The purpose of this review is to examine 3 clinical practise guidelines (CPG’s) and their recommendations for non-invasive (non-surgical) low back pain treatments. The 3 CPG’s are the 2012 American Physical Therapy Association (APTA 12) clinical low back practise guidelines. The National Institute for Health and Care Excellence (NICE 16) [part of the U.K Department of Health]) 2016 low back pain and sciatica in over 16: assessment and management. Finally, the American College of Physicians 2017 (ACP 17) CPG’s for non-invasive treatments for acute, subacute and chronic low back pain. It should be noted that the international classification of disease (ICD) defines acute as less than a month. Sub-acute as 1-3 months and chronic as more than 3 months.

Treatments reviewed are:
Chiropractic
Medications
Exercise
Soft Tissue Therapy (massage)
Acupuncture
Electrotherapies
Ultrasound
Other Therapies and Low Back Pain
Summary of Treatments for Low Back Pain

Chiropractic and Low Back Pain:

The APTA 12 CPG recommends (highest levels of evidence and grade) that physical therapist and clinicians consider spinal manipulative therapy (SMT) to reduce pain and disability in acute, subacute and low back pain. In addition, the APTA found SMT improves spine and hip mobility and reduces back-related buttock or thigh pain.

APTA 12 CPG outlined 5 variables as predictors of rapid treatment success with chiropractic adjustments. Rapid success was defined as a 50% or greater reduction on an objective measure (Oswestry), within 2 visits. These predictors are:

• Duration of symptoms of less than 16 days
• No symptoms distal to the knee
• Lumbar hypomobility (restricted movement)
• At least 1 hip with greater than 35 degrees of internal rotation
• FABQ-W score less than 19

“Presence of 4 or more predictors increased the probability of success with thrust manipulation from 45% to 95%”

Furthermore, the NICE 16 CPG recommends manual therapy (chiropractic adjustments, mobilization or soft tissue techniques) for managing low back pain with or without sciatica, but only when incorporated with exercise and possibly psychological treatment

Finally, the ACP 17 CPG states that medical doctors should recommend chiropractic adjustments to patients as first line therapy for acute and subacute low back pain. In addition, the clinical practice guidelines found that chiropractic adjustments and exercise was superior to exercise alone at improving function in acute low back pain patients. ACP 17 also recommends chiropractic adjustments for chronic low back pain.

Medications and Low Back Pain:

ACP 17 states that medical doctors should not prescribe medicine as a first line of treatment in patients with acute, subacute or chronic low back pain.  Furthermore, doctors are advised to prescribe NSAID’s or muscle relaxants as a first line of treatment only in chronic patients who do not respond to non-pharmacological treatment. This is because NSAIDs carry a risk of complications, including: gastrointestinal, liver and cardio-renal toxicity. Second line of medications should include Cymbalta and Tramadol

NICE 16 recommends only prescribing oral NSAIDs at the lowest effective dose for the shortest possible period of time. acetaminophen (Tylenol or paracetamol) should not be offered alone. Weak opioids should only be considered if NSAIDs are contraindicated or ineffective. Other medications that NICE 16 does not recommended include SSRI’s, SNRI’s, tricyclic antidepressants or anticonvulsants.

Exercises and Low Back Pain:

APTA 12 strongly recommends core exercises (trunk endurance, strengthening and endurance exercise); as well centralization and directional exercises (McKenzie).

In addition, the NICE 16 recommends group exercise programs for low back pain with or without sciatica. NICE recommends taking into accounts patients specific needs, preferences and capabilities.

In contrast, the ACP 17 found that exercise did not produce significant reductions compared to usual care for pain or function in acute and subacute low back pain patients. The ACP 17 found no difference in pain or function among 20 different exercise regimes.

However, the ACP 17 did find that exercises improved function and decreased pain in chronic patients. The ACP 17 also recommends core exercises (motor control exercises). Nevertheless, the practice guidelines found no difference in pain or function between core and normal exercises.

Soft Tissue Therapy (Massage) and Low Back Pain:

The ACP 17 guidelines state medical doctors should recommend soft tissue therapy (massage) as a first line therapy for patients with acute and subacute low back pain. The ACP also recommends soft tissue therapy for chronic low back pain.

The NICE 16 also recommends soft tissue therapy for the management of low back pain with or without sciatica

APTA 12 did not comment on soft tissue therapy for low back pain

Acupuncture and Low Back Pain:

The ACP 17 guidelines state medical doctors should recommend acupuncture as a first line therapy for patients with acute and subacute low back pain. The ACP also recommends acupuncture for chronic low back pain.

In contrast, the NICE 16 CPG does not recommend acupuncture for managing low back pain with or without sciatica.

The APTA 12 did not review the efficacy of acupuncture for low back pain.

Electrotherapies and Low Back Pain:

NICE 16 examine 3 variations of electrotherapy. Percutaneous electrical nerve stimulation [(PENS) – like electrical acupuncture but needles are only inserted at pain sites]. Transcutaneous electrical nerve stimulation (TENS, i.e Dr. Ho’s) and interferential current (IFC – used in physio and chiro clinics). NICE 16 found no effect of any of the 3 electrotherapies on the management of low back pain with or without sciatica.

In addition, the ACP 17 found no difference between TENS and sham TENS for pain or disability.

Ultrasound Therapy and Low Back Pain:

NICE 16 found no effect of ultrasound therapy on the management of low back pain with or without sciatica.

In addition, the ACP 17 found no effect of ultrasound in decreasing pain or improving function in patients with chronic low back pain.

Other Therapies and Low Back Pain:

ACP 17 found that clinicians should consider recommending low level laser therapy, Tai Chi, yoga and cognitive-behavioral therapy to patients with chronic low back pain before trying pharmacological intervention.

Furthermore, the ACP 17 does not support the utilization of Pilates or kin tape in patients with acute, subacute or chronic low back pain. The ACP 17 and NICE 16 do not recommend spinal traction in patients with low back pain

Summary of Treatments for Low Back Pain:

All 3 CPG’s state that medical doctors and healthcare practitioners should recommend chiropractic adjustments as a first line therapy in acute and subacute low back pain patients.

Other low back pain treatments that should be recommended before pharmacological intervention include: acupuncture, exercise, heat, soft tissue therapy (massage), low-level laser therapy and other psychological interventions.

Finally, non-invasive therapies that have been shown to be ineffective include electrotherapy, kin tape and ultrasound.

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