What are the guidelines for Chronic Low Back Pain (CLBP)?

From the Guidelines

Chronic Low Back Pain (CLBP) guidelines recommend nonpharmacologic treatment as the initial approach.

Nonpharmacologic Treatments

• Exercise is a recommended treatment for CLBP, as it has been shown to have small to moderate effects on pain and function 1.
• Multidisciplinary rehabilitation is also recommended, as it has been associated with small to moderate effects on pain and function 1.
• Mindfulness-based stress reduction, tai chi, and yoga are other nonpharmacologic treatments that have been shown to be effective for CLBP, with moderate-quality evidence 1.
• Acupuncture and spinal manipulation are also recommended, although the evidence is of lower quality 1.

Pharmacologic Treatments

If pharmacologic treatment is desired, nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants may be considered, with moderate-quality evidence 1.

Key Considerations

• The American College of Physicians (ACP) recommends a strong approach to nonpharmacologic treatment for CLBP, with a focus on exercise, multidisciplinary rehabilitation, and mind-body interventions 1.
• The evidence for nonpharmacologic treatments is generally of moderate quality, with small to moderate effects on pain and function 1.

From the Research

Diagnosis of Chronic Low Back Pain (CLBP)

• The diagnosis of CLBP may lack precision, and most international guidelines recommend searching for "yellow, blue and black flags" to stratify the risk of chronicity and/or persistent disability 2
• Clinical examination and imaging are under debate, and their relevance is not clearly established 2

Management of CLBP

• Most international guidelines recommend non-pharmacological treatments, including:
  • Exercise therapy
  • Physical activity
  • Physiotherapy
  • Education 2, 3
• Multidisciplinary rehabilitation is the core treatment recommended for people with non-specific CLBP, and may be offered to selected cases 2
• Oral, topical or injected pharmacological treatments may be offered to selected and well-phenotyped patients, but are under debate 2
• Over-the-counter analgesics, such as NSAIDs and acetaminophen, are commonly used as first-line medication for CLBP 4
• Antidepressants, muscle relaxants, and opioids may also be effective treatments for CLBP, but their use should be carefully considered and monitored 4, 5

Guideline Recommendations

• The North American Spine Society's Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain provides evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain 5
• The guideline recommends a multidisciplinary approach to care, and provides guidance on the use of pharmacological and non-pharmacological treatments 5
• Clinical practice guidelines, such as those published in Israel, can provide a summary of the existing evidence and support decisions, but should not replace careful clinical judgment and personal acquaintance with the patient 6