Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain

Publication Date: April 1, 2017
Last Updated: March 14, 2022


Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants. (SM)

For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation. (SL)

In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (WM)

Recommendation Grading




Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain

Authoring Organization

Publication Month/Year

April 1, 2017

Last Updated Month/Year

June 5, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.

Target Patient Population

Patients with low back pain

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Long term care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D059350 - Chronic Pain, D059408 - Pain Management, D001416 - Back Pain, D010146 - Pain, D059787 - Acute Pain, D017116 - Low Back Pain


nonsteroidal anti-inflammatory drugs (NSAIDs), low back pain, low back pain (LBP), chronic low back pain

Supplemental Methodology Resources

Systematic Review Document, Systematic Review Document


Number of Source Documents
Literature Search Start Date
January 1, 2008
Literature Search End Date
November 1, 2016