Implementing AHRQ Effective Health Care Reviews

Helping Clinicians Make Better Treatment Choices

Noninvasive Treatments for Low Back Pain

 

Am Fam Physician. 2017 Sep 1;96(5):324-327.

Key Clinical Issue

What are the benefits and harms of noninvasive treatments for acute, subacute, and chronic low back pain?

Evidence-Based Answer

Exercise, nonsteroidal anti-inflammatory drugs (NSAIDs), and spinal manipulation with home exercise and advice have small benefits for radicular low back pain. (Strength of Recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.) Massage, heat wrap, and NSAIDs improve pain and function for non-radicular acute and subacute low back pain, whereas skeletal muscle relaxants improve pain alone. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Multiple exercise programs improve nonradicular chronic low back pain, in addition to acupuncture and multidisciplinary rehabilitation. (SOR: A, based on consistent, good-quality patient-oriented evidence.) Psychological therapies improve chronic low back pain, but not function. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) NSAIDs and antidepressants improve pain and function in nonradicular, chronic low back pain. Opioids show small, short-term improvements in pain and function. (SOR: A, based on consistent, good-quality patient-oriented evidence.)

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Clinical Bottom Line: Summary of Key Findings and Strength of Evidence for Interventions for Radicular Low Back Pain

InterventionCompared interventionOutcomeStudiesFindingsSOE

Nonpharmacologic interventions

Exercise

Usual care

Pain, function

3 RCTs

+

●○○

Traction

Physiotherapy or other interventions

Pain, function

2 SRs

●○○

Spinal manipulation + home exercise + advice

Home exercise + advice

Pain

1 RCT

+

●○○

Pharmacologic interventions

Nonsteroidal anti-inflammatory drugs

Placebo

Pain

1 SR

+

●○○

Diazepam

Placebo

Pain

1 SR

●○○

Systemic corticosteroids

Placebo

Pain, function

5 RCTs

●●○


Strength-of-evidence scale

High: ●●● High confidence that the evidence reflects the true effect. Further research is very unlikely to change the confidence in the estimate of effect.

Moderate: ●●○ Moderate confidence that the evidence reflects the true effect. Further research may change the confidence in the estimate of effect and may change the estimate.

Low: ●○○ Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.

Insufficient: ○○○ Evidence either is unavailable or does not permit a conclusion.

RCT = randomized controlled trial; SOE = strength of evidence; SR = systematic review.

+ = small effect favoring the intervention;= no effect vs. placebo;= no difference between the interventions.

Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Noninvasive treatments for low back pain: current state of the evidence. Clinician research summary. Rockville, Md.: Agency for Health-care Research and Quality; November 2016. https://www.effectivehealthcare.ahrq.gov/ehc/products/553/2327/back-pain-treatment-clinician-161115.pdf. Accessed December 14, 2016.

Clinical Bottom Line: Summary of Key Findings and Strength of Evidence for Interventions for Radicular Low Back Pain

InterventionCompared interventionOutcomeStudiesFindingsSOE

Nonpharmacologic interventions

Exercise

Usual care

Pain, function

3 RCTs

+

●○○

Traction

Physiotherapy or other interventions

Pain, function

2 SRs

●○○

Spinal manipulation + home exercise + advice

Home exercise + advice

Pain

1 RCT

+

●○○

Pharmacologic interventions

Nonsteroidal anti-inflammatory drugs

Placebo

Pain

1 SR

+

●○○

Diazepam

Placebo

Pain

1 SR

●○○

Systemic corticosteroids

Placebo

Pain, function

5 RCTs

●●○


Strength-of-evidence scale

High: ●●● High confidence that the evidence reflects the true effect. Further research is very unlikely to change the confidence in the estimate of effect.

Moderate: ●●○ Moderate confidence that the evidence reflects the true effect. Further research may change the confidence in the estimate of effect and may change the estimate.

Low: ●○○ Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.

Insufficient: ○○○ Evidence either is unavailable or does not permit a conclusion.

RCT = randomized controlled trial; SOE = strength of evidence; SR = systematic review.

+ = small effect favoring the intervention;= no effect vs. placebo;= no difference between the interventions.

Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Noninvasive treatments for low back pain: current state of the evidence. Clinician research summary. Rockville, Md.: Agency for Health-care Research and Quality; November 2016. https://www.effectiveh

Author disclosure: No relevant financial affiliations.

Address correspondence to Tyler W. Barreto, MD, at tb908@georgetown.edu. Reprints are not available from the authors.

REFERENCES

show all references

1. Agency for Healthcare Research and Quality, Effective Healthcare Program. Noninvasive treatments for low back pain: current state of the evidence. Clinician summary. Rockville, Md.: Agency for Healthcare Research and Quality; November 2016. https://effectivehealthcare.ahrq.gov/ehc/products/553/2327/back-pain-treatment-clinician-161115.pdf. Accessed December 14, 2016....

2. Dieleman J, Baral R, Birger M, et al. US spending on personal health care and public health, 1996–2013. JAMA. 2016;316(24):2627–2646.

3. Chou R, Huffman LH; American Pain Society; American College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline [published correction appears in Ann Intern Med. 2008;148(3):247–248]. Ann Intern Med. 2007;147(7):492–504.

4. Chou R, Huffman LH; American Pain Society; American College of Physicians. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline [published correction appears in Ann Intern Med. 2008;148(3):247–248]. Ann Intern Med. 2007;147(7): 505–514.

5. Chou R, Deyo R, Friedly J, et al.; Agency for Healthcare Research and Quality. Noninvasive treatments for low back pain. Comparative Effectiveness Review No. 169. Rockville, Md.: Agency for Healthcare Research and Quality; February 2016. https://effectivehealthcare.ahrq.gov/ehc/products/553/2178/back-pain-treatment-report-160922.pdf. Accessed June 2, 2017.

6. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014;384(9954):1586–1596.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based upon the review. AHRQ's summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions. For the full review, clinician summary, and consumer summary, go to https://www.effectivehealthcare.ahrq.gov/ehc/index.cfm/search-for-guides-reviews-and-reports/?pageAction=displayProduct&productID=2326.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.

A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at http://www.aafp.org/afp/ahrq.

 

 

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