Applied Evidence

Managing lower back pain: You may be doing too much

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New guidelines call for a measured approach to imaging and medication, while emphasizing psychosocial evaluation.



A 32-year-old construction worker seeks treatment for the lower back pain (LBP) he’s been experiencing since painting his house a few days ago.

A 48-year-old man with a history of LBP comes in because he needs a refill of his hydrocodone prescription.

Both patients are probably pretty typical of the back pain patients you see on a regular basis. But how would you care for each of these patients, and how does your care compare to the latest evidence? This review will help you to find out. In this article we take a look at guidelines from the American College of Physicians (ACP) and the American Pain Society (APS),1 as well as findings from other recent studies, and apply them to these 2 patient cases.

But first, a word about the ACP/APS guidelines.

What’s new?

ACP/APS conducted a systematic review of studies of LBP epidemiology, clinical diagnosis, utility of imaging, and outcomes of pharmacologic2 and nonpharmacologic interventions.3 Whereas previous guidelines dealt with either acute or chronic pain, the ACP/APS guidelines synthesized the literature to apply to both.

Moreover, rather than focusing mostly on pain reduction, the ACP/APS panel was interested in functional outcomes such as back-specific functioning, general health status, disability, and patient satisfaction.

Finally, the panel’s recommendations ( TABLE ) considered the unique environment of primary care (including presentations typically seen in this setting), the ability of primary care physicians to advise and counsel patients, continuity of care, and the role of the physician in coordinating care.

Recommendations from the ACP/APS guidelines for low back pain1

Conduct a focused history and exam to place patients into 1 of 3 broad categories: nonspecific LBP, LBP potentially associated with radiculopathy or spinal stenosis, or LBP associated with another specific cause (strength of recommendation [SOR]: B).
Assess for psychosocial factors and emotional distress, as they are stronger predictors of LBP outcomes, including disability, than physical exam findings and severity of pain (SOR: B).
Do not routinely obtain imaging for patients with nonspecific LBP. MRI or CT is recommended for patients with LBP associated with a specific cause, for those with severe or progressive neurologic deficits or persistent radiculopathy/spinal stenosis symptoms, and for those who are candidates for surgical interventions (SOR: B).
Advise patients with nonspecific LBP to remain active and provide information on LBP’s expected course and effective self-care options (SOR: B).
Consider the addition of nonpharmacologic treatments, including selective alternative modalities, when self-care fails. These treatments include spinal manipulation for acute LBP and acupuncture for chronic LBP (SOR: B).
Consider acetaminophen or nonsteroidal anti-inflammatory drugs as first-line medication options for most patients. Keep in mind the limited effectiveness and potential harm of others, including opioids (SOR: B).
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Patient with acute nonspecific LBP

While painting his home, a 32-year-old construction worker felt a twinge in his lower back as he stepped off a ladder. He remained active, relying on over-the-counter ibuprofen and heat packs to relieve soreness. Two days later he visits his physician because the soreness has not abated. He reports no bowel or bladder complaints, worsening of pain, radiation of symptoms, nausea, vomiting, abdominal pain, or fever. He tells his doctor that he strained his back before and that this “feels the same way it did before.” The last time this happened he received physical therapy (PT), which helped. He thinks he may need PT again, but wants to discuss it with his physician.

Physical exam reveals mild tenderness to palpation over the right lumbar paraspinal muscle, but no spasms are apparent. Otherwise, his musculoskeletal exam—including range-of-motion testing—is within normal limits. The neurologic exam also is within normal limits, including normal deep tendon reflexes of the lower extremities and negative straight-leg-raise testing. His gait is normal, with no sign of discomfort.

Specific anatomic diagnoses are elusive. In the primary care setting, fewer than 15% of LBP cases have an identifiable underlying disease or spinal abnormality.4 An exhaustive search for a specific anatomic diagnosis lacks utility in selecting initial therapy or affecting patient outcomes. Instead, when caring for a patient like the one in our case, it’s important to focus on a thorough medical history and examination that assess the location and duration of symptoms, as well as uncover symptoms suggestive of radiculopathy or spinal stenosis.


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