Article Figures & Tables
Figures
- Figure 1:
Diagnosis and management of low-back pain according to current clinical practice guidelines from the United Kingdom and United States.14,15 NSAID = nonsteroidal anti-inflammatory drug.
Tables
- Table 1:
Recent guideline recommendations for management of acute nonspecific low-back pain
Type Intervention Size of effect* Quality of evidence* Endorsement 2016 UK guideline14 2017 US guideline15 Nonpharmacologic Advice to stay active v. bed rest Small Moderate† (2 RCTs)35 Yes Yes Massage v. sham treatment Moderate Low (2 RCTs) Yes, if part of an exercise program Yes Spinal manipulation v. inert treatment No effect Low (3 RCTs) Yes, if part of an exercise program Yes Acupuncture v. sham treatment Small Low (3 RCTs) Do not offer Yes Heat v. sham treatment Moderate Moderate (4 RCTs) No mention Yes Exercise v. usual care No effect Low (6 RCTs) Yes No mention Psychologically informed physiotherapy v. usual care No trials N/A† Yes, for those at high risk of poor outcome No mention Pharmacologic NSAIDs v. placebo Small Moderate (5 RCTs) Yes Yes, depending on patient preferences and drug risk profile Muscle relaxants v. placebo Small Moderate (5 RCTs) No mention Yes, depending on patient preferences and drug risk profile Opioids v. placebo No trials N/A† Yes, if NSAIDs are unsafe or ineffective; weak opioid only Do not offer Paracetamol v. placebo No effect High† (2 RCTs)36 Do not offer Do not offer Systemic corticosteroids v. placebo No effect Low (2 RCTs) No mention Do not offer Note: GRADE = Grading of Recommendations Assessment, Development and Evaluation, N/A = No evidence from RCTs, NSAID = nonsteroidal anti-inflammatory drug, RCT = randomized controlled trial.
↵* 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.
- Table 2:
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.
- Table 3:
Recent guideline recommendations for management of radicular pain of the lower back
Management type Intervention Size of effect* Quality of evidence* Endorsement 2016 UK guideline14 2017 US guideline15 Nonpharmacologic Exercise v. usual care Small Low (3 RCTs) Yes Yes Multidisciplinary therapy v. usual care No trials N/A† Yes, if previous treatment not effective or at risk of poor prognosis Insufficient evidence Traction v. other active treatments No effect Low (2 RCTs) Do not offer Do not offer Pharmacologic Diazepam v. placebo Harm Low (1 RCT) No mention Do not offer Systemic corticosteroids v. placebo No effect Moderate (6 RCTs) No mention Do not offer Pregabalin v. placebo No effect High† (1 RCT)27 Yes Insufficient evidence Gabapentin v. placebo Unclear Very low† (2 RCTs)52,53 Yes Insufficient evidence Opioids v. placebo No effect Low† (1 crossover study) Yes, rescue/short-term only Yes, second-line therapy only if nonpharmacologic therapy fails Amitriptyline v. placebo No trials N/A† Yes Do not offer Duloxetine v. placebo No trials N/A† Yes Insufficient evidence Injection therapy Epidural steroid injection v. placebo Small High† (23 RCTs)54 Yes No mention Surgery Lumbar discectomy v. conservative management Discectomy associated with faster reduction in pain intensity Low† (3 RCTs)55 Yes, if nonsurgical treatment failed and radiologic findings are consistent with sciatic symptoms No mention Note: GRADE = Grading of Recommendations Assessment, Development and Evaluation, N/A = No evidence from RCTs, RCT = randomized controlled trial.
↵* Based on the 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.
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- Article
- How can physicians decide if low-back pain has a serious cause?
- Is it always necessary to determine a cause?
- Which patients require diagnostic imaging?
- How should acute low-back pain be managed?
- How should persistent nonspecific low-back pain be managed?
- What is the approach to a patient with radicular pain or neurogenic claudication?
- Who needs referral?
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