23 January, 2019

American College of Physicians recommends traditional and complementary therapies as first line treatments for low back pain

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WHILE the Australian Government ignores positive evidence and legislates to remove public access to Private Health Insurance (PHI) rebates for natural therapies, respected medical bodies in other developed countries have released evidence-based guidelines recommending the integrative use of traditional and complementary therapies to treat common health conditions.

American College of Physicians clinical practice guideline for low back pain:

In developed countries such as the United States and Australia, low back pain is the most common form of pain and the third most common reason people visit their doctor. It is a leading cause of disability worldwide and one of the main reasons people leave the workforce.

In 2017, the American College of Physicians (ACP) updated its evidence-based clinical practice guideline recommending that physicians and patients should treat acute or subacute lower back pain with non-drug therapies such as massage, acupuncture, spinal manipulation (chiropractic/ osteopathy), mindfulness, tai chi and yoga.

The ACP is the largest medical specialty organisation in the United States, whose members include 148,000 internal medicine physicians (internists, who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness), related subspecialists and medical students.

The ACP guideline was developed based on an extensive review of the highest quality evidence available (including randomized control trials and data from observational studies) assessing the efficacy, comparative effectiveness, and safety of noninvasive pharmacologic and nonpharmacologic treatments for acute (<4 weeks), subacute (4 to 12 weeks), and chronic (>12 weeks) low back pain in primary care.

ACP recommendations:

“For the treatment of chronic low back pain, physicians should select therapies that have the fewest harms and costs, since there were no clear comparative advantages for most treatments compared to one another. […] Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients.”

“For patients with chronic low back pain, ACP recommends that physicians and patients initially select non-drug therapy with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (MCE), progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioural therapy, or spinal manipulation.”

The ACP recommends these therapies as front-line treatment options in preference to pharmacologic agents.

Published evidence showed that systemic steroids were not effective in treating acute or subacute low back pain and that acetaminophen was not effective at improving pain outcomes compared with placebo.

“If drug therapy is desired, physicians and patients should select nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants.”

“Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies, as they are associated with substantial harms, including the risk of addiction or accidental overdose.”

Recommendation 1:

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

Recommendation 2:

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

Recommendation 3:

In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)



Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.


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