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Care Reviews
Helping Clinicians Make Better Treatment Choices
The Agency for Healthcare Key Clinical Issue of Recommendation [SOR]: B, based on
Research and Quality
(AHRQ) conducts the What are the benefits and harms of nonin- inconsistent or limited-quality patient-
Effective Health Care Pro- vasive treatments for acute, subacute, and oriented evidence.) Massage, heat wrap, and
gram as part of its mission chronic low back pain? NSAIDs improve pain and function for non-
to produce evidence to
radicular acute and subacute low back pain,
improve health care and
to make sure the evidence
Evidence-Based Answer whereas skeletal muscle relaxants improve
is understood and used. Exercise, nonsteroidal anti-inflammatory pain alone. (SOR: B, based on inconsistent
A key clinical question drugs (NSAIDs), and spinal manipulation or limited-quality patient-oriented evidence.)
based on the AHRQ Effec-
tive Health Care Program
with home exercise and advice have small Multiple exercise programs improve nonra-
systematic review of the benefits for radicular low back pain. (Strength dicular chronic low back pain, in addition to
literature is presented,
followed by an evidence-
based answer based upon Clinical Bottom Line: Summary of Key Findings and Strength of Evidence
the review. AHRQ’s sum-
for Interventions for Radicular Low Back Pain
mary is accompanied by
an interpretation by an
AFP author that will help Intervention Compared intervention Outcome Studies Findings SOE
guide clinicians in making
treatment decisions. For Nonpharmacologic interventions
the full review, clinician Exercise Usual care Pain, function 3 RCTs +
summary, and consumer
summary, go to https://
Traction Physiotherapy or other Pain, function 2 SRs
interventions
www.effectivehealthcare.
Spinal manipulation + home Home exercise + advice Pain 1 RCT +
ahrq.gov/ehc/index.cfm/
exercise + advice
search-for-guides-reviews-
and-reports/?page Pharmacologic interventions
Action=displayProduct& Nonsteroidal anti- Placebo Pain 1 SR +
productID=2326. inflammatory drugs
Diazepam Placebo Pain 1 SR –
This series is coordinated
Systemic corticosteroids Placebo Pain, function 5 RCTs –
by Kenny Lin, MD, MPH,
Associate Deputy Editor
for AFP Online. Strength-of-evidence scale
High: High confidence that the evidence reflects the true effect. Further research is very unlikely to
A collection of Implement- change the confidence in the estimate of effect.
ing AHRQ Effective Health
Moderate: Moderate confidence that the evidence reflects the true effect. Further research may
Care Reviews published in
change the confidence in the estimate of effect and may change the estimate.
AFP is available at http://
www.aafp.org/afp/ahrq. Low: Low confidence that the evidence reflects the true effect. Further research is likely to change
the confidence in the estimate of effect and is likely to change the estimate.
CME This clinical content Insufficient: Evidence either is unavailable or does not permit a conclusion.
conforms to AAFP criteria
for continuing medical RCT = randomized controlled trial; SOE = strength of evidence; SR = systematic review.
education (CME). See
+ = small effect favoring the intervention; – = no effect vs. placebo; = no difference between the interventions.
CME Quiz on page 286.
Author disclosure: No rel- Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Noninvasive treat-
evant financial affiliations. ments for low back pain: current state of the evidence. Clinician research summary. Rockville, Md.: Agency for Health-
care Research and Quality; November 2016. https://www.effectivehealthcare.ahrq.gov/ehc/products/553/2327/
back-pain-treatment-clinician-161115.pdf. Accessed December 14, 2016.
324 American
Downloaded Family
from the Physician
American www.aafp.org/afp
Family Physician website at www.aafp.org/afp. American Academy
Copyright © 2017 Volume 96, Physicians.
of Family Number 5For September 1, 2017
the private, noncom-
◆
mercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
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AHRQ
Clinical Bottom Line: Summary of Key Findings and Strength of Evidence for Interventions
for Nonradicular Acute or Subacute Low Back Pain
Nonpharmacologic interventions
Massage Sham massage or usual care Pain, function 1 SR + to ++
Pharmacologic interventions
NSAIDs Placebo Pain 1 SR +
Strength-of-evidence scale
High: High confidence that the evidence reflects the true effect. Further research is very unlikely to change the confidence in the
estimate of effect.
Moderate: Moderate confidence that the evidence reflects the true effect. Further research may change the confidence in the
estimate of effect and may change the estimate.
Low: Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate
of effect and is likely to change the estimate.
Insufficient: Evidence either is unavailable or does not permit a conclusion.
NSAID = nonsteroidal anti-inflammatory drug; RCT = randomized controlled trial; SOE = strength of evidence; SR = systematic review.
+ = small effect favoring the intervention; ++ = moderate effect favoring the intervention; – = no effect vs. placebo; = no difference between the
interventions.
Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Noninvasive treatments for low back pain: current
state of the evidence. Clinician research summary. Rockville, Md.: Agency for Healthcare Research and Quality; November 2016. https://www.
effectivehealthcare.ahrq.gov/ehc/products/553/2327/back-pain-treatment-clinician-161115.pdf. Accessed December 14, 2016.
acupuncture and multidisciplinary rehabilitation. (SOR: changes in pain, function, or both. Benefits of treatments
A, based on consistent, good-quality patient-oriented evi- for pain were in the small to moderate range—less than
dence.) Psychological therapies improve chronic low back a two-point change on a 10-point pain scale. Effects on
pain, but not function. (SOR: B, based on inconsistent or function were included in studies less often than effects on
limited-quality patient-oriented evidence.) NSAIDs and pain, and showed even smaller benefits.
antidepressants improve pain and function in nonradicu- This AHRQ review found moderate strength of evi-
lar, chronic low back pain. Opioids show small, short- dence that heat, NSAIDs, and muscle relaxants are effec-
term improvements in pain and function. (SOR: A, based tive for acute and subacute low back pain. The American
on consistent, good-quality patient-oriented evidence.) Pain Society and American College of Physicians also
found good evidence that these three interventions have
Practice Pointers a positive effect.3,4
Low back pain is one of the most common presenting For chronic low back pain, exercise therapy, acupunc-
problems in primary care, affecting 84% of adults at some ture, multidisciplinary rehabilitation, NSAIDs, opioids,
point in their lives.1 At an estimated $87.6 billion in 2013, and duloxetine all produced improvements in pain and
neck and back pain was the third most expensive condi- function.1 Studies on opioids found only short-term
tion in the United States behind diabetes mellitus and effects.
ischemic heart disease.2 The American Pain Society/American College of Phy-
This Agency for Healthcare Research and Quality sicians review showed evidence for moderate improve-
(AHRQ) review identified 156 randomized controlled tri- ment in pain with cognitive behavior therapy and
als and systematic reviews of randomized controlled trials progressive relaxation.3 This AHRQ review found an
on the effectiveness of pharmacologic and noninvasive improvement with psychological therapy, although this
nonpharmacologic treatments for low back pain. Acute low finding is based on low strength of evidence.1 Beneficial
back pain was defined as pain lasting less than four weeks, psychological therapies included progressive relaxation,
subacute as pain lasting four to 12 weeks, and chronic as electromyographic biofeedback, and operant therapy;
pain lasting more than 12 weeks. Acute low back pain 10 trials showed no difference among these therapies,
had generally favorable outcomes. The outcomes included and a systematic review showed no difference between
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Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
AHRQ
Clinical Bottom Line: Summary of Key Findings and Strength of Evidence for Nonpharmacologic
Interventions for Nonradicular Chronic Low Back Pain
Function 1 SR +
General exercise or physical Pain, function 2 SRs + to ++
therapy
Motor control exercise + Exercise therapy alone Pain 2 RCTs
exercise
Tai chi Waitlist control† or no tai chi Pain 2 RCTs ++
Psychological therapies Waitlist control or placebo Pain 4 SRs ++ (except + for
(include progressive operant therapy)
relaxation, operant ther- Function 4 SRs – (except + for pro-
apy, electromyographic gressive relaxation)
biofeedback, and cogni-
tive behavior therapy)
Another psychological therapy Function 10 RCTs
Acupuncture No acupuncture Pain, function 1 SR ++
Multidisciplinary Usual care or no multidisci- Pain, function (short- 2 SRs + to ++ (pain) to
rehabilitation‡ plinary rehabilitation and long-term) + (function)
Strength-of-evidence scale
High: High confidence that the evidence reflects the true effect. Further research is very unlikely to change the confidence in the
estimate of effect.
Moderate: Moderate confidence that the evidence reflects the true effect. Further research may change the confidence in the
estimate of effect and may change the estimate.
Low: Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate
of effect and is likely to change the estimate.
Insufficient: Evidence either is unavailable or does not permit a conclusion.
psychological therapy and exercise therapy. There was Although prior reviews of lower-quality studies con-
insufficient evidence in two trials of cognitive behavior cluded that acetaminophen was effective for acute back
therapy because each study included only 34 patients, pain, the first placebo-controlled trial of acetaminophen
and one did not report treatment details.5 found that it is not effective.6 The second new finding is
326 American Family Physician www.aafp.org/afp Volume 96, Number 5 ◆ September 1, 2017
Descargado para Anonymous User (n/a) en Colegio Medico Del Peru de ClinicalKey.es por Elsevier en septiembre 12, 2017.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
AHRQ
Clinical Bottom Line: Summary of Key Findings and Strength of Evidence for Pharmacologic
Interventions for Nonradicular Chronic Low Back Pain
Function 1 SR +
Strength-of-evidence scale
High: High confidence that the evidence reflects the true effect. Further research is very unlikely to change the confidence in the
estimate of effect.
Moderate: Moderate confidence that the evidence reflects the true effect. Further research may change the confidence in the
estimate of effect and may change the estimate.
Low: Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate
of effect and is likely to change the estimate.
Insufficient: Evidence either is unavailable or does not permit a conclusion.
NSAID = nonsteroidal anti-inflammatory drug; RCT = randomized controlled trial; SOE = strength of evidence; SR = systematic review.
+ = small effect favoring the intervention; ++ = moderate effect favoring the intervention; – = no effect vs. placebo; = no difference between the
interventions.
*—Other opioids that were evaluated included oxycodone, hydrocodone, hydromorphone, morphine, and fentanyl.
†—Other antidepressants that were evaluated included tricyclic antidepressants, selective serotonin reuptake inhibitors, and tetracyclic antidepressants.
Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Noninvasive treatments for low back pain: current
state of the evidence. Clinician research summary. Rockville, Md.: Agency for Healthcare Research and Quality; November 2016. https://www.
effectivehealthcare.ahrq.gov/ehc/products/553/2327/back-pain-treatment-clinician-161115.pdf. Accessed December 14, 2016.
yoga. If available, physicians should also consider refer- 5. Chou R, Deyo R, Friedly J, et al.; Agency for Healthcare Research
and Quality. Noninvasive treatments for low back pain. Comparative
ring these patients for progressive relaxation, acupunc- Effectiveness Review No. 169. Rockville, Md.: Agency for Healthcare
ture, and exercise therapy. Research and Quality; February 2016. https://effectivehealthcare.ahrq.
gov/ehc/products/553/2178/back-pain-treatment-report-160922.pdf.
EDITOR’S NOTE: American
Family Physician SOR ratings are different from Accessed June 2, 2017.
the AHRQ Strength of Evidence (SOE) ratings.
6. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for
Address correspondence to Tyler W. Barreto, MD, at tb908@ acute low-back pain: a double-blind, randomised controlled trial. Lan-
georgetown.edu. Reprints are not available from the authors. cet. 2014;384(9954):1586-1596. ■
Descargado para Anonymous User (n/a) en Colegio Medico Del Peru de ClinicalKey.es por Elsevier en septiembre 12, 2017.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.