Initial therapy with non-pharmacological agents may be preferable for lower back pain

1. Among non-pharmacological interventions; pain and disability reduction were best achieved by manual therapy, heat wrap, and exercise at immediate (<1 week) follow-up.

2. Among pharmacological findings, pain and disability reduction were best achieved by non-steroidal anti-inflammatory (NSAID) medications and muscle relaxants at immediate-term follow-up.

Evidence Rating Level: 1 (Excellent)

Non-specific low back pain (NS-LBP) is a prevalent condition that places a huge morbidity burden on society. Though most guidelines agree on the first line of care during an acute episode (reassurance, advice, encouragement to engage in light activity), the relative effects of second line options are uncertain. Consequently, the present study sought to determine the efficacy of available treatments on pain and disability outcomes in those suffering from NS-LBP.

From 6779 identified articles, 46 trials were included (8765 participants) since the inception date up to October 2020. To be eligible, studies needed to study various pharmacological and non-pharmacological interventions on disability and pain intensity in patients experiencing NS-LBP less than 6 weeks (acute) or 6-12 weeks (subacute). Risk of bias was assessed using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Study outcomes assessed pain intensity and disability, as well as occurrence of adverse events.

Results demonstrated that among non-pharmacological interventions; pain and disability reduction were best achieved by manual therapy, heat wrap and exercise at immediate (<1 week) follow-up. Among pharmacological interventions, pain and disability reduction were best achieved by non-steroidal anti-inflammatory (NSAID) medications and muscle relaxants at immediate-term follow-up. Mild or moderate adverse events were reported in patients treated with steroids, NSAIDs, or opioids. This study was limited by the discrepancies in classification systems which have changed with time which may have influenced treatment guidelines. However, given that this is the largest network meta-analysis to date on the topic, the present study paves the way for future research questions to be answered in the treatment of NS-LBP.

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Click to read the study in British Journal of Sports Medicine

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