Abstract
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).
Key Points
Over 70% of people in developed countries develop low back pain at some time, which usually improves within 2 weeks, however about 10% remained off work and about 20% had persistent symptoms at 1 year.
Non-steroidal anti-inflammatory drugs (NSAIDs) may be more effective than placebo at improving pain intensity in people with chronic low back pain.
Opioid analgesics (with or without paracetamol) may improve pain and function compared with placebo. However, long-term use of NSAIDs or opioids may be associated with well-recognised adverse effects.
We don't know whether antidepressants decrease chronic low back pain or improve function compared with placebo in people with or without depression.
Benzodiazepines may improve pain, but studies of non-benzodiazepine muscle relaxants 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 (www.fda.gov/medwatch).
We don't know whether epidural corticosteroid 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.
Fusion surgery is more effective than standard rehabilitation for improving pain in people with chronic non-radicular low back pain, but it is no better than intensive rehabilitation with a cognitive behavioural component.
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 beneficial.
Acupuncture, back schools, behavioural therapy, and spinal manipulation may reduce pain in the short term, but effects on function are unclear.
Massage may improve pain and function compared with sham or other active treatment.
We don't know whether electromyographic biofeedback, lumbar supports, traction, or TENS improve pain relief.
We also don't know whether intradiscal electrothermal therapy, radiofrequency denervation, or disc replacement improve pain relief or function.
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 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 (>12 weeks' duration).
Incidence/ Prevalence
Over 70% of people in developed countries will experience low back pain at some time in their lives. Each year, between 15% and 45% of adults suffer low back pain, and 5% of people present to hospital with a new episode. About 10% remained off work and about 20% had persistent symptoms at 1 year.
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% to 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, and 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. One 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
Symptom improvement: Pain intensity (visual analogue [VAS] or numerical rating scale); overall improvement (self-reported or observed); Functional improvement: 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); adverse effects.
Methods
Clinical Evidence search and appraisal April 2009. The authors also searched Medline (1966 to May April 2009), Embase (1980 to April 2009), Psychlit (1984 to April 2009), and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2009, Issue 1. 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 National Institute for Health and Clinical Excellence (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 (<50 people/intervention group; range 9–169), short term (mostly <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 that included people both with and without radiation, if the proportion of people with radiation was <50%. 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 >20 individuals of whom >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. We excluded outdated systematic reviews, systematic reviews that pooled RCTs with observational studies, systematic reviews that did not evaluate RCT quality, and systematic reviews that did not focus on trials of people with low back pain. 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. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ). The categorisation of the quality of the evidence (into high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).
Table 1.
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 SR (3 RCTs, 908 people) | Symptom improvement | Tramadol with or without paracetamol v placebo | 4 | 0 | 0 | 0 | 0 | High | |
| 2 RCTs (591) | Symptom improvement | Sustained release opioids v placebo | 4 | 0 | 0 | 0 | 0 | High | |
| 5 (808) | Symptom improvement | Opioids v placebo/control | 4 | −3 | −1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, inclusion of weak studies, and not defining control. Consistency point deducted for conflicting results |
| 1 SR, 3 RCTs (878) | Functional improvement | Tramadol with or without paracetamol v placebo | 4 | 0 | 0 | 0 | 0 | High | |
| 5 (336) | Symptom improvement | Opioids v opioids | 4 | −2 | 0 | −1 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of weak studies. Directness point deducted for uncertainty about benefit |
| 17 (941) | 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 conflicting results |
| 1 (42) | Symptom improvement | Antidepressants v each other | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 SR, 2 RCTs (132) | Functional improvement | Antidepressants v placebo | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and methodological weaknesses (including baselines differences between groups) |
| 5 (1345) | Symptom improvement | NSAIDs v placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 12 (unclear) | Symptom improvement | NSAIDs v each other | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (29) | Symptom improvement | 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 (325) | Functional improvement | NSAIDs v placebo | 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 (97) | Symptom improvement | Local injections v placebo | 4 | −2 | –1 | −1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for conflicting results. Directness point deducted for disparity in injections given |
| 2 (210) | Symptom improvement | Facet joint 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 ungeneraliseable population. |
| 1 (101) | Functional improvement | Facet joint injections v saline injections | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| What are the effects of non-drug treatments for people with chronic low back pain? | |||||||||
| 4 (at least 2336 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 uncertainty about bias. Consistency point deducted for conflicting results. Directness points deducted for variations in exercise programmes and inclusion of additional interventions |
| 3 (at least 1628 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 uncertainty about bias. Directness points deducted for variations in exercise programmes and inclusion of additional interventions |
| At least 9 RCTs (at least 1940 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 different results at different end points. Directness points deducted for variations in exercise programmes |
| At least 9 RCTs (at least 1940 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 different results at different end points. 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 |
| 4 (at least 260) | 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 (181) | 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 576 people) | Symptom improvement | Multidisciplinary treatment programmes v waiting list control/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 576 people) | Functional improvement | Multidisciplinary treatment programmes v waiting list control/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 5 RCTs (at least 120 people) | Return to work | Multidisciplinary treatment programmes v waiting list control/usual care/non-multidisciplinary treatments | 4 | –1 | –1 | 0 | 0 | Very low | Quality point deducted for incomplete reporting of results. Consistency point deducted for lack of consistent beneficial effects |
| 3 RCTs (at least 298) | Symptom improvement | Acupuncture v no treatment | 4 | −2 | –1 | −1 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of poor-quality RCTs. Consistency point deducted for conflicting results. Directness point deducted for inclusion of other interventions in large RCT |
| 3 RCTs (298) | Functional improvement | Acupuncture v no treatment | 4 | −2 | –1 | −1 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of poor-quality RCTs. Consistency point deducted for conflicting results. Directness point deducted for inclusion of other interventions in large RCT |
| 3 (1650) | Symptom improvement | Acupuncture v sham treatment | 4 | −2 | −1 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of poor-quality RCTs. Consistency point deducted for conflicting results. Directness point deducted for inclusion of other interventions in large RCT |
| 3 (1650) | Functional improvement | Acupuncture v sham treatment | 4 | −2 | –1 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of poor-quality RCTs. Consistency point deducted for conflicting results. Directness point deducted for inclusion of other interventions in large RCT |
| 6 (at least 200 people) | Symptom improvement | Acupuncture v other treatment | 4 | –2 | –1 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of poor-quality RCTs. Consistency point deducted for conflicting results. Directness point deducted for inclusion of other interventions in large RCT |
| 6 (at least 200 people) | Functional improvement | Acupuncture v other treatment | 4 | –2 | –1 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of poor-quality RCTs. Consistency point deducted for conflicting results. Directness point deducted for inclusion of other interventions in large RCT |
| 5 RCTs (not reported) | Symptom improvement | Addition of acupuncture to other interventions v intervention alone | 4 | −2 | –1 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of poor-quality RCTs. Consistency point deducted for conflicting results. Directness point deducted for inclusion of other interventions in large RCT |
| 5 RCTs (not reported) | Functional improvement | Addition of acupuncture to other interventions v intervention alone | 4 | −2 | –1 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of poor-quality RCTs. Consistency point deducted for conflicting results. Directness point deducted for inclusion of other interventions in large RCT |
| 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 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 no direct comparison between groups |
| 4 (433) | Functional improvement | Back schools v other treatments | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting and no direct comparison between groups |
| 6 (611) | Return to work | Back schools v no treatment or inactive control | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of poor-quality studies. Consistency point deducted for conflicting results |
| 6 (611) | Return to work | Back schools v other treatments | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of poor-quality studies. Consistency point deducted for conflicting results |
| 11 (at least 579 people) | 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 |
| 1 (211) | 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/sham/other treatments | 4 | −1 | −1 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results. |
| at least 7 RCTs (at least 1205 people) | Functional improvement | Spinal manipulative therapy v placebo/no treatment/waiting list control/sham/ other treatments | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results. |
| 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 |
| 4 (108) | 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 |
| 4 (108) | 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 (44) | 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 (44) | Functional improvement | Electromyographic biofeedback v other treatments | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (79) | Symptom improvement | Lumbar support v no intervention | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (79) | Functional improvement | Lumbar support v no intervention | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (91) | Symptom improvement | Massage v sham treatment | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 2 (91) | Functional improvement | Massage v sham treatment | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 5 (404) | Symptom improvement | Massage v other interventions | 4 | 0 | 0 | 0 | 0 | High | |
| 4 (369) | Functional improvement | Massage v other interventions | 4 | 0 | 0 | 0 | 0 | High | |
| 2 (175) | Symptom improvement | TENS v placebo | 4 | −3 | −2 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, poor follow-up, and sparse data. Consistency points deducted for conflicting results and heterogeneity among RCTs |
| 1 (145) | Functional improvement | TENS v placebo | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting of results and sparse data. |
| 1 (28) | Symptom improvement | TENS plus massage v sham TENS plus massage | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted sparse data and incomplete results |
| What are the effects of non surgical treatment for chronic low back pain? | |||||||||
| 2 (121) | Symptom improvement | IDETT v sham IDETT | 4 | –1 | –1 | –1 | 0 | Very low | Quality point deducted for sparse data. Consistency point deducted for conflicting results. Directness point deducted for the lack of generalisability of population |
| 2 (121) | Functional improvement | IDETT v sham IDETT | 4 | –1 | –1 | –1 | 0 | Very low | Quality point deducted for sparse data. Consistency point deducted for conflicting results. Directness point deducted for the lack of generalisability of population |
| 6 (371) | Symptom improvement | Radiofrequency denervation v sham/placebo | 4 | –3 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, including low-quality studies, and inadequate randomisation. Consistency point deducted for conflicting results. |
| 6 (371) | Functional improvement | Radiofrequency denervation v sham/placebo | 4 | –3 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, including low-quality studies, and inadequate randomisation. Consistency point deducted for conflicting results |
| What are the effects of surgical treatments for chronic low back pain? | |||||||||
| 4 (767) | Symptom improvement | Fusion surgery v non-surgical treatment | 4 | 0 | –1 | 0 | 0 | Moderate | Consistency point deducted for conflicting results |
| 4 (767) | Functional improvement | Fusion surgery v non-surgical treatment | 4 | 0 | –1 | 0 | 0 | Moderate | Consistency point deducted for conflicting results |
| 3 (418) | Return to work | Fusion surgery v non-surgical treatment | 4 | 0 | –1 | 0 | 0 | Moderate | Consistency point deducted for conflicting results |
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.
- Beck Depression Inventory
Standardised scale to assess depression. This instrument consists of 21 items to assess the intensity of depression. Each item is a list of 4 statements (rated 0, 1, 2, or 3), arranged in increasing severity, about a particular symptom of depression. The range of scores possible are 0 = least severe depression to 63 = most severe depression. It is recommended for people aged 13 to 80 years. Scores of more than 12 or 13 indicate the presence of depression.
- 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.
- 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.
- Oswestry Disability Index
Back-specific, self-reported questionnaire measuring pain and function in completing physical and social activities. The scale score ranges from 0 (no disability) to 100 (maximum disability).
- 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).
- Roland Morris Disability Questionnaire
A 24-item, self-reported, disability scale specific to back pain recommended for use in primary care and community studies. Measures daily function in completing activities affected by back pain. The scale score ranges from 0 (no disability) to 24 (severe disability).
- 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.
- Transcutaneous electrical nerve stimulation (TENS)
Electrodes are placed on the skin and different electrical pulse rates and intensities are used to stimulate the area. Low-frequency TENS (also referred to as acupuncture-like TENS) usually consists of pulses delivered at 1 to 4 Hz at high intensity, so they evoke visible muscle fibre contractions. High-frequency TENS (conventional TENS) usually consists of pulses delivered at 50 to 120 Hz at a low intensity, so there are no muscle contractions.
- 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.
References
- 1.Van der Heijden GJMG, Bouter LM, Terpstra-Lindeman E. The efficacy of traction for low back pain. Results of a pilot study.[In Dutch] 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 reported. [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.Chou R, Shekelle P, Chou Roger, et al. Will this patient develop persistent disabling low back pain? JAMA 2010;303:1295-1302. [DOI] [PubMed] [Google Scholar]
- 5.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]
- 6.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]
- 7.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]
- 8.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]
- 9.Von Korff M, Saunders K. The course of back pain in primary care. Spine 1996;21:2833–2837. [DOI] [PubMed] [Google Scholar]
- 10.Waddell G. The clinical course of low back pain. In: The back pain revolution. Edinburgh: Churchill Livingstone, 1998:103–117. [Google Scholar]
- 11.Evans G, Richards S. Low back pain: an evaluation of therapeutic interventions. Bristol: Health Care Evaluation Unit, University of Bristol, 1996. Search date 1995. [Google Scholar]
- 12.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]
- 13.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. [DOI] [PubMed] [Google Scholar]
- 14.Chou R, Huffman LH, American Pain Society, et al. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. [erratum appears in Ann Intern Med 2008;148:247–248. Ann Intern Med 2007;147:505–514. [DOI] [PubMed] [Google Scholar]
- 15.Davies RA, Maher CG, Hancock MJ, et al. A systematic review of paracetamol for non-specific low back pain. Eur Spine J 2008;17:1423–1430. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.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]
- 17.Deshpande A, Furlan A, Mailis GA, et al. Opioids for chronic low-back pain. In: The Cochrane Library, Issue 3, 2007. Chichester, UK: John Wiley & Sons, Ltd. Search date 2007. [Google Scholar]
- 18.Vorsanger GJ, Xiang J, Gana TJ, et al. Extended-release tramadol (tramadol ER) in the treatment of chronic low back pain. J Opioid Manag 2008;4:87–97. [DOI] [PubMed] [Google Scholar]
- 19.Moore RA, McQuay HJ. Prevalence of opioid adverse events in chronic non-malignant pain: systematic review of randomised trials of oral opioids. Arthritis Res Ther 2005;7:R1046–R1051. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.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. [DOI] [PubMed] [Google Scholar]
- 21.Urquhart DM, Hoving JL, Assendelft WW, et al. Antidepressants for non-specific low back pain. In: The Cochrane Library, Issue 1, 2008. Chichester, UK: John Wiley & Sons, Ltd. Search date 2008. [Google Scholar]
- 22.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]
- 23.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]
- 24.Roelofs PD, Deyo RA, Koes BW, et al. Nonsteroidal anti-inflammatory drugs for low back pain: an updated Cochrane review. Spine 2008;33:1766–1774. [DOI] [PubMed] [Google Scholar]
- 25.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]
- 26.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]
- 27.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]
- 28.Medicines and Healthcare Products Regulatory Agency. Harms alert for Bextra: European suspension of Bextra. MHRA Press Release 2005. [Google Scholar]
- 29.Kearney PM, Baigent C, Godwin J, et al. Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ 2006;332:1302–1308. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.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. [Google Scholar]
- 31.Worz R, Bolten W, Heller J, et al. Flupirtine compared with chlormezanone and placebo for chronic muskuloskeletal and back pain. Fortschr Ther 1996;114:3–6. [In German] [PubMed] [Google Scholar]
- 32.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]
- 33.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]
- 34.Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine 2009;34:1078–1093. [DOI] [PubMed] [Google Scholar]
- 35.Staal JB, de Bie R, de Vet HCW, et al. Injection therapy for subacute and chronic low-back pain. In: The Cochrane Library, Issue 3, 2008. Chichester, UK: John Wiley & Sons, Ltd. Search date 2007. [Google Scholar]
- 36.Hayden JA, van Tulder MW, Malmivaara A, et al. 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. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Lewis A, Morris ME, Walsh C. Are physiotherapy exercises effective in reducing chronic low back pain? (Provisional abstract). Phys Ther Rev 2008;13:37–44. [Google Scholar]
- 38.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]
- 39.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]
- 40.Rackwitz B, de Bie R, Limm H, et al. Segmental stabilizing exercises and low back pain: what is the evidence? A systematic review of randomized controlled trials. Clin Rehab 2006;20:553–567. [DOI] [PubMed] [Google Scholar]
- 41.Hauggaard A, Persson AL. Specific spinal stabilisation exercises in patients with low back pain: a systematic review. Phys Ther Rev 2007;12:233–248. [Google Scholar]
- 42.Macedo LG, Maher CG, Latimer J, et al. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther 2009;89:9–25. [DOI] [PubMed] [Google Scholar]
- 43.Clare HAA. A systematic review of efficacy of McKenzie therapy for spinal pain. Aust J Phys 2004;50:209–216. [DOI] [PubMed] [Google Scholar]
- 44.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]
- 45.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]
- 46.Johnson RE, Jones GT, Wiles NJ, et al. Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: a randomized controlled trial. Spine 2007;32:1578–1585. [DOI] [PubMed] [Google Scholar]
- 47.Kuukkanen T, Malkia E, Kautiainen H, et al. Effectiveness of a home exercise programme in low back pain: a randomized five-year follow-up study. Physiother Res Int 2007;12:213–224. [DOI] [PubMed] [Google Scholar]
- 48.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]
- 49.Kofotolis ND, Vlachopoulos SP, Kellis E, et al. Sequentially allocated clinical trial of rhythmic stabilization exercises and TENS in women with chronic low back pain. Clin Rehab 2008;22:99–111. [DOI] [PubMed] [Google Scholar]
- 50.Little P, Lewith G, Webley F, et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ 2008;337:438–441. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Sertpoyraz F, Eyigor S, Karapolat H, et al. Comparison of isokinetic exercise versus standard exercise training in patients with chronic low back pain: a randomized controlled study. Clin Rehab 2009;23:238–247. [DOI] [PubMed] [Google Scholar]
- 52.Harts CC, Helmhout PH, de Bie RA, et al. A high-intensity lumbar extensor strengthening program is little better than a low-intensity program or a waiting list control group for chronic low back pain: a randomised clinical trial. Austral J Physiother 2008;54:23–31. [DOI] [PubMed] [Google Scholar]
- 53.Petersen T, Larsen K, Jacobsen S, et al. One-year follow-up comparison of the effectiveness of McKenzie treatment and strengthening training for patients with chronic low back pain: outcome and prognostic factors. Spine 2007;32:2948–2956. [DOI] [PubMed] [Google Scholar]
- 54.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]
- 55.Tekur P, Singphow C, Nagendra HR, et al. Effect of short-term intensive yoga program on pain, functional disability and spinal flexibility in chronic low back pain: a randomized control study. J Alt Complement Med 2008;14:637–644. [DOI] [PubMed] [Google Scholar]
- 56.Hayden JA, van Tulder MW, Tomlinson G, et al. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med 2005;142:776–785. [DOI] [PubMed] [Google Scholar]
- 57.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. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58.van Geen JW, Edelaar MJ, Janssen M, et al. The long-term effect of multidisciplinary back training: a systematic review. Spine 2007;32:249–255. [DOI] [PubMed] [Google Scholar]
- 59.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]
- 60.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]
- 61.Roche G, Ponthieux A, Parot-Shinkel E, et al. Comparison of a functional restoration program with active individual physical therapy for patients with chronic low back pain: a randomized controlled trial. Arch Phys Med Rehab 2007;88:1229–1235. [DOI] [PubMed] [Google Scholar]
- 62.Smeets RJ, Vlaeyen JW, Hidding A, et al. Active rehabilitation for chronic low back pain: cognitive-behavioral, physical, or both? First direct post-treatment results from a randomized controlled trial. BMC Musculoskel Disord 2006;7:5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 63.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. [Google Scholar]
- 64.Yuan J, Purepong N, Kerr DP, et al. Effectiveness of acupuncture for low back pain: a systematic review. Spine 2008;33:E887–E900. [DOI] [PubMed] [Google Scholar]
- 65.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]
- 66.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. [Google Scholar]
- 67.Brox JI, Storheim K, Grotle M, et al. Evidence-informed management of chronic low back pain with back schools, brief education, and fear-avoidance training. Spine J 2008;8:28–39. [DOI] [PubMed] [Google Scholar]
- 68.Tavafian SS, Jamshidi A, Mohammad K, et al. Low back pain education and short term quality of life: a randomized trial. BMC Musculoskelet Disord 2007;8:21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 69.Ribeiro LH, Jennings F, Jones A, et al. Effectiveness of a back school program in low back pain. Clin Exp Rheumatol 2008;26:81–88. [PubMed] [Google Scholar]
- 70.Dalichau S, Scheele K, Perrey RM, et al. Ultrasound-guided postural and movement analysis of lumbar spine for demonstrating the effectiveness of a back school. Zentralbl Arbeitsmed 1999;49:148–156. [In German] [Google Scholar]
- 71.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]
- 72.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]
- 73.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]
- 74.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]
- 75.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]
- 76.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]
- 77.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]
- 78.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]
- 79.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]
- 80.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]
- 81.Ostelo RW, van Tulder MW, Vlaeyen JW, et al. Behavioural treatment for chronic low-back pain. In: The Cochrane Library, Issue 1, 2005. Chichester, UK: John Wiley & Sons, Ltd. Search date 2003. [Google Scholar]
- 82.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]
- 83.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. [DOI] [PubMed] [Google Scholar]
- 84.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]
- 85.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]
- 86.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]
- 87.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. [DOI] [PubMed] [Google Scholar]
- 88.van Duijvenbode I, Jellema P, van-Poppel MNM, et al. Lumbar supports for prevention and treatment of low back pain. In: The cochrane Library, Issue 2, 2008. Chichester, UK: John Wiley & Sons, Ltd. Search date 2006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 89.Furlan AD, Imamura M, Dryden T, et al. Massage for low-back pain. In: The Cochrane Library, Issue 4, 2008. Chichester, UK: John Wiley & Sons, Ltd. Search date 2008. [Google Scholar]
- 90.Clarke JA, van-Tulder MW, Blomberg SEI, et al. Traction for low-back pain with or without sciatica. In: The Cochrane Library, Issue 2, 2007. Chichester, UK: John Wiley & Sons, Ltd. Search date 2006. [Google Scholar]
- 91.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]
- 92.Shimoji K, Takahashi N, Nishio Y, et al. Pain relief by transcutaneous electric nerve stimulation with bidirectional modulated sine waves in patients with chronic back pain: a randomized, double-blind, sham-controlled study. Neuromodulation 2007;10:42–51. [DOI] [PubMed] [Google Scholar]
- 93.Gibson JN, Waddell G. Surgery for degenerative lumbar spondylosis. In: The Cochrane Library, Issue 4, 2005. Chichester, UK: John Wiley & Sons, Ltd. [Google Scholar]
- 94.Urrutia G, Kovacs F, Nishishinya MB, et al. Percutaneous thermocoagulation intradiscal techniques for discogenic low back pain. Spine 2007;32:1146–1154. [DOI] [PubMed] [Google Scholar]
- 95.Freeman BJ, Mehdian R, et al. Intradiscal electrothermal therapy, percutaneous discectomy, and nucleoplasty: what is the current evidence? Curr Pain Headache Rep 2008;12:14–21. [DOI] [PubMed] [Google Scholar]
- 96.Pauza KJ, Howell S, Dreyfuss P, et al. A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J 2004;4:27–35. [DOI] [PubMed] [Google Scholar]
- 97.Freeman BJ, Fraser RD, Cain CM, et al. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine. 2005;30:2369–2377. [DOI] [PubMed] [Google Scholar]
- 98.Leclaire R, Fortin L, Lambert R, et al. Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy. Spine 2001;26:1411–1416. [DOI] [PubMed] [Google Scholar]
- 99.Nath S, Nath CA, Pettersson K, et al. Percutaneous lumbar zygapophysial (Facet) joint neurotomy using radiofrequency current, in the management of chronic low back pain: a randomized double-blind trial. Spine 2008;33:1291-1297. [DOI] [PubMed] [Google Scholar]
- 100.van Kleef M, Barendse GA, Kessels A, et al. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine 1999;24:1937–1942. [DOI] [PubMed] [Google Scholar]
- 101.van Wijk RM, Geurts JW, Wynne HJ, et al. Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: a randomized, double-blind, sham lesion-controlled trial. Clin J Pain 2005;21:335–344 [erratum appears in Clin J Pain 2005;21:462]. [DOI] [PubMed] [Google Scholar]
- 102.Ibrahim T, Tleyjeh IM, Gabbar O, et al. Surgical versus non-surgical treatment of chronic low back pain: a meta-analysis of randomised trials. Int Orthop 2008;32:107–113. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 103.Mirza SK, Deyo RA. Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine 2007;32:816–823. [DOI] [PubMed] [Google Scholar]
- 104.Chou R, Baisden J, Carragee EJ, et al. Surgery for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine 2009;34:1094–1109. [DOI] [PubMed] [Google Scholar]
- 105.Fritzell P, Hagg O, Wessberg P, et al. 2001 Volvo award winner in clinical studies: lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 2001;26:2521–2532. [DOI] [PubMed] [Google Scholar]
- 106.Brox JI, Reikeras O, Nygaard O, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain 2006;122:145–155. [DOI] [PubMed] [Google Scholar]
- 107.Brox JI, Sorensen R, Friis A, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913–1921. [DOI] [PubMed] [Google Scholar]
- 108.Fairbank J, Frost H, Wilson-MacDonald J, et al. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial [erratum appears in BMJ 2005;330:1485]. BMJ 2005;330:1233. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 109.Zigler J, Delamarter R, Spivak JM, et al. Results of the prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of the ProDisc-L total disc replacement versus circumferential fusion for the treatment of 1-level degenerative disc disease. Spine 2007;32:1155–1162. [DOI] [PubMed] [Google Scholar]
- 110.Blumenthal S, McAfee PC, Guyer RD, et al. A prospective, randomized, multicenter Food and Drug Administration investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I: evaluation of clinical outcomes. Spine 2005;30:1565–1575 [erratum appears in Spine 2005;30:2356]. [DOI] [PubMed] [Google Scholar]
- 111.Berg S, Tullberg T, Branth B, et al. Total disc replacement compared to lumbar fusion: a randomised controlled trial with 2-year follow-up. Eur Spine J 2009;18:1512–1519. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 112.Katz N, Rauck R, Ahdieh H, et al. A 12-week, randomized, placebo-controlled trial assessing the safety and efficacy of oxymorphone extended release for opioid-naive patients with chronic low back pain. Curr Med Res Opin 2007;23:117–128. [DOI] [PubMed] [Google Scholar]
- 113.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]
- 114.Brox JI, Storheim K, Grotle M, et al. Systematic review of back schools, brief education, and fear-avoidance training for chronic low back pain. Spine J 2008;8:948−958. [DOI] [PubMed] [Google Scholar]
- 115.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]