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.