New Clinical Guidelines for Low Back Pain Say “No!” to Drugs


With an opioid epidemic raging in the United States and a wave of obesity and sedentary living that promotes chronic low back pain, clinicians are seeking ways to treat and resolve back pain that are efficacious, safe and effective. In 2017, the American College of Physicians (ACP) updated its Guidelines for treating low back pain, effectively putting drugs on the back burner.

How the Guidelines Were Determined

The authors of the ACP Guidelines for treating low back pain reviewed randomized controlled studies conducted and published through November 2016 regarding the efficacy of pharmacologic and non-pharmacologic treatments for low back pain. Using their own grading scale for quality of evidence, they looked at treatments for acute (less than 4 weeks), subacute (4 to 12 weeks) and chronic (longer than 12 weeks) low back pain cases. Based on evidence gleaned from the review, they then made recommendations for treatment.

Who the Guidelines Are For

The target audience for the Guidelines includes all clinicians who treat patients with low back pain. The target patient population includes adults with acute, subacute, or chronic low back pain, or symptomatic spinal stenosis. It does not include children or adolescents, pregnant females, or patients whose pain stems from non-spinal causes. The Guidelines are not intended to address thoracic or cervical spinal pain.

What the New Guidelines Recommend

After looking at a plethora of treatments, both pharmacological and non-pharmacological, the authors came up with three subgroups of guidelines for treating low back pain:

  1. Patients with acute or subacute low back pain: Most cases of acute and subacute low back pain improve over time, regardless of treatment. The Guidelines recommend non-pharmacologic treatments including superficial heat, massage, acupuncture, and/or spinal manipulation. If a patient wants a pharmacologic treatment, the ACP recommends NSAIDs like ibuprofen or naproxen, and muscle relaxants. They discourage the use of opioid pain medications due to their potential for addiction.
  1. Patients with chronic low back pain: To treat chronic low back pain, the Guidelines recommend non-pharmacologic treatment, including exercise, multi-modal rehabilitation, acupuncture, stress reduction, tai chi, yoga, motor control exercises, relaxation, biofeedback, laser therapy, operant conditioning therapy, cognitive behavioral therapy, and spinal manipulation.
  1. Patients with chronic low back pain who do not respond to non-pharmacologic therapy: Once non-pharmacologic treatment options have been exhausted without success, pharmacologic treatment should begin with NSAIDs as a first line of treatment. As second-line pharmacologic treatments, Tramadol (a narcotic pain medication) or Duloxetine (a nerve pain and anti-depressant medication) may be considered. Opioids should be a last resort treatment, and only if the potential benefits outweigh the risks. Clinicians should discuss the risks and potential benefits with patients before prescribing opioids.

Back Pain Treatment in NYC

Whether your low back pain is acute, subacute or chronic, the back pain specialists at NYDNRehab have the expertise and technology to accurately diagnose and treat it. We are dedicated to getting to the source of your pain, not just treating the symptoms. If you are tired of low back pain and want to improve your quality of life, contact NYDNRehab today, to get rid of pain and get on with living.


Qaseem, Amir, et al. “Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians.” Annals of internal medicine 166.7 (2017): 514-530.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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