Table 2.
Overview of the level of evidence of non-pharmacological methods in the management of low back pain. If the levels of evidence were explicitly reported in the guidelines they were extracted and are mentioned in this table
| Intervention | Guidelines | Level of evidence |
|---|---|---|
| Self-management | ||
| Advice to stay active: maintaining usual levels of daily activity despite pain, including work [37] | Denmark [37]a,b | Low |
| Germany [40] | Good to weak | |
| UK [36] | Moderate to very low | |
| USA_ACP [38]a,b | Not reported | |
| USA_ICSI [39]a,b | Moderate | |
| Patient education: regarding health literacy, competencies, and adaptation of behavior [37] | Denmark [37]a,b | Very low |
| Germany [40] | Good to weak | |
| UK [36] | Moderate to very low | |
| USA_ACP [38]a,b | Not reported | |
| USA_ICSI [39]a,b | High to moderate | |
| Manual therapy | ||
| Spinal manual therapy: any mobilization or spinal manipulation technique [37] | Denmark [37]a,b (in addition to usual care) | Low |
| USA_ACP [38] | Low | |
| USA_ICSI [39]a,b | Moderate to low | |
| Manual therapy (spinal manipulation, mobilization or soft tissue techniques such as massage) in combination with exercise, with or without psychological therapy | UK [36] | High to very low |
| Massage | USA_ACP [38]a,b | Low |
| Exercise | ||
| (Supervised) exercise: individualized exercises or physical activity (e.g. back-specific strengthening, stretching, motor control exercise or mobilizing exercises and cardiovascular training) delivered by a trained healthcare professional [37] | Denmark [37]a,b | Low |
| USA_ACP [38]c | Moderate, motor control therapy: low | |
| Movement therapy, including educative approach | Germany [40]b,c | Good to weak |
| Group exercise | UK [36] | Moderate to very low |
| USA_ACP [38]c | Moderate | |
| Sport rehabilitation program or functional training (if the limitation in daily activities remains and the occupational rehabilitation is at risk) | Germany [40]b,c | Expert consensus |
| Tai chi | USA_ACP [38]c | Low |
| Yoga | USA_ACP [38]c | Low |
| Psychological therapy and/or interventions | ||
| Psychological therapy (using a cognitive behavioral approach) in combination with other treatments (e.g. exercise, manual therapy) or a multimodal program | Germany [40]c | Good to weak |
| UK [36] | Moderate to very low | |
| Cognitive behavioral therapy | Germany [40]b (if psycho-social risk factors exist) | Weak |
| USA_ACP [38]c | Low | |
| Operant therapy | USA_ACP [38]c | Low |
| Mindfulness-based stress reduction | USA_ACP [38]c | Moderate |
| Progressive relaxation | Germany [40]c | Weak |
| USA_ACP [38]c | Low | |
| Multidisciplinary programs | ||
| Multidisciplinary rehabilitation: combines a physical and psychological program | UK [36] (if significant psychosocial obstacles to recovery exist or previous treatments have not been effective) | Moderate to very low |
| USA_ACP [38]c | Moderate | |
| Return to work | ||
| Return to work programs (work or normal activities of daily living) | UK [36] | High to very low |
| Acupuncture | ||
| Acupuncture | USA_ACP [38] | Lowa, b, moderatec |
| USA_ICSI [39]a,b | Low | |
| Biofeedback, laser therapy | ||
| Electromyography biofeedback | USA_ACP [38]c | Low |
| Low-level laser therapy | USA_ACP [38]c | Low |
| Others | ||
| Superficial heat | USA_ACP [38]a,b | Moderate |
| USA_ICSI [39]a,b | Moderate | |
| Cryotherapy | USA_ICSI [39]a,b | Expert consensus |
The guidelines used different modified versions of the Grading of Recommendations Assessment, Development and Evaluation (GRADE): Denmark (high, moderate, low, very low) [37], Germany (weak that refers to very low-low, good that refers to moderate-high) [40, 41], UK (high, moderate, low) [36], USA_ACP (high, moderate, low) [38], USA_ICSI (high, moderate, low, very low) [39]
USA_ACP American College of Physicians, USA_ICSI Institute for Clinical Systems Improvement
aFor acute low back pain patients
bFor subacute low back pain patients
cFor chronic low back pain patients