Few trials investigated the effectiveness of treatments for radicular low back pain, but low-level evidence found that benzodiazepines, corticosteroids, traction, and spinal manipulation were either ineffective or were associated with small effects. Few trials directly compared the effectiveness of different medications or different pharmacologic therapies, and few compared pharmacologic versus nonpharmacologic therapies.

More detailed findings are listed in Table 4.

The researchers stated, “our findings are generally consistent with those of prior systematic reviews on noninvasive treatment for low back pain, in part, because our report builds on a prior review and utilizes previously published high-quality systematic reviews to inform its findings.”

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Applicability and Implications for Clinical and Policy Decision-Making

Several issues impact the potential applicability of the review’s findings, according to the authors. For example, some studies did not specifically enroll patients with acute, subacute, or chronic low back pain but rather enrolled mixed populations or did not clearly describe the duration of symptoms. Few studies included patients specifically with radicular symptoms and many studies did not specify whether patients with radicular symptoms were excluded. For nonpharmacologic treatments, there was great variability among trials in the interventions and comparators evaluated.

In terms of clinical decision-making, the researches noted several important points. For example, clinical practice guidelines generally recommend acetaminophen as first-line pharmacologic therapy for acute and chronic low back pain.4 Evidence assessed by the review calls this recommendation into question, although other factors (eg, cost, favorable side effect profile, and effectiveness for other acute pain conditions) might impact decisions regarding its use. Duloxetine appears to be more effective than tricyclic antidepressants and has a more favorable safety profile.

Patients with low back pain frequently receive prescriptions for opioids, but the use of opioids for chronic pain has uncertain long-term effectiveness, increases in the number of accidental overdoses, and increased abuse potential. Short-term, relatively modest benefits must be weighed against potential harms.

The review found insufficient evidence to recommend most physical modalities, other than superficial heat, and insufficient evidence to determine which patients are most likely to benefit from specific nonpharmacologic therapies. A stratified approach (ie, patients are assessed for risk factors for chronicity, and higher-risk patients receive more intensive cognitive behaviorally-based physical therapy) is more effective than usual care without a stratified approach. This suggests that psychologically based therapies and multidisciplinary rehabilitation may be the most effective approach in higher risk patients. Patient expectations of benefit may play an important role and should be taken into account in the decision-making process. They added that most nonpharmacologic therapies have a more favorable side effect profile.


The researchers concluded that “a number of pharmacological and nonpharmacologic noninvasive treatments for low back pain are associated with small to moderate, primarily short-term, effects on pain versus placebo, sham, wait list, or no treatment. Effects on function are generally smaller than effects on pain. More research is needed to understand optimal selection of treatments, effective combinations and sequencing of treatments, and effectiveness of treatments for radicular low back pain.”