Non-pharmacological treatments are more beneficial to patients suffering from long-term low back pain, without radiculopathy however, more research is needed to confirm this. Spinal News International

Stephanie Mathieson

For patients suffering from chronic, or nonspecific back pain, without radiculopathy non-pharmacological treatments like acupuncture and spinal manipulation offer more benefits in comparison to invasive or pharmacological 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 actual fact, Mathieson et al note that, at present, “there are no published studies that evaluate non-pharmacological, pharmaceutical and invasive treatments that treat persistent low back pain in adults , and give summary statistics on benefits and negatives.”

The purpose for the meta-analysis and systematic reviews was to evaluate the advantages and risks of treatment options for the management for chronic lower back pain, without radiculopathy. It also aimed to present the results in a way that allows straight comparison.

Randomised controlled trials, as well as trial registers, derived using electronic databases until 22 May 2022 are employed. Adults suffering from non-specific persistent low back pain, but not the radicular region within any clinical setting were included.

The primary outcome measure was the comparison of pain the immediate-term (<=2 weeks) and short-term (>2 weeks to less than 12 weeks) and grave adverse events, by using the Benefit-Harm Scale (Level 1 to 7).

Interventions comprised treatments that were not pharmacological (acupuncture, spinal manipulation) as well as invasive and pharmacological treatments in comparison with placebo. Best evidence criteria were utilized as well as two independent reviewers performed eligibility assessment as well as data extraction, and evaluation of quality.

The database searches yielded 17362 records. Three studies offered evidence of the benefits of interventions, while 30 reported on the risks. The studies included acupuncture-related interventions (n=8) as well as manipulation (n=2) and pharmacological treatments (n=9) which included nonsteroidal anti-inflammatory medicines (NSAIDs) along with opioid analgesics, surgery (n=8) Epidural corticosteroid injections (n=3).

Treatments that worked in reducing pain when compared to sham treatment were Acupuncture (standardised mean value [SMD] 0.51, 95 percent confidence interval -0.88 to -0.14 1 trial moderately high quality evidence and a the benefit score was three) or manipulation (SMD -0.39 (95 percent CCI -0.56 to -0.21 two trials decent quality evidence and a benefit score of five).

According to the research team the results associated with other strategies were assessed as uncertain due to the lack of being effective, the existence of statistical heterogeneity or the absence of studies that were relevant to the issue.

According to Spinal News International, Mathieson said: “We weren’t surprised to find holes in the current research. It is essential to have a concise overview of evidence-based therapies for people who suffer with chronic lower back pain. That is why that we have created this list. Patients are looking for clear recommendations. When information on the benefits and severe harms of treatments are presented in separate ways, it can make interpretation difficult.”

The warnings for harms levels were at the lowest level for acupuncture, spinal manipulation NSAIDs and combination injections of steroid and opioids however, they were more for opioid analgesics with a single ingredient (Level 4,) and surgical procedures (Level 6.).

“Quantifying harms, and particularly the most severe harms, is essential since they are much easier to cause and be more damaging over benefits” said Mathieson. “Systematic reviews that offer harms information provide guidance to the physician and patients. A clinical decision could be to differ based on the frequency of the harms. Are the risks of serious injury one in ten or one in a million? This Benefit-Harm Scale that was used in our study aids in the calculation of harms as well as benefits.

“We are aware that certain treatments are more risky than other treatments. We now have an easy, evidence-based comparison. I hope this provides clinicians with an actual tool to facilitate conversations with patients on the most common strategies for managing pain within an integrated decision-making model.

“People are seeking out information on how to take care of their back pain in a safe manner. We know that doctors wish to assist their patients. However, what’s clear from our analysis is that more research of high-quality is required.”