Low back pain (chronic)
INTRODUCTION: Over 70% of people in developed countries develop low back pain (LBP) at some time. But recovery is not always favourable: 82% of non recent-onset patients still experience pain 1 year later. Many patients with chronic LBP who were initially told that their natural history was good spend months or years seeking relief. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatments? What are the effects of injection therapy? What are the effects of non-drug treatments? What are the effects of non-surgical and surgical treatments? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 64 systematic reviews or RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, analgesics, antidepressants, back schools, behavioural therapy, electromyographic biofeedback, exercise, injections (epidural corticosteroid injections, facet joint injections, local injections), intensive multidisciplinary treatment programmes, lumbar supports, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), non-surgical interventional therapies (intradiscal electrothermal therapy, radiofrequency denervation), spinal manipulative therapy, surgery, traction, and transcutaneous electrical nerve stimulation (TENS).
Chou R. Low back pain (chronic). Clinical Evidence 2010; 10:1116.
Analgesics (paracetamol, opioids) Three systematic reviews and one subsequent RCT added. The first two reviews compared paracetamol versus placebo but found no RCTs. The third review and the subsequent RCT compared opioids versus placebo. The review found that tramadol with or without paracetamol improved pain and function at 4 weeks to 3 months compared with placebo.  The RCT found that sustained opioids improved pain-relief maintenance compared with placebo at 12 weeks. Categorisation unchanged (Unknown effectiveness) as there remains insufficient consistent high-quality evidence to assess analgesics.
Antidepressants One systematic review added comparing antidepressants with placebo. The review found no significant difference between groups in pain relief, depression, or functional status. Subgroup analysis also found no significant difference in pain relief between either SSRIs or tricyclic antidepressants and placebo. Categorisation changed from Trade-off between benefits and harms to Unknown effectiveness as methodological issues in the trials render the results inconclusive.
NSAIDs One systematic review updated. The review found that NSAIDs reduced pain intensity at 2 to 12 weeks compared with placebo. Categorisation unchanged (Trade-off between benefits and harms).
Muscle relaxants One systematic review updated, which included no new RCTs.Categorisation unchanged (Trade-off between benefits and harms).
Local injections Two systematic reviews added. The reviews included three RCTs comparing local injections versus placebo. The review did not pool data owing to heterogeneity. Two RCTs found no difference between local injections and placebo in self-reported improvement or pain intensity. The third RCT found that corticosteroid injections significantly improved self-reported improvement compared with placebo; however, the review reported that this RCT was of low quality.Categorisation unchanged (Unknown effectiveness) as there remains insufficient good-quality evidence to assess the effects of local injections.
Facet joint injections One systematic review updated and one review added. Both reviews included the same two RCTs comparing facet joint injections versus placebo/saline injection. The RCTs found no differences between groups for pain, disability, and work attendance. Categorisation unchanged (Unknown effectiveness) as there remains insufficient good-quality evidence to assess facet joint injections.
Back exercises Four systematic review and eight subsequent RCTs added. The trend of the evidence suggests that back exercise reduces pain and improves function in people with non-specific chronic low back pain. The evidence supports the categorisation of Beneficial.
Multidisciplinary programmes One systematic reviewand two subsequent RCTs added. The review found no difference between multidisciplinary treatment and control for pain or function, but reported that multidisciplinary treatment improved work participation. The first RCT found no difference between multidisciplinary treatment compared with active therapy for pain, function, or return to work.  The second RCT found that multidisciplinary treatment, CBT, and active physical treatment all improved pain and function compared with waiting list control; however, there was no difference for pain or function between the active treatment groups. Categorisation changed from Beneficial to Likely to be beneficial as there is moderate evidence that intensive (but not less intensive) multidisciplinary programmes are more effective than waiting list control/usual care/non-multidisciplinary treatments.
Acupuncture One systematic review added. Overall the review found that acupuncture and acupuncture plus other treatment was more effective than no treatment for improving pain relief and function; however, there seemed to be no significant difference between acupuncture and sham or other active treatment in pain relief and function. Categorisation changed from Unknown effectiveness to Likely to be beneficial.
Back schools One systematic review and one subsequent RCTadded comparing back school versus inactive control or other treatment. The review reported conflicting results for back school versus inactive control or other treatment, but the majority of the evidence included in the review and the subsequent RCT found no difference between groups for pain, disability, recurrence, sick leave, or depression. Categorisation changed from Likely to be beneficial to Unknown effectiveness owing to conflicting results and small effect sizes in the positive trials.
Behavioural therapy One systematic review updated comparing behavioural therapy (including progressive relaxation, EMG biofeedback, operant therapy, and respondent plus cognitive therapy) versus waiting list controls. The majority of the evidence included in the review found that behavioural therapy improved pain intensity and behavioural outcomes compared with waiting list control. Categorisation unchanged (Likely to be beneficial).
Spinal manipulative therapy: Evidence reassessed, categorisation changed from Unknown effectiveness to Likely to be beneficial and the weight of evidence suggests improvement for spinal manipulation therapy compared with no treatment, sham treatment and other treatments judged ineffective or harmful.
Electromyographic biofeedback One systematic review updated. The review found no significant differences between electromyographic biofeedback versus waiting list control or other treatments for pain or behavioural outcomes. However, the review included two RCTs reporting conflicting results for general functional status and one RCT that found that electromyographic feedback improved back-specific functional status. Categorisation unchanged (Unknown effectiveness) as there remains insufficient high-quality evidence to assess the effects of electromyographic biofeedback.
Lumbar supports One systematic review updated. The review included one RCT comparing lumbar support versus no intervention. The RCT found no difference between groups for short-term pain or function. Categorisation unchanged (Unknown effectiveness) as there remains insufficient high-quality evidence to assess the effects of lumbar supports in people with chronic low back pain.
Massage One systematic review added. It found that massage improved short- but not long-term pain intensity compared with sham treatment, and that massage improved back-specific function in the short and long term compared with sham treatment. Overall the review also found that massage improved pain and function compared with other active interventions (including exercise, physiotherapy, acupuncture, and manipulation) in the short and long term. Categorisation changed from Unknown effectiveness to Likely to be beneficial.
TENS One additional RCT added, which compared TENS plus massage versus sham TENS plus massage. It found no significant difference between groups in pain intensity.  Categorisation unchanged (Unknown effectiveness) as there remains insufficient high-quality evidence to assess the effects of TENS.
Intradiscal electrothermal therapy (IDETT) We found four systematic reviews that all reported the same two RCTs. The RCTs included in the reviews reported conflicting results for IDETT compared with placebo for both pain and function outcomes. Categorised as Unknown effectiveness.
Radiofrequency denervation We found one systematic review comparing radiofrequency denervation versus sham treatment/placebo. The RCTs included in the review found conflicting results for radiofrequency denervation for both pain and function in people with presumed facet joint or discogenic low back pain. Categorised as Unknown effectiveness.
Fusion surgery We found four systematic reviews comparing fusion surgery with non-surgical treatment. All four reviews included the same four high-quality RCTs, which reported inconsistent results. The first and fourth RCTs found that fusion surgery improved pain and disability scores, and also increased the proportion of people who returned to work at 2 years compared with non-surgical therapy. The second and third RCTs found no significant difference between groups for any of those outcomes at 1 year in people with or without prior discectomy. Categorised as Likely to be beneficial.
Artificial disc replacement We found no RCTs on the effectiveness of disc replacement compared with no treatment or non-surgical treatment for people with chronic low back pain. Categorised as Unknown effectiveness.
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