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PHILADELPHIA, Oct. 2 -- Reliance on a focused history and physical and judicious use of diagnostic imaging are hallmarks of new guidelines for management of low back pain issued jointly by the American College of Physicians and the American Pain Society.

The guidelines, published in the October issue of Annals of Internal Medicine, also emphasize patient education, and use of nondrug therapies and over-the-counter medications as first-line treatment.

In explaining the basis for the guidelines, Amir Qaseem, M.D., Ph.D., of the ACP, and colleagues stated, "Many options are available for evaluation and management of low back pain. However, there has been little consensus . . . on appropriate clinical evaluation and management."

"Numerous studies show unexplained, large variations in the use of diagnostic tests and treatments," the authors continued. "Despite wide variations in practice, patients seem to experience broadly similar outcomes, although costs of care can differ substantially among and within specialties."

The new guidelines were developed by a multidisciplinary panel of specialists who relied on published studies, systematic reviews, and expert opinion to arrive at their recommendations. Interventions were considered "proven" only when supported by at least "fair-quality evidence" and were associated with at least moderate benefits (or small benefits but no significant harms, costs, or burdens).

The panel's deliberations and discussions yielded seven core recommendations for diagnosis and treatment of low back pain:

1. A focused history and physical examination should be used to categorize low back pain as nonspecific, potentially associated with radiculopathy or spinal stenosis, or potentially associated with another specific spinal cause.
2. Routine use of diagnostic imaging or other tests in patients with nonspecific low back pain is strongly discouraged.
3. Diagnostic imaging and testing are appropriate when patients have severe low back pain, when progressive neurologic deficits are present, or when serious underlying conditions are suspected.
4. MRI (preferred) or computed tomography should be used only if a patient is a potential candidate for surgery or epidural steroid injection.
5. Clinicians should provide patients with evidence-based information about low back pain, the patient's expected clinical course, and effective self-care options.
6. Medications with proven benefits should be considered for use in conjunction with self-care and information about back care. In most cases, first-line medication will be acetaminophen or nonsteroidal anti-inflammatory drugs.
7. For patients who do not improve with self-care options, clinicians should consider adding nonpharmacologic therapy that offers proven benefits, including spinal manipulation, acupuncture, and exercise.

The authors remind clinicians that "clinical practice guidelines are 'guides' only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment."

Among the authors, R. Chou has received honoraria from Bayer Healthcare Pharmaceuticals and V. Snow reported grants from the CDC, the Agency for Healthcare Research and Quality, Novo Nordisk, Pfizer, Merck & Co., Bristol-Myers Squibb, Atlantic Philanthropics, and Sanofi-Pasteur. The study was supported exclusively by the American College of Physicians and the American Pain Society.

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