Low Back Pain Treatment Guideline Highlights Exercise and Stress Reduction

The American College of Physicians recommends nondrug therapies for most types of back pain. Nayan R. Patel, MD, comments.

Peer Reviewed

The American College of Physicians (ACP) recently published its non-surgical treatment guideline for various types of low back pain—from short-term bouts of pain to debilitating chronic pain. The guideline focuses primarily on exercise, stress reduction, and integrative therapies—with medications recommended only when nondrug therapies don’t reduce pain.
Man and woman stretching in an exercise class.The guideline focuses primarily on exercise, stress reduction, and integrative therapies.The intent of the ACP’s guideline is to help guide doctors toward the most effective non-surgical treatments for low back pain. While this guideline does not address topical drugs or epidural spinal injections, a wide range of non-invasive spine treatments were reviewed.

What Is the ACP—and Why Should You Care?

The ACP is a national health care organization of internal medicine specialists.

Why should you care about the ACP’s recommendations? Because its members are at the forefront of the internal medicine field. They share knowledge, set rigorous scientific standards, and advance quality health care. In short, the ACP is among the most respected medical societies in the world.

To produce this guideline, the ACP reviewed studies that focused on non-surgical low back pain treatments published through April 2015. They looked at how well certain low back pain therapies:

  • Reduced or eliminated of back pain
  • Improved spine function
  • Improved health-related quality of life
  • Reduced work disability
  • Impacted the number of back pain episodes
  • Improved patient satisfaction

3 Recommendations: A Look at the ACP’s Nonsurgical Treatment Guideline

Different types of pain may require different treatments. The ACP’s guideline includes 3 recommendations that address 3 distinct types of back pain: acute, subacute, and chronic back pain.

  • Acute back pain: Pain that lasts less than 4 weeks.
  • Subacute back pain: Pain that lasts between 4 and 12 weeks.
  • Chronic back pain: Pain that lasts more than 12 weeks.

Recommendation 1: People with acute or subacute low back pain often see a reduction of symptoms with time, so the ACP recommends that doctors first recommend heat therapy, massage, acupuncture, or spinal manipulation before using medications. If drug therapy is needed, the ACP recommends using non-steroidal anti-inflammatory drugs (NSAIDs) or muscle relaxants.

Recommendation 2: For people with chronic low back pain, the ACP recommends first participating in exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy (reward vs punishment), cognitive behavioral therapy, or spinal manipulation.

Recommendation 3: When nondrug therapies don’t help people with chronic low back pain, the ACP recommends doctors consider medications to manage pain. The first-line drug treatment should be NSAIDs, followed by or tramadol or duloxetine as second-line therapy. The ACP guideline states that doctors only prescribe opioids if patients have not found success with the first- and second-line medications. If opioids are an option, the ACP says they should be used only if the potential benefits outweigh the risks—and doctors should discuss all the risks and benefits with patients before starting treatment.

Talk to Your Doctor About the ACP’s Guideline

The next time you visit your doctor about low back pain, discuss the recommendations in the American College of Physicians’ guideline. Perhaps massage could be a successful therapy if you have occasional bouts of back pain, or maybe stress-reducing exercises will help you achieve long-term pain relief. Many non-surgical options exist to treat low back pain. The recommendations outlined in the ACP’s guideline may help you and your doctor explore treatments you may not have considered.


Nayan R Patel, MD
Texas Back Institute
Plano, TX

The intent of the American College of Physicians’ guideline is to advise the physician on what may work to manage pain, but care should still be individualized to the patient by their physician. Also, unresolved back pain still needs to be evaluated to make sure to more serious causes are ruled out.

Updated on: 07/10/18
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Nayan R Patel, MD
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