In the last week, the American College of Physicians (ACP) published new guidelines for the care of low back pain. The guidelines are their recommendations based on the available research on the subject. The most important thing to remember is this information is designed for physicians to assist with the management of particular problems.
However, the recommendations are only as good as the knowledge and ability of those who put together the data. These guidelines provide some reasonable information, but they do not contain significant information from board certified pain practitioners who are treating the problem every day. The reason why we need to highlight this issue is because the guidelines attack back pain as if it has one single cause, which we know is not always the case.
Where The Guidelines Fall Short
For the pain practitioner and as it should be for every doctor, pain is one symptom, and the low back region covers a large number of structures that can cause problems. A diagnosis is based on a history of symptoms, a physical exam, and then the application of medical knowledge to determine the causes related to the problem.
The new guidelines move away from coming up with a specific diagnosis of the pain problem. They also recommend any number of treatments that have a limited scientific basis, like acupuncture and spine manipulation, and they did not address medications very well. Muscle relaxants are recommended as well as duloxetine (Cymbalta), while many more common medications like Celebrex were not studied. The guidelines also recommend many psychological therapies and exercises that are not readily available or not covered by insurance.
Treating Back Pain
Guidelines are meant to serve as a road map to help practitioners establish appropriate treatment for patients. The new ACP guidelines lack instruction on establishing appropriate diagnoses and true evidence-based treatment alternatives. The guidelines appear to be the answer to what is the cheapest way to get a complex problem patient out of an office. They recommend everything but appropriate diagnostic testing, referrals to experts in pain, or advice on all the non-opioid options available and when to use them. These guidelines made headlines in the national news, but they surely are not truly newsworthy.
Acute, subacute, and chronic low back pain all have different meanings and can be quite well treated with a variety of interventions. It is true that most acute back pain is short lived, but primary care physicians should learn much more about all the causes and treatments available. For the patient, telling them “No matter what you do, it usually gets better in a month,” as these guidelines suggest, is poor quality care. No patient wants to be sidelined for a month, and they want to have a definitive diagnosis and treatment plan. These guidelines fall short of offering the best care for each patient with back pain.
Thomas Cohn, MD
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