Low Back Pain: What the Medical Guidelines Actually Recommend First

Short answer: the American College of Physicians’ guideline on low back pain gives a strong recommendation to start with non-drug care, for new pain and for long-term pain alike. The hands-on spinal care chiropractors deliver is named on that list, next to heat, massage, acupuncture, exercise and yoga. Opioids come last, only after everything else has failed. Every source in this article is a medical journal, not a chiropractic one.

Back pain is one of the most common reasons anyone sees a doctor. So it’s worth knowing what medicine’s own guidelines say about where to start.

What the guideline says

In 2017 the American College of Physicians (ACP) published its guideline on low back pain in the Annals of Internal Medicine. Its three recommendations, in plain language:

1. New pain (under 12 weeks): most people get better over time whatever they do. Start with non-drug options such as superficial heat, massage, acupuncture or spinal manipulation (that is the guideline’s term for the hands-on spinal care we deliver). Strong recommendation.
2. Long-term pain: start with non-drug options again: exercise, rehabilitation, acupuncture, mindfulness, tai chi, yoga, spinal manipulation and others. Strong recommendation.
3. Medication: only if the above isn’t enough. Opioids only for people who have failed the other options, and only when the benefits outweigh the risks.

What actually happened in practice

A study in JAMA Internal Medicine looked at nearly 24,000 US back-pain visits between 1999 and 2010, representing about 440 million visits. Over those years:

• opioid prescriptions rose from 19.3% to 29.1% of visits
• the simpler pain medicines the guidelines of the time recommended fell from 36.9% to 24.5%
• CT and MRI scans rose from 7.2% to 11.3%
• referrals to physiotherapy stayed flat, at about 20%

The authors’ own conclusion was that back pain was increasingly being managed with care that did not follow the guidelines. That study ends in 2010, before the 2017 guideline, but the advice to avoid early opioids and unnecessary scans was already there in the guidelines of its time.

Where chiropractic care fits

A 2020 review in Pain Medicine pooled six studies of people with spinal pain. Those who saw a chiropractor had 64% lower odds of being prescribed an opioid.

The honest part

• Strong recommendation, low-quality evidence. The ACP’s recommendation is strong, but it rated the evidence for spinal manipulation specifically as low quality. Both are true.
• The guideline names the technique, not the profession. Osteopaths and some physiotherapists deliver versions of it too.
• The 64% is an association, not proof. All six studies were observational, and they disagreed a lot with each other. People who choose a chiropractor may simply be people who never wanted an opioid in the first place.

What doesn’t change: hands-on spinal care isn’t on the fringe of back pain care. It’s in the guideline.

When to see a doctor first

Go to A&E or call 112 if back pain comes with loss of bladder or bowel control, numbness around the groin or inner thighs, or weakness in the legs that is getting worse. See your doctor promptly if you have a fever, unexplained weight loss, a history of cancer, or pain that started after a serious fall or accident. These aren’t chiropractic cases, and we’ll tell you so.

What we do at illumINNATE

We start with a history, an exam and an INSiGHT nervous-system scan, then explain what we found before we adjust anything. You’ll leave with the adjustment and the movement to do at home, because the guideline is right that staying active matters. Read more about back pain care in Barcelona and sciatica.

Frequently asked questions

Do medical guidelines recommend chiropractic for low back pain? The American College of Physicians’ 2017 guideline strongly recommends starting with non-drug care and names spinal manipulation, the hands-on spinal care chiropractors deliver, among the options for both new and long-term back pain. It rates the evidence for it as low quality.

Should I get an MRI for back pain? Most back pain doesn’t need a scan to start with. Guidelines reserve imaging for warning signs or for pain that doesn’t improve. If your history or exam suggests a scan, we’ll refer you.

Can I see a chiropractor while taking pain medication? Yes. Tell us what you take. Never stop or change medication without talking to your doctor.

How many visits will I need? It depends on how long you’ve had the pain and what your exam shows. We give you a clear plan after the first assessment, not before.

The sources

• Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 2017. PubMed
• Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Internal Medicine, 2013. PubMed
• Corcoran KL, Bastian LA, Gunderson CG, et al. Association between chiropractic use and opioid receipt among patients with spinal pain: a systematic review and meta-analysis. Pain Medicine, 2020. PubMed

Living with back pain? Book an assessment and start where the guideline says to.