Top

Published in:

01-11-2007 | Review article

Effect sizes of non-surgical treatments of non-specific low-back pain

Authors: A. Keller, J. Hayden, C. Bombardier, M. van Tulder

Published in: European Spine Journal | Issue 11/2007

Abstract

Numerous randomized trials have been published investigating the effectiveness of treatments for non-specific low-back pain (LBP) either by trials comparing interventions with a no-treatment group or comparing different interventions. In trials comparing two interventions, often no differences are found and it raises questions about the basic benefit of each treatment. To estimate the effect sizes of treatments for non-specific LBP compared to no-treatment comparison groups, we searched for randomized controlled trials from systematic reviews of treatment of non-specific LBP in the latest issue of the Cochrane Library, issue 2, 2005 and available databases until December 2005. Extracted data were effect sizes estimated as Standardized Mean Differences (SMD) and Relative Risk (RR) or data enabling calculation of effect sizes. For acute LBP, the effect size of non-steroidal anti-inflammatory drugs (NSAIDs) and manipulation were only modest (ES: 0.51 and 0.40, respectively) and there was no effect of exercise (ES: 0.07). For chronic LBP, acupuncture, behavioral therapy, exercise therapy, and NSAIDs had the largest effect sizes (SMD: 0.61, 0.57, and 0.52, and RR: 0.61, respectively), all with only a modest effect. Transcutaneous electric nerve stimulation and manipulation had small effect sizes (SMD: 0.22 and 0.35, respectively). As a conclusion, the effect of treatments for LBP is only small to moderate. Therefore, there is a dire need for developing more effective interventions.

Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G (2006) Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 15(Suppl 2):S192–S300PubMedCrossRef

Arbus L, Fajadet B, Aubert D, Morre M, Goldfinger E (1990) Activity of tetrazepam in low back pain. Clin Trials J 27:58–67

Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004) Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev CD000447

Aure OF, Nilsen JH, Vasseljen O (2003) Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up. Spine 28:525–531; discussion 531–522

Babej-Dolle R, Freytag S, Eckmeyer J, Zerle G, Schinzel S, Schmeider G, Stankov G (1994) Parenteral dipyrone versus diclofenac and placebo in patients with acute lumbago or sciatic pain: randomized observer-blind multicenter study. Int J Clin Pharmacol Ther 32:204–209PubMed

Barrata R (1982) A double-blind study of cyclobenzaprine and placebo in the treatment of acute musculoskeletal conditions of the low back pain. Curr Ther Res 32:646–652

Bendix AF, Bendix T, Lund C, Kirkbak S, Ostenfeld S (1997) Comparison of three intensive programs for chronic low back pain patients: a prospective, randomized, observer-blinded study with one- year follow-up. Scand J Rehabil Med 29:81–89PubMed

Bergquist-Ullman M, Larsson U (1977) Acute low back pain in industry. A controlled prospective study with special reference to therapy and confounding factors. Acta Orthop Scand 1–117

Berry H, Hutchinson D (1988) A multicenter placebo-controlled study in general practice to evaluate the efficacy and safety of tizanidine in acute low-back pain. J Int Med Res 16:75–82PubMed

10.

Birbara CA, Puopolo AD, Munoz DR, Sheldon EA, Mangione A, Bohidar NR, Geba GP (2003) Treatment of chronic low back pain with etoricoxib, a new cyclo-oxygenase-2 selective inhibitor: improvement in pain and disability—a randomized, placebo-controlled, 3-month trial. J Pain 4:307–315PubMedCrossRef

11.

Bombardier C (2000) Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine 25:3100–3103PubMedCrossRef

12.

Carlsson CP, Sjolund BH (2001) Acupuncture for chronic low back pain: a randomized placebo-controlled study with long-term follow-up. Clin J Pain 17:296–305PubMedCrossRef

13.

Chok B, Lee R, Latimer J, Tan SB (1999) Endurance training of the trunk extensor muscles in people with subacute low back pain. Phys Ther 79:1032–1042PubMed

14.

Coan RM, Wong G, Ku SL, Chan YC, Wang L, Ozer FT, Coan PL (1980) The acupuncture treatment of low back pain: a randomized controlled study. Am J Chin Med 8:181–189PubMedCrossRef

15.

Coats TL, Borenstein DG, Nangia NK, Brown MT (2004) Effects of valdecoxib in the treatment of chronic low back pain: results of a randomized, placebo-controlled trial. Clin Ther 26:1249–1260PubMedCrossRef

16.

Cohen J (1977) Statistical power analysis for the behavioral sciences. Academic, New York

17.

Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Ramamurthy S (1990) A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. N Engl J Med 322:1627–1634PubMedCrossRef

18.

Dreiser RL, Marty M, Ionescu E, Gold M, Liu JH (2003) Relief of acute low back pain with diclofenac-K 12.5 mg tablets: a flexible dose, ibuprofen 200 mg and placebo-controlled clinical trial. Int J Clin Pharmacol Ther 41:375–385PubMed

19.

Egger M, Smith G, Altman DG (2001) Systematic reviews in health care. Meta-analysis in context. BMJ Books, London

20.

European Commission COST B13 Management Committee (2002) European guidelines for the management of low back pain. Acta Orthop Scand Suppl 73:20–25

21.

Evans DP, Burke MS, Lloyd KN, Roberts EE, Roberts GM (1978) Lumbar spinal manipulation on trial. Part I—clinical assessment. Rheumatol Rehabil 17:46–53PubMedCrossRef

22.

Fritzell P, Hagg O, Wessberg P, Nordwall A (2001) 2001 Volvo award winner in clinical studies: lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish lumbar spine study group. Spine 26:2521–2532; discussion 2532–2524

23.

Furlan AD, Brosseau L, Imamura M, Irvin E (2002) Massage for low back pain. Cochrane Database Syst Rev CD001929

24.

Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM (2005) Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev CD001351

25.

Furukawa TA, Barbui C, Cipriani A, Brambilla P, Watanabe N (2006) Imputing missing standard deviations in meta-analyses can provide accurate results. J Clin Epidemiol 59:7–10PubMedCrossRef

26.

Faas A, Chavannes AW, van Eijk JT, Gubbels JW (1993) A randomized, placebo-controlled trial of exercise therapy in patients with acute low back pain. Spine 18:1388–1395PubMed

27.

Gibson JN, Grant IC, Waddell G (2000) Surgery for lumbar disc prolapse. Cochrane Database Syst Rev CD001350

28.

Gibson JN, Waddell G, Grant IC (2000) Surgery for degenerative lumbar spondylosis. Cochrane Database Syst Rev CD001352

29.

Glover JR, Morris JG, Khosla T (1974) Back pain: a randomized clinical trial of rotational manipulation of the trunk. Br J Ind Med 31:59–64PubMed

30.

Guzman J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C (2002) Multidisciplinary bio-psycho-social rehabilitation for chronic low back pain. Cochrane Database Syst Rev CD000963

31.

Hagen K, Hilde G, Jamtvedt G, Winnem M (2004) Bed rest for acute low-back pain and sciatica. Cochrane Database Syst Rev CD001254

32.

Hayden JA, van Tulder MW, Malmivaara AV, Koes BW (2005) Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med 142:765–775PubMed

33.

Heymans M, Tulder M, Esmail R, Bombardier C, Koes B (2004) Back schools for non-specific low-back pain. Cochrane Database Syst Rev CD000261

34.

Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560PubMedCrossRef

35.

Hilde G, Hagen KB, Jamtvedt G, Winnem M (2002) Advice to stay active as a single treatment for low back pain and sciatica. Cochrane Database Syst Rev CD003632

36.

Hurley DA, McDonough SM, Dempster M, Moore AP, Baxter GD (2004) A randomized clinical trial of manipulative therapy and interferential therapy for acute low back pain. Spine 29:2207–2216PubMedCrossRef

37.

Indahl A (2004) Low back pain: diagnosis, treatment, and prognosis. Scand J Rheumatol 33:199–209PubMedCrossRef

38.

Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12PubMedCrossRef

39.

Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B (2003) Multidisciplinary biopsychosocial rehabilitation for subacute low back pain among working age adults. Cochrane Database Syst Rev CD002193

40.

Katz N, Ju WD, Krupa DA, Sperling RS, Bozalis Rodgers D, Gertz BJ, Gimbel J, Coleman S, Fisher C, Nabizadeh S, Borenstein D (2003) Efficacy and safety of rofecoxib in patients with chronic low back pain: results from two 4-week, randomized, placebo-controlled, parallel-group, double-blind trials. Spine 28:851–858; discussion 859

41.

Kazis LE, Anderson JJ, Meenan RF (1989) Effect sizes for interpreting changes in health status. Med Care 27:S178–S189PubMedCrossRef

42.

Kerr DP, Walsh DM, Baxter GD (2001) A study of the use of acupuncture in physiotherapy. Complement Ther Med 9:21–27PubMedCrossRef

43.

Khadilkar A, Milne S, Brosseau L, Wells G, Tugwell P, Robinson V, Shea B, Saginur M (2005) Transcutaneous electrical nerve stimulation for the treatment of chronic low back pain: a systematic review. Spine 30:2657–2666PubMedCrossRef

44.

Kopec JA (2000) Measuring functional outcomes in persons with back pain: a review of back-specific questionnaires. Spine 25:3110–3114PubMedCrossRef

45.

Kuukkanen T, Malkia E (2000) Effects of a three-month therapeutic exercise programme on flexibility in subjects with low back pain. Physiother Res Int 5:46–61PubMedCrossRef

46.

Leibing E, Leonhardt U, Koster G, Goerlitz A, Rosenfeldt JA, Hilgers R, Ramadori G (2002) Acupuncture treatment of chronic low-back pain—a randomized, blinded, placebo-controlled trial with 9-month follow-up. Pain 96:189–196PubMedCrossRef

47.

Lepisto P (1979) A comparative trial of DS 103–282 and placebo in the treatment of acute skeletal muscle spasms due to disorders of the back. Ther Res 26:454–459

48.

Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W, Swift J Jr (2003) Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine 28:1355–1362PubMedCrossRef

49.

Linton SJ, Bradley LA, Jensen I, Spangfort E, Sundell L (1989) The secondary prevention of low back pain: a controlled study with follow-up. Pain 36:197–207PubMedCrossRef

50.

Malmivaara A, Hakkinen U, Aro T, Heinrichs ML, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V, et al (1995) The treatment of acute low back pain—bed rest, exercises, or ordinary activity? N Engl J Med 332:351–355PubMedCrossRef

51.

Mannion AF, Junge A, Taimela S, Muntener M, Lorenzo K, Dvorak J (2001) Active therapy for chronic low back pain: part 3. Factors influencing self-rated disability and its change following therapy. Spine 26:920–929PubMedCrossRef

52.

Mannion AF, Muntener M, Taimela S, Dvorak J (1999) A randomized clinical trial of three active therapies for chronic low back pain. Spine 24:2435–2448PubMedCrossRef

53.

Marchand S, Charest J, Li J, Chenard JR, Lavignolle B, Laurencelle L (1993) Is TENS purely a placebo effect? A controlled study on chronic low back pain. Pain 54:99–106PubMedCrossRef

54.

Mayer JM, Ralph L, Look M, Erasala GN, Verna JL, Matheson LN, Mooney V (2005) Treating acute low back pain with continuous low-level heat wrap therapy and/or exercise: a randomized controlled trial. Spine J 5:395–403PubMedCrossRef

55.

Mendelson G, Selwood TS, Kranz H, Loh TS, Kidson MA, Scott DS (1983) Acupuncture treatment of chronic back pain. A double-blind placebo-controlled trial. Am J Med 74:49–55PubMedCrossRef

56.

Mitchell RI, Carmen GM (1990) Results of a multicenter trial using an intensive active exercise program for the treatment of acute soft tissue and back injuries. Spine 15:514–521PubMedCrossRef

57.

Molsberger AF, Mau J, Pawelec DB, Winkler J (2002) Does acupuncture improve the orthopedic management of chronic low back pain—a randomized, blinded, controlled trial with 3 months follow up. Pain 99:579–587PubMedCrossRef

58.

Nelemans PJ, de Bie RA, de Vet HC, Sturmans F (2000) Injection therapy for subacute and chronic benign low back pain. Cochrane Database Syst Rev CD001824

59.

Niemisto L, Lahtinen-Suopanki T, Rissanen P, Lindgren KA, Sarna S, Hurri H (2003) A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain. Spine 28:2185–2191PubMedCrossRef

60.

Nouwen A (1983) EMG biofeedback used to reduce standing levels of paraspinal muscle tension in chronic low back pain. Pain 17:353–360PubMedCrossRef

61.

Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ (1987) A new approach to the treatment of chronic low back pain. Lancet 2:143–146PubMedCrossRef

62.

Pallay RM, Seger W, Adler JL, Ettlinger RE, Quaidoo EA, Lipetz R, O’Brien K, Mucciola L, Skalky CS, Petruschke RA, Bohidar NR, Geba GP (2004) Etoricoxib reduced pain and disability and improved quality of life in patients with chronic low back pain: a 3 month, randomized, controlled trial. Scand J Rheumatol 33:257–266PubMedCrossRef

63.

Postacchini F, Facchini M, Palieri P (1988) Efficacy of various forms of conservative treatment in low back pain. A comparative study. Neuro Orthop 6:28–35

64.

Preyde M (2000) Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. CMAJ 162:1815–1820PubMed

65.

Risch SV, Norvell NK, Pollock ML, Risch ED, Langer H, Fulton M, Graves JE, Leggett SH (1993) Lumbar strengthening in chronic low back pain patients. Physiologic and psychological benefits. Spine 18:232–238PubMedCrossRef

66.

Salzmann E, Pforringer W, Paal G, et al (1992) Treatment of chronic low-back syndrome with tetrazepamin a placebo controlled double-blind trial. J Drug Dev 4:219–228

67.

Schonstein E, Kenny DT, Keating J, Koes BW (2003) Work conditioning, work hardening and functional restoration for workers with back and neck pain. Cochrane Database Syst Rev CD001822

68.

Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA (2005) Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial. Ann Intern Med 143:849–856PubMed

69.

Soukup MG, Glomsrod B, Lonn JH, Bo K, Larsen S (1999) The effect of a Mensendieck exercise program as secondary prophylaxis for recurrent low back pain. A randomized, controlled trial with 12-month follow-up. Spine 24:1585–1591; discussion 1592

70.

Stuckey SJ, Jacobs A, Goldfarb J (1986) EMG biofeedback training, relaxation training, and placebo for the relief of chronic back pain. Percept Mot Skills 63:1023–1036PubMed

71.

Szpalski M, Hayez JP (1994) Objective functional assessment of the efficacy of tenoxicam in the treatment of acute low back pain. A double-blind placebo-controlled study. Br J Rheumatol 33:74–78PubMedCrossRef

72.

Thomas M, Lundberg T (1994) Importance of modes of acupuncture in the treatment of chronic nociceptive low back pain. Acta Anaesthesiol Scand 38:63–69PubMedCrossRef

73.

Triano JJ, McGregor M, Hondras MA, Brennan PC (1995) Manipulative therapy versus education programs in chronic low back pain. Spine 20:948–955PubMedCrossRef

74.

Turner JA, Chapman CR (1982) Psychological interventions for chronic pain: a critical review I. Relaxation training and biofeedback. Pain 12:1–21PubMedCrossRef

75.

Turner JA, Clancy S (1988) Comparison of operant behavioral and cognitive-behavioral group treatment for chronic low back pain. J Consult Clin Psychol 56:261–266PubMedCrossRef

76.

Turner JA, Clancy S, McQuade KJ, Cardenas DD (1990) Effectiveness of behavioral therapy for chronic low back pain: a component analysis. J Consult Clin Psychol 58:573–579PubMedCrossRef

77.

Turner JA, Jensen MP (1993) Efficacy of cognitive therapy for chronic low back pain. Pain 52:169–177PubMedCrossRef

78.

Tuzun F, Unalan H, Oner N, Ozguzel H, Kirazli Y, Icagasioglu A, Kuran B, Tuzun S, Basar G (2003) Multicenter, randomized, double-blinded, placebo-controlled trial of thiocolchicoside in acute low back pain. Joint Bone Spine 70:356–361PubMedCrossRef

79.

Urrutia G, Burton AK, Morral A, Bonfill X, Zanoli G (2004) Neuroreflexotherapy for non-specific low-back pain. Cochrane Database Syst Rev CD003009

80.

van Tulder M, Furlan A, Bombardier C, Bouter L (2003) Updated method guidelines for systematic reviews in the cochrane collaboration back review group. Spine 28:1290–1299PubMedCrossRef

81.

van Tulder M, Malmivaara A, Esmail R, Koes B (2002) Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group. Spine 25:2784–2796CrossRef

82.

van Tulder MW, Jellema P, van Poppel MN, Nachemson AL, Bouter LM (2000) Lumbar supports for prevention and treatment of low back pain. Cochrane Database Syst Rev CD001823

83.

van Tulder MW, Ostelo R, Vlaeyen JW, Linton SJ, Morley SJ, Assendelft WJ (2000) Behavioral treatment for chronic low back pain: a systematic review within the framework of the cochrane back review group. Spine 25:2688–2699PubMedCrossRef

84.

van Tulder MW, Scholten RJ, Koes BW, Deyo RA (2000) Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev CD000396

85.

van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM (2003) Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev CD004252

86.

Von Korff M, Jensen MP, Karoly P (2000) Assessing global pain severity by self-report in clinical and health services research. Spine 25:3140–3151CrossRef

87.

Waddell G (1987) 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine 12:632–644PubMedCrossRef

88.

Wand BM, Bird C, McAuley JH, Dore CJ, MacDowell M, De Souza LH (2004) Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise. Spine 29:2350–2356PubMedCrossRef

89.

Waagen G, Haldeman S, Cook G, Lopez D, DeBoer K (1986) Short term trial of chiropractic adjustments for the relief of chronic low back pain. Manual Med 2:63–67

90.

Yelland MJ, Mar C, Pirozzo S, Schoene ML, Vercoe P (2004) Prolotherapy injections for chronic low-back pain. Cochrane Database Syst Rev CD004059

91.

Zylbergold R, Piper M (1981) Lumbar disc disease: comparative analysis of physical therapy. Arch Phys Med Rehabil 62:176–179PubMed

Title: Effect sizes of non-surgical treatments of non-specific low-back pain
Authors: A. Keller
J. Hayden
C. Bombardier
M. van Tulder
Publication date: 01-11-2007
Publisher: Springer-Verlag
Published in: European Spine Journal / Issue 11/2007
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI: https://doi.org/10.1007/s00586-007-0379-x

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Effect sizes of non-surgical treatments of non-specific low-back pain

Abstract

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 11/2007

Health-related quality of life in patients with adolescent idiopathic scoliosis after treatment: short-term effects after brace or surgical treatment, a comment

Abstracts

Biological and mechanical consequences of transient intervertebral disc bending

Association between the -1306C/T polymorphism of matrix metalloproteinase-2 gene and lumbar disc disease in Chinese young adults

CT-based classification of long spinal allograft fusion

PDGF, bFGF and IGF-I stimulate the proliferation of intervertebral disc cells in vitro via the activation of the ERK and Akt signaling pathways