In addition to reducing pain, tai chi reduced “bothersome” back symptoms and improved self- reported disability. 80 Yoga Several relatively high-quality RCTs suggest that yoga can modestly reduce chronic pain. A recent study, for example, found that people with chronic LBP who took weekly yoga classes for 12 weeks had less pain and greater physical function compared to those who just got information about how to deal with back pain. 82 The yoga in the study emphasized strengthening back and core muscles. In addition to reducing pain, those in the yoga group were more likely to have stopped taking pain relievers at one-year follow-up. A 2012 systematic review comparing yoga to standard care found moderate effect sizes for reductions in pain-related disability, with evidence that even short-term interventions might be effective. 83 A 2017 Cochrane review of 9 RCTs involving 810 participants with chronic low back pain found small to moderate improvements in pain and function associated with yoga compared to no-exercise controls. For pain, a clinically meaningful reduction in pain score based on the RMDQ of 15 points was not achieved. 84 (A 2017 systematic review of 14 RCTs by the American College of Physicians came to similar conclusions.) 35 Meditation Mindfulness meditation elicits the relaxation response and can promote pain relief. A randomized trial of 342 adults with LBP found that participating in 8 weekly training sessions in mindfulness meditation was associated with significantly higher levels of function and reduced pain compared to usual care (61% vs. 44%, p=0.04). 85 The neural correlates of the analgesic effects of mindfulness meditation were explored in a trial at Wake Forest University in which 76 healthy volunteers were taught mindfulness meditation and then monitored by MRI while a pain-inducing heat device was applied to their leg for six minutes. 86 Meditation reduced pain unpleasantness by more than half (57%) and pain intensity by 40%. 86 Acupuncture A 2017 systematic review of four trials evaluating acupuncture vs. sham acupuncture in patients with chronic LBP found modest improvements in pain, but no improvements in function. 35 A meta-analysis of 4 trials comparing acupuncture to no acupuncture found larger effect sizes, but the quality of the evidence is lower due to the large placebo effects known to manifest in acupuncture studies without a sham comparison. 35
Massage A 2015 Cochrane review of 25 RCTs compared massage vs. inactive (e.g., sham treatment or waitlist) or active (e.g., TNES, acupuncture, traction, physical therapy) controls in 3,096 adults with LBP. 87 Massage compared to sham massage or no treatment showed moderate reductions in pain and disability in the short term (<6 months), but not in the long-term. In studies comparing massage to active therapies, massage resulted in greater pain reduction both in the short term, and in the long term, but no difference in disability reduction was observed. 87 TENS Existing clinical studies indicate that TENS has no beneficial effect on pain or function versus sham or placebo. 74,87,88
NSAIDs A review of six RCTs for the American College of Physicians showed that oral NSAIDs are more effective than placebo regarding pain intensity, with a small reduction in pain at 12 weeks. 93 No differences in efficacy between different NSAIDs, including non-selective NSAIDs vs. selective COX2 inhibitors, were identified. No trials were identified evaluating the efficacy of topical NSAIDs on chronic LBP.
Antidepressants
Duloxetine An analysis of three moderate-quality RCTs found small improvements in pain and function with duloxetine vs. placebo at 12 to 13 weeks. 94 One of the studies involved 401 patients randomized to duloxetine 60 mg daily or placebo. Compared with placebo, duloxetine-treated patients reported a significantly greater reduction (P≤0.001) in pain on the Brief Pain Inventory (BPI). 95 A 2017 systematic review found that SSRIs and TCAs were not significantly better than placebo for reducing pain or improving function in patients with chronic LBP. 94 Other therapies Other drug options such as gabapentin, pregabalin, topical lidocaine, and muscle relaxants have little or no data for use in managing chronic low back pain. For the anticonvulsants pregabalin and gabapentin, a small number of low-quality RCTs failed to show a reduction in pain or improvement in function compared to placebo. 96 No data exist to support the use of topical lidocaine for low back pain without a neuropathic component. While widely prescribed, use of skeletal muscle relaxants for chronic LBP is not supported by evidence. 96
Cognitive and behavioral/mindfulness therapies
A meta-analysis of five RCTs evaluating CBT found no difference in function but a moderate reduction in pain intensity compared to waitlist controls. 35 A more recent trial randomized 342 patients with chronic LBP to CBT, mindfulness-based stress reduction, or usual care. Both the CBT and mindfulness intervention consisted of eight weekly two-hour classes. Both mindfulness and CBT were associated with greater improvements in pain and function compared to usual care at 26 weeks (with benefit persisting at 52 week follow-up vs. usual care) with no statistically significant differences between CBT and mindfulness groups. 87
Drug options Acetaminophen
Two small trials have evaluated acetaminophen in patients with chronic LBP. A trial conducted in the early 1980s randomized 30 patients to 1000 mg acetaminophen four times daily vs. the NSAID diflunisal 500 mg twice daily for 4 weeks. 89 Another trial randomized 45 patients with either acute or chronic LBP to 500 mg acetaminophen vs. amitriptyline 37.5 mg four times daily. 90 No significant differences were found between acetaminophen and diflunisal in pain relief or reduced disability, and acetaminophen was less effective than amitriptyline for reducing pain. 91 No trials have compared acetaminophen vs. placebo for chronic pain, however a 2016 Cochrane review of three trials with 1,825 patients with acute LBP found high-quality evidence that acetaminophen was no more effective than placebo for pain, disability, function, and quality of life. 92
Additional interventions Epidural steroid injections
Lumbar epidural steroid injections under fluoroscopic guidance are commonly used to treat low back pain. 97 . The strength of the evidence varies according to the type and cause of the pain and the type of injection. 98 For example, the evidence for the efficacy of treatment of disc herniation with interlaminar lumbar epidural and transformaminal lumbar epidural injections is strong.. In contrast, for spinal stenosis, the evidence is moderate-to- fair for interlaminar lumbar epidural injections and fair-to-limited for intraforaminal lumbar epidural injections. 98 Spinal fusion An RCT of 349 patients with chronic low back pain comparing spinal fusion surgery against intensive rehabilitation showed small functional benefits in favor of surgery.
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