Nonpharmacologic and Nonsurgical Treatment of Low Back Pain in Adults

Are nonpharmacologic and nonsurgical treatment options safe and effective for nonspecific acute or chronic low back pain?

Patients with nonspecific acute low back pain lasting less than 6 weeks should be advised to stay active; continued activity improves pain intensity and function more than rest.¹ Spinal manipulation does not improve short-term function compared with placebo. (Strength of Recommendation [SOR]: B, inconsistent patient-oriented evidence.)

In patients with nonspecific chronic low back pain, multidisciplinary interventions and exercise therapy reduce pain intensity for subacute and chronic low back pain compared with no treatment or usual care.¹ Acupuncture moderately reduces pain intensity and improves function vs no treatment. Psychological therapies using techniques such as progressive muscle relaxation and behavioral approaches reduce pain but have no impact on function compared with usual care. Traction is ineffective. (SOR: B, inconsistent patient-oriented evidence.)

Nonpharmacologic and nonsurgical treatments are probably safe, although data regarding serious adverse effects are limited.¹ (SOR: B, inconsistent or limited-quality patient-oriented evidence.)

Low back pain is a leading cause of disability worldwide and is associated with poor quality of life, high health care costs, and increased absence from work.^1,2 Low back pain is termed non-specific when not linked to conditions such as radiculopathy or spinal canal stenosis.¹ Low back pain duration is classified as acute (less than 6 weeks), subacute (6–12 weeks), or chronic (greater than 12 weeks).¹ The authors of this Cochrane review evaluated the safety and effectiveness of various nonpharmacologic and nonsurgical treatment options available for non-specific acute or chronic low back pain.

A total of 31 systematic Cochrane reviews were included, encompassing 644 randomized controlled trials (N = 97,183).¹ The review included any adult with nonspecific low back pain (ie, pain between the twelfth rib and gluteal fold) for any duration. These trials compared nonpharmacologic (eg, acupuncture, advice and education, exercise therapy, heat and cold therapies, manual therapies, psychological therapies) and non-surgical treatment options with sham/placebo interventions; no intervention; or another nonpharmacologic, pharmacologic, or surgical intervention.

Outcomes reflected the core outcome set for nonspecific low back pain: physical functioning, pain intensity, and health-related quality of life.^1,3 Outcomes were grouped into three categories postrandomization: short term (3 months or less), intermediate term (more than 3 months to 12 months), and long term (greater than 12 months). Primary outcomes included pain intensity, physical function, and safety, measured by tools such as the Brief Pain Inventory and Roland-Morris Disability Questionnaire. Secondary outcomes included subjective clinical improvement, health-related quality of life, and workplace participation.

For nonspecific acute low back pain, the authors found that patients who stayed active have reduced pain intensity in the short term compared with those who focused on rest (standardized mean difference [SMD] = −0.22; 95% CI, −0.02 to −0.41; moderate-certainty evidence).¹ Similarly, advice to stay active was found to improve function vs rest (SMD = −0.29; 95% CI, −0.09 to −0.49; moderate-certainty evidence). The effect of spinal traction was found to be no different from placebo regarding pain intensity. No other significant findings were reported for other nonpharmacologic or nonsurgical interventions included in this review for treatment of acute low back pain.