Assessing the Effectiveness and Safety of Treatments for Acute Low Back Pain

Welcome back to SpineIQ’s BackBlog! Most of our blogs discuss chronic spinal pain, as that is the leading cause of the disability burden of spine pain. However, 25% of Americans report having one episode of acute low back pain within the last 3 months and 8% of adults report at least one episode of severe acute low back pain within the last year.¹ While the prognosis for acute low back pain is good with 50% recovered within 2 weeks and 80% recovered within 6 weeks, there is still a need for pain reduction in the short-term especially for severe episodes.^2–4 This begs the question, what is the most effective treatment for acute low back pain? A systematic review by Gianola et al. set out to assess treatments for acute low back pain and we summarize the clinically relevant findings below.⁵

Methods

This systematic review aimed to use a statistical model called network meta-analysis. The difference between a network meta-analysis and the traditional meta-analysis (commonly called pairwise meta-analysis) is that it lets you compare different treatments to each other as long the treatments were compared to the same comparator. For example, if study A compared manual therapy (treatment) to placebo (comparator) and study B compared NSAIDs (treatment) to placebo (comparator) then a network meta-analysis allows us to compare NSAIDs to manual therapy using the two studies since they both were compared to the same comparator (placebo). Network meta-analysis will be an important research tool for researchers as the challenge of comparing one mode of treatment is costly and time consuming.  Many comparative modes of care will now become more readily analyzed.  The inclusion criteria for this systematic review were patients with acute low back pain (<6 weeks) and the study must have compared any treatment to placebo or no intervention group.

Results

This systematic review included 46 studies with a total of 8765 participants. They assessed the effectiveness of treatments for acute low back pain on important key issue for patients, pain intensity, disability, and adverse events.

The most effective treatments delivered by a healthcare professional in order of largest significant effect on pain intensity are:

• Exercise
• Heat wrap
• Opioids
• Manual therapy
• NSAIDs

The most effective treatments delivered by a healthcare professional in order of largest significant effect on disability are:

• Exercise
• Heat wrap
• Manual therapy
• NSAIDs
• Muscle relaxants
• Education

No adverse were reported for:

• Acupuncture
• Education
• Exercise
• Manual therapy

Mild-moderate adverse events were reported for:

• Heat wrap
• Muscle relaxants
• NSAIDs
• Opioids
• Paracetamol
• Steroids

Conclusion

These results suggest that the most effective and safest treatments for acute low back pain are treatments commonly delivered by conservative spine clinicians (e.g., exercise and manual therapy). This is consistent with clinical practice guidelines that commonly recommend education, reassurance, and advice to stay active for an episode of acute low back pain.⁶ If patients are seeking further pain relief then heat wraps should be recommended with education on how to use them properly to avoid burning the skin followed by manual therapy and NSAIDs when appropriate.

References

1. Patrick N, Emanski E, Knaub MA. Acute and Chronic Low Back Pain. Med Clin North Am. 2014;98(4):777-789. doi:10.1016/j.mcna.2014.03.005
2. Schreijenberg M, Chiarotto A, Mauff KAL, Lin CWC, Maher CG, Koes BW. Inferential reproduction analysis demonstrated that “paracetamol for acute low back pain” trial conclusions were reproducible. J Clin Epidemiol. 2020;121:45-54. doi:10.1016/j.jclinepi.2020.01.010
3. Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337:a171. doi:10.1136/bmj.a171
4. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X
5. Gianola S, Bargeri S, Castillo GD, et al. Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis. Br J Sports Med. 2022;56(1):41-50. doi:10.1136/bjsports-2020-103596
6. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367