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.