Low Back Pain Nonmedical Monotherapies

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Physical Therapies

Massage: There is very low to low quality evidence of benefit but it is not clinically meaningful (-0.6 to -0.94 reduction in 0 to10 point pain scale). There is slightly better short-term pain relief and function than sham therapy, waiting list or no treatment. There is also slightly better short-term pain relief than manipulation, mobilisation, acupuncture, traction, relaxation, physiotherapy, exercises, TENS or self-care education. Increased pain intensity occurs in in 1.5-25%. [1][2]

Traction: There is little or no impact on pain intensity compared with sham treatment with moderate quality evidence.[3][4]

Manual Therapy: This modality appears to be effective in the short-term compared to other active therapies, but with small differences. There is also no evidence of long-term benefit.[2] A review that only looked at manipulation and mobilisation found that it was as effective as other common therapies such as exercise, physiotherapy, and standard medical care.[5]

Mechanical Diagnosis and Treatment (McKenzie): Previous reviews have found little evidence of benefit.[6][7] A more recent review which included newer studies and only included those studies where the therapies had standardised training found that the McKenzie method had a superior treatment effect for pain and disability to other interventions and exercise alone, but the effect may not be clinically meaningful. It also had similar outcomes compared to a combination of manual therapy and exercise.[8]

TENS: The evidence does not support its use.[9]

Lumbar Supports: In acute low back pain, lumbar supports plus an educational program is no more effective than an educational program alone, or other active interventions.[10] There are no data on chronic low back pain.

Exercise Therapy: There are mixed statements: low- to high-quality evidence: slightly effective at improving short-, intermediate- and long-term pain and function. Individually designed strengthening or stabilising programs appear to be effective in healthcare settings[11][2][12]

There is low quality evidence that for non-specific chronic low back pain the most effective exercise treatments are Pilates, stabilisation/motor control, resistance training, and aerobic exercise training. Stretching and McKenzie exercises did not differ from control[12]

For Pilates, there is low- to moderate-quality evidence that it is more effective than minimal intervention for pain and disability short- and intermediate-term; possibly slightly superior to other exercises at improving pain and disability at intermediate-term follow-up (3-12 months)[13][12]

For Yoga there in low- to moderate-quality evidence that it may provide small to moderate improvements in function at 3 and 6 months compared to non-exercise controls, and may also be slightly more effective for pain at 3 and 6 months[14]

Physical Activity: Low-quality evidence that may improve pain severity and physical function, and quality of life in short-, medium- and long-term. Walking as good as other forms of physical activity. Low-quality evidence that exercise is better than hands-on therapy for reducing pain and improving function[15][12][16]

Back School: This involves education and exercise, a therapeutic programme, often done in groups. It started in 1969 with the Swedish Back School. There is only very-low quality evidence available. It has uncertain effectiveness, with no difference or trivial effect in favour of Back School.[17]

Psychological Interventions

A review looking at CBT for all chronic pain except headache found that it had a very small benefit at treatment end for pain, disability, and distress. The effects were largely maintained at follow up for CBT versus treatment as usual, but not for CBT versus active control. The quality of the evidence was moderate to low for CBT. The quality of evidence for behavioural therapy and ACT was low, limiting conclusions for these modalities.[18]

Behavioural treatment (operant therapy) has moderate quality evidence in the short term than waiting list for a small reduction in pain, but no differences in the intermediate or long term. There is also no difference between behavioural therapy and group exercises. There is low-quality evidence that progressive relaxation therapy moderate improves pain compared to wait list controls.[19]

For mindfulness there is possibly better improvements in short-term pain and function compared with usual care or education. There are no differences between outcomes for mindfulness versus CBT.[2]

Combining physiotherapy and psychological therapies does not improve outcomes.[2]A recent variation called "cognitive functional therapy" slightly better for disability outcome compared to manual therapy and exercise, but no benefit for pain.[20]

See Also


  1. โ†‘ FurlanAD, GiraldoM, BaskwillA, IrvinE, ImamuraM. Massage for low-back pain. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD001929. DOI: 10.1002/14651858.CD001929.pub3.
  2. โ†‘ 2.0 2.1 2.2 2.3 2.4 Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt ED. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Apr 4;166(7):493-505. doi: 10.7326/M16-2459. Epub 2017 Feb 14. PMID: 28192793.
  3. โ†‘ James McKivigan, Brittany Krisak, Brittni Vogel, Ashley Harrington, Van Nguyen. Evaluating the Efficacy of Vertebral Axial Decompression Therapy in Treatment of Patients with Chronic Lower Back Pain: A Systematic Review. Rehabilitation Science. Vol. 4, No. 2, 2019, pp. 25-34. doi: 10.11648/j.rs.20190402.12
  4. โ†‘ Cochrane: WegnerI, WidyaheningIS, van TulderMW, BlombergSEI, de VetHCW, BrรธnfortG, BouterLM, van der HeijdenGJ.Traction for low-back pain with or without sciatica. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003010. DOI: 10.1002/14651858.CD003010.pub5.
  5. โ†‘ Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J. 2008 Jan-Feb;8(1):213-25. doi: 10.1016/j.spinee.2007.10.023. PMID: 18164469.
  6. โ†‘ Clare HA, Adams R, Maher CG. A systematic review of efficacy of McKenzie therapy for spinal pain. Aust J Physiother. 2004;50(4):209-16. doi: 10.1016/s0004-9514(14)60110-0. PMID: 15574109.
  7. โ†‘ Machado LA, de Souza Mv, Ferreira PH, Ferreira ML. The McKenzie method for low back pain: a systematic review of the literature with a meta-analysis approach. Spine (Phila Pa 1976). 2006 Apr 20;31(9):E254-62. doi: 10.1097/01.brs.0000214884.18502.93. PMID: 16641766.
  8. โ†‘ Lam OT, Strenger DM, Chan-Fee M, Pham PT, Preuss RA, Robbins SM. Effectiveness of the McKenzie Method of Mechanical Diagnosis and Therapy for Treating Low Back Pain: Literature Review With Meta-analysis. J Orthop Sports Phys Ther. 2018 Jun;48(6):476-490. doi: 10.2519/jospt.2018.7562. Epub 2018 Mar 30. PMID: 29602304.
  9. โ†‘ Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev. 2008 Oct 8;2008(4):CD003008. doi: 10.1002/14651858.CD003008.pub3. PMID: 18843638; PMCID: PMC7138213.
  10. โ†‘ Oleske DM, Lavender SA, Andersson GB, Kwasny MM. Are back supports plus education more effective than education alone in promoting recovery from low back pain?: Results from a randomized clinical trial. Spine (Phila Pa 1976). 2007 Sep 1;32(19):2050-7. doi: 10.1097/BRS.0b013e3181453fcc. PMID: 17762804.
  11. โ†‘ HaydenJ, van TulderMW, MalmivaaraA, KoesBW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD000335. DOI: 10.1002/14651858.CD000335.pub2.
  12. โ†‘ 12.0 12.1 12.2 12.3 Owen et al.. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. British journal of sports medicine 2020. 54:1279-1287. PMID: 31666220. DOI. Full Text.
  13. โ†‘ YamatoTP, MaherCG, SaragiottoBT, HancockMJ, OsteloRWJG, CabralCMN, Menezes CostaLC, CostaLOP. Pilates for low back pain. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD010265. DOI: 10.1002/14651858.CD010265.pub2.
  14. โ†‘ WielandLS, SkoetzN, PilkingtonK, VempatiR, D'AdamoCR, BermanBM. Yoga treatment for chronic non-specific low back pain. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD010671. DOI: 10.1002/14651858.CD010671.pub2.
  15. โ†‘ GeneenLJ, MooreRA, ClarkeC, MartinD, ColvinLA, SmithBH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews 2017, Issue 4. Art. No.: CD011279. DOI: 10.1002/14651858.CD011279.pub3.
  16. โ†‘ Vanti C, Andreatta S, Borghi S, Guccione AA, Pillastrini P, Bertozzi L. The effectiveness of walking versus exercise on pain and function in chronic low back pain: a systematic review and meta-analysis of randomized trials. Disabil Rehabil. 2019 Mar;41(6):622-632. doi: 10.1080/09638288.2017.1410730. Epub 2017 Dec 5. PMID: 29207885.
  17. โ†‘ ParreiraP, HeymansMW, van TulderMW, EsmailR, KoesBW, PoquetN, LinCWC, MaherCG. Back Schools for chronic non-specific low back pain. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011674. DOI: 10.1002/14651858.CD011674.pub2.
  18. โ†‘ Williams ACC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020 Aug 12;8(8):CD007407. doi: 10.1002/14651858.CD007407.pub4. PMID: 32794606; PMCID: PMC7437545.
  19. โ†‘ Henschke N, Ostelo RW, van Tulder MW, Vlaeyen JW, Morley S, Assendelft WJ, Main CJ. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010 Jul 7;2010(7):CD002014. doi: 10.1002/14651858.CD002014.pub3. PMID: 20614428; PMCID: PMC7065591.
  20. โ†‘ Vibe Fersum K, Smith A, Kvรฅle A, Skouen JS, O'Sullivan P. Cognitive functional therapy in patients with non-specific chronic low back pain-a randomized controlled trial 3-year follow-up. Eur J Pain. 2019 Sep;23(8):1416-1424. doi: 10.1002/ejp.1399. Epub 2019 May 14. PMID: 30974479.