Skip to main content

ACP: Guidelines for Noninvasive Treatment of Low Back Pain

February 27, 2017

The American College of Physicians has released new guidelines for the noninvasive treatment of low back pain, which serves as a partial update of their guidelines published in 2007.

The new recommendations are based on a systematic review of randomized, controlled trials published through April 2015 on noninvasive pharmacologic treatment and nonpharmacologic treatment of acute back pain (less than 4 weeks), subacute back pain (4 to 12 weeks), and chronic back pain (more than 12 weeks).

Among the recommendations:

  • Nonpharmacologic treatment with heat is recommended for acute or subacute back pain (moderate-quality evidence), as well as massage, acupuncture, or spinal manipulation (low-quality evidence). NSAIDs or muscle relaxants are recommended if patients desire pharmacologic treatment for acute or subacute back pain (moderate-quality evidence).
  • Exercise, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction is recommended as initial treatment for chronic low back pain (moderate quality evidence). In addition, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation are recommended as nonpharmacologic treatment for patients with chronic back pain (low-quality evidence).
  • NSAIDs are recommended as the first line of treatment for chronic low back pain if patients had an inadequate response to nonpharmacologic therapy. Tramadol or duloxetine is recommended as the second-line of therapy, and opioids should only be considered if other pharmacological or nonpharmacologic treatments are not working and if the benefits outweigh the risks for the patient (moderate-quality evidence).

“Systemic steroids were not shown to provide benefit and should not be prescribed for patients with acute or subacute low back pain, even with radicular symptoms,” the guidelines stated.

The guidelines recommend clinicians select therapies that are cost effective and have the fewest harms for treating patients with chronic low back pain.

“Clinicians should reassure patients that acute or subacute low back pain usually improves over time, regardless of treatment,” the guidelines concluded.

—Melissa Weiss


Qaseem A, Wilt TJ, McLean RM, and Forciea MA. Noninvasive treatments for actue, subacute, and chronic low back pain: a clinical practice guidelines from the American College of Physicians [published online February 14, 2017]. Annals of Internal Medicine. doi:10.7326/M16-2367.

Back to Top