Abstract
Introduction
Over 70% of people in resource-rich countries develop low back pain (LBP) at some time. But recovery is not always favourable: 82% of non-recent-onset patients still experience pain one year later. Many chronic patients 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? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2007 (BMJ 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 74 systematic reviews, RCTs, or observational studies 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 steroid injections, facet joint injections, local injections), intensive multidisciplinary treatment programmes, lumbar supports, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), spinal manipulative therapy, traction, and transcutaneous electrical nerve stimulation (TENS).
Key Points
Over 70% of people in resource-rich countries develop low back pain at some time, which usually improves within 2 weeks, but up to 7% of affected people develop chronic low back pain.
Opioid analgesics, with or without paracetamol, and NSAIDs may improve pain and function compared with placebo.
Antidepressants decrease chronic low back pain compared with placebo in people with or without depression, but their effects on function are unclear.
Muscle relaxants may improve pain, but studies have given conflicting results.
CAUTION: Since the last update of this review, a drug safety alert has been issued on increased suicidal behaviour with antidepressants, and on major congenital malformations with paroxetine (www.fda.gov/medwatch).
We don't know whether epidural steroid injections or local injections with corticosteroids and local anaesthetic improve chronic low back pain in people without sciatica.
Facet joint corticosteroid injections may be no more effective than placebo at reducing pain.
Exercise improves pain and function compared with other conservative treatments.
Intensive multidisciplinary treatment programmes improve pain and function compared with usual care, but less-intensive programmes do not seem to be beneficial.
Acupuncture, back schools, behavioural therapy, and spinal manipulation may reduce pain in the short term, but we don't know how they compare with other active treatments.
We don't know whether electromyographic biofeedback, lumbar supports, massage, traction, or TENS improve pain relief.
About this condition
Definition
Low back pain is pain, muscle tension, or stiffness localised below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica), and is defined as chronic when it persists for 12 weeks or more (see definition of low back pain [acute]). Non-specific low back pain is pain that is not attributed to a recognisable pathology (such as infection, tumour, osteoporosis, rheumatoid arthritis, fracture, or inflammation). This review excludes chronic low back pain with symptoms or signs at presentation that suggest a specific underlying condition. People solely with sciatica (lumbosacral radicular syndrome) and pain due to herniated discs, or both, are also excluded. People in this review have chronic low back pain (greater than 12 weeks' duration).
Incidence/ Prevalence
Over 70% of people in resource-rich countries will experience low back pain at some time in their lives. Each year, 15-45% of adults suffer low back pain, and 1/20 people present to hospital with a new episode. About 2-7% of people with acute low back pain will go on to become chronic. Low back pain is most common between 35-55 years of age.
Aetiology/ Risk factors
Symptoms, pathology, and radiological appearances are poorly correlated. Pain is non-specific in about 85% of people. About 4% of people with low back pain in primary care have compression fractures, and about 1% have a tumour. The prevalence of prolapsed intervertebral disc among people with low back pain in primary care is about 1-3%. Ankylosing spondylitis and spinal infections are less common. This review only covers chronic low back pain where a definitive diagnosis cannot be made. Risk factors include heavy physical work, frequent bending, twisting, lifting, and prolonged static postures. Psychosocial risk factors include anxiety, depression, and mental stress at work. Having a previous history of low back pain and a longer duration of the present episode are significant risk factors for chronicity. A recently published systematic review of prospective cohort studies found that some psychological factors (distress, depressive mood, and somatisation) are associated with an increased risk of chronic low back pain. Individual and workplace factors have also been reported to be associated with the transition to chronic low back pain.
Prognosis
Generally, the clinical course of an episode of low back pain appears favourable, but back pain among people in a primary-care setting typically has a recurrent course (characterised by variation and change), rather than an acute, self-limiting course. Most people with back pain have experienced a previous episode, and acute attacks often occur as exacerbations of chronic low back pain. In general, recurrences will occur more frequently and be more severe if people have had frequent or long-lasting low back pain complaints in the past. The course of sick leave caused by low back pain can be favourable; however, the longer the period of sick leave, the less likely the return to work becomes. Less than 50% of people with low back pain who have been off work for 6 months will return to work. After 2 years of work absenteeism, the chance of returning to work is almost zero.
Aims of intervention
To relieve pain; to improve function; to return to work; to develop coping strategies for pain, with minimal adverse effects from treatment.
Outcomes
Pain intensity (visual analogue [VAS] or numerical rating scale); overall improvement (self-reported or observed); back-pain specific functional status (such as Roland Morris Questionnaire, Oswestry questionnaire); impact on employment (days of sick leave, number of people returned to work); medication use.
Methods
BMJ Clinical Evidence search and appraisal May 2007. The authors also searched Medline (1966 to May 2007), Embase (1980 to May 2007), Psychlit (1984 to May 2007), and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2007, Issue 2. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA), Turning Research into Practice (TRIP), and NICE, using the search strategy recommended by the Cochrane Back Review Group. Most of the earlier RCTs of treatments for low back pain were small (less than 50 people/intervention group; range 9-169), short term (mostly less than 6 months' follow-up), and of low overall quality. Problems included lack of power, no description of randomisation procedure, incomplete analysis with failure to account for people who withdrew from trials, and lack of blinding. The quality of the methods used by many recent RCTs is higher. Many early RCTs had incomplete descriptions of the study population (e.g. whether people had radiating symptoms or not, or the presence or absence of sciatica or nerve root symptoms). In this review, we have excluded studies undertaken solely in people with sciatica or disc herniation. We have included studies in people with chronic low back pain with no radiation, or studies which included people both with and without radiation, if the proportion of people with radiation was less than 50%. The authors have also included data based on their own searches to May 2007 from the process of updating their own files. Study design criteria for inclusion in this review were: published systematic reviews and RCTs limited to English language journals only, at least single blinded, and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. We excluded all studies described as "open", "open label", or not blinded, unless blinding was impossible. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the review as required. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ).
Table.
Important outcomes | Symptom improvement, functional improvement, return to work, adverse effects | ||||||||
Number of studies (participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
What are the effects of oral drug treatments for people with chronic low back pain? | |||||||||
1 (311) | Symptom improvement | Analgesics v placebo | 4 | 0 | 0 | −1 | 0 | Moderate | Directness point deducted for narrow range of comparators |
1 (297) | Functional improvement | Analgesics v placebo | 4 | 0 | 0 | −1 | 0 | Moderate | Directness point deducted for narrow range of comparators |
5 (808) | Symptom improvement | Opioids v placebo/control | 4 | −3 | −1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, for inclusion of weak studies and for not defining control. Consistency point deducted for conflicting results |
1 (254) | Functional improvement | Opioids v placebo | 4 | −1 | 0 | −1 | 0 | Low | Quality point deducted for short follow-up. Directness point deducted for narrow range of comparators |
5 (336) | Symptom improvement | Opioids v opioids | 4 | −2 | 0 | −1 | 0 | Very low | Quality points deducted for incomplete reporting of results and for inclusion of weak studies. Directness point deducted for uncertainty about benefit |
7 (440) | Symptom improvement | Antidepressants v placebo | 4 | −1 | −2 | 0 | 0 | Very low | Quality point deducted for incomplete reporting of results. Consistency points deducted for heterogeneity among RCTs and for conflicting results |
5 (649) | Symptom improvement | Traditional NSAIDs v each other | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
1 (196) | Functional improvement | Traditional NSAIDs v each other | 4 | −2 | 0 | −1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for narrow range of comparators |
1 (29) | Symptom improvement | Traditional NSAIDs v analgesics | 4 | −2 | 0 | −1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for narrow range of comparators |
1 (319) | Symptom improvement | COX-2 inhibitors v placebo | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
1 (319) | Functional improvement | COX-2 inhibitors v placebo | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
1 (446) | Symptom improvement | COX-2 inhibitors v NSAIDs | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
1 (446) | Functional improvement | COX-2 inhibitors v NSAIDs | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
2 (222) | Symptom improvement | Benzodiazepines v placebo | 4 | −1 | 0 | −1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for narrow range of comparators |
2 (219) | Symptom improvement | Non-benzodiazepines v placebo | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
What are the effects of injection therapy for people with chronic low back pain? | |||||||||
3 (121) | Symptom improvement | Local injections v placebo | 4 | −2 | 0 | −1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for disparity in injections given |
2 (161) | Symptom improvement | Facet joint injections v placebo | 4 | −3 | −1 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results and for no direct comparison between groups. Consistency point deducted for conflicting results |
1 (101) | Functional improvement | Corticosteroid injections v saline injections | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data, incomplete reporting of results |
What are the effects of non-drug treatments for people with chronic low back pain? | |||||||||
33 (at least 2067 people) | Symptom improvement | Generic back exercise (other than McKenzie exercise and Yoga) v placebo/ no treatment/ other conservative interventions | 4 | −3 | −1 | −2 | 0 | Very low | Quality points deducted for incomplete reporting of results, inclusion of poor-quality RCTs and for uncertainty about bias. Consistency point deducted for conflicting results. Directness points deducted for variations in exercise programmes and inclusion of additional interventions |
33 (at least 337 people) | Functional improvement | Generic back exercise (other than McKenzie exercise and Yoga) v placebo/ no treatment/ other conservative interventions | 4 | −3 | 0 | −2 | 0 | Very low | Quality points deducted for incomplete reporting of results, inclusion of poor-quality RCTs and for uncertainty about bias. Directness points deducted for variations in exercise programmes and inclusion of additional interventions |
At least 6 RCTs (at least 86 people) | Symptom improvement | Trunk-strengthening/stabilisation v other back exercises or no exercise | 4 | −1 | −2 | −1 | 0 | Very low | Quality point deducted for incomplete reporting of results. Consistency points deducted for conflicting results and for different results at different endpoints. Directness points deducted for variations in exercise programmes |
At least 6 RCTs (at least 86 people) | Functional improvement | Trunk-strengthening/stabilisation v other back exercises or no exercise | 4 | −1 | −2 | −1 | 0 | Very low | Quality point deducted for incomplete reporting of results. Consistency points deducted for conflicting results and for different results at different endpoints. Directness point deducted for variations in exercise programmes |
2 (at least 56 people) | Symptom improvement | McKenzie method v other back exercise | 4 | −1 | 0 | −1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for variations in exercise programmes |
3 (not reported) | Functional improvement | McKenzie method v other back exercise | 4 | −1 | 0 | −1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for variations in exercise programmes |
1 (101) | Symptom improvement | Yoga v other back exercises | 4 | −2 | 0 | −1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for variations in exercise programmes |
1 (101) | Functional improvement | Yoga v other back exercises | 4 | −2 | 0 | −1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for variations in exercise programmes |
At least 7 RCTs (at least 283 people) | Symptom improvement | Multidisciplinary treatment programmes v usual care/non-multidisciplinary treatments | 4 | −1 | −1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for lack of consistent beneficial effects |
At least 7 RCTs (at least 283 people) | Functional improvement | Multidisciplinary treatment programmes v usual care/non-multidisciplinary treatments | 4 | −1 | −1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for lack of consistent beneficial effects |
2 (2816) | Symptom improvement | Acupuncture v no treatment | 4 | −2 | 0 | −1 | 0 | Very low | Quality points deducted for incomplete reporting of results and for inclusion of poor-quality RCTs. Directness points deducted for inclusion of other interventions in large RCT |
2 (2816) | Functional improvement | Acupuncture v no treatment | 4 | −2 | 0 | −1 | 0 | Very low | Quality points deducted for incomplete reporting of results and for inclusion of poor-quality RCTs. Directness points deducted for inclusion of other interventions in large RCT |
4 (at least 314 people) | Symptom improvement | Acupuncture v sham treatment | 4 | −1 | −1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for different results at different endpoints |
4 (not reported) | Functional improvement | Acupuncture v sham treatment | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
4 (289) | Symptom improvement | Addition of acupuncture to other interventions v intervention alone | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
4 (289) | Functional improvement | Addition of acupuncture to other interventions v intervention alone | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
9 (1458) | Symptom improvement | Back schools v no treatment or inactive control treatments | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting of results and for inclusion of poor-quality studies |
6 (1200) | Functional improvement | Back schools v no treatment or inactive control treatments | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting of results and for inclusion of poor-quality studies |
4 (575) | Symptom improvement | Back schools v other treatments | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting and for no direct comparison between groups |
4 (433) | Functional improvement | Back schools v other treatments | 4 | −2 | −1 | 0 | 0 | Low | Quality points deducted for incomplete reporting and for no direct comparison between groups |
8 (630) | Symptom improvement | Behavioural therapy v placebo/ no treatment/ waiting list control | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
8 (630) | Functional improvement | Behavioural therapy v placebo/ no treatment/ waiting list control | 4 | −1 | −1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results |
9 (308) | Symptom improvement | Different types of behavioural therapy v each other | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
9 (308) | Functional improvement | Different types of behavioural therapy v each other | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
1 (84) | Return to work | Different types of behavioural therapy v each other | 4 | −3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results and for baseline differences between groups |
8 (545) | Symptom improvement | Behavioural therapy v other treatments | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
At least 7 RCTs (at least 1205 people) | Symptom improvement | Spinal manipulative therapy v placebo/ no treatment/ waiting list control | 4 | −1 | −1 | −2 | 0 | Very low | Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results. Directness points deducted for wide range of comparators, for inclusion of people with non-chronic pain and for inclusion of mobilisation therapies |
at least 7 RCTs (at least 1205 people) | Functional improvement | Spinal manipulative therapy v placebo/ no treatment/ waiting list control | 4 | −1 | −1 | −2 | 0 | Very low | Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results. Directness points deducted for wide range of comparators, for inclusion of people with non-chronic pain and for inclusion of mobilisation therapies |
1 (49) | Return to work | Spinal manipulative therapy v exercise therapy | 4 | −1 | −1 | 0 | +1 | Moderate | Quality points deducted for sparse data and incomplete reporting of results. Effect-size point added for RR 0.2–0.5 |
3 (102) | Symptom improvement | Electromyographic biofeedback v placebo/ waiting list control | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
3 (102) | Functional improvement | Electromyographic biofeedback v placebo/ waiting list control | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
1 (30) | Symptom improvement | Electromyographic biofeedback v other treatments | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
3 (70) | Functional improvement | Electromyographic biofeedback v other treatments | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
4 (351) | Symptom improvement | TENS v placebo | 4 | −2 | −2 | −1 | 0 | Very low | Quality points deducted for incomplete reporting of results and for poor follow-up. Consistency points deducted for conflicting results and for heterogeneity among RCTs. Directness point deducted for uncertainty about clinical benefit |
3 (323) | Functional improvement | TENS v placebo | 4 | −1 | −2 | −1 | 0 | Very low | Quality point deducted for incomplete reporting of results. Consistency points deducted for heterogeneity among RCTs. Directness point deducted for uncertainty about clinical benefit |
Type of evidence: 4 = RCT; 2 = Observational Consistency: similarity of results across studies Directness: generalisability of population or outcomes Effect size: based on relative risk or odds ratio
Glossary
- Acupuncture
Acupuncture is needle puncture of the skin at traditional “meridian” acupuncture points. Modern acupuncturists also use non-meridian points and trigger points (tender sites occurring in the most painful areas). The needles may be stimulated manually or electrically. Placebo acupuncture is needling of traditionally unimportant sites or non-stimulation of the needles once placed.
- Back school
Back school techniques vary widely, but essentially consist of repeated sessions of instruction about anatomy and function of the back and isometric exercises to strengthen the back.
- Behavioural graded activity
Graded activity is an operant behavioural treatment that aims to increase activity levels by means of quota systems. The training includes registration of baseline levels during the first 2 weeks, a treatment contract, positive reinforcement for activity increments, and a workplace visit.
- Cognitive behavioural therapy
Cognitive behavioural therapy aims to identify and modify peoples understanding of their pain and disability using cognitive restructuring techniques (such as imagery and attention diversion) or by modifying maladaptive thoughts, feelings, and beliefs.
- Electromyographic biofeedback
With electromyographic biofeedback, a person receives external feedback of their own electromyogram (using visual or auditory scales), and uses this to learn how to control the electromyogram and hence the tension within their own muscles. Electromyogram biofeedback for low back pain aims to relax the paraspinal muscles.
- Generic back exercise (low back pain)
In this review, generic back exercise denotes undifferentiated exercise/movements performed in multiple directions or planes without emphasis on the person’s pattern of pain or directional preference for pain control.
- Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
- Massage
Massage is manipulation of soft tissues (i.e. muscle and fascia) using the hands or a mechanical device, to promote circulation and relaxation of muscle spasm or tension. Different types of soft tissue massage include Shiatsu, Swedish, friction, trigger point, or neuromuscular massage.
- Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
- Multidisciplinary treatment
Multidisciplinary programmes are typically taken to comprise treatments provided by two or more healthcare providers with different professional training to obtain different perspectives and approaches to recovery. The term multidisciplinary does not imply a mandatory roster of specialists and does not dictate the nature of the treatment.
- Operant behavioural treatments
Operant behavioural treatments include positive reinforcement of healthy behaviours and consequent withdrawal of attention from pain behaviours, time contingent instead of pain contingent pain management, and spouse involvement, while undergoing a programme aimed at increasing exercise tolerance towards a preset goal.
- Respondent behavioural treatment
Respondent behavioural treatment aims to modify physiological responses directly (e.g. reducing muscle tension by explaining the relation between tension and pain, and using relaxation techniques).
- Sciatica
Pain that radiates from the back into the buttock or leg and is most commonly caused by prolapse of an intervertebral disk; the term may also be used to describe pain anywhere along the course of the sciatic nerve.
- Very low-quality evidence
Any estimate of effect is very uncertain.
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
Contributor Information
Hamilton Hall, Department of Surgery, University of Toronto, Toronto, Canada.
Greg McIntosh, CBI Health Research Dept, Toronto, Canada.
References
- 1.Van der Heijden GJMG, Bouter LM, Terpstra-Lindeman E. De effectiviteit van tractie bij lage rugklachten. De resultaten van een pilotstudy. Ned T Fysiotherapie 1991;101:37–43. [Google Scholar]
- 2.Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical Practice Guideline no. 14. AHCPR Publication No. 95-0642. Rockville MD: Agency for Health Care Policy and Research, Public Health Service, US, Department of Health and Human Services. December 1994. Search date not stated; primary sources The Quebec Task Force on Spinal Disorders Review to 1984, search carried out by National Library of Medicine from 1984, and references from expert panel. [Google Scholar]
- 3.Andersson GBJ. The epidemiology of spinal disorders. In: Frymoyer JW, ed. The adult spine: principles and practice. 2nd ed. New York: Raven Press, 1997:93–141. [Google Scholar]
- 4.Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992;268:760–765. [PubMed] [Google Scholar]
- 5.Bongers PM, de Winter CR, Kompier MA, et al. Psychosocial factors at work and musculoskeletal disease. Scand J Work Environ Health 1993;19:297–312. [DOI] [PubMed] [Google Scholar]
- 6.Pincus T, Burton AK, Vogel S, et al. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine 2002;27:E109–E120. [DOI] [PubMed] [Google Scholar]
- 7.Fransen M, Woodward M, Norton R, et al. Risk factors associated with the transition from acute to chronic occupational back pain. Spine 2002;27:92–98. [DOI] [PubMed] [Google Scholar]
- 8.Von Korff M, Saunders K. The course of back pain in primary care. Spine 1996;21:2833–2837. [DOI] [PubMed] [Google Scholar]
- 9.Waddell G. The clinical course of low back pain. In: The back pain revolution. Edinburgh: Churchill Livingstone, 1998:103–117. [Google Scholar]
- 10.Evans G, Richards S. Low back pain: an evaluation of therapeutic interventions. Bristol: Health Care Evaluation Unit, University of Bristol, 1996. Search date 1995; primary sources Medline, Embase, A-Med, Psychlit, and hand searches of references. [Google Scholar]
- 11.Van Tulder MW, Assendelft WJJ, Koes BW, et al. Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for spinal disorders. Spine 1997;22:2323–2330. [DOI] [PubMed] [Google Scholar]
- 12.Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine 1997;22:2128–2156. Search date 1995; primary sources Medline, Embase, Psychlit, and hand searches of references. [DOI] [PubMed] [Google Scholar]
- 13.Ruoff GE, Rosenthal N, Jordan D, et al. Tramadol/acetaminophen combination tablets for the treatment of chronic lower back pain: a multicenter, randomized, double-blind, placebo-controlled outpatient study. Clin Ther 2003;23:1123–41. [DOI] [PubMed] [Google Scholar]
- 14.Martell BA, O'Connor PG, Kerns RD, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med 2007;146:116–127. [DOI] [PubMed] [Google Scholar]
- 15.Schnitzer TJ, Gray WL, Paster RZ, et al. Efficacy of tramadol in treatment of chronic low back pain. J Rheumatol 2000;27:772–778. [PubMed] [Google Scholar]
- 16.De Craen AJM, Di Giulio G, Lampe-Schoenmaeckers AJEM, et al. Analgesic efficacy and safety of paracetamol–codeine combinations versus paracetamol alone: a systematic review. BMJ 1996;313:321–325. Search date 1995; primary sources Medline, Embase, International Pharmaceutical Abstracts, Biosis, contact with pharmaceutical companies, and hand searches of references. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Staiger TO, Barak G, Sullivan MD, et al. Systematic review of antidepressants in the treatment of chronic low back pain. Spine 2003;28:2540–2545. Search date 2002; primary sources Medline, Psychinfo, and Cochrane Controlled Trials Registry. [DOI] [PubMed] [Google Scholar]
- 18.Atkinson JH, Slater MA, Wahlgren DR, et al. Effects of noradrenergic and serotonergic antidepressants on chronic low back pain intensity. Pain 1999;83:137–145. [DOI] [PubMed] [Google Scholar]
- 19.Atkinson JH, Slater MA, Williams RA, et al. A placebo-controlled randomized clinical trial of nortriptyline for chronic low back pain. Pain 1998;76:287–296. [DOI] [PubMed] [Google Scholar]
- 20.Van Tulder MW, Scholten RJPM, Koes BW, et al. Non-steroidal anti-inflammatory drugs for low back pain. In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. Search date 1998; primary sources Medline, Embase, Cochrane Controlled Trials Register, and hand searches of reference lists from relevant papers. [Google Scholar]
- 21.Famaey JP, Bruhwyler J, Vandekerckhove K, et al. Open controlled randomised multicenter comparison of nimesulide and diclofenac in the treatment of subacute and chronic low back pain. J Drug Assess 1998;1:349–368. [Google Scholar]
- 22.Birbara CA, Puopolo AD, Munoz DR, et al. Treatment of chronic low back pain with etoricoxib, a new cyclo-oxygenase-2 selective inhibitor: improvement in pain and disability: a randomised, placebo-controlled, 3-month trial. J Pain 2003;4:307–315. [DOI] [PubMed] [Google Scholar]
- 23.Pallay RM, Seger W, Adler JL, et al. Etoricoxib reduced pain and disability and improved quality of life in patients with chronic low back pain: a 3 month, randomized, controlled trial. Scand J Rheumatol 2004;33:257–266. [DOI] [PubMed] [Google Scholar]
- 24.Zerbini C, Ozturk ZE, Grifka J, et al. Efficacy of etoricoxib 60 mg/day and diclofenac 150 mg/day in reduction of pain and disability in patients with chronic low back pain: results of a 4-week, multinational, randomized, double-blind study. Curr Med Res Opin 2005;21:2037–2049. [DOI] [PubMed] [Google Scholar]
- 25.Waddell G, Feder G, McIntosh A, et al. Low back pain evidence review. London: Royal College of General Practitioners, 1996. Search date 1996; primary sources Medline, Embase, Science Citation Index, Social Sciences Citation Index, correspondence with experts and researchers, and hand searches of references. [Google Scholar]
- 26.Watts RW, Silagy CA. A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica. Anaesth Intensive Care 1995;23:564–569. Search date not reported; primary sources Medline, hand searches from published reviews and clinical trials, and personal contact with published authors in the field and the pharmaceutical manufacturer. [DOI] [PubMed] [Google Scholar]
- 27.Harms alert for Bextra: European suspension of Bextra. MHRA Press Release 2005. [Google Scholar]
- 28.Van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low back pain. In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. Search date 2001; primary sources Medline, Embase, The Cochrane Library, and reference lists. [Google Scholar]
- 29.Worz R, Bolten W, Heller J, et al. Flupirtin im vergleich zu chlormezanon und placebo bei chronische muskuloskelettalen ruckenschmerzcn. Fortschr Ther 1996;114:3–6. [In German] [PubMed] [Google Scholar]
- 30.Pratzel HG, Alken RG, Ramm S. Efficacy and tolerance of repeated oral doses of tolperisone hydrochloride in the treatment of painful reflex muscle spasm: results of a prospective placebo-controlled double-blind trial. Pain 1996;67:417–425. [DOI] [PubMed] [Google Scholar]
- 31.Basmajian J. Cyclobenzaprine hydrochloride effect on skeletal muscle spasm in the lumbar region and neck: two double-blind controlled clinical and laboratory studies. Arch Phys Med Rehabil 1978;59:58–63. [PubMed] [Google Scholar]
- 32.Nelemans PJ, de Bie RA, de Vet HCW, et al. Injection therapy for subacute and chronic benign low back pain. In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. Search date 1996; primary sources Medline, Embase, and hand searches of reference lists. [Google Scholar]
- 33.Fuchs S, Erbe T, Fischer HL, et al. Intraarticular hyaluronic acid versus glucocorticoid injections for nonradicular pain in the lumbar spine. J Vasc Interv Radiol 2005;16:1493–1498. [DOI] [PubMed] [Google Scholar]
- 34.Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. In: The Cochrane Library, Issue 3, 2005. Chichester, UK: John Wiley & Sons, Ltd. Search date 2003; primary sources Cochrane Central Register of Controlled Trials (Issue 3, 2004), Medline, Embase, Psychinfo, Cinahl databases to October 2004, citation searches, and bibliographic reviews of previous systematic reviews. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Slade SC, Keating JL. Trunk-strengthening exercises for chronic low back pain: a systematic review. J Manipulative Physiol Ther 2006;29:163–173. [DOI] [PubMed] [Google Scholar]
- 36.Ferreira PH, Ferreira ML, Maher CG, et al. Specific stabilisation exercise for spinal and pelvic pain: A systematic review. Aust J Phys 2006;52:79–88. [DOI] [PubMed] [Google Scholar]
- 37.Clare HAA. A systematic review of efficacy of McKenzie therapy for spinal pain. Aust J Phys 2004;50:209–216. [DOI] [PubMed] [Google Scholar]
- 38.Slade SCK. Unloaded Movement Facilitation Exercise Compared to No Exercise or Alternative Therapy on Outcomes for People with Nonspecific Chronic Low Back Pain: A Systematic Review. J Manipulative Physiol Ther 2007;30:301–311. [DOI] [PubMed] [Google Scholar]
- 39.Carneiro Machado LA, De Souza MVS, Ferreira PH, et al. The McKenzie method for low back pain: A systematic review of the literature with a meta-analysis approach. Spine 2006;31:E254–E262. [DOI] [PubMed] [Google Scholar]
- 40.Kofotolis N, Kellis E. Effects of two 4-week proprioceptive neuromuscular facilitation programs on muscle endurance, flexibility, and functional performance in women with chronic low back pain. Phys Ther 2006;86:1001–1012. [PubMed] [Google Scholar]
- 41.Sherman KJ, Cherkin DC, Erro J, et al. Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial. Ann Intern Med 2005;143:849–856. [DOI] [PubMed] [Google Scholar]
- 42.Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001;322:1511–1516. Search date 1998; primary sources Medline, Embase, Psychlit, Cinahl, Healthstar, The Cochrane Library, citation tracking, and personal contact with content experts. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Vollenbroek-Hutten MMR, Hermens HJ, Wever D, et al. Differences in outcome of a multidisciplinary treatment between subgroups of chronic low back pain patients defined using two multiaxial assessment instruments: the multidimensional pain inventory and lumbar dynamometry. Clin Rehabil 2004;18:566–579. [DOI] [PubMed] [Google Scholar]
- 44.Kaapa EH, Frantsi K, Sarna S, et al. Multidisciplinary group rehabilitation versus individual physiotherapy for chronic nonspecific low back pain: a randomized trial. Spine 2006;31:371–376. [DOI] [PubMed] [Google Scholar]
- 45.Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry-needling for low back pain. In: The Cochrane Library, Issue 1, 2005. Chichester, UK: John Wiley & Sons, Ltd. Search date 2003; primary sources Central, Medline, Embase, Chinese Cochrane Centre database of clinical trials, and Japanese databases. [Google Scholar]
- 46.Witt CM, Jena S, Selim D, et al. Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol 2006;164:487–496. [DOI] [PubMed] [Google Scholar]
- 47.Hsieh LL, Kuo CH, Lee LH, et al. Treatment of low back pain by acupressure and physical therapy: randomised controlled trial. BMJ 2006;332:696–700. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Heymans MW, Van Tulder MW, Esmail R, et al. Back schools for non-specific low back pain. In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. Search date 2003; primary sources Medline, Embase, and hand searches of references. [Google Scholar]
- 49.Tavafian SS, Jamshidi A, Mohammad K, et al. Low back pain education and short term quality of life: A randomized trial. BMC Musculoskeletal Disorders 1921;8, 2007. Article Number:21 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Dalichau S, Scheele K, Perrey RM, et al. Ultraschallgestützte Haltungs-und Bewegungsanalyse der Lendenwirbelsaüle zum Nachweis der Wirksamkeit einer Rückenschule. Zentralbl Arbeitsmed 1999;49:148–156. [In German] [Google Scholar]
- 51.Keijsers JFEM, Groenman NH, Gerards FM, et al. A back school in the Netherlands: evaluating the results. Patient Educ Couns 1989;14:31–44. [DOI] [PubMed] [Google Scholar]
- 52.Linton SJ, Bradley LA, Jensen I, et al. The secondary prevention of low back pain: a controlled study with follow-up. Pain 1989;36:197–207. [DOI] [PubMed] [Google Scholar]
- 53.Postacchini F, Facchini M, Palieri P. Efficacy of various forms of conservative treatment in low-back pain. A comparative study. Neuro-Orthopedics 1988;6:28–35. [Google Scholar]
- 54.Harkapaa K, Jarvikoski A, Mellin G, et al. A controlled study on the outcome of inpatient and outpatient treatment of low-back pain. Part I. Scand J Rehab Med 1989;21:81–89. [PubMed] [Google Scholar]
- 55.Hurri H. The Swedish back school in chronic low-back pain. Part I. Benefits. Scand J Rehab Med 1989;21:33–40. [PubMed] [Google Scholar]
- 56.Keijsers JFME, Steenbakkers WHL, Meertens RM, et al. The efficacy of the back school: a randomized trial. Arthritis Care Res 1990;3:204–209. [Google Scholar]
- 57.Lonn JH, Glomsrod B, Soukup MG, et al. Active back school: prophylactic management for low back pain. A randomized, controlled, 1-year follow-up study. Spine 1999;24:865–871. [DOI] [PubMed] [Google Scholar]
- 58.Donchin M, Woolf O, Kaplan L, et al. Secondary prevention of low-back pain. A clinical trial. Spine 1990;15:1317–1320. [DOI] [PubMed] [Google Scholar]
- 59.Klaber Moffett JA, Chase SM, Portek I, et al. A controlled prospective study to evaluate the effectiveness of a back school in the relief of chronic low-back pain. Spine 1986;11:120–122. [DOI] [PubMed] [Google Scholar]
- 60.Maier-Riehle B, Hårter M. The effects of back schools: a meta-analysis. Int J Rehab Res 2001;24:199–206. Search date 2000; primary sources Medline, Psychlit, Psyindex, and hand searches of reference lists from relevant publications. [DOI] [PubMed] [Google Scholar]
- 61.Henrotin YE, Cedraschi C, Duplan B, et al. Information and low back pain management: A systematic review. Spine 2006;31:E326–E334. [DOI] [PubMed] [Google Scholar]
- 62.Van Tulder MW, Ostelo R, Vlaeyen JWS, et al. Behavioural treatment for chronic low back pain. In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. Search date 1999; primary sources Medline, Psychlit, Cochrane Controlled Trials Register, Embase, and hand searches of reference lists. [Google Scholar]
- 63.Van den Hout JHC, Vlaeyen JWS, Heuts PHTG, et al. Secondary prevention of work-related disability in non-specific low back pain: does problem-solving therapy help? A randomised clinical trial. Clin J Pain 2003;19:87–96. [DOI] [PubMed] [Google Scholar]
- 64.Smeets RJ, Vlaeyen JW, Kester AD, et al. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J Pain 2006;7:261–271. [DOI] [PubMed] [Google Scholar]
- 65.Assendelft WJJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain: a meta-analysis of effectiveness relative to other therapies. Ann Intern Med 2003;138:71–81. Search date 2001; primary sources Medline, Embase, Cinahl, Cochrane Controlled Trials Register, reviews, and reference lists. [DOI] [PubMed] [Google Scholar]
- 66.Aure OF, Nilsen JH, Vasseljen O. Manual therapy and exercise therapy in patients with chronic low back pain: a randomised, controlled trial with 1-year follow-up. Spine 2003;28:525–532. [DOI] [PubMed] [Google Scholar]
- 67.Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I. Stabilizing training compared with manual treatment in sub-acute and chronic low-back pain. Man Ther 2003;8:233–241. [DOI] [PubMed] [Google Scholar]
- 68.Hurwitz EL, Morgenstern H, Kominski GF, et al. A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study. Spine 2006;31:611–621. [DOI] [PubMed] [Google Scholar]
- 69.Shekelle PG, Adams AH, Chassin MR, et al. Spinal manipulation for low back pain. Ann Intern Med 1992;117:590–598. Search date not reported; primary sources Medline, Index Medicus, contact with experts, and hand searches of references. [DOI] [PubMed] [Google Scholar]
- 70.Van Tulder MW, Jellema P, van Poppel MNM, et al. Lumbar supports for prevention and treatment of low back pain. In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. Search date 1999; primary sources Medline, Cinahl, Current Contents, Cochrane Controlled Trials Register, Embase, Science Citation Index, and hand searches of reference lists. [Google Scholar]
- 71.Furlan AD, Brosseau L, Welch V, et al. Massage for low back pain. In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. Search date 2001; primary sources Medline, Embase, Cochrane Controlled Trials Register, Healthstar, Cinahl, Dissertation Abstracts, hand searches of reference lists, and contact with content experts and massage associations. [Google Scholar]
- 72.Clarke JA, van-Tulder MW, Blomberg SEI, et al. Traction for low-back pain with or without sciatica-UPDATED COCHRANE SR. Cochrane Database of Systematic Reviews: Reviews 2007 Issue 2. Chichester, UK: John Wiley & Sons, Ltd 2007. [Google Scholar]
- 73.Milne S, Welch V, Brosseau L, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain. In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. Search date 2000; primary sources Medline; Embase; Pedro; Cochrane Controlled Trials Register; hand searches of bibliographic references, reference lists, Current Contents, abstracts in specialised journals, and conference proceedings; and personal contact with coordinating offices of the trials registries of the Cochrane Field of Physical and Related Therapies and Cochrane Musculoskeletal Group and content experts. [Google Scholar]
- 74.Khadilkar A, Milne S, Brosseau L, et al. Transcutaneous electrical nerve stimulation for the treatment of chronic low back pain: a systematic review. Spine 2005;30:2657–2666. [DOI] [PubMed] [Google Scholar]
- 75.Cheing GLY, Hui-Chan CWY. Transcutaneous electrical nerve stimulation: nonparallel antinociceptive effects on chronic clinical pain and acute experimental pain. Arch Phys Med Rehabil 1999;80:305–312. [DOI] [PubMed] [Google Scholar]