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## Complete Summary

#### GUIDELINE TITLE

Diagnosis and treatment of low back pain: A joint clinical practice
guideline from the American College of Physicians and the American Pain
Society.

#### BIBLIOGRAPHIC SOURCE(S)

Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK,
Clinical Efficacy Assessment Subcommittee of the American College of
Physicians, American College of Physicians, American Pain Society Low
Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a
joint clinical practice guideline from the American College of
Physicians and the American Pain Society. Ann Intern Med 2007 Oct
2;147(7):478-91.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17909209)

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute and chronic low back pain not associated with major trauma

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Treatment

#### CLINICAL SPECIALTY

Chiropractic\
Family Practice\
Internal Medicine\
Neurological Surgery\
Neurology\
Orthopedic Surgery\
Pediatrics\
Physical Medicine and Rehabilitation\
Radiology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To present the available evidence for evaluation and management of acute
and chronic low back pain in primary care settings

#### TARGET POPULATION

Adults with acute and chronic low back pain not associated with major
trauma

**Note**: Children or adolescents with low back pain; pregnant women;
patients with low back pain from sources outside the back (nonspinal low
back pain); fibromyalgia or other myofascial pain syndromes; and
thoracic or cervical back pain are not included.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  History, including assessment psychological risk factors

2.  Physical examination

3.  Diagnostic imaging and testing, including magnetic resonance imaging
    or computed tomography

**Treatment/Management**

1.  Patient education on back care and self care

2.  Acetaminophen or nonsteroidal anti-inflammatory drugs

3.  Intensive interdisciplinary rehabilitation

4.  Spinal manipulation

5.  Exercise therapy

6.  Acupuncture

7.  Massage therapy

8.  Yoga

9.  Cognitive behavioral therapy

10. Progressive relaxation

See appendix tables 5 and 6 in the original guideline document for
levels of evidence and summary grades for other noninvasive
interventions in patients with acute or chronic/subacute low back pain.

#### MAJOR OUTCOMES CONSIDERED

-   Sensitivity and specificity of diagnostic tests

-   Pain reduction

-   Frequency of side effects from medication

-   Cost

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The literature search for this guideline included studies from MEDLINE
(1966 through November 2006), the Cochrane Database of Systematic
Reviews, the Cochrane Central Register of Controlled Trials, and EMBASE.
The literature search included all English-language articles reporting
on randomized, controlled trials of nonpregnant adults (age \>18 years)
with low back pain (alone or with leg pain) of any duration that
evaluated a target medication and reported at least 1 of the following
outcomes: back-specific function, generic health status, pain, work
disability, or patient satisfaction.

#### NUMBER OF SOURCE DOCUMENTS

**Nonpharmacologic**

Searches for systematic reviews of low back pain identified 1292
abstracts. Of these, 96 reviews seemed potentially relevant and were
retrieved. A total of 40 nonpharmacologic systematic reviews met
inclusion criteria; 59 systematic reviews were excluded, most frequently
because they met the criteria for outdated reviews or did not report
results for patients with low back pain. Five recent, large (\>200
patients) trials of acupuncture and spinal manipulation or exercise
supplemented the systematic reviews. No systematic reviews were
identified for interferential therapy, low-level laser therapy,
shortwave diathermy, ultrasonography, or yoga for low back pain. Five
(5) searches for randomized trials of these interventions identified 532
citations. Three (3) trials of interferential therapy, 7 trials of
low-level laser therapy, 3 trials of shortwave diathermy, 3 trials of
ultrasonography, and 3 trials of yoga met inclusion criteria.

**Pharmacologic**

Searches for systematic reviews of low back pain identified 1292
abstracts for review. An additional 1586 citations were identified
through 8 searches for randomized trials of acetaminophen, celecoxib,
aspirin, the serotonin-norepinephrine reuptake inhibitors duloxetine and
venlafaxine, antiepileptic drugs, opioids, tramadol, and systemic
corticosteroids.

In all, 21 reviews appeared potentially relevant and were retrieved.
Seven outdated reviews of nonsteroidal anti-inflammatory drugs (NSAIDs),
antidepressants, and multiple drugs were excluded. Also excluded were 3
reviews that did not clearly use systematic methods and 4 systematic
reviews that evaluated target medications but did not report results
specifically for patients with low back pain. Seven systematic reviews
of NSAIDs, antidepressants, skeletal muscle relaxants, and
benzodiazepines, or multiple medications were included.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Grading of Quality of Evidence**

*High Quality Evidence*

Evidence obtained from one or more well-designed and well-executed
randomized control trials (RCTs) yielding consistent directly applicable
results.

*Moderate Quality Evidence*

Evidence obtained from RCTs with important limitations. For example,
biased assessment of the treatment effect, large loss of follow-up,
unblended study, unexplained heterogeneity (even if it is generated from
rigorous RCTs), indirect evidence originating from similar (but not
identical) populations of interest, and RCTs with a very small N or
observed very few events. Evidence from well designed controlled trials
without randomization, well-designed cohort or case control analytic
studies, multiple time series with or without intervention also fall in
this category.

*Low Quality Evidence*

Evidence obtained from observational studies. However, on very rare
occasions, it can be classified as moderate or even high. For example,
when they yield extremely large and consistent estimates of the
magnitude of a treatment effect or when all plausible biases from
observational studies may be working to underestimate an apparent
treatment effect.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Information about study design, population characteristics,
interventions, outcomes, and adverse events was abstracted. The Oxman
criteria for systematic reviews and the Cochrane Back Review Group
criteria for individual trials were used to grade methodological
quality.

The primary source of data was systematic reviews. Non--English-language
trials were included only if they were included in English-language
systematic reviews.

The evidence in this guideline was first evaluated by the American
College of Physicians (ACP)/American Pain Society (APS) panel by using a
system adopted from the U.S. Preventive Services Task Force for grading
strength of evidence, estimating magnitude of benefits, and assigning
summary ratings (see Appendix Tables 2, 3, and 4 of the original
guideline document). The evidence was independently reviewed by the
ACP\'s Clinical Efficacy Assessment Subcommittee. The ratings for
individual low back pain interventions discussed in this guideline are
summarized in Appendix Table 5 of the original guideline document for
acute low back pain (\<4 weeks\' duration) and in Appendix Table 6 of
the original guideline document for chronic/subacute low back pain (\>4
weeks\' duration). This guideline considered interventions to have
\"proven\" benefits only when they were supported by at least
fair-quality evidence and were associated with at least moderate
benefits (or small benefits but no significant harms, costs, or
burdens).

See the background papers by Chou & Hoyt Huffman for more details of the
methods to analyze the evidence (see \"Availability of Companion
Documents\" field).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The American College of Physicians (ACP) and the American Pain Society
(APS) convened a multidisciplinary panel of experts to develop the key
questions and scope used to guide the evidence report, review its
results, and formulate recommendations.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grading of Guideline Recommendations\***

*Strong Recommendation*

Benefits clearly outweigh risks and burden OR risks and burden clearly
outweigh benefits.

*Weak Recommendation*

Benefits are finely balanced with risks and burden or appreciable
uncertainty exists about magnitude of benefits and risks.

*I or Insufficient Recommendation*

The evidence is insufficient to recommend for or against routinely
providing the service. Evidence is conflicting, of poor quality, or
lacking and the balance of benefits and harms cannot be determined.

  -----------------------------------------------------------------------
  **Quality of      **Strength of              
  Evidence**        Recommendation**           
  ----------------- -------------------------- --------------------------
                    Benefits clearly outweigh  Benefits finely balanced
                    risks and burden\          with risks and burden
                    OR risks and burden        
                    clearly outweigh benefits  

  High              Strong                     Weak

  Moderate          Strong                     Weak

  Low               Strong                     Weak

  Insufficient      **I** recommendation       
  evidence to                                  
  determine net                                
  benefits or risks                            
  -----------------------------------------------------------------------

**Note**: Adopted from the classification developed by the Grading of
Recommendations, Assessment, Development, and Evaluation (GRADE)
Workshop.

#### COST ANALYSIS

Published cost analyses were reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

This guideline was approved by the American College of Physicians Board
of Regents on July 14, 2007 and American Pain Society Board Executive
Committee on July 18, 2007.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The strength of evidence (High, Moderate, Low) and the strength of the
recommendations (Strong or Weak) are defined at the end of the \"Major
Recommendations\" field.

**Evaluation of Low Back Pain**

**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, or back 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
(***strong recommendation, 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 evaluate patients 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***).

**Treatment of Low Back Pain**

**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 should
consider 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 are acetaminophen or
nonsteroidal anti-inflammatory drugs.

**Recommendation 7**: For patients who do not improve with self-care
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, spinal manipulation, yoga, cognitive-behavioral therapy, or
progressive relaxation (***weak recommendation, moderate-quality
evidence***).

Note: See appendix tables 5 and 6 in the original guideline document for
levels of evidence and summary grades for other noninvasive
interventions in patients with acute or chronic/subacute low back pain.

**[Definitions]{.underline}**:

**Grading of Quality of Evidence**

*High Quality Evidence*

Evidence obtained from one or more well-designed and well-executed
randomized control trials (RCTs) yielding consistent directly applicable
results.

*Moderate Quality Evidence*

Evidence obtained from RCTs with important limitations. For example,
biased assessment of the treatment effect, large loss of follow-up,
unblended study, unexplained heterogeneity (even if it is generated from
rigorous RCTs), indirect evidence originating from similar (but not
identical) populations of interest, and RCTs with a very small N or
observed very few events. Evidence from well designed controlled trials
without randomization, well-designed cohort or case control analytic
studies, multiple time series with or without intervention also fall in
this category.

*Low Quality Evidence*

Evidence obtained from observational studies. However, on very rare
occasions, it can be classified as moderate or even high. For example,
when they yield extremely large and consistent estimates of the
magnitude of a treatment effect or when all plausible biases from
observational studies may be working to underestimate an apparent
treatment effect.

**Grading of Guideline Recommendations\***

*Strong Recommendation*

Benefits clearly outweigh risks and burden OR risks and burden clearly
outweigh benefits.

*Weak Recommendation*

Benefits are finely balanced with risks and burden or appreciable
uncertainty exists about magnitude of benefits and risks.

*I or Insufficient Recommendation*

The evidence is insufficient to recommend for or against routinely
providing the service. Evidence is conflicting, of poor quality, or
lacking and the balance of benefits and harms cannot be determined.

  -----------------------------------------------------------------------
  **Quality of      **Strength of              
  Evidence**        Recommendation**           
  ----------------- -------------------------- --------------------------
                    Benefits clearly outweigh  Benefits finely balanced
                    risks and burden\          with risks and burden
                    OR risks and burden        
                    clearly outweigh benefits  

  High              Strong                     Weak

  Moderate          Strong                     Weak

  Low               Strong                     Weak

  Insufficient      **I** recommendation       
  evidence to                                  
  determine net                                
  benefits or risks                            
  -----------------------------------------------------------------------

**Note**: Adopted from the classification developed by the Grading of
Recommendations, Assessment, Development, and Evaluation (GRADE)
Workshop.

#### CLINICAL ALGORITHM(S)

The original guideline document contains clinical algorithms for:

-   Initial evaluation of low back pain

-   Management of low back pain

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting most recommendations is specifically
stated (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Accurate diagnosis and effective treatment of low back pain

#### POTENTIAL HARMS

-   Acetaminophen is associated with asymptomatic elevations of
    aminotransferase levels at dosages of 4 grams per deciliter (g/d)
    (the upper limit of U.S. Food and Drug Administration--\[FDA\]
    approved dosing) even in healthy adults, although the clinical
    significance of these findings are uncertain. Nonselective
    nonsteroidal anti-inflammatory drugs (NSAIDs) are more effective for
    pain relief than is acetaminophen, but they are associated with
    well-known gastrointestinal and renovascular risks. In addition,
    there is an association between exposure to
    cyclooxygenase-2--selective or most nonselective NSAIDs and
    increased risk for myocardial infarction. Clinicians should
    therefore assess cardiovascular and gastrointestinal risk factors
    before prescribing NSAIDs and recommend the lowest effective doses
    for the shortest periods necessary. Clinicians should also remain
    alert for new evidence about which NSAIDs are safest and consider
    strategies for minimizing adverse events in higher-risk patients who
    are prescribed NSAIDs (such as co-administration with a proton-pump
    inhibitor).

-   Because of substantial risks of opioid analgesics or tramadol,
    including aberrant drug-related behaviors with long-term use in
    patients vulnerable or potentially vulnerable to abuse or addiction,
    potential benefits and harms of opioid analgesics should be
    carefully weighed before starting therapy.

-   Skeletal muscle relaxants are associated with central nervous system
    adverse effects (primarily sedation). There is no compelling
    evidence that skeletal muscle relaxants differ in efficacy or
    safety. Because skeletal muscle relaxants are not pharmacologically
    related, however, risk--benefit profiles could in theory vary
    substantially. For example, carisoprodol is metabolized to
    meprobamate (a medication associated with risks for abuse and
    overdose), dantrolene carries a black box warning for potentially
    fatal hepatotoxicity, and both tizanidine and chlorzoxazone are
    associated with hepatotoxicity that is generally reversible and
    usually not serious.

-   Benzodiazepines seem similarly effective to skeletal muscle
    relaxants for short-term pain relief but are also associated with
    risks for abuse, addiction, and tolerance.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The authors of this article are responsible for its contents,
    including any clinical or treatment recommendations. The views and
    opinions expressed are those of Veterans Affairs/Department of
    Defense Evidence-Based Practice Workgroup members and do not
    necessarily reflect official Veterans Health Affairs or Department
    of Defense positions.

-   Clinical practice guidelines are \"guides\" only and may not apply
    to all patients and all clinical situations. Thus, they are not
    intended to override clinicians\' judgment. All American College of
    Physicians (ACP) clinical practice guidelines are considered
    automatically withdrawn or invalid 5 years after publication or once
    an update has been issued.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Patient Resources\
Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK,
Clinical Efficacy Assessment Subcommittee of the American College of
Physicians, American College of Physicians, American Pain Society Low
Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a
joint clinical practice guideline from the American College of
Physicians and the American Pain Society. Ann Intern Med 2007 Oct
2;147(7):478-91.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17909209)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2007 Oct 2

#### GUIDELINE DEVELOPER(S)

American College of Physicians - Medical Specialty Society\
American Pain Society - Professional Association

#### SOURCE(S) OF FUNDING

American College of Physicians

American Pain Society

#### GUIDELINE COMMITTEE

Clinical Efficacy Assessment Subcommittee of the American College of
Physicians/American Pain Society Low Back Pain Guideline Panel

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: 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

*Clinical Efficacy Assessment Subcommittee of the American College of
Physicians*: Douglas K. Owens, MD, MS (Chair)\*; Donald E. Casey Jr.,
MD, MPH, MBA\*\*; J. Thomas Cross Jr., MD, MPH\*\*; Paul Dallas, MD;
Nancy C. Dolan, MD; Mary Ann Forciea, MD; Lakshmi Halasyamani, MD;
Robert H. Hopkins Jr., MD; and Paul Shekelle, MD, PhD\*\*

*Co-chairs and members of the American College of Physicians/American
Pain Society Low Back Pain Guidelines Panel*: John D. Loeser, MD
(Cochair); Douglas K. Owens, MD, MS (Co-chair); Richard W. Rosenquist,
MD (Co-chair); Paul M. Arnstein, RN, PhD, APRN-BC; Steven Julius Atlas,
MD, MPH; Jamie Baisden, MD; Claire Bombardier, MD; Eugene J. Carragee,
MD; John Anthony Carrino, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA;
Daniel Cherkin, PhD; Penney Cowan; J. Thomas Cross Jr., MD, MPH; Anthony
Delitto, PhD, MHS; Robert J. Gatchel, PhD, ABPP; Lee Steven Glass, MD,
JD; Martin Grabois, MD; Timothy R. Lubenow, MD; Kathryn Mueller, MD,
MPH; Donald R. Murphy, DC, DACAN; Marco Pappagallo, MD; Kenneth G. Saag,
MD, MSc; Paul G. Shekelle, MD, PhD; Steven P. Stanos, DO; and Eric
Martin Wall, MD, MPH

*Participants from the Veterans Affairs/Department of Defense
Evidence-Based Practice Workgroup*: Carla L. Cassidy, ANP, MSN; COL Leo
L. Bennett, MC, MD, MPH; John Dooley, MD; LCDR Leslie Rassner, MD;
Robert Ruff, MD, PhD; and Suzanne Ruff, MHCC

\*Also a co-chair of the American College of Physicians/American Pain
Society Low Back Pain Guidelines Panel

\*\*Also members of the American College of Physicians/American Pain
Society Low Back Pain Guidelines Panel

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

**Honoraria**: R. Chou (Bayer Healthcare Pharmaceuticals). **Grants
received**: V. Snow (Centers for Disease Control and Prevention, Agency
for Healthcare Research and Quality, Novo Nordisk, Pfizer Inc., Merck &
Co. Inc., Bristol-Myers Squibb, Atlantic Philanthropics,
Sanofi-Pasteur).

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Physicians (ACP) Web
site](http://www.annals.org/cgi/reprint/147/7/478.pdf).

Print copies: Available from the American College of Physicians (ACP),
190 N. Independence Mall West, Philadelphia PA 19106-1572.

Also available for Personal Digital Assistant (PDA) download from the
[American College of Physicians (ACP) Web
site](http://www.acponline.org/pda/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Chou R, Huffman LH; American Pain Society; American College of
    Physicians. Nonpharmacologic therapies for acute and chronic low
    back pain: a review of the evidence for an American Pain
    Society/American College of Physicians clinical practice guideline.
    Ann Intern Med. 2007 Oct 2;147(7):492-504. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Physicians (ACP) Web
    site](http://www.annals.org/cgi/reprint/147/7/492.pdf).

-   Chou R, Huffman LH; American Pain Society; American College of
    Physicians. Medications for acute and chronic low back pain: a
    review of the evidence for an American Pain Society/American College
    of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct
    2;147(7):505-14. Available in Portable Document Format (PDF) from
    the [American College of Physicians (ACP) Web
    site](http://www.annals.org/cgi/reprint/147/7/505.pdf).

Print copies: Available from the American College of Physicians (ACP),
190 N. Independence Mall West, Philadelphia PA 19106-1572.

#### PATIENT RESOURCES

The following is available:

-   Diagnosis and treatment of low back pain: recommendations from the
    American College of Physicians/American Pain Society. Ann Int Med
    2007 Oct 2;147(7):I-45.

Available in Portable Document Format (PDF) from the [Annals of Internal
Medicine Web site](http://www.annals.org/cgi/reprint/147/7/I-45.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI Institute on December 10, 2007.
The information was verified by the guideline developer on December 13,
2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008