Correction: Diagnosis and Treatment of Low Back Pain
Authors: Roger Chou, Paul Shekelle, Amir Qaseem, Douglas K. Owens
Journal: Annals of Internal Medicine (2008)

Corrections5 February 2008Correction: Diagnosis and Treatment of Low Back PainFREERoger Chou, MD, Paul Shekelle, MD, PhD, Amir Qaseem, MD, PhD, MHA, and Douglas K. Owens, MD, MSRoger Chou, MDFrom Oregon Health & Science University, Portland, OR 97239; Veterans Affairs Health Care System and RAND, Santa Monica, CA 90407; American College of Physicians, Philadelphia, PA 19106; Veterans Affairs Palo Alto Health Care System and Stanford University, Stanford, CA 94305., Paul Shekelle, MD, PhDFrom Oregon Health & Science University, Portland, OR 97239; Veterans Affairs Health Care System and RAND, Santa Monica, CA 90407; American College of Physicians, Philadelphia, PA 19106; Veterans Affairs Palo Alto Health Care System and Stanford University, Stanford, CA 94305., Amir Qaseem, MD, PhD, MHAFrom Oregon Health & Science University, Portland, OR 97239; Veterans Affairs Health Care System and RAND, Santa Monica, CA 90407; American College of Physicians, Philadelphia, PA 19106; Veterans Affairs Palo Alto Health Care System and Stanford University, Stanford, CA 94305., and Douglas K. Owens, MD, MSFrom Oregon Health & Science University, Portland, OR 97239; Veterans Affairs Health Care System and RAND, Santa Monica, CA 90407; American College of Physicians, Philadelphia, PA 19106; Veterans Affairs Palo Alto Health Care System and Stanford University, Stanford, CA 94305.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-148-3-200802050-00020 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The recent joint guideline by the American College of Physicians and the American Pain Society on diagnosis and treatment of low back pain (1) and supporting evidence reviews (2, 3) contained several errors. In the original print version of the guideline, the target populations were described incorrectly (1). The word not was inadvertently dropped from a sentence that described populations that were excluded from the guideline. Children or adolescents with low back pain; pregnant women; and 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 covered by the guideline.In response to an online letter to the editor (4), we re-reviewed the evidence on acetaminophen and believe we originally graded the evidence too positively in the guideline and evidence review (1, 2). However, our guideline recommendations remain the same. Acetaminophen for acute low back pain should be rated fair rather than good quality. Acetaminophen for chronic low back pain should be rated fair rather than good quality, and magnitude of benefit should be small rather than moderate. (Appendix Table 5 and Appendix Table 6 in the guideline [1] and Appendix Table 10 and Appendix Table 11 in the evidence review [2] have been corrected.) The Data Synthesis section in the abstract of the evidence review (2) should have read: "We found good evidence that NSAIDs [nonsteroidal anti-inflammatory drugs], skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain) are effective for pain relief. … We also found fair evidence that acetaminophen, opioids, tramadol, benzodiazepines, and gabapentin (for radiculopathy) are effective for pain relief." The Conclusions section of the abstract should have read: "Medications with good evidence of short-term effectiveness for low back pain are NSAIDs, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain)." Similar changes should be applied to the Discussion section. As noted, these changes do not affect Recommendation 6, which suggests acetaminophen as an option for first-line pharmacologic therapy (1). This recommendation is based largely on the safety profile of acetaminophen, when taken in appropriate dosages in patients without a contraindication.Reference 62 in the evidence review on medications for low back pain is incorrect and should refer to a different trial by the same first author (5).In the evidence review on medications, we inverted (calculated 1/relative risk) results for "not achieving pain relief" as reported in a Cochrane review (6) in order to report the likelihood of achieving pain relief. This conversion was incorrect because relative risk is not a symmetric statistic. The evidence review (2) is now corrected, stating results as originally reported in the Cochrane review: For skeletal muscle relaxants, relative risks for not achieving pain relief were 0.80 (95% CI, 0.71 to 0.89) at 2 to 4 days and 0.67 (CI, 0.13 to 3.44) at 5 to 7 days and relative risks for not achieving global efficacy were 0.49 (CI, 0.25 to 0.95) at 2 to 4 days and 0.68 (CI, 0.41 to 1.13) at 5 to 7 days. For benzodiazepines, relative risks were 0.71 (CI, 0.54 to 0.93) for not achieving pain relief at 8 to 14 days and 0.63 (CI, 0.42 to 0.97) for not achieving global efficacy at 8 to 14 days (6). Similarly, in the evidence review on nonpharmacologic therapies (3), results for a systematic review by Kool and colleagues (7) on exercise therapy should state a relative risk of 0.73 (CI, 0.56 to 0.95) for not returning to work after 1 year. None of these corrections affect the conclusions of the evidence reviews or guidelines.All corrections have been applied to the online version of the articles.Roger Chou, MDOregon Health & Science UniversityPortland, OR 97239Paul Shekelle, MD, PhDVeterans Affairs Health Care System and RANDSanta Monica, CA 90407Amir Qaseem, MD, PhD, MHAAmerican College of PhysiciansPhiladelphia, PA 19106Douglas K. Owens, MD, MSVeterans Affairs Palo Alto Health Care System and Stanford UniversityStanford, CA 94305References1. Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. 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;147:478-91. [PMID: 17909209] LinkGoogle Scholar2. Chou R, Huffman LH; American Pain Society. 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;147:505-14. [PMID: 17909211] LinkGoogle Scholar3. Chou R, Huffman LH; American Pain Society. 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;147:492-504. [PMID: 17909210] LinkGoogle Scholar4. Bjordal JM, Lopes-Martin RA, Klovning A, Roland PH, Slordal L. Overviews are methodically inferior to systematic reviews and contribute to myths of effective drugs. Accessed at www.annals.org/cgi/eletters/147/7/505#36904 on 4 December 2007. Google Scholar5. Berry H, Bloom B, Hamilton EB, Swinson DR. Naproxen sodium, diflunisal, and placebo in the treatment of chronic back pain. Ann Rheum Dis. 1982;41:129-32. [PMID: 6462116] CrossrefMedlineGoogle Scholar6. van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev. 2003;:CD004252. [PMID: 12804507] MedlineGoogle Scholar7. Kool J, de Bie R, Oesch P, Knüsel O, van den Brandt P, Bachmann S. Exercise reduces sick leave in patients with non-acute non-specific low back pain: a meta-analysis. J Rehabil Med. 2004;36:49-62. [PMID: 15180219] CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Oregon Health & Science University, Portland, OR 97239; Veterans Affairs Health Care System and RAND, Santa Monica, CA 90407; American College of Physicians, Philadelphia, PA 19106; Veterans Affairs Palo Alto Health Care System and Stanford University, Stanford, CA 94305. 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