Controversy Over New Clinical Guidelines for Low Back Pain

In 1994, the Agency for Health Care Policy and Research (AHCPR) published Acute Low Back Problems in Adults. These clinical guidelines have been used by many doctors in advising patients with low back pain (LBP) to stay active.

A new set of clinical guidelines has been added to the previous AHCPR document. These new guidelines aren’t meant to replace the AHCPR publication. Instead, they focus on primary care and the treatment of pain as the underlying disease.

The American College of Physicians and the American Pain Society developed the new guidelines. They are evidence-based, follow a clear path, and are user-friendly. Seven main recommendations are made and include:

  • LBP patients should be classified into one of three groups based on
    the history and physical exam. The categories are nonspecific back pain, back pain with stenosis or radiculopathy (leg pain), and back pain from some other cause.

  • Routine X-rays or other imaging studies are not needed for patients
    with nonspecific LBP.

  • Diagnostic tests should be ordered for patients with severe or
    neurologic symptoms that are getting worse.

  • MRI or CT scans should be used for patients with symptoms of
    radiculopathy or stenosis.

  • Patients should be advised to stay active, told what to expect, and
    given information about self-care options.

  • When needed, medications can be combined with self-care.
  • Conservative care is always recommended first. When this fails, other treatment such as manipulation, exercise, or acupuncture can be tried. There is weak evidence that yoga, relaxation, and cognitive behavioral therapy may help some patients.

    There are some concerns about the new guidelines. Experts have suggested this new model is focused too much on a medical solution to back pain. Many studies show that psychosocial factors are an important key to the treatment of LBP.

    There was no mention of other forms of treatment such as injections, surgery, laser, or other invasive approaches. It is expected that the next phase of these guidelines will focus on the new invasive treatments.