Patient-Oriented Evidence That Matters

Exercise Is the Only Intervention to Provide Long-Term Improvement in Patients with Chronic Low Back Pain


Am Fam Physician. 2021 Jun 1;103(11):696-697.

Clinical Question

What interventions are effective in managing patients with chronic low back pain?

Bottom Line

The interventions that are better than control in achieving at least a 30% reduction in pain are exercise, oral nonsteroidal anti-inflammatory drugs (NSAIDs), duloxetine (Cymbalta), and opioids, but discontinuations of the latter two treatments were common. Lower-quality data suggest that manipulation and topical capsaicin are also effective. It is possible the authors' inclusion criteria missed important studies. (Level of Evidence = 1a–)


The authors performed 15 individual systematic reviews focusing on individual interventions for managing patients with chronic (at least three months' duration) low back pain. They searched the Medline, EMBASE, and Cochrane databases, as well as clinical trials registries to identify randomized trials. Two authors independently evaluated potential studies for inclusion and risk of bias. They included 63 trials with more than 16,000 participants. Several interventions resulted in no search results because they lacked a responder analysis: acetaminophen, cannabinoids, muscle relaxants, and antidepressants other than duloxetine. The quality of the included studies was mixed. The authors reported meaningful reductions in pain (at least a 30% reduction) as the primary outcome for the included studies. They included 18 studies of exercise, most commonly guided by a physiotherapist. After pooling, they estimated that 50% of exercising patients and 35% of control patients achieved meaningful pain relief (number needed to treat [NNT] = 7; 95% CI, 6 to 10). They reported that a significant proportion of patients who were randomized to receive an exercise intervention had sustained relief even after the intervention was completed (NNT = 6; 95% CI, 5 to 9). In four trials, oral NSAIDs were more effective than control (NNT = 6; 95% CI, 5 to 8) while patients were taking them. Four trials of duloxetine also found it to be more effective

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.

This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.



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