Table.
GRADE evaluation of interventions for low back pain (chronic)
| 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