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Clinical Guidelines
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice
Guideline from the American College of Physicians and the American
Pain Society
Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH;
Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS, for the Clinical Efficacy Assessment Subcommittee ofthe American College of
Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel*

Recommendation 1: Clinicians should conduct a focused history
and physical examination to help place patients with low back pain
into 1 of 3 broad categories: nonspecific low back pain, back pain
potentially associated with radiculopathy or spinal stenosis, orback
pain potentially associated with another specific spinal cause. The
history should include assessment of psychosocial risk factors, which
predict risk for chronic disabling back pain (strong recommendation,
moderate-quality evidence).
Recommendation 2: Clinicians should not routinely obtain imaging
or other diagnostic tests in patients with nonspecific low back pain
(strongrecommendation, moderate-quality evidence).
Recommendation 3: Clinicians should perform diagnostic imaging
and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying
conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).
Recommendation 4: Clinicians should evaluatepatients with persistent low back pain and signs or symptoms of radiculopathy or
spinal stenosis with magnetic resonance imaging (preferred) or
computed tomography only if they are potential candidates for
surgery or epidural steroid injection (for suspected radiculopathy)
(strong recommendation, moderate-quality evidence).

L

ow back pain is the fifth most common reason for all
physicianvisits in the United States (1, 2). Approximately one quarter of U.S. adults reported having low back
See also:
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Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Related articles . . . . . . . . . . . . . . . . . . . . . . . . 492, 505
Summary for Patients. . . . . . . . . . . . . . . . . . . . . . . I-45
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Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their
expected course, advise patients to remain active, and provide
information about effective self-care options (strong recommendation, moderate-quality evidence).
Recommendation 6: For patients with low back pain, clinicians
shouldconsider the use of medications with proven benefits in
conjunction with back care information and self-care. Clinicians
should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and
safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options areacetaminophen or nonsteroidal anti-inflammatory drugs.
Recommendation 7: For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain,
spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture,
massage therapy, spinalmanipulation, yoga, cognitive-behavioral
therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
Ann Intern Med. 2007;147:478-491.
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pain lasting at least 1 whole day in the past 3 months (2),
and 7.6% reported at least 1 episode of severe acute low
back pain (see Glossary) within a 1-year period (3)....