearly 80% of the patients said they would rather have relief from their pain than greater mobility, the study published recently in Neurology found.

“Even the patients who could not stand long enough to pick up a letter from their mailbox or wash the dishes after dinner chose pain relief,” said Markman.

The authors pointed out patients are playing a greater role in setting new standards for pain relief, demanding new medications that are both safe and effective.