Noninvasive Treatments for Low Back Pain [Entered Retrospectively]

Project Summary Title and Description

Title
Noninvasive Treatments for Low Back Pain [Entered Retrospectively]
Description
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 [NSAID]s, 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 NRS 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 analogue scale [VAS] or 0.5 to 1.0 points on a 0- to 10-point numerical 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 associated with small effects (SOE: low). Relatively few trials directly compared the effectiveness of different medications, different nonpharmacological therapies, or compared pharmacological versus nonpharmacological therapies, and 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 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.
Attribution
N/A
Authors of Report
N/A
Methodology description
Review Methods. Using predefined criteria, we selected systematic reviews of randomized trials of pharmacological treatments (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAID]s, 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.
PROSPERO
CRD42014014735
DOI
10.7301/Z0JM27J2
Notes
Data was entered retrospectively. The uploaded files contain the following data: "E" files- Evidence tables containing study information including inclusion criteria, interventions, duration of pain, during of followup, results, adverse events, funding source and quality rating. "F" files- Quality tables containing quality assessment criteria for included studies in addition to overall rating.
Funding Source
This project was funded under Contract No. HHSA 290-2012-00014-I from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.

Key Questions

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? (Including NSAIDs, acetaminophen, opioids, muscle relaxants, antiseizure medications, antidepressants, corticosteroids and topicals/patch-delivered medications)
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? (Including but not limited to interdisciplinary rehabilitation, exercise (various types), physical modalities (ultrasound, transcutaneous electrical nerve stimulation [TENS], electrical muscle stimulation [EMS], interferential therapy [IFT], 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)

Associated Extraction Forms

Associated Studies (each link opens a new tab)

TitleAuthorsYear
Guideline for the evaluation and management of low back pain: evidence review
Is there a role for benzodiazepines in the management of lumbar disc prolapse with acute sciatica?2010
Escitalopram 20 mg versus duloxetine 60 mg for the treatment of chronic low back pain.2010
The efficacy and safety of pregabalin in the treatment of neuropathic pain associated with chronic lumbosacral radiculopathy.2010
A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial.
Therapeutic evaluation of lumbar tender point deep massage for chronic non-specific low back pain.2012
Controlled-release oxycodone and naloxone in the treatment of chronic low back pain: a placebo-controlled, randomized study.-- Not Found --
A randomized, double-blind, placebo-controlled, parallel-group study to evaluate the efficacy and safety of the extended-release tramadol hydrochloride/acetaminophen fixed-dose combination tablet for the treatment of chronic low back pain.2013
The effectiveness of Swedish massage with aromatic ginger oil in treating chronic low back pain in older adults: a randomized controlled trial.2014
Combination therapy with transdermal buprenorphine and pregabalin for chronic low back pain.2012
Deep tissue massage and nonsteroidal anti-inflammatory drugs for low back pain: a prospective randomized trial.2014
Effectiveness and Safety of Tapentadol Prolonged Release (PR) Versus a Combination of Tapentadol PR and Pregabalin for the Management of Severe, Chronic Low Back Pain With a Neuropathic Component: A Randomized, Double-blind, Phase 3b Study.
Prednisone for emergency department low back pain: a randomized controlled trial.2014
An open labeled randomized controlled trial of pregabalin versus amitriptyline in chronic low backache.
Efficacy and safety of lornoxicam compared with placebo and diclofenac in acute sciatica/lumbo-sciatica: an analysis from a randomised, double-blind, multicentre, parallel-group study.2009
A double-blind, randomized controlled, prospective trial assessing the effectiveness of oral corticoids in the treatment of symptomatic lumbar canal stenosis.2014
Pregabalin, celecoxib, and their combination for treatment of chronic low-back pain.2009
Efficacy and safety of duloxetine in patients with chronic low back pain.2010
Duloxetine versus placebo in patients with chronic low back pain: a 12-week, fixed-dose, randomized, double-blind trial.
Multicenter randomized controlled trial to evaluate the effect of home-based exercise on patients with chronic low back pain: the Japan low back pain exercise therapy study.2010
A comparison of the effects of deep tissue massage and therapeutic massage on chronic low back pain.2012
Chinese massage combined with herbal ointment for athletes with nonspecific low back pain: a randomized controlled trial.
Single-entity hydrocodone extended-release capsules in opioid-tolerant subjects with moderate-to-severe chronic low back pain: a randomized double-blind, placebo-controlled study.
Do analgesics improve functioning in patients with chronic low back pain? An explorative triple-blinded RCT.2014
Double-blind, randomized, controlled, crossover trial of pregabalin for neurogenic claudication.2015
Effects of using dexamethasone and placebo in the treatment of prolapsed lumbar disc.1982
The efficiency of gabapentin therapy in patients with lumbar spinal stenosis.2007
Non-steroidal anti-inflammatory drugs for low back pain.
A randomized placebo-controlled trial of single-dose IM corticosteroid for radicular low back pain.2008
Oral steroids in initial treatment of acute sciatica.-- Not Found --
A double-blind, randomized trial of duloxetine versus placebo in the management of chronic low back pain.2009
Opioids compared to placebo or other treatments for chronic low-back pain
Comparison between the effects of amitriptyline and bupropione on the quality of life and the reduction in the severity of pain in patients with chronic low-back pain2013
Massage for low back pain
Antidepressants for non-specific low back pain2010
Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial2014
Drug Class Review: Long-Acting Opioid Analgesics: Final Update 6 Report [Internet].2011
Spinal manipulation, epidural injections, and self-care for sciatica: a pilot study for a randomized clinical trial.2004
A randomized clinical trial of continuous low-level heat therapy for acute muscular low back pain in the workplace.2005
A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain.1994
Combined neuromuscular electrical stimulation and transcutaneous electrical nerve stimulation for treatment of chronic back pain: a double-blind, repeated measures comparison.1997
Effect of the duration of electrical stimulation on the analgesic response in patients with low back pain.1999
Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation.2000
Evaluation of the effects of shortwave diathermy in patients with chronic low back pain.2009
Westeinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica.
Randomised controlled trial comparing the effectiveness of electroacupuncture and TENS for low back pain: a preliminary study for a pragmatic trial.2002
Treatment- and cost-effectiveness of early intervention for acute low-back pain patients: a one-year prospective study.2003
Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up.2010
Electrical muscle stimulation as an adjunct to exercise therapy in the treatment of nonacute low back pain: a randomized trial.2001
Superficial heat or cold for low back pain.
The efficacy of a short education program and a short physiotherapy program for treating low back pain in primary care: a cluster randomized trial.2010
Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations.
Physiotherapist-directed exercise, advice, or both for subacute low back pain: a randomized trial.2007
In chronic low back pain, low level laser therapy combined with exercise is more beneficial than exercise alone in the long term: a randomised trial.
Are back supports plus education more effective than education alone in promoting recovery from low back pain?: Results from a randomized clinical trial.
Is low-level laser therapy effective in acute or chronic low back pain?
Impact of continuous low level heatwrap therapy in acute low back pain patients: subjective and objective measurements.
Immediate effects of a high-velocity spine manipulation in paraspinal muscles activity of nonspecific chronic low-back pain subjects.2010
Double-blind, placebo-controlled trial of carisoprodol 250-mg tablets in the treatment of acute lower-back spasm.2008
Comparison of 3 physical therapy modalities for acute pain in lumbar disc herniation measured by clinical evaluation and magnetic resonance imaging.2008
Isolated lumbar extensor strengthening versus regular physical therapy in an army working population with nonacute low back pain: a randomized controlled trial.2008
A randomized trial of behavioral physical therapy interventions for acute and sub-acute low back pain (NCT00373867).2008
Efficacy of percutaneous electrical nerve stimulation and therapeutic exercise for older adults with chronic low back pain: a randomized controlled trial.2008
Effects of deep heat therapy on the patients with chronic low back pain.2008
Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain.2008
Effects of electrical stimulation program on trunk muscle strength, functional capacity, quality of life, and depression in the patients with low back pain: a randomized controlled trial.2009
Effectiveness of a lumbar belt in subacute low back pain: an open, multicentric, and randomized clinical study.2009
Orthopaedic manual therapy, McKenzie method or advice only for low back pain in working adults: a randomized controlled trial with one year follow-up.2008
Aceclofenac-tizanidine in the treatment of acute low back pain: a double-blind, double-dummy, randomized, multicentric, comparative study against aceclofenac alone.
The efficacy of systematic active conservative treatment for patients with severe sciatica: a single-blind, randomized, clinical, controlled trial.2012
Effects of therapeutic ultrasound and electrical stimulation program on pain, trunk muscle strength, disability, walking performance, quality of life, and depression in patients with low back pain: a randomized-controlled trial.2010
Acute low back pain with radiculopathy: a double-blind, randomized, placebo-controlled study.2010
Role of physical exercise in low back pain rehabilitation: a randomized controlled trial of a three-month exercise program in patients who have completed multidisciplinary rehabilitation.2010
The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial.
Supervised and non-supervised Nordic walking in the treatment of chronic low back pain: a single blind randomized clinical trial.2010
Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis.
Exercise therapy for chronic nonspecific low-back pain.2010
Value of TENS for relief of chronic low back pain with or without radicular pain.2012
Effectiveness of exercise on work disability in patients with non-acute non-specific low back pain: Systematic review and meta-analysis of randomised controlled trials.2010
Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: a prospective randomized controlled trial.2010
A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain.2011
Kinesio Taping reduces disability and pain slightly in chronic non-specific low back pain: a randomised trial.2012
The response of persons with chronic nonspecific low back pain to three different volumes of periodized musculoskeletal rehabilitation.2011
Adding a physical exercise programme to brief intervention for low back pain patients did not increase return to work.2010
A randomised controlled trial of yoga for the treatment of chronic low back pain: results of a pilot study.2010
Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?
Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial.2011
The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization: a randomized controlled trial.2011
Kinesio Taping applied to lumbar muscles influences clinical and electromyographic characteristics in chronic low back pain patients.2011
Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial.
Short-term effects of high-intensity laser therapy versus ultrasound therapy in the treatment of low back pain: a randomized controlled trial.2011
Effects of transcutaneous electrical nerve stimulation (TENS) and interferential currents (IFC) in patients with nonspecific chronic low back pain: randomized clinical trial.2011
Tai chi exercise for treatment of pain and disability in people with persistent low back pain: a randomized controlled trial.2011
Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial.2012
Pain relief by transcutaneous electric nerve stimulation with bidirectional modulated sine waves in patients with chronic back pain: a randomized, double-blind, sham-controlled study.2007
Group cognitive behavioural interventions for low back pain in primary care: extended follow-up of the Back Skills Training Trial (ISRCTN54717854).
Inversion therapy in patients with pure single level lumbar discogenic disease: a pilot randomized trial.2012
Rest versus exercise as treatment for patients with low back pain and Modic changes. A randomized controlled clinical trial.
A model of integrative care for low-back pain.2012
Effects of Functional Fascial Taping on pain and function in patients with non-specific low back pain: a pilot randomized controlled trial.2012
A comprehensive yoga programs improves pain, anxiety and depression in chronic low back pain patients more than exercise: an RCT.2012
Lumbar lordosis rehabilitation for pain and lumbar segmental motion in chronic mechanical low back pain: a randomized trial.2012
Extension traction treatment for patients with discogenic lumbosacral radiculopathy: a randomized controlled trial.2013
Acupuncture in patients with acute low back pain: a multicentre randomised controlled clinical trial.
Effects of long-term corset wearing on chronic low back pain.2012
Clinical and functional evaluation of patients with acute low back pain and radiculopathy treated with different energy doses of low level laser therapy.2012
Manual therapy followed by specific active exercises versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain: a randomized controlled trial.
Spinal manipulative therapy for acute low-back pain.
Spinal high-velocity low amplitude manipulation in acute nonspecific low back pain: a double-blinded randomized controlled trial in comparison with diclofenac and placebo.
Acupuncture for chronic low back pain: a multicenter, randomized, patient-assessor blind, sham-controlled clinical trial.
Short-term effects of interferential current electro-massage in adults with chronic non-specific low back pain: a randomized controlled trial.
Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study.2013
Cognitive treatment of illness perceptions in patients with chronic low back pain: a randomized controlled trial.2013
A systematic review and meta-analysis of yoga for low back pain.2013
Acupuncture for acute low back pain: a systematic review.2013
Effect of core stabilization exercises versus conventional exercises on pain and functional status in patients with non-specific low back pain: a randomized clinical trial.2013
A multidisciplinary rehabilitation programme improves disability, kinesiophobia and walking ability in subjects with chronic low back pain: results of a randomised controlled pilot study.
Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial.
Effect of diode laser in the treatment of patients with nonspecific chronic low back pain: a randomized controlled trial.
Effectiveness of back school versus McKenzie exercises in patients with chronic nonspecific low back pain: a randomized controlled trial.2013
Motor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis.2013
Osteopathic manual treatment and ultrasound therapy for chronic low back pain: a randomized controlled trial.-- Not Found --
The efficacy of lumbar extension traction for sagittal alignment in mechanical low back pain: a randomized trial.2013
Occupational low back pain in nursing workers: massage versus pain.2014
Effectiveness and acceptance of acupuncture in patients with chronic low back pain: results of a prospective, randomized, controlled trial.2013
Short-term therapeutic effects of 890-nanometer light therapy for chronic low back pain: a double-blind randomized placebo-controlled study.
Comparing Once- versus Twice-Weekly Yoga Classes for Chronic Low Back Pain in Predominantly Low Income Minorities: A Randomized Dosing Trial.
The effect of core stability exercises on variations in acceleration of trunk movement, pain, and disability during an episode of acute nonspecific low back pain: a pilot clinical trial.2013
Traction for low-back pain with or without sciatica.2013
Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis.2013
Dose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial.
Acupuncture for acute non-specific low back pain: a randomised, controlled, double-blind, placebo trial.
The effects of kinesio taping on potential in chronic low back pain patients anticipatory postural control and cerebral cortex.2013
Influence of Mckenzie protocol and two modes of endurance exercises on health-related quality of life of patients with long-term mechanical low-back pain.2014
Therapeutic ultrasound for chronic low-back pain.
Effectiveness of myofascial release in the management of chronic low back pain in nursing professionals.
Kinesio taping to generate skin convolutions is not better than sham taping for people with chronic non-specific low back pain: a randomised trial.2014
The effectiveness of Pilates exercise in people with chronic low back pain: a systematic review.
The effectiveness of Cognitive Behavioral Therapy (CBT) with general exercises versus general exercises alone in the management of chronic low back pain.2014
Changes in pain intensity and health related quality of life with Iyengar yoga in nonspecific chronic low back pain: A randomized controlled study.
A randomized clinical trial comparing extensible and inextensible lumbosacral orthoses and standard care alone in the management of lower back pain.2014
Effect of diode laser in the treatment of patients with nonspecific chronic low back pain: a randomized controlled trial.2014
Multidisciplinary biopsychosocial rehabilitation for chronic low back pain.2014
Comparison between Kinesio Taping and a Traditional Physical Therapy Program in Treatment of Nonspecific Low Back Pain.2014
Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation.2014
The efficacy of thermotherapy and cryotherapy on pain relief in patients with acute low back pain, a clinical trial study.
Continuous low-level heatwrap therapy relieves low back pain and reduces muscle stiffness.
Comparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: a randomized clinical trial.2015
Supervised walking in comparison with fitness training for chronic back pain in physiotherapy: results of the SWIFT single-blinded randomized controlled trial (ISRCTN17592092).2015
Chinese massage combined with core stability exercises for nonspecific low back pain: a randomized controlled trial.2015
Superficial heat or cold for low back pain2006
Behavioural treatment for chronic low-back pain2010
Percutaneous electrical nerve stimulation versus dry needling: effectiveness in the treatment of chronic low back pain2010
Lumbar supports for prevention and treatment of low back pain2011
Effectiveness of tai chi practice for non-specific chronic low back pain on retired athletes: A randomized controlled study2013
Acupuncture at the back-pain-acupoints for chronic low back pain of Peacekeepers in Lebanon: A randomized controlled trial2012

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