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Published by Department of Veterans Affairs and Department of Defense · GRADE
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.
Key Takeaways
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.
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.
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.
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.
For patients with low back pain, we suggest assessing psychosocial factors and using predictive screening instruments to inform treatment planning.
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.
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.
For the self-management of low back pain, there is insufficient evidence to recommend for or against technology-based modalities.
For patients with chronic low back pain, we suggest cognitive behavioral therapy.
For patients with low back pain, we suggest a structured clinician-directed exercise program.
For patients with chronic low back pain, we suggest spinal mobilization/manipulation.
For patients with acute low back pain, there is insufficient evidence to recommend for or against spinal mobilization/manipulation.
For patients with chronic low back pain, there is insufficient evidence to recommend for or against mindfulness-based stress reduction.
For patients with low back pain, there is insufficient evidence to recommend for or against lumbar supports.
For patients with low back pain, with or without radicular symptoms, there is insufficient evidence to recommend for or against mechanical lumbar traction.
For patients with chronic low back pain, there is insufficient evidence to recommend for or against auricular acupressure.
For patients with low back pain, there is insufficient evidence to recommend for or against yoga or qi gong.
For patients with low back pain, there is insufficient evidence to recommend for or against cupping, laser therapy, transcutaneous electrical nerve stimulation, and ultrasound.
For patients with chronic low back pain, we suggest duloxetine.
For patients with low back pain, we suggest nonsteroidal anti-inflammatory drugs.
For patients with low back pain, with or without radicular symptoms, there is insufficient evidence to recommend for or against gabapentin or pregabalin.
For patients with low back pain, there is insufficient evidence to recommend for or against tricyclic antidepressants.
For patients with low back pain, there is insufficient evidence to recommend for or against topical preparations.
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.
For patients with chronic low back pain, we suggest against offering a non-benzodiazepine muscle relaxant.
For patients with low back pain, we suggest against acetaminophen.
For patients with low back pain, we suggest against monoclonal antibodies.
For patients with chronic low back pain, we suggest against opioids.
For patients with low back pain, with or without radicular symptoms, we suggest against systemic corticosteroids (oral or intramuscular injection).
For patients with low back pain, we recommend against benzodiazepines.
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.
For patients with chronic low back pain, we suggest lumbar medial branch and/or sacral lateral branch radiofrequency ablation.
For patients with low back pain, there is insufficient evidence to recommend for or against sacroiliac joint injections.
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.
For patients with chronic low back pain, we suggest acupuncture.
For patients with acute low back pain, there is insufficient evidence to recommend for or against acupuncture.
For patients with low back pain, there is insufficient evidence to recommend for or against ortho-biologics (e.g., platelet-rich plasma, stem cells).
For patients with low back pain, with radicular symptoms, there is insufficient evidence to recommend for or against epidural steroid injections.
For patients with low back pain, we suggest against spinal cord stimulation.
For patients with chronic low back pain, we suggest a multidisciplinary or interdisciplinary program.
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
Therapeutic Area
Pain ManagementGuideline Scope
Inclusion Criteria
Exclusion Criteria
Care Settings
Special Populations
System: GRADE
Evidence Distribution
Evidence Levels
Recommendation Strength
Contraindications
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.
Difficulty
advanced
Learning Paths