Study (first author) | Setting | Duration of back pain | Participants: n, mean age in years, % female | Baseline mean RMDQ score (SD) | Intervention | Control | Outcome of usual care: mean (SD) unless stated | Outcome of intervention in comparison with usual care | Methodological quality score (0–5, with 5 being best) |
---|---|---|---|---|---|---|---|---|---|
Brealey12 | UK general practice | Mixed | 338, 42.5, 53 | 9 (3.9) | Physical treatments; exercise | Best care | RMDQ: base 9 (3.9), 3 months 6.8 (0.3), 12 months 6.1 (0.3) versus exercise group. Pain (MVK): base 60.5 (17.6), 3 months 49.3 (1.6), 12 months 48.4 (1.7) versus exercise group | Compared with best care — exercise: small benefit at 3 months, nil at 12 months. Manipulation: small to moderate benefit at 3 months and small benefit at 12 months. Manipulation + exercise: moderate benefit at 3 months and small benefit at 12 months | 3 |
Burton13 | UK 5 general practices and 1 osteopath practice | Acute | 79, 44.7, 48 | 9.7 (4.6) | Back book (biopsychosocial) or handy-hints pamphlet (biomedical) | Usual care + pamphlet | RMDQ: base 9.7 (4.6), 12 months ∼4.5 (–). Pain (VAS 0–100) worst/best: base 68.7 (18.5)/50.8 (27.8) 12 months 15.6 (18.7)/10.6 (17.8) | Improved beliefs about low back pain; reduced fear-avoidance and RMDQ score; no effect on pain | 5 |
Cherkin14 | US primary care | Acute | 66, 40.1, 42 | 11.7 (5.4) | Physical therapy; chiropractic booklet | Usual care + booklet | RMDQ: base 11.7 (1.3), 4 weeks 4.9 (1.1), 12 weeks 4.3 (1.2) | Physical and chiropractic therapy improves satisfaction, but nothing else | 4 |
Curtis15 | US, primary care | Acute | 143, 42.7, 57 | 15.6 (5.4) | Manual therapy given by GP | Enhanced care patient-centred approach, careful examination, including palpation and functional assessment, use of national guidelines and patient handouts regarding activities of daily living and exercise. Option to use standard prescription, bed rest, trigger-point injections referral to others | RMDQ at base 15.6 (5.4); improvement in RMDQ from randomisation: base 2.6 (5.7), 2 weeks 8.7 (8.0), 4 weeks 9.8 (7.3), 8 weeks 11.1 (7.9). Pain (0–10): 4.6 (2.1). Satisfaction (1–5, 1 = best): endpoint 2.1 (1.1) | GP giving limited manual therapy offers very modest benefit compared with enhanced care alone. However, only 43% of patients in manual treatment group given full treatment course by the GP | 4 |
Damush16 | US inner-city health centres and emergency rooms | Subacute | 106, 45.5, 75 | 13.9 (6.8) | Self-management programme for patients on low income with acute low back pain: long-term outcomes (1 year) | Usual care referral to occupational health, physical therapy, or a neurologist; analgesics, back exercise advice sheets | RMDQ: base 13.9 (6.8), 12 months 11.3 (8.1). Satisfaction (higher score better): base 24.3 (5.7), 12 months 25.4 (5.4) | At 12 months patients who participated in the self-management programme showed significantly better RMDQ scores, mental functioning, self-efficacy to manage acute low back pain, time in physical activity, and reduced fear of movement/re-injury | 4 |
Dey3 | UK primary care | Mixed | 1138, 41.3, 54.3 | – | Education of GPs to promote use of guidelines on low back pain | Usual care | Patients receiving the following (%): X-ray 13.7, sick note 19.2, opiates/muscle relaxant 18.7, referral to secondary care 2.3, referral to physiotherapy 13.8 | No difference between study and control patients in terms of proportion referred to X-ray, given a sick certificate, prescribed opioids or muscle relaxants, or referred to secondary care. Only 21% of patients had evidence that they were given advice about avoiding bed rest; 0.6% in both arms recommended to take bed rest. Suggested that GPs know about guidelines but feel pressurised by patient expectations to behave differently | 4 |
Molde Hagen17 | Norway spine clinic | Chronic | 220, 41.1, 48 | – | Light mobilisation | Usual care | 19.6 days of compensated sick leave in 2 years | Brief examination, information giving, reassurance and encouragement to resume physical activity reduces long-term sick leave in the first year. Those returning to work mainly do so in the first year | 3 |
Hagen42 | Norway spine clinic | Subacute | 457, 41, 48 | – | Reassurance about prognosis and advice | Usual care | – | – | 3 |
Jellema18 | The Netherlands primary care | Subacute | 171, 42, 47 | 12.2 (5); median 13 IQR (8–16) | Assessment and modification of psychological factors | Usual care as per Dutch College of GP guidelines | RMDQ: base 12.2 (5.0);a base 13 (8–16), 6 weeks 4 (1–10); 13 weeks 2 (0–5), 26 weeks 1 (0–3), 1 year 1 (0–4). Pain (0–10):a base 5 (3–6), 6 weeks 2 (0–4), 13 weeks 1 (0–3), 26 weeks 0 (0–2), 1 year 0 (0–2) | No difference in outcome measures versus usual care | 4 |
Karjalainen19 | Finnish primary care | Subacute | 57, 43, 60 | – | Mini-intervention versus usual care, 2-year follow-up | Leaflet + usual care | Disability (ODI) mean (range): base 34 (13–67), 3 months 25 (0–76), 6 months 21 (0–51), 1 year 19 (0–51), 2 years 18 (0–51). Pain (0–10): base 5.7 (1–10), 3 months 4.1 (0–9), 6 months 3.7 (0–10), 1 year 3.7 (0–10), 2 years 3.4 (0–9) | Examination, information, support, and simple advice reduces daily symptoms and sick leave, and increases satisfaction and adaptation by patients, without increasing healthcare costs | 3 |
Karjalainen20 primary care | Finland | Subacute | 57, 43, 60 | – | Mini-intervention (involving light mobilisation, graded activity programme, addressing patient concerns) versus usual care, 1-year follow-up | Leaflet + usual care | As above | As above | 3 |
Kendrick21 | UK primary care | Subacute | 211, 39,a 60 | 8 (4–12)a | X-rays for low back pain | Usual care | Median (IQR) RMDQ: base 8 (4–12), 3 months 3 (1–7). Pain (0–10): base 2 (1–2), 3 months 1 (0–2). Satisfaction (EuroQol): base 20 (17.75–22), 3 months (19–23) | X-rays don't improve care of low back pain sufferers, but increase doctors' workload | 3 |
Kerry22 | UK primary care | Mixed | 332, 41.1, 53 | 10.8 (5.4) | X-rays for first presentation of low back pain | Usual care | RMDQ: base 10.8 (5.4), 6 weeks 5.4 (0.3), 1 year 4.2 (0.3). Pain (SF-36 BP): base 45 (26), 6 weeks 56 (2), 1 year 65 (2) | Referral for lumbar X-ray doesn't improve pain, function, or disability. There is a small possible improvement in psychological status, but need to balance against radiation risk | 3 |
Kovacs23 | Mallorca primary care | Chronic | 45, 45.6,a 66.7 | 12.17 (–) | Neuroreflexotherapy | Usual care | Median (range) RMDQ: base 12.2 (6.5–18.0), 1-year improvement 2.1 (−1.5 to 6.7). Pain (VAS): base 5.2 (4.1–8), 1-year improvement 1.9 (−1.3 to 2.0) | Neuroreflexotherapy reduced pain, disability, specialist referral, X-ray requests, drug costs, and sick leave | 4 |
Licciardone24 | US university clinic | Chronic | 20, 49, 65 | 7.3 (5.4) | Osteopathic manipulation in chronic low back pain | Usual care | RMDQ: base 7.3 (5.4). Pain (VAS): base 3.1 (2.3), 6 months ∼3.9 (–). Global satisfaction: base ∼1.8 (–), 6 months ∼2.1 (–) | Osteopathic manipulation improved pain, treatment satisfaction, function, and mental health compared with usual care. Sham manipulation improved pain, treatment satisfaction, and function compared with usual care. There were no differences between osteopathic and sham manipulation | 4 |
Linton25 | Sweden primary care | Chronic | 70, 45, 71 | – | CBT and different forms of information | Pamphlet | Pain (0–10): base 4.8 (0.45), 1 year 4.0 (0.55) | CBT caused a nine-fold reduction in sick leave and physician and physiotherapy usage | 4 |
Meng26 | US various clinics in private and hospital sectors | Chronic | 24, 70, 62.5 | 11.8 (5.3) | Acupuncture for chronic low back pain | Usual care (narcotics, muscle relaxants, transcutaneous electrical nerve stimulation, epidurals, trigger-point injections prohibited) | RMDQ: base 11.8 (5.3), 6 weeks improved by 0.6 (2.7). Pain (VAS): base 1.7 (1.0), 6 weeks worsened by 0.6 (1.2) | Acupuncture reduced RMDQ scores and was safe | 3 |
Miller27 | UK primary care | Subacute | 211, 39, 16 | 8 (4–12)a | Cost effectiveness of X-rays | Usual care | Median (IQR) RMDQ: base 8 (4–12) Pain (VAS, 0–10): base 2 (1–2) Satisfaction (0–27): base 20 (17.8–22), 9 months (16–21) | X-rays are only cost-effective when patient satisfaction is high. Other ways of obtaining satisfaction are to be preferred | 2 |
Klaber Moffett28 | UK primary care | Mixed | 98, 42.6, 56 | 5.56 (3.94) | Exercise programme | Usual care | RMDQ: base 5.56 (3.94), % of patients with improvement ≤2 points; 6 weeks 46, 6 months 47, 1 year 47.5 | High fear-avoiders benefit most from an exercise programme and the effect is maintained at 1 year. Patients who are depressed/distressed gained a short-term benefit | 4 |
Moffett29 | UK primary care | Mixed | 98, 42.6, 56 | 5.56 (3.94) | Exercise programme | Usual care | RMDQ: base 5.56 (3.94), improvement from base 6; 6 weeks 1.94, 6 months 1.64, 1 year 1.77. Pain (ALBPS): 25.52 (10.85), improvement from base; 6 weeks 8.99, 6 months 8.11, 1 year 8.48 | Exercise programme reduced pain, disability, and healthcare usage | 3 |
Moore30 | US HMO clinics | Mixed | 113, 49.1, 49.6 | 8.29 (5.88) | Self-care (CBT) | Book on back care | RMDQ: 8.29 (5.88), 3 months 6.55 (6.13), 6 months 6.4 (5.99), 1 year 5.56 (5.8). Pain (0–10): base 5.2 (1.95), 3 months 4.06 (2.17), 6 months 3.71 (2.28), 1 year 2.98 (1.99) | CBT approach reduced back-related worry, fear-avoidance, pain, and functional problems | 2 |
Moseley31 | Australia physiotherapy clinic | Chronic | 28, 398, 54 | 11.9 (3.2) | Combined physiotherapy and education | Usual care | RMDQ: base 11.9 (3.2), 1-year improvement 4.3. Pain (0–10): base 4.7 (1.5), 1-year improvement 1.4 | A combined programme of manual therapy, exercise, and education reduced pain and disability | 4 |
Roberts32 | UK primary care | Acute | 28, 29.2, 32 | – | Back-care leaflet | Usual care | – | The leaflet improved posture but had no effect on function | 3 |
Rossignol33 | Canadian worker compensation scheme | Subacute | 56, 38.3, 23.2 | – | Advice and support for physicians treating low back pain | Usual care | Pain (VAS, 0–100): base 52.4 (20.7), 3 months 10.9 (24.0), 6 months 12.8 (27.0). Satisfaction (0–65, best–worst): base 30.3 (12.8), little change during trial | Advice and support to doctors about management of low back pain reduces patient sick leave, pain, dysfunction, and X-ray usage. It improves exercise levels | 4 |
Schectman34 | US HMO clinics | Acute | 590, 45.5, 54 | – | Physician education versus patient educational material versus both versus neither | Usual care | – | Education of physicians improves compliance with low back pain guidelines. Patient educational material has no effect | 1 |
Seferlis35 | Sweden hospital clinic | Acute | 60, 38, 47 | – | Manual therapy versus intensive training versus usual care | Usual care | – | Most patients return to work by 1 month regardless of treatment. Satisfaction is improved by manual therapy or intensive training | 4 |
Seferlis36 | Swedish hospital clinic previous study | Acute | 60, 38, 47 | – | Cost-minimisation analysis of conservative treatment for back pain | Usual care | – | Usual care has lowest cost | 4 |
Skouen37 | Norway hospital clinic | Chronic | 86, 44, 64 | – | Extensive versus light multidisciplinary treatments versus usual care | Usual care | – | Light programme more effective than usual care. Extensive programme no more effective than usual care | 3 |
Staal38 | The Netherlands occupational health airline | Subacute | 67, 37, 7 | 13 (4.9) | Graded activity | Usual care | RMDQ: base 13.0 (4.9), improvement frame base: 3 months 4.9 (6.2), 6 months 6.4 (6.6). Pain (0–10): base 6.4 (1.7), improvement frame base: 3 months 2.5 (2.8), 6 months 2.7 (2.8) | Graded activity reduces days of work lost due to low back pain | 4 |
Thomas43 | UK acupuncture clinics and primary care | Mixed | 241, 44, 58 | – | Acupuncture | Usual care | Disability (ODI): baseline 31.4 (14.2), 12 months 19.6 (15.4), 24 months 21.0 (14.2). Pain (SF-36 BP, 0–100): baseline 30.4 (18.0), 12 months 58.3 (22.2), 24 months 59.5 (23.4). Pain (MPQ): baseline 2.7 (1.0), 12 months 1.53 (0.9), 24 months 1.71 (1.1) | Weak evidence that acupuncture has an effect on persistent back pain at 2 months, stronger evidence of a smaller effect at 24 months | 3 |
Underwood39 | UK primary care | Acute | 40, 41, 45 | – | Back extension exercises | Usual care | Disability (ODI): base 35.6, 1 year 24% patients had a score <20. Pain (VAS): base 50.4, 1 year 18% had score <20 | No evidence to show that it is more effective than usual care | 4 |
Von Korff40 | US primary care | Mixed | 126, 50.3, 56 | 9.4 (6.5) | Lay-led selfmanagement | Usual care | RMDQ (approximate): base 9.0, 3 months 7.4, 6 months 7.3, 1 year 7.0. Pain (average): base 5.7 (2.1), 3 months 4.0 (2.1), 6 months 4.1 (0.9), 1 year 3.8 (2.4) | Self-help group reduced worried, produced positive attitudes, and reduced activity limitations | 3 |
Williams41 | UK primary care osteopathy clinic | Subacute | 106, –, – | – | Effectiveness and healthcare costs of a a primary care osteopathy service | Usual care | Pain (VAS, 0–100): base 46.3 (22.4), 2 months 6.8 (23.4), 6 months 10.1 (24.1) | Primary care osteopathy improved short-term physical and long-term psychological outcomes at a little extra cost | 3 |
↵a Media (interquartile range). ALBPS = Aberdeen Low Back Pain Scale (0–100, 0 = best). CBT = cognitive behavioural therapy. HMO = health maintenance organisation. IQR = interquartile range. MPQ = McGill Pain Questionnaire (0–5, 0=best). MVK = modified Von Korff Pain Scale (0–100, 0 = best). ODI = Oswestry Disability Index (0–100, 0 = best). SF-16 BP = SF-16 Bodily Pain (0–100, 0 = best). RMDQ = Roland–Morris Disability Questionnaire (0–24, 0 = best). VAS = Visual Analogue Scale (0–100 or 0–10, best = 0).