Non-pharmacological interventions more beneficial for patients with chronic low back pain without radiculopathy, but more evidence needed

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Stephanie Mathieson

For patients with chronic non-specific low back pain without radiculopathy, non-pharmacological interventions of acupuncture and spinal manipulation provide safer benefits than pharmacological or invasive interventions. This is according to a new systematic review and meta-analysis—published in The Spine Journal by co-lead author Stephanie Mathieson (The University of Sydney, Sydney Australia) et al—which did however note that more research on the subject is needed, as only a limited number of trials have been conducted.

In fact, Mathieson et al note that currently, “there are no published studies that compare non-pharmacological, pharmacological and invasive treatments for chronic low back pain in adults and provide summary statistics for benefits and harms.”

As such, the aim of the systematic review and meta-analysis was to compare the benefits and harms of treatments for the management of chronic low back pain without radiculopathy and to report the findings in a format that facilitates direct comparison.

Randomised controlled trials, including trial registries, from electronic databases up to 23 May 2022 were used. Adults with non-specific chronic low back pain, excluding radicular pain, in any clinical setting were included.

The main outcome measure was comparison of pain at immediate-term (≤2 weeks) and short-term (>2 weeks to ≤12 weeks) and serious adverse events using the Benefit-Harm Scale (Level 1 to 7).

Interventions included non-pharmacological (acupuncture, spinal manipulation), pharmacological and invasive treatments compared to placebo. Best evidence criteria were used, and two independent reviewers conducted eligibility assessment, data extraction and quality appraisal.

The database searches retrieved a total of 17,362 records. Three studies provided data on the benefits of interventions, and 30 provided data on harms. Studies included interventions of acupuncture (n=8); manipulation (n=2); pharmacological therapies (n=9), including nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics; surgery (n=8); and epidural corticosteroid injections (n=3).

Treatments that were effective in reducing pain compared to sham were acupuncture (standardised mean difference [SMD] 0.51, 95% confidence interval [CI] -0.88 to -0.14, n=1 trial, moderate quality of evidence, benefit rating of 3) and manipulation (SMD -0.39, 95% CI -0.56 to -0.21, n=2 trials, moderate quality of evidence, benefit rating of 5).

According to the researchers, the benefits of other interventions were scored as uncertain due to not being effective, the presence of statistical heterogeneity, or the lack of relevant trials.

Speaking to Spinal News International, Mathieson said: “We were not surprised there were gaps in the current evidence. It is important to have a clear summary of evidence-based treatments to manage people suffering from chronic low back pain. It is the main reason we made this summary. Patients want straightforward recommendations. When data on the benefits and serious harms of treatments are reported separately, it makes interpretation difficult.”

The harms level warnings were lowest for acupuncture, spinal manipulation, NSAIDs, combination ingredient opioids, and steroid injections, while they were higher for single ingredient opioid analgesics (Level 4) and surgery (Level 6).

“Quantifying harms, especially serious harms, is important, because harms are easier to inflict and can have larger effects than benefits,” added Mathieson. “Systematic reviews that provide harms data give guidance to the practitioner and patient. A clinical decision is likely different depending on the frequency of harms. Is the risk of serious harm one in 10 or one in one million? The Benefit-Harm Scale that was used in our review helps facilitate the quantification of harms and benefits.

“We innately know that some treatments have more risks than others. Now, we have a direct, evidence-based comparison. Hopefully, this gives clinicians a tangible tool to aid conversations with patients about common pain management strategies in a shared decision-making model.

“People want to know how to best manage their back pain safely. We know that clinicians want to help their patients. But what is clear from our review is that more high-quality research is needed.”


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