Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline

By R. Chou, R. Deyo, J. Friedly, A. Skelly, Robin E. Hashimoto, M. Weimer, Rochelle Fu, T. Dana, Paul Kraegel, Jessica C. Griffin and 2 more. Annals of Internal Medicine, 2017

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Low back pain is very common and is associated with more global disability than any other condition (1). Several nonpharmacologic, noninvasive therapies are available for low back pain, including exercise, complementary and alternative therapies (such as spinal manipulation, acupuncture, massage, and mindbody interventions), psychological therapies (such as cognitive behavioral and operant therapy), physical techniques (such as traction, ultrasound, transcutaneous electrical nerve stimulation, low-level laser therapy, superficial heat or cold, and back supports), and multidisciplinary rehabilitation. A 2007 guideline (2) and an associated systematic review (3) from the American College of Physicians (ACP) and American Pain Society (APS) recommended spinal manipulation as a treatment option for acute low back pain and several nonpharmacologic therapies for subacute or chronic low back pain. New evidence is now available. The purpose of this article is to review the current evidence on the benefits and harms of nonpharmacologic therapies for low back pain. The ACP will use this review to develop an updated clinical practice guideline. Methods Detailed methods for this review, including the analytic framework, additional nonpharmacologic therapies (physical techniques), medications (addressed in a separate article) (4), search strategies, inclusion criteria, data extraction and quality-rating methods, and additional outcomes (such as quality of life, global improvement, and patient satisfaction) are available in the full report (5). The protocol was developed by using a standardized process (6) with input from experts and the public and is registered in the PROSPERO database (7). This article addresses the following question: What are the comparative benefits and harms of nonpharmacologic, noninvasive therapies for acute or chronic nonradicular or radicular low back pain or for symptomatic spinal stenosis? Data Sources and Search A research librarian searched several electronic databases, including Ovid MEDLINE (January 2007 through April 2015) and the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through April 2015). We used the previous ACP/APS review to identify earlier studies (8). Searches were updated through November 2016. We also reviewed reference lists and searched ClinicalTrials.gov. Study Selection Two investigators independently reviewed abstracts and full-text articles against prespecified eligibility criteria. The population was adults with acute (<4 weeks), subacute (4 to 12 weeks), or chronic (12 weeks) nonradicular or radicular low back pain. Excluded conditions were low back pain due to cancer, infection, inflammatory arthropathy, high-velocity trauma, or fracture; low back pain during pregnancy; and the presence of severe or progressive neurologic deficits. We included randomized trials of exercise, spinal manipulation, acupuncture, massage, mindbody interventions (yoga, tai chi, mindfulness-based stress reduction), psychological therapies, or multidisciplinary rehabilitation versus sham (functionally inert) treatment, wait list, or usual care (usually defined as care provided at the discretion of the clinician), as well as comparisons between 1 therapy and another. Outcomes were long-term (1 year) or short-term (6 months) pain, function, return to work, and harms. Given the large number of interventions, we included systematic reviews of randomized trials (6, 9). For each intervention, we selected the most recent, relevant, and comprehensive systematic review that was of the highest quality on the basis of a validated assessment tool (9, 10). If more than 1 good-quality systematic review was available, we preferentially selected updates of reviews used in the ACP/APS review. We supplemented systematic reviews with additional randomized trials. We did not include systematic reviews identified in update searches but checked reference lists for additional studies. We excluded nonEnglish-language articles and abstract-only publications. Data Extraction and Quality Assessment One investigator extracted study data, and a second verified the accuracy of the extractions. For systematic reviews, we abstracted details about review methods and results (Supplement Table 1). For randomized trials not included in a systematic review, we abstracted details regarding the study, population, and treatment characteristics, as well as the results (Supplement Table 2). Supplement. Supplemental Tables Two investigators independently assessed the quality of each study as good, fair, or poor by using criteria developed by the U.S. Preventive Services Task Force (11) (for randomized trials [Supplement Table 3]) and AMSTAR (A Measurement Tool to Assess Systematic Reviews; for systematic reviews [Supplement Table 4]) (9). For primary studies included in systematic reviews, we relied on the quality ratings as performed in the reviews. We used the overall grade (for example, good, fair, or poor; or high or low) as determined in the systematic review. We classified the magnitude of effects for pain and function by using the same system used in the ACP/APS review ( Table 1) (2, 12). We also reported risk estimates based on the proportion of patients achieving successful pain or function outcomes (such as >30% or >50% improvement). Table 1. Definitions for Magnitude of Effects, Based on Mean Between-Group Differences Data Synthesis and Analysis We synthesized data qualitatively for each intervention, stratified according to the duration of symptoms (acute, subacute, or chronic) and presence or absence of radicular symptoms. We reported meta-analysis results from systematic reviews. If statistical heterogeneity was present, we examined the degree of inconsistency and evaluated subgroup and sensitivity analyses. We did not conduct an updated meta-analysis; rather, we qualitatively examined whether the results of new studies were consistent with pooled or qualitative findings from previous systematic reviews. Qualitative assessments were based on whether the findings from the new studies were in the same direction as those of the previous systematic reviews and whether the magnitude of effects was similar; if previous meta-analyses were available, we assessed whether the estimates and CIs from the new studies were encompassed in the CIs of previous pooled estimates. We assessed the strength of evidence (SOE) for each body of evidence as high, moderate, low, or insufficient on the basis of aggregate study quality, precision, consistency, and directness (6). Role of the Funding Source This project was funded by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. Staff members of AHRQ assisted in developing the scope and key questions. The AHRQ had no role in study selection, quality assessment, or synthesis. Results The search and selection of articles are summarized in the literature flow diagram (Figure). Database searches resulted in 2847 potentially relevant articles. After dual review of abstracts and titles, we selected 814 articles for full-text dual review; 114 publications met our inclusion criteria. Details for the systematic reviews included are shown in Supplement Table 1, and details for additional trials included are shown in Supplement Table 2; quality ratings are shown in Supplement Table 3 (systematic reviews) and Supplement Table 4 (trials). Figure. Literature search and selection. ACP = American College of Physicians; AHRQ = Agency for Healthcare Research and Quality; APS = American Pain Society; KQ = key question; RCT = randomized, controlled trial; SR = systematic review. *Cochrane databases include the Cochrane Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Other sources include prior reports, reference lists of relevant articles, systematic reviews, and others. Publications may be included or excluded for several interventions. Exercise We found 122 trials that evaluated exercise. Three systematic reviews included 71 unique trials (total sample sizes ranged from 1993 to 4138) (1315), and we identified 51 additional trials (sample sizes, 100 in 18 trials [1634] and <100 in 33). One systematic review focused on exercise for chronic low back pain (37 trials) (14), 1 evaluated the effects of exercise on work disability in patients with subacute or chronic low back pain (23 trials) (15), and 1 examined the effects of motor control exercise (MCE) (16 trials) (13). One review classified 41% of trials as low risk of bias, and another classified 62% as high quality; among the additional trials with 100 or more patients, we rated 4 good, 7 fair, and 7 poor quality. For acute (3 trials) or subacute (5 trials) low back pain, the ACP/APS review previously found no difference between exercise therapy and no exercise on pain. Three additional trials of exercise versus no exercise or usual care reported inconsistent effects on pain and function (21, 31, 32). For chronic low back pain, the ACP/APS review found that exercise was associated with greater pain relief than no exercise (19 trials: weighted mean difference [WMD], 10 on a 0- to 100-point scale [95% CI, 1.31 to 19.09]); the effects on function were small and not statistically significant (17 trials: WMD, 3.00 on a 0- to 100-point scale [CI, 0.53 to 6.48]). In a more recent systematic review that used more restrictive criteria, exercise therapy was associated with less pain intensity (3 trials: WMD, 9.23 [CI, 16.02 to 2.43]) and better function (3 randomized, controlled trials: WMD, 12.35 on a 0- to 100-point scale [CI, 23.0 to 1.69]) versus usual care at treatment end; the effects were smaller at long-term follow-up (mean difference, 4.94 [CI, 10.45 to 0.58] for pain and 3.17 [CI, 5.96 to 0.38] for function) (14). Another systematic review found that compared with minimal intervention, MCE decreased pain intensity (2 trials: WMD, 12.48 on

Subfields: Cognitive Neuroscience, Complementary and alternative medicine, Pharmacology

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