A multi-disciplinary research team assessed the effectiveness of interventions for acute and subacute non-specific low back pain (NS-LBP) based on pain and disability outcomes. For this purpose, they conducted a systematic review of the literature with network meta-analysis.
They included all 46 randomized clinical trials (RCTs) involving adults with NS-LBP who experienced pain for less than 6 weeks (acute) or between 6 and 12 weeks (subacute). Non-pharmacological treatments (eg, manual therapy) including acupuncture and dry needling or pharmacological treatments for improving pain and/or reducing disability considering any delivery parameters were included. The comparator had to be an inert treatment encompassing sham/placebo treatment or no treatment. The risk of bias was
- low in 9 trials (19.6%),
- unclear in 20 (43.5%),
- high in 17 (36.9%).
At immediate-term follow-up, for pain decrease, the most efficacious treatments against an inert therapy were:
- exercise (standardised mean difference (SMD) -1.40; 95% confidence interval (CI) -2.41 to -0.40),
- heat wrap (SMD -1.38; 95% CI -2.60 to -0.17),
- opioids (SMD -0.86; 95% CI -1.62 to -0.10),
- manual therapy (SMD -0.72; 95% CI -1.40 to -0.04).
- non-steroidal anti-inflammatory drugs (NSAIDs) (SMD -0.53; 95% CI -0.97 to -0.09).
Similar findings were confirmed for disability reduction in non-pharmacological and pharmacological networks, including muscle relaxants (SMD -0.24; 95% CI -0.43 to -0.04). Mild or moderate adverse events were reported in the opioids (65.7%), NSAIDs (54.3%), and steroids (46.9%) trial arms.
The authors concluded that NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate-term. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best harm-benefit balance.
The authors point out that previous published systematic reviews on spinal manipulation, exercise, and heat wrap did overlap with theirs: exercise (eg, motor control exercise, McKenzie exercise), heat wrap, and manual therapy (eg, spinal manipulation, mobilization, trigger points or any other technique) were found to reduce pain intensity and disability in adults with acute and subacute phases of NS-LBP.
I would add (as I have done so many times before) that the best approach must be the one that has the most favorable risk/benefit balance. Since spinal manipulation is burdened with considerable harm (as discussed so many times before), exercise and heat wraps seem to be preferable. Or, to put it bluntly:
if you suffer from NS-LBP, see a physio and not osteos or chiros!
24 Responses to Which treatments are best for acute and subacute mechanical non-specific low back pain? A systematic review with network meta-analysis
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This certainly questions pharmaceuticals (opioids and NSAIDs) as a first line approach. So the question arises, why go to a MD as a first intervention for acute or subacute LBP?
There are many other important finding to unravel from this paper, which, once again, Ernst failed to comment on.
Luckily, we have you!
This paper certainly questions the claim that spinal manipulation may just be a placebo. Hmmm, I wonder who keeps claiming that?
I wonder who is trying to distract from my main message:
WITH BACK PROBLEMS, SEE A PHYSIO AND AVOID A CHIRO!
You do know that of the physical therapy approaches that they looked at only one was in the final recommendation? Heat wrap. None of the others made the cut which doesn’t that question what most PTs are doing for this condition?
You do know that other research has indicated that the best approach is multi-modal? A combination of exercise and manual therapy?
You do know they lumped manual therapies into one pile and only a couple of papers actually included spinal manipulation?
You do know that most PTs can’t legally read imaging thus, in those cases, requiring the addition of a MD (or DO, DC) adding potential time and cost to care?
You do know that most “adverse events” are mild and transient regardless if one uses exercise, PT or a DC?
You do know that based on this paper manual therapy is recommended before the use of pharmaceuticals based on risk:benefit?
psst: this is the current recommendations for physical therapists: note the word “should”.
Manual and Other Directed Therapies for Acute Low Back Pain
Physical therapists should use thrust or nonthrust joint mobilization to reduce pain and disability in patients with acute LBP.
Manual and Other Directed Therapies for Chronic Low Back Pain
Physical therapists should use thrust or nonthrust joint mobilization to reduce pain and disability in patients with chronic LBP.
Journal of Orthopaedic & Sports Physical Therapy
Published Online:October 31, 2021Volume51Issue11PagesCPG1-CPG60
It is not just what treatment is offered- it is also the approach/language used. We know more about MSK pain than just speaking in terms of damage and long-term maintenance treatment required, which seems to be the language of chiros and more about biopsychosocial elements and self management and empowerment which is more the language of physios.
“The chiropractic approach to health care has a history that is grounded in key aspects of the BPS model. The profession has inherently implemented certain features of the BPS model throughout its history, perhaps without a full understanding or realization.” June 2017 Chiropractic and Manual Therapies 25(1)
“The chiropractic approach to health care has a history that is grounded in key aspects of the BPS model.”
Only if BSP somewhat oddly stands for bullshit.
all health professions have a history of some “bullshit”.
Regardless, back to the paper:
You do know that BJ Palmer built one of the most extensive rehab labs in the region back in the 1940s and 50s?
You do know that DD Palmer was recommending “exercise” in the early 1900’s for mental well-being?
You do know that today most chiropractors recommend exercise to their patients?
They may well do – .but they also.prescribe frequent repeat visits to chiropractic for so called maintenance- contrary to evidence based approach.
After all how else do they get paid?
“ frequent repeat visits to chiropractic for so called maintenance- contrary to evidence based approach.”
An evidence based approach has three legs. If you wish to focus on the research leg, what does the research reveal regarding maintenance care and LBP? Have you even looked into it?
“An evidence-based approach has three legs.”
That’s put in a most misleading way!
ALL THREE ARE MANDATORY FOR A MODALITY OT BE EVIDENCE-BASED
ALL THREE ARE MANDATORY FOR A MODALITY OT BE EVIDENCE-BASED
I never stated otherwise
@DC – please tell me why in the UK a chiropractor not 5 miles from me is regularly treating a 10 year old for ADHD . Also tell me why the same chiropractor tells me he can straighten a scoliosis ? Also tell me why so many people have been visiting the same chiro year in year out for their back pain.
You can claim that treatment bases itself on BPS but BPS is about self management?
I have never had an explanation as to why DC studied ‘chiropractic’, trained as and practises ‘chiropractic’ – and not physiotherapy, osteopathy, or medicine.
Following which DC could have studied more as a post-grad and manipulated as he wished.
What did DC perceive as being the USP of ‘chiropractic’.
The principal issue surrounding ‘chiropractic’ is on account of their practitioners wanting to practice medicine with having gained appropriate qualifications – other than those they have devised for themselves so they can style themselves as ‘Doctor’.
This misleads the patients and is to be deprecated.
Sigh.
why not PT: at the time i was looking into a career change (about 30 years ago) DPT was not a program. Thus, a step below even chiropractic (no imaging rights for one).
why not MD: my desire was to focus on MSK with conservative methods (non-pharmaceutical). The MD programs had poor education in the MSK area and certainly little to no emphasis on manual therapy.
why not DO: I looked at some DO programs and talked to some DOs. MSK teaching was better than the MD program and OMM were required classes but participation was voluntary. Those who didn’t participate gave those who did a hard time and made fun of them (per the reports of recent DO grads). Seemed immature to me.
why DC: best and widest scope of the professional programs which emphasized conservative care using manual therapy for MSK conditions.
Sure, I have to deal with the crap in my profession. I have to deal with the crap from pseudo-skeptics. I have to deal with low reimbursement from insurance. I have to deal poor with public perception. But to be able to help keep people off of opioids or other drugs, to keep them from having unnecessary surgery…worth it.
Does that satisfy your query Richard?
I don’t know what that chiropractor is doing or saying. But there is a difference between treating for ADHD and treating someone with ADHD.
https://www.asdclinic.co.uk/conditions/adhd/physiotherapy-for-attention-deficit-hyperactivity-disorder.php
Same re scoliosis
https://www.choosept.com/guide/physical-therapy-guide-scoliosis
Maintenance care, it is not unique to chiropractic
https://www.inmotionoc.com/what-is-maintenance-physical-therapy/
Of course, none of this has to do with the actual paper but a spin-off of Ernst’s final comment (which wasn’t even the topic of the paper).
“there is a difference between treating for ADHD and treating someone with ADHD.”
You are definitely the top white washer of chiro BS!
Yet you didn’t disagree with my statement.
That is why my comment specifically said ‘for’. There is no non biased evidence for treating adhd in a child with chiropractic
Ok. Just wanted to make sure it was “for” and not “with”.
So perhaps you could answer the question ?
My guesses
please tell me why in the UK a chiropractor not 5 miles from me is regularly treating a 10 year old for ADHD .
Perhaps because he thinks he sees a change in some symptoms
Also tell me why the same chiropractor tells me he can straighten a scoliosis ?
Perhaps because he thought he saw some evidence of a change
Also tell me why so many people have been visiting the same chiro year in year out for their back pain.
Perhaps because they have chronic or recurrent back pain.
Of course there could be other reasons.