Recent guideline recommendations for management of persistent nonspecific low-back pain
| Management type | Intervention | Size of effect* | Quality of evidence* | Endorsement | |
|---|---|---|---|---|---|
| 2016 UK guideline14 | 2017 US guideline15 | ||||
| Nonpharmacologic | Exercise v. no exercise | Small | Moderate (19 RCTs) | Yes, for patients with flare-up (a temporary increase in severity of the ongoing symptoms) | Yes |
| Spinal manipulation v. inert treatment | Small | Low (7 RCTs) | Yes, if part of an exercise program | Yes | |
| Cognitive behavioural therapy v. no treatment | Moderate | Low (5 RCTs) | Yes, if part of an exercise program | Yes | |
| Behavioural (operant) therapy v. no treatment | Small | Low (3 RCTs) | Yes, if part of an exercise program | Yes | |
| Multidisciplinary therapy v. usual care | Moderate | Moderate (9 RCTs) | Yes, if previous treatment not effective or at high risk of poor outcome | Yes | |
| Massage v. usual care | No effect | Low (1 RCT) | Yes, if part of an exercise program | Yes | |
| Acupuncture v. placebo | Moderate | Low (9 RCTs) | Do not offer | Yes | |
| Ultrasonography v. no treatment | No effect | Low (5 RCTs) | Do not offer | Do not offer | |
| TENS v. sham treatment | No effect | Low (4 RCTs) | Do not offer | Do not offer | |
| Pharmacologic | NSAIDs v. placebo | Small | Moderate (6 RCTs) | Yes, if safe, at lowest dose and short term only | Yes, if nonpharmacologic options fail |
| Opioids v. placebo | Small | Moderate† (15 RCTs)44 | Do not offer | Yes, only as last resort | |
| Paracetamol v. placebo | No effect | Very low† (1 RCT)36 | Do not offer | Insufficient evidence | |
| Tricyclic antidepressants v. placebo | No effect | Moderate (4 RCTs) | Do not offer | Do not offer | |
| Benzodiazepines v. placebo | Lower likelihood of failure to improve | Low (2 RCTs) | Do not offer | Insufficient evidence | |
| Injection therapy | Epidural steroid injection v. placebo | No effect | Low† (2 RCTS)45 | Do not offer | No mention |
| Facet joint steroid injection v. placebo | No effect | Low† (2 RCTS)45 | Do not offer | No mention | |
| Radiofrequency denervation v. sham intervention | Facet: small | Low† (4 RCTs)14 | Yes, if nonsurgical treatment failed and positive response to medial branch block | No mention | |
| Surgery | Spinal fusion v. rehabilitation | No effect | Moderate† (4 RCTs)46 | Do not offer unless as part of a trial | No mention |
Note: GRADE = Grading of Recommendations Assessment, Development and Evaluation, NSAID = nonsteroidal anti-inflammatory drug, RCT = randomized controlled trial, TENS = transcutaneous electrical nerve stimulation.
↵* Based on 2017 American College of Physicians guideline summary of evidence except where otherwise noted. Comparisons are to placebo, sham treatment, no treatment or usual care, and on short-term pain outcomes.
↵† Our summary of evidence used the GRADE approach.