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Veterans Health Administration / Department of DefensePrimary Care2022advanced

Diagnosis and Treatment of Low Back Pain (LBP)

Published by Department of Veterans Affairs and Department of Defense · GRADE

39Recommendations
224References
11Tables
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Summary

AI-generated

This clinical practice guideline updates the 2017 VA/DoD framework for the diagnosis and treatment of acute, subacute, and chronic low back pain in adults. Emphasizing a biopsychosocial model and shared decision-making, the guideline strongly recommends against routine imaging for acute LBP without red flags. It promotes non-pharmacologic treatments like structured exercise, cognitive behavioral therapy, and spinal manipulation over invasive therapies, and expressly advises against the use of opioids and benzodiazepines for LBP management.

low back painVA/DoDprimary careopioidsbenzodiazepinesexercise therapycognitive behavioral therapyguidelines

Key Takeaways

  • 1
    Conduct a focused history and physical exam to identify red flags for serious underlying pathology.
  • 2
    Avoid routine diagnostic imaging for acute low back pain unless progressive neurologic deficits or red flags are present.
  • 3
    Use a shared decision-making process to develop individualized care plans.
  • 4
    Prioritize active, non-pharmacologic interventions such as clinician-directed exercise and cognitive behavioral therapy.
  • 5
    Opioids, benzodiazepines, and systemic corticosteroids are strongly suggested against for the management of low back pain.

What's New in This Version

The 2022 update implements a stricter GRADE methodology, changing the strength of numerous recommendations compared to the 2017 version. It adds new assessments for complementary and integrative health approaches, ortho-biologics (PRP/stem cells), neuromodulation, technology-based self-management, and novel pharmacotherapies like monoclonal antibodies. Specific recommendations around opioids for acute LBP were also removed/adjusted based on current evidence.

Key Recommendations

Evaluation and Diagnostic Approach

  • 1

    For patients with low back pain, we recommend the history and physical examination include evaluation for progressive or otherwise serious neurologic deficits and other red flags associated with serious underlying pathology.

    Strong forEvidence: Very lowDiagnosis
  • 2

    For patients with low back pain, we recommend diagnostic imaging and appropriate laboratory testing when neurologic deficits are progressive or otherwise serious or when other red flags are present.

    Strong forEvidence: Very lowDiagnosis
  • 3

    For patients with acute low back pain, without focal neurologic deficits or other red flags, we recommend against routinely obtaining imaging studies or performing invasive diagnostic tests.

    Strong againstEvidence: ModerateDiagnosis
  • 4

    For patients with low back pain, we suggest assessing psychosocial factors and using predictive screening instruments to inform treatment planning.

    Weak forEvidence: Very lowDiagnosis
  • 5

    For patients with low back pain, with or without radicular symptoms, there is insufficient evidence to recommend for or against specific physical exam maneuvers to assist in the diagnosis of facet or sacroiliac joint pain, or a lumbar/lumbo-sacral radiculopathy.

    Neither for nor againstEvidence: Very lowDiagnosis

Patient Education and Self-care

  • 6

    For patients with low back pain, there is insufficient evidence to recommend for or against pain neuroscience education, clinician-directed education with patient-led goal setting, or back school.

    Neither for nor againstEvidence: Very lowTreatment
  • 7

    For the self-management of low back pain, there is insufficient evidence to recommend for or against technology-based modalities.

    Neither for nor againstEvidence: Very lowTreatment

Non-pharmacologic and Non-invasive Therapy

  • 8

    For patients with chronic low back pain, we suggest cognitive behavioral therapy.

    Weak forEvidence: LowTreatment
  • 9

    For patients with low back pain, we suggest a structured clinician-directed exercise program.

    Weak forEvidence: Very lowTreatment
  • 10

    For patients with chronic low back pain, we suggest spinal mobilization/manipulation.

    Weak forEvidence: LowTreatment
  • 11

    For patients with acute low back pain, there is insufficient evidence to recommend for or against spinal mobilization/manipulation.

    Neither for nor againstEvidence: Very lowTreatment
  • 12

    For patients with chronic low back pain, there is insufficient evidence to recommend for or against mindfulness-based stress reduction.

    Neither for nor againstEvidence: LowTreatment
  • 13

    For patients with low back pain, there is insufficient evidence to recommend for or against lumbar supports.

    Neither for nor againstEvidence: Very lowTreatment
  • 14

    For patients with low back pain, with or without radicular symptoms, there is insufficient evidence to recommend for or against mechanical lumbar traction.

    Neither for nor againstEvidence: LowTreatment
  • 15

    For patients with chronic low back pain, there is insufficient evidence to recommend for or against auricular acupressure.

    Neither for nor againstEvidence: LowTreatment
  • 16

    For patients with low back pain, there is insufficient evidence to recommend for or against yoga or qi gong.

    Neither for nor againstEvidence: Very lowTreatment
  • 17

    For patients with low back pain, there is insufficient evidence to recommend for or against cupping, laser therapy, transcutaneous electrical nerve stimulation, and ultrasound.

    Neither for nor againstEvidence: LowTreatment

Pharmacotherapy

  • 18

    For patients with chronic low back pain, we suggest duloxetine.

    Weak forEvidence: ModerateTreatment
  • 19

    For patients with low back pain, we suggest nonsteroidal anti-inflammatory drugs.

    Weak forEvidence: LowTreatment
  • 20

    For patients with low back pain, with or without radicular symptoms, there is insufficient evidence to recommend for or against gabapentin or pregabalin.

    Neither for nor againstEvidence: Very lowTreatment
  • 21

    For patients with low back pain, there is insufficient evidence to recommend for or against tricyclic antidepressants.

    Neither for nor againstEvidence: Very lowTreatment
  • 22

    For patients with low back pain, there is insufficient evidence to recommend for or against topical preparations.

    Neither for nor againstTreatment
  • 23

    For patients with acute low back pain, there is insufficient evidence to recommend for or against a non-benzodiazepine muscle relaxant for short-term use.

    Neither for nor againstEvidence: LowTreatment
  • 24

    For patients with chronic low back pain, we suggest against offering a non-benzodiazepine muscle relaxant.

    Weak againstEvidence: Very lowTreatment
  • 25

    For patients with low back pain, we suggest against acetaminophen.

    Weak againstEvidence: LowTreatment
  • 26

    For patients with low back pain, we suggest against monoclonal antibodies.

    Weak againstEvidence: Very lowTreatment
  • 27

    For patients with chronic low back pain, we suggest against opioids.

    Weak againstEvidence: LowTreatment
  • 28

    For patients with low back pain, with or without radicular symptoms, we suggest against systemic corticosteroids (oral or intramuscular injection).

    Weak againstEvidence: LowTreatment
  • 29

    For patients with low back pain, we recommend against benzodiazepines.

    Strong againstEvidence: Moderate (acute) / Low (chronic)Treatment

Dietary Supplements

  • 30

    For patients with low back pain, there is insufficient evidence to recommend for or against any specific diet or nutritional, herbal, or homeopathic supplements, cannabis, or cannabinoids.

    Neither for nor againstEvidence: Very lowTreatment

Non-surgical Invasive Therapy

  • 31

    For patients with chronic low back pain, we suggest lumbar medial branch and/or sacral lateral branch radiofrequency ablation.

    Weak forEvidence: ModerateTreatment
  • 32

    For patients with low back pain, there is insufficient evidence to recommend for or against sacroiliac joint injections.

    Neither for nor againstTreatment
  • 33

    For patients with low back pain, we suggest against the injection of corticosteroids for intra-articular facet joint injections and therapeutic medial branch blocks with steroid.

    Weak againstEvidence: Very lowTreatment
  • 34

    For patients with chronic low back pain, we suggest acupuncture.

    Weak forEvidence: LowTreatment
  • 35

    For patients with acute low back pain, there is insufficient evidence to recommend for or against acupuncture.

    Neither for nor againstEvidence: LowTreatment
  • 36

    For patients with low back pain, there is insufficient evidence to recommend for or against ortho-biologics (e.g., platelet-rich plasma, stem cells).

    Neither for nor againstEvidence: LowTreatment
  • 37

    For patients with low back pain, with radicular symptoms, there is insufficient evidence to recommend for or against epidural steroid injections.

    Neither for nor againstEvidence: LowTreatment
  • 38

    For patients with low back pain, we suggest against spinal cord stimulation.

    Weak againstEvidence: LowTreatment

Team Approach

  • 39

    For patients with chronic low back pain, we suggest a multidisciplinary or interdisciplinary program.

    Weak forEvidence: Very lowTreatment

Scope & Objectives

Clinical Topic

Low Back Pain

Objectives

To provide an evidence-based framework for the diagnosis and treatment of patients with acute, subacute, or chronic low back pain with or without neurological symptoms to improve clinical outcomes.

Target Patient Population

Adults (ages 18 years or older) with acute, subacute, or chronic low back pain with or without neurological symptoms.

Diagnostic Criteria

Diagnosis centers on history and physical exam to rule out serious conditions via 'red flags' (e.g., progressive neurological deficits, urinary retention, cancer history, immunosuppression). Psychosocial factors should also be screened using predictive instruments like the STarT Back Tool.

Target Providers

VA and DoD primary care providersCommunity-based cliniciansHealthcare team members caring for patients with LBP

Patient Criteria & Setting

Therapeutic Area

Pain Management

Guideline Scope

DiagnosisTreatmentManagement

Inclusion Criteria

  • Adults ages 18 years or older
  • Acute, subacute, or chronic low back pain
  • With or without neurological symptoms
  • Eligible for care in the VA or DoD healthcare delivery systems

Exclusion Criteria

  • Low back pain from visceral disorders
  • Fracture
  • Cancer
  • Infection
  • Inflammatory arthropathy
  • Pregnant women

Care Settings

Primary careSpecialty care clinicsCommunity-based settings

Special Populations

VeteransActive duty Service MembersDependents

Evidence Grading

System: GRADE

Evidence Distribution

4 SRs, 10 diagnostic cohort studies, 2 SRs, 21 prognostic studiesKQ1
9 SRs, 7 RCTsKQ2
10 SRs, 2 RCTsKQ3
4 SRs, 15 RCTsKQ4
2 SRs, 4 RCTsKQ5
1 SR, 2 RCTsKQ6
1 SRKQ7
10 SRs, 5 RCTs, 1 randomized crossover trialKQ8
1 SR, 15 RCTsKQ9
3 SRs, 5 RCTsKQ10
2 RCTsKQ11
2 SRs, 6 RCTsKQ12
143total_studies_included

Evidence Levels

LowLow confidence in the quality of the evidence.
HighHigh confidence in the quality of the evidence. Further research is very unlikely to change confidence in the estimate of effect.
ModerateModerate confidence in the quality of the evidence.
Very lowVery low confidence in the quality of the evidence. Any estimate of effect is very uncertain.

Recommendation Strength

Weak forWe suggest. The desirable effects of an intervention likely outweigh its undesirable effects.
Strong forWe recommend. The desirable effects of an intervention outweigh its undesirable effects.
Weak againstWe suggest against. The undesirable effects of an intervention likely outweigh its desirable effects.
Strong againstWe recommend against. The undesirable effects of an intervention outweigh its desirable effects.
Neither for nor againstThere is insufficient evidence to recommend for or against.

Safety & Contraindications

Contraindications

  • Systemic corticosteroids
  • Benzodiazepines
  • Opioids
  • Acetaminophen
  • Monoclonal antibodies

Monitoring Guidance

Assess patient response to implemented treatments regularly. If LBP is not improved or resolved, re-evaluate for red flags or progressive neurological deficits, and consider functional deficits for multidisciplinary/interdisciplinary programs or specialist referral.

Authors & Contributors

The Diagnosis and Treatment of Low Back Pain Work Group

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinaryPatient involvementDrug interactions discussed

Learning Context

Difficulty

advanced

Learning Paths

Low Back PainEvidence-Based PracticeClinical GuidelinesPain ManagementPrimary CareOrthopedicsRehabilitation