Non-pharmacological and non-surgical treatments for low back pain in adults: an overview of Cochrane reviews.

backgroundLow back pain (LBP) is a significant public health issue due to its high prevalence and associated disability burden. Clinical practice guidelines recommend non-pharmacological/non-surgical interventions for managing pain and function in people with LBP.

objectivesTo provide accessible, high-quality evidence on the effects of non-pharmacological and non-surgical interventions for people with LBP and to highlight areas of remaining uncertainty and gaps in the evidence regarding the effects of these interventions for people with LBP.

methodsWe searched the Cochrane Database of Systematic Reviews from inception to 15 April 2023, to identify Cochrane reviews of randomised controlled trials testing the effect of non-pharmacological/non-surgical interventions, unrestricted by language. Major outcomes were pain intensity, function and safety. Two authors independently assessed eligibility, extracted data and assessed the quality of the reviews using AMSTAR 2 (A MeaSurement Tool to Assess Systematic Reviews) and the certainty of the evidence using GRADE. The primary comparison was placebo/sham. MAIN

resultsWe included 31 Cochrane reviews of 644 trials that randomised 97,183 adults with LBP. We have high confidence in the findings of 19 reviews, moderate confidence in the findings of two reviews, and low confidence in the findings of 10 reviews. We present results for non-pharmacological/non-surgical interventions compared to placebo/sham or no treatment/usual care at short-term (≤ three months) follow-up. Placebo/sham comparisons Acute/subacute LBP Compared to placebo, there is probably no difference in function (at one-week follow-up) for spinal manipulation (standardised mean difference (SMD) -0.08, 95% confidence interval (CI) -0.37 to 0.21; 2 trials, 205 participants; moderate-certainty evidence). Data for safety were reported only for heated back wrap. Compared to placebo, heated back wrap may result in skin pinkness (6/128 participants versus 1/130; 2 trials; low-certainty evidence). Chronic LBP Compared to sham acupuncture, acupuncture probably provides a small improvement in function (SMD -0.38, 95% CI -0.69 to -0.07; 3 trials, 957 participants; moderate-certainty evidence). Compared to sham traction, there is probably no difference in pain intensity for traction (0 to 100 scale, mean difference (MD) -4, 95% CI -17.7 to 9.7; 1 trial, 60 participants; moderate-certainty evidence). Data for safety were reported only for acupuncture. There may be no difference between acupuncture and sham acupuncture for safety outcomes (risk ratio (RR) 0.68, 95% CI 0.42 to 1.10; I AUTHORS'

conclusionsSpinal manipulation probably makes no difference to function compared to placebo for people with acute/subacute LBP. Acupuncture probably improves function slightly for people with chronic LBP, compared to sham acupuncture. There is probably no difference between traction and sham traction for pain intensity in people with chronic LBP. Compared to advice to rest, advice to stay active probably reduces pain intensity slightly and improves function slightly for people with acute LBP. Acupuncture probably reduces pain intensity, and improves function slightly for people with chronic LBP, compared to no treatment. Acupuncture probably improves function slightly for people with chronic LBP, compared to usual care. Exercise therapies probably reduce pain intensity, and improve function slightly for people with chronic LBP, compared to no treatment/usual care. Multidisciplinary therapies probably reduce pain intensity, and improve function slightly for people with chronic LBP, compared to usual care. Compared to usual care, psychological therapies probably reduce pain intensity slightly, but probably make no difference to function for people with chronic LBP.