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Noninvasive Treatments for Low Back Pain
Comparative Effectiveness Reviews, No. 169
Investigators: Roger Chou, MD, FACP, Richard Deyo, MD, MPH, Janna Friedly, MD, Andrea Skelly, PhD, MPH, Robin Hashimoto, PhD, Melissa Weimer, DO, MCR, Rochelle Fu, PhD, Tracy Dana, MLS, Paul Kraegel, MSW, Jessica Griffin, MS, Sara Grusing, BA, and Erika Brodt, BS.
Author Information and AffiliationsStructured Abstract
Objectives:
Low back pain is common, and many pharmacological and nonpharmacological therapies are available. This review examines the evidence on the comparative benefits and harms of noninvasive treatments for low back pain.
Data sources:
A prior systematic review (searches through October 2008), electronic databases (Ovid MEDLINE® and the Cochrane Libraries, January 2008 to April 2015), reference lists, and clinical trials registries.
Review methods:
Using predefined criteria, we selected systematic reviews of randomized trials of pharmacological treatments (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], opioids, skeletal muscle relaxants, benzodiazepines, antidepressants, antiseizure medications, and systemic corticosteroids) and nonpharmacological treatments (psychological therapies, multidisciplinary rehabilitation, spinal manipulation, acupuncture, massage, exercise and related therapies, and various physical modalities) for nonradicular or radicular low back pain that addressed effectiveness or harms versus placebo, no treatment, usual care, a sham therapy, an inactive therapy, or another active therapy. We also included randomized trials that were not in systematic reviews. The quality of included studies was assessed, data were extracted, and results were summarized qualitatively based on the totality of the evidence.
Results:
Of the 2,545 citations identified at the title and abstract level, a total of 156 publications were included. Most trials enrolled patients with pain symptoms of at least moderate intensity (e.g., >5 on a 0- to 10-point numeric rating scale for pain). Across interventions, pain intensity was the most commonly reported outcome, followed by back-specific function. When present, observed benefits for pain were generally in the small (5 to 10 points on a 0- to 100-point visual analog scale or 0.5 to 1.0 points on a 0- to 10-point numeric rating scale) to moderate (10 to 20 points) range. Effects on function were generally smaller than effects on pain; in some cases, there were positive effects on pain but no effects on function, and fewer studies measured function than pain. Benefits were mostly measured at short-term followup. For acute low back pain, evidence suggested that NSAIDs (strength of evidence [SOE]: low to moderate), skeletal muscle relaxants (SOE: moderate), opioids (SOE: low), exercise (SOE: low), and superficial heat (SOE: moderate) are more effective than placebo, no intervention, or usual care, and that acetaminophen (SOE: low) and systemic corticosteroids (SOE: low) are no more effective than placebo. For chronic low back pain, effective therapies versus placebo, sham, no treatment, usual care, or wait list are NSAIDs, opioids, tramadol, duloxetine, multidisciplinary rehabilitation, acupuncture, and exercise (SOE: moderate) and benzodiazepines, psychological therapies, massage, yoga, tai chi, and low-level laser therapy (SOE: low); spinal manipulation was as effective as other active interventions (SOE: moderate). Few trials evaluated the effectiveness of treatments for radicular low back pain, but the available evidence found that benzodiazepines, corticosteroids, traction, and spinal manipulation were not effective or were associated with small effects (SOE: low). Relatively few trials directly compared the effectiveness of different medications or different nonpharmacological therapies, or compared pharmacological versus nonpharmacological therapies, and they generally found no clear differences in effects. Pharmacological therapies were associated with increased risk of adverse events versus placebo (SOE: low to moderate). Trials were not designed or powered to detect serious harms from pharmacological therapies. Although rates appeared to be low and there was not an increased risk of serious harms versus placebo, this does not rule out significant risk from some treatments. For nonpharmacological therapies, assessment of harms was suboptimal, but serious harms appeared to be rare (SOE: low).
Conclusions:
A number of pharmacological and nonpharmacological noninvasive treatments for low back pain are associated with small to moderate, primarily short-term effects on pain versus placebo, sham, wait list, or no treatment. Effects on function were generally smaller than effects on pain. More research is needed to understand optimal selection of treatments, effective combinations and sequencing of treatments, effectiveness of treatments for radicular low back pain, and effectiveness on outcomes other than pain and function.
Contents
- Preface
- Investigator Affiliations
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Topic Refinement and Review Protocol
- Literature Search Strategy
- Study Selection
- Data Extraction and Data Management
- Assessing Methodological Quality of Individual Studies
- Assessing Applicability
- Evidence Synthesis and Rating the Body of Evidence
- Grading the Strength of Evidence for Each Key Question
- Peer Review and Public Commentary
- Results
- Results of Literature Searches
- Key Question 1 What are the comparative benefits and harms of different pharmacological therapies for acute or chronic nonradicular low back pain, radicular low back pain, or spinal stenosis? Includes NSAIDs, acetaminophen, opioids, muscle relaxants, antiseizure medications, antidepressants, corticosteroids, and topical/patch-delivered medications
- Key Question 2 What are the comparative benefits and harms of different nonpharmacological noninvasive therapies for acute or chronic nonradicular low back pain, radicular low back pain, or spinal stenosis? Includes but is not limited to multidisciplinary rehabilitation, exercise (various types), physical modalities (ultrasound, transcutaneous electrical nerve stimulation, electrical muscle stimulation, interferential therapy, heat [various forms], and ice), traction tables/devices, back supports/bracing, spinal manipulation, various psychological therapies, acupuncture, massage therapy (various types), yoga, magnets, and low-level lasers
- Discussion
- Conclusions
- References
- Abbreviations
- Appendix A Search Strategies
- Appendix B Inclusion and Exclusion Criteria
- Appendix C Included Studies
- Appendix D Excluded Studies
- Appendix E Data Abstraction
- Appendix F Quality Assessment
- Appendix G Outcome Measures
- Appendix H Strength of Evidence
- Appendix I Abbreviations Used in the Appendixes
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1 . Contract No. 290-2012-00014-I. Prepared by: Pacific Northwest Evidence-based Practice Center, Portland, OR
Suggested citation:
Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt E. Noninvasive Treatments for Low Back Pain. Comparative Effectiveness Review No. 169. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.) AHRQ Publication No. 16-EHC004-EF. Rockville, MD: Agency for Healthcare Research and Quality; February 2016. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2012-00014-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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.ahrq.gov
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