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Am Fam Physician. 2021;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 than control (NNT = 10; 95% CI, 7 to 18), but discontinuation of treatment due to adverse effects was more common with duloxetine (number needed to harm [NNH] = 11). Spinal manipulation (five trials; low-quality evidence) was more effective than control in achieving pain relief (57% vs. 39%; NNT = 6; 95% CI, 4 to 10). Three trials (overall lower quality) evaluated topical capsaicin for three weeks. It was effective (NNT = 6; 95% CI, 4 to 10) at the cost of a superficial burning. Acupuncture was more effective than control in eight trials (54% vs. 35%; NNT = 6; 95% CI, 5 to 7); however, when only higher-quality studies were included, it was no better than control. The authors identified six opioid trials lasting four to 12 weeks, which found that 39% of patients achieved relief compared with 32% of control patients (NNT = 16; 95% CI, 10 to 35), but discontinuation due to side effects was more common with opioids (27% vs. 5%; NNH = 5). In 10 trials of corticosteroid injections (overall poor quality), there was no difference in pain relief compared with controls. The authors found significant heterogeneity for many of the interventions. One trial each of gabapentin (Neurontin) and topical flurbiprofen (in tape form) found neither to be effective in achieving pain relief. The authors did not address function in their analyses.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Government

Setting: Various (meta-analysis)

Reference: Kolber MR, Ton J, Thomas B, et al. PEER systematic review of randomized controlled trials: management of chronic low back pain in primary care. Can Fam Physician. 2021;67(1):e20–e30.

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 Copyright Wiley-Blackwell. Used with permission.

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