Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis

Silvia Gianola, Silvia Bargeri, Gabriele Del Castillo, Davide Corbetta, Andrea Turolla, Anita Andreano, Lorenzo Moja, Greta Castellini, Silvia Gianola, Silvia Bargeri, Gabriele Del Castillo, Davide Corbetta, Andrea Turolla, Anita Andreano, Lorenzo Moja, Greta Castellini

Abstract

Objective: To assess the effectiveness of interventions for acute and subacute non-specific low back pain (NS-LBP) based on pain and disability outcomes.

Design: A systematic review of the literature with network meta-analysis.

Data sources: Medline, Embase and CENTRAL databases were searched from inception until 17 October 2020.

Eligibility criteria for selecting studies: Randomised clinical trials (RCTs) involving adults with NS-LBP who experienced pain for less than 6 weeks (acute) or between 6 and 12 weeks (subacute).

Results: Forty-six RCTs (n=8765) were included; risk of bias was low in 9 trials (19.6%), unclear in 20 (43.5%), and high in 17 (36.9%). At immediate-term follow-up, for pain decrease, the most efficacious treatments against an inert therapy were: exercise (standardised mean difference (SMD) -1.40; 95% confidence interval (CI) -2.41 to -0.40), heat wrap (SMD -1.38; 95% CI -2.60 to -0.17), opioids (SMD -0.86; 95% CI -1.62 to -0.10), manual therapy (SMD -0.72; 95% CI -1.40 to -0.04) and non-steroidal anti-inflammatory drugs (NSAIDs) (SMD -0.53; 95% CI -0.97 to -0.09). Similar findings were confirmed for disability reduction in non-pharmacological and pharmacological networks, including muscle relaxants (SMD -0.24; 95% CI -0.43 to -0.04). Mild or moderate adverse events were reported in the opioids (65.7%), NSAIDs (54.3%) and steroids (46.9%) trial arms.

Conclusion: With uncertainty of evidence, NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate-term. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best harm-benefit balance.

Keywords: disability; evidence based review; lower back; pharmacology; rehabilitation.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Figures

Figure 1
Figure 1
Flow chart of study selection.
Figure 2
Figure 2
Pain at immediate-term (1 week): network plot (A) and interval plot (B). NSAIDs, non-steroidal anti-inflammatory drugs; SMD, standardised mean difference.
Figure 3
Figure 3
Disability at immediate-term (1 week): network plot (A) and interval plot (B) for non-pharmacological interventions and (C) for pharmacological interventions. NSAIDs, non-steroidal anti-inflammatory drugs; SMD, standardised mean difference.

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