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  • Revised Physician Guidelines Shift to Non-Drug Approaches as First-Line Treatment for LBP

    In brief:

    • In a revision of clinical guidelines, the American College of Physicians is recommending nonpharmacologic approaches over the use of medications as first-line treatment for acute, subacute, and chronic LBP.
    • Changes are based in part on new evidence showing that acetaminophen and antidepressants were no better than placebos.
    • Guidelines recommend that physicians advise patients that pain is likely to diminish through exercise and maintenance of as many daily activities as possible.

    The latest advice on low back pain (LBP) from the American College of Physicians (ACP) makes it clear: patients with acute LBP will generally improve over time regardless of treatment, and that when treatments are necessary, nondrug approaches including exercise are preferred for all but the most stubbornly chronic manifestations of the condition. The new guidelines represent a shift from ACP's previous position, which called for the use of medication as part of first-line treatment.

    The guidelines, released on February 13, include 3 recommendations—1 each for acute (fewer than 4 weeks) or subacture (4 to 12 weeks) LBP, chronic LBP (more than 12 weeks), and chronic LBP that persists after the use of nonpharmacologic therapy. Researchers analyzed studies on the effectiveness of both pharmacologic and nonpharmacologic treatments among the 3 types of LBP. Drug-based treatments studied ran the gamut from acetaminophen to opioids, including antidepressant medications. Nonpharmocologic treatments reviewed included spinal manipulation, multidisciplinary rehabilitation, massage, "exercise and related therapies, and various physical modalities," among other approaches.

    In the end, what researchers found had less to do with breakthrough understandings of the effectiveness of exercise and maintaining daily activities—benefits of which were reestablished through a systematic review conducted as part of guideline development—and more to do with a weakening of evidence supporting the use of medications.

    "The [review that served as the basis for the previous guidelines published in 2007] concluded that acetaminophen was effective for acute low back pain," authors write. "However, [the 2017] update included a placebo-controlled RCT in patients with low back pain that showed no difference in effectiveness between acetaminophen and placebo," with the same results surfacing when it came to the use of antidepressants. On the other hand, they add, "many conclusions about nonpharmacologic interventions are similar between the 2007 review and the update."

    At the acute and subacute levels, the new guidelines strongly recommend that physicians advise patients that the pain is likely to improve over time, and discuss the use of "superficial heat, massage, acupuncture, or spinal manipulation." At the chronic level, the guidelines strongly recommend "exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (supported by moderate-quality evidence), tai chi, yoga, motor control exercise," and other approaches that include low-level laser therapy and spinal manipulation (supported by low-quality evidence). In all cases, they write, "it is important that physical therapies be administered by providers with appropriate training."

    For patients with chronic LBP that persists after nonpharmacologic approaches have been tried, the guidelines make a "weak" recommendation for considering nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, with tramadol or duloxetine as a 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 related benefits with the patients," authors add.

    The updated guidelines generated wide media coverage, including stories from CBS News, NBC News, and the New York Times, which characterized the recommendations as "bucking what many doctors do."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Comments

    • Hello, Does the APTA have any plans to address these recommendations in terms to their lack of our professions involvement? It seems as though we allready have well thought out clinical practice guidelines for LBP, jospt.2012.0301, and could use them to lobby for our involvement. Just a thought.

      Posted by Patrick on 2/14/2017 9:38 PM

    • I notice that the guidelines do not really mention physical therapy despite physical therapists being optimally suited to deliver most of the treatment approaches highlighted, should we be doing more to put ourselves out there as clinicians of choice?

      Posted by Christopher Konle -> AJWZAF on 2/15/2017 11:18 AM

    • I am very excited about the new guidelines, however I am a bit disturbed by the fact that physical therapy has not been clearly listed as a provider of these services in most of the national media I have seen. While the treatments desctibed are largely our methods of treatment, the Wall Street Journal article from 2/14/17 lists non-drug therapies guidelines for acute and subacute and then closes the list with "which is often done by a chiropractor." TV news reports listed alternative therapies of yoga and Tai Chi, while never specifically listing or mentioning physical therapy. How did we miss the boat on getting our profession out there when the new guidelines describe our services to a "t"?

      Posted by Patricia Rouleau -> =NXbCI on 2/16/2017 9:26 AM

    • LOVE LOVE LOVE these articles! Information that us PTs have known for a long time - I'll be taking this to my next MD visit. #GetPT1st

      Posted by Jesse Roles on 2/16/2017 5:23 PM

    • As much as I am disheartened that PT didn't play a large role in this, I am excited that the door is opened wider for us to educate the public. Jeff Moore says it on his podcast that we share the responsibility to educate the public and referral sources. This is not the APTAs responsibility. There are only so many fights that can be won by an organization that doesn't even represent half of the professionals. To get more from the organization, we have to convince our colleagues to join so that our voice can be bigger on the hill, in our state and in our community. This should do well to start curbing the thousands seeking treatment daily for opioid misuse and the > 40 deaths that occur per day due to opioids. This is a start and our window of opportunity.

      Posted by Vince Gutierrez on 2/19/2017 12:09 AM

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