Nonpharmacologic Interventions Beneficial for Chronic, Nonspecific Low Back Pain

Authors of a systematic review and meta-analysis published in The Spine Journal found that nonpharmacologic interventions were safe and beneficial among patients with chronic, nonspecific low back pain without radiculopathy.

Investigators searched publication databases through May 2022 for randomized controlled trials for pain management among adults with chronic, nonspecific low back pain. A total of 30 studies were included in the analysis about harms, and 4 studies were included in the analysis about benefits.

The included studies were published between 2002 and 2020 and were primarily conducted in the United States (n=11) and Germany (n=8). All of the studies included in the benefits analysis evaluated nonpharmacologic interventions; 10 of the harms studies evaluated nonpharmacologic interventions, 10 evaluated pharmacologic interventions, 8 evaluated surgical interventions, and 3 evaluated steroid injections.

Evaluated interventions included acupuncture, spinal manipulation, nonsteroidal anti-inflammatory drugs (NSAIDs), single-ingredient opioids, combination opioids, surgery, and corticosteroid injections, and the interventions were compared with placebo or sham controls.

The pooled study population included 6475 patients. Patients included in the harms analysis were older (mean, 50.2 vs 43.2 years) and fewer were women (58.2% vs 64.0%) compared with the patients included in the benefits analysis.

In the benefits analysis, acupuncture and spinal manipulation were associated with significant reductions in pain intensity in the short-term compared with sham treatment (standardized mean difference [SMD] range, -0.52 to -0.39).

In the harms analysis, risk for serious adverse events did not differ between acupuncture (risk difference [RD], 0.00) or spinal manipulation (RD, 0.00) compared with sham treatments nor did it differ for NSAIDs (RD, 0.00), single-ingredient opioids (RD, 0.00), or combination opioids (RD, 0.00) compared with placebo. A total of 87 serious adverse events were reported by patients who underwent surgery, but no risk estimate could be performed. No serious adverse events were reported in studies that involved steroid injections.

A major limitation of this analysis is the overall lack of studies evaluating nonpharmacologic approaches to management of lower back pain, especially with regard to benefits.

Study authors concluded, “Of the 3 studies that provided evidence of the benefits of interventions compared to sham or placebo, acupuncture and spinal manipulation were found to be effective compared to sham at short-term. However, because a small number of trials were conducted, the evidence is insufficient to draw conclusions that nonpharmacological treatments are superior to other treatments. Insufficient data was found regarding pain relief or serious adverse events for paracetamol, muscle relaxants, gabapentinoids and oral systematic corticosteroids for the management of chronic LBP.”