Effectiveness of mobile apps in the rehabilitation of patients with low back pain. A systematic review with meta-analysis of randomized controlled trials.

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This is an update of a Cochrane Review published in 2014. Chronic non-specific low back pain (LBP) has become one of the main causes of disability in the adult population around the world. Although therapeutic ultrasound is not recommended in recent clinical guidelines, it is frequently used by physiotherapists in the treatment of chronic LBP.The objective of this review was to determine the effectiveness of therapeutic ultrasound in the management of chronic non-specific LBP. A secondary objective was to determine the most effective dosage and intensity of therapeutic ultrasound for chronic LBP.We performed electronic searches in CENTRAL, MEDLINE, Embase, CINAHL, PEDro, Index to Chiropractic Literature, and two trials registers to 7 January 2020. We checked the reference lists of eligible studies and relevant systematic reviews and performed forward citation searching.We included randomised controlled trials (RCTs) on therapeutic ultrasound for chronic non-specific LBP. We compared ultrasound (either alone or in combination with another treatment) with placebo or other interventions for chronic LBP.Two review authors independently assessed the risk of bias of each trial and extracted the data. We performed a meta-analysis when sufficient clinical and statistical homogeneity existed. We determined the certainty of the evidence for each comparison using the GRADE approach.We included 10 RCTs involving a total of 1025 participants with chronic LBP. The included studies were carried out in secondary care settings in Turkey, Iran, Saudi Arabia, Croatia, the UK, and the USA, and most applied therapeutic ultrasound in addition to another treatment, for six to 18 treatment sessions. The risk of bias was unclear in most studies. Eight studies (80%) had unclear or high risk of selection bias; no studies blinded care providers to the intervention; and only five studies (50%) blinded participants. There was a risk of selective reporting in eight studies (80%), and no studies adequately assessed compliance with the intervention. There was very low-certainty evidence (downgraded for imprecision, inconsistency, and limitations in design) of little to no difference between therapeutic ultrasound and placebo for short-term pain improvement (mean difference (MD) -7.12, 95% confidence interval (CI) -17.99 to 3.75; n = 121, 3 RCTs; 0-to-100-point visual analogue scale (VAS)). There was also moderate-certainty evidence (downgraded for imprecision) of little to no difference in the number of participants achieving a 30% reduction in pain in the short term (risk ratio 1.08, 95% CI 0.81 to 1.44; n = 225, 1 RCT). There was low-certainty evidence (downgraded for imprecision and limitations in design) that therapeutic ultrasound has a small effect on back-specific function compared with placebo in the short term (standardised mean difference -0.29, 95% CI -0.51 to -0.07 (MD -1.07, 95% CI -1.89 to -0.26; Roland Morris Disability Questionnaire); n = 325; 4 RCTs), but this effect does not appear to be clinically important. There was moderate-certainty evidence (downgraded for imprecision) of little to no difference between therapeutic ultrasound and placebo on well-being (MD -2.71, 95% CI -9.85 to 4.44; n = 267, 2 RCTs; general health subscale of the 36-item Short Form Health Survey (SF-36)). Two studies (n = 486) reported on overall improvement and satisfaction between groups, and both reported little to no difference between groups (low-certainty evidence, downgraded for serious imprecision). One study (n = 225) reported on adverse events and did not identify any adverse events related to the intervention (low-certainty evidence, downgraded for serious imprecision). No study reported on disability for this comparison. We do not know whether therapeutic ultrasound in addition to exercise results in better outcomes than exercise alone because the certainty of the evidence for all outcomes was very low (downgraded for imprecision and serious limitations in design). The estimate effect for pain was in favour of the ultrasound plus exercise group (MD -21.1, 95% CI -27.6 to -14.5; n = 70, 2 RCTs; 0-to-100-point VAS) at short term. Regarding back-specific function (MD - 0.41, 95% CI -3.14 to 2.32; n = 79, 2 RCTs; Oswestry Disability Questionnaire) and well-being (MD -2.50, 95% CI -9.53 to 4.53; n = 79, 2 RCTs; general health subscale of the SF-36), there was little to no difference between groups at short term. No studies reported on the number of participants achieving a 30% reduction in pain, patient satisfaction, disability, or adverse events for this comparison.The evidence from this systematic review is uncertain regarding the effect of therapeutic ultrasound on pain in individuals with chronic non-specific LBP. Whilst there is some evidence that therapeutic ultrasound may have a small effect on improving low back function in the short term compared to placebo, the certainty of evidence is very low. The true effect is likely to be substantially different. There are few high-quality randomised trials, and the available trials were very small. The current evidence does not support the use of therapeutic ultrasound in the management of chronic LBP.

Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement conventional management of musculoskeletal disorders, including those that cause low back pain (LBP). Osteopathic manipulative treatment is defined in the Glossary of Osteopathic Terminology as "The therapeutic application of manually guided forces by an osteopathic physician (U.S. Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. OMT employs a variety of techniques" (eAppendix). Somatic dysfunction is defined as "Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment." These guidelines update the AOA guidelines for osteopathic physicians to utilize OMT for patients with nonspecific acute or chronic LBP published in 2010 on the National Guideline Clearinghouse.1 METHODS: This update process commenced with literature searches that included electronic databases, personal contact with key researchers of OMT and low back pain, and Internet search engines. Early in the process, the Task Force on the Low Back Pain Clinical Practice Guidelines discovered the 2014 systematic literature review conducted by Franke et al2; this study serves as the basis for this updated guideline and further builds upon the literature used to support the previous guidelines. Findings from other eligible studies published after the search parameters of the Franke et al systematic review were also incorporated. The authors of the systematic review identified 307 studies. Thirty-one were evaluated and 16 were excluded. Of the 15 studies included in the review, 6 were retrieved from Germany, 5 from the United States, 2 from the United Kingdom, and 2 from Italy. Two additional studies published after the Franke et al review were also included. Osteopathic manipulative treatment significantly reduces pain and improves functional status in patients, including pregnant and postpartum women, with nonspecific acute and chronic LBP. Franke et al found that in acute and chronic nonspecific LBP, moderate-quality evidence suggested that OMT had a significant effect on pain relief (mean difference [MD], -12.91; 95% CI, -20.00 to -5.82) and functional status (standard mean difference [SMD], -0.36; 95% CI, -0.58 to -0.14). More specifically, in chronic nonspecific LBP, the evidence suggested a significant difference in favor of OMT regarding pain (MD, -14.93; 95% CI, -25.18 to -4.68) and functional status (SMD, -0.32; 95% CI, -0.58 to -0.07). When examining nonspecific LBP in pregnancy, low-quality evidence suggested a significant difference in favor of OMT for pain (MD, -23.01; 95% CI, -44.13 to -1.88) and functional status (SMD, -0.80; 95% CI, -1.36 to -0.23). Conversely for nonspecific LBP postpartum, Franke et al found that moderate-quality evidence suggested a significant difference in favor of OMT for pain (MD, -41.85; 95% CI, -49.43 to -34.27) and functional status (SMD, -1.78; 95% CI, -2.21 to -1.35).2 CONCLUSION: The conclusions of Franke et al further strengthen the findings that OMT reduces LBP. In a 2005 systematic review conducted by Licciardone et al3 and the basis of the LBP guidelines published in 2010, it was determined that OMT reduces pain more than expected from placebo effects alone, and these results had the potential to last beyond the first year of treatment. Franke et al specifically stated that clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women 3 months after treatment. Larger randomized controlled trials with robust comparison groups are needed to further validate the effects of OMT on LBP. In addition, more research is needed to understand the mechanics of OMT and its short- and long-term effects, as well as the cost-effectiveness of such treatment.

BackgroundLow back pain is the most frequent cause of rheumatic diseases in Africa (1). However the studies are scarce, especially in sub-Saharan Africa.ObjectivesTo determine the main characteristics of non-specific chronic...

Background:Nonspecific chronic low back (nCLBP) pain is prevalent among adult population and often leads to functional limitations, psychological symptoms, lower quality of life (QOL), and higher healthcare costs. The purpose of this study was to determine the efficacy of Iyengar yoga therapy on pain intensity and health related quality of life (HRQOL) with nCLBP.Aim of the Study:To compare the effect of Iyengar yoga therapy and conventional exercise therapy on pain intensity and HRQOL in nonspecific chronic low back pain.Materials and Methods:Experimental study with random sampling technique.Subjects/Intervention:Sixty subjects who fulfilled the selection criteria were randomly assigned to Iyengar yoga (yoga group, n = 30) and control group (exercise group, n = 30). Participants completed low back pain evaluation form and HRQOL-4 questionnaire before their intervention and again 4 weeks and 6 month later. Yoga group underwent 29 yogic postures training and exercise group had undergone general exercise program for 4 weeks.Statistics:Repeated measures analysis of variance (ANOVA) was used to analyze group differences over time, while controlling for baseline differences.Results:Patients in both groups experienced significant reduction in pain and improvement in HRQOL. In visual analogue scale (VAS) yoga group showed reduction of 72.81% (P = 0.001) as compared to exercise group 42.50% (P = 0.001). In HRQOL, yoga group showed reduction of 86.99% (P = 0.001) as compared to exercise group 67.66% (P = 0.001).Conclusion:These results suggest that Iyengar yoga provides better improvement in pain reduction and improvement in HRQOL in nonspecific chronic back pain than general exercise.

Long-term effectiveness of non-surgical interventions for chronic low back pain: a systematic review and meta-analysis.

BackgroundLow-back pain is one of the most common health conditions worldwide. It is defined as pain below the costal margin and above the inferior gluteal folds. Current guidelines recommend management of chronic health (e.g., low back pain) conditions in older people at primary health care settings using active strategies (e.g., exercise). In non-specific low back pain, high quality evidence supports active strategies for general population. However, the management of non-specific low back pain in the older people has been overlooked and evidence is limited to a small number of low powered randomized controlled trials with high risk of bias.MethodsThis is a prospectively registered, open, two-arm randomised controlled trial comparing the group-based exercise and waiting list in pain intensity (11-item Pain Numerical Rating Scale) and disability (Roland Morris questionnaire) of older people (i.e., 60 years old or over) with chronic non-specific low back pain. One hundred and twenty patients will be recruited from Diamantina, Brazil. Follow-ups will be conducted in post-treatment (8 week) and 6- and 12-months post-randomisation.DiscussionOur hypothesis is that group-based exercise will be better than waiting list in reducing pain intensity and disability in older people with chronic non-specific low back pain.ImpactThe practice of individualized exercise has been studied for the management of chronic non-specific low back pain in older people. However, the group exercise, even showing high quality evidence for the improvement of several important outcomes in this population, has been ignored until now. Thus, the results of this study have the potential to indicate a viable and accessible strategy for managing chronic non-specific low back pain in the older people.Trial registrationThe study was prospectively registered at www.ensaiosclinicos.gov.br (RBR-9j5pqs). Date-11/18/2020.

Exercise therapy is widely used as an intervention in low back pain. To evaluate the effectiveness of exercise therapy in adult nonspecific acute, subacute, and chronic low back pain versus no treatment and other conservative treatments. MEDLINE, EMBASE, PsychInfo, CINAHL, and Cochrane Library databases to October 2004; citation searches and bibliographic reviews of previous systematic reviews. Randomized, controlled trials evaluating exercise therapy for adult nonspecific low back pain and measuring pain, function, return to work or absenteeism, and global improvement outcomes. Two reviewers independently selected studies and extracted data on study characteristics, quality, and outcomes at short-, intermediate-, and long-term follow-up. 61 randomized, controlled trials (6390 participants) met inclusion criteria: acute (11 trials), subacute (6 trials), and chronic (43 trials) low back pain (1 trial was unclear). Evidence suggests that exercise therapy is effective in chronic back pain relative to comparisons at all follow-up periods. Pooled mean improvement (of 100 points) was 7.3 points (95% CI, 3.7 to 10.9 points) for pain and 2.5 points (CI, 1.0 to 3.9 points) for function at earliest follow-up. In studies investigating patients (people seeking care for back pain), mean improvement was 13.3 points (CI, 5.5 to 21.1 points) for pain and 6.9 points (CI, 2.2 to 11.7 points) for function, compared with studies where some participants had been recruited from a general population (for example, with advertisements). Some evidence suggests effectiveness of a graded-activity exercise program in subacute low back pain in occupational settings, although the evidence for other types of exercise therapy in other populations is inconsistent. In acute low back pain, exercise therapy and other programs were equally effective (pain, 0.03 point [CI, -1.3 to 1.4 points]). Limitations of the literature, including low-quality studies with heterogeneous outcome measures inconsistent and poor reporting, and possibility of publication bias. Exercise therapy seems to be slightly effective at decreasing pain and improving function in adults with chronic low back pain, particularly in health care populations. In subacute low back pain populations, some evidence suggests that a graded-activity program improves absenteeism outcomes, although evidence for other types of exercise is unclear. In acute low back pain populations, exercise therapy is as effective as either no treatment or other conservative treatments.

BackgroundThe inflammatory profiles of patients with acute and chronic nonspecific low back pain (LBP) patients are distinct. Spinal manipulative therapy (SMT) has been shown to modulate the production of nociceptive chemokines differently in these patient cohorts. The present study further investigates the effect(s) of SMT on other inflammatory mediators in the same LBP patient cohorts.MethodsAcute (n = 22) and chronic (n = 25) LBP patients with minimum pain scores of 3 on a 10-point numeric scale, and asymptomatic controls (n = 24) were recruited according to stringent exclusion criteria. Blood samples were obtained at baseline and after 2 weeks during which patients received 6 SMTs in the lumbar or lumbosacral region. The in vitro production of tumor necrosis factor (TNFα), interleukin-1 β (IL-1β), IL-6, IL-2, interferon ɣ (IFNɣ), IL-1 receptor antagonist (IL-1RA), TNF soluble receptor type 2 (sTNFR2) and IL-10 was determined by specific immunoassays. Parametric as well as non-parametric statistics (PAST 3.18 beta software) was used to determine significance of differences between and within study groups prior and post-SMT. Effect size (ES) estimates were obtained using Cohen’s d.ResultsCompared with asymptomatic controls, SMT-related change scores were significant (P = 0.03–0.01) in reducing the production levels of TNFα in both patient cohorts and those of IL-6, IFNɣ and sTNFR2 (P = 0.001–0.02) in patients with chronic LBP. Above-moderate to large ES (d > 0.6–1.4) was observed for these mediators. Compared with respective baselines, a significant post-SMT reduction (P = 0.01) of IL-6 production was detected only in patients with chronic LBP while a significant increase of IL-2 production (P = 0.001 vs. control, and P = 0.004 vs. chronic LBP group) and a large ES (d = 0.87) were observed in patients with acute LBP. Pain and disability scores declined significantly (P < 0.001) in all LBP patients, and were positively correlated (P = 0.03) with IFNɣ and IL-2 levels in the acute LBP cohort.ConclusionThe short course of SMT treatments of non-specific LBP patients resulted in significant albeit limited and diverse alterations in the production of several of the mediators investigated in this study. This exploratory study highlights the potential of SMT to modulate the production of inflammatory components in acute and chronic non-specific LBP patients and suggests a need for further, randomized controlled clinical trials in this area.Trial registrationThis study was prospectively registered April 2012 with Clinical Trials.gov (#NCT01766141).https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0003ZIL&selectaction=Edit&uid=U0001V74&ts=2&cx=-axvqtg

Osteopathic manipulative treatment (OMT) is frequently offered to people with nonspecific low back pain (LBP) but never compared with sham OMT for reducing LBP-specific activity limitations. To compare the efficacy of standard OMT vs sham OMT for reducing LBP-specific activity limitations at 3 months in persons with nonspecific subacute or chronic LBP. This prospective, parallel-group, single-blind, single-center, sham-controlled randomized clinical trial recruited participants with nonspecific subacute or chronic LBP from a tertiary care center in France starting February 17, 2014, with follow-up completed on October 23, 2017. Participants were randomly allocated to interventions in a 1:1 ratio. Data were analyzed from March 22, 2018, to December 5, 2018. Six sessions (1 every 2 weeks) of standard OMT or sham OMT delivered by nonphysician, nonphysiotherapist osteopathic practitioners. The primary end point was mean reduction in LBP-specific activity limitations at 3 months as measured by the self-administered Quebec Back Pain Disability Index (score range, 0-100). Secondary outcomes were mean reduction in LBP-specific activity limitations; mean changes in pain and health-related quality of life; number and duration of sick leaves, as well as number of LBP episodes at 12 months; and consumption of analgesics and nonsteroidal anti-inflammatory drugs at 3 and 12 months. Adverse events were self-reported at 3, 6, and 12 months. Overall, 200 participants were randomly allocated to standard OMT and 200 to sham OMT, with 197 analyzed in each group; the median (range) age at inclusion was 49.8 (40.7-55.8) years, 235 of 394 (59.6%) participants were women, and 359 of 393 (91.3%) were currently working. The mean (SD) duration of the current LBP episode was 7.5 (14.2) months. Overall, 164 (83.2%) patients in the standard OMT group and 159 (80.7%) patients in the sham OMT group had the primary outcome data available at 3 months. The mean (SD) Quebec Back Pain Disability Index scores for the standard OMT group were 31.5 (14.1) at baseline and 25.3 (15.3) at 3 months, and in the sham OMT group were 27.2 (14.8) at baseline and 26.1 (15.1) at 3 months. The mean reduction in LBP-specific activity limitations at 3 months was -4.7 (95% CI, -6.6 to -2.8) and -1.3 (95% CI, -3.3 to 0.6) for the standard OMT and sham OMT groups, respectively (mean difference, -3.4; 95% CI, -6.0 to -0.7; P = .01). At 12 months, the mean difference in mean reduction in LBP-specific activity limitations was -4.3 (95% CI, -7.6 to -1.0; P = .01), and at 3 and 12 months, the mean difference in mean reduction in pain was -1.0 (95% CI, -5.5 to 3.5; P = .66) and -2.0 (95% CI, -7.2 to 3.3; P = .47), respectively. There were no statistically significant differences in other secondary outcomes. Four and 8 serious adverse events were self-reported in the standard OMT and sham OMT groups, respectively, though none was considered related to OMT. In this randomized clinical trial of patients with nonspecific subacute or chronic LBP, standard OMT had a small effect on LBP-specific activity limitations vs sham OMT. However, the clinical relevance of this effect is questionable. ClinicalTrials.gov Identifier: NCT02034864.

Low back pain is pain in the posterior aspect of the body between the lower margin of the twelfth rib and the lower gluteal folds, and can radiate to the lower limbs. Classified by the American Physical Therapy Association's Clinical Practice Guideline as acute (up to six weeks) or chronic (more than six weeks). Studies show that 41.2% of university students suffer from low back pain exacerbated by biopsychosocial factors, such as catastrophizing, affecting their daily life. Therefore, the aim of this studywas to identify whether there is a relationship between catastrophizing and the intensity of chronic nonspecific low back pain in university students. This is an analytical cross-sectional study, approved by the Human Research Ethics Committee of the State University of Northern Paraná (Opinion: 6,082,631; CAAE 68394522.3.0000.8123). The sample consisted of 40 students from the State University of Northern Paraná (UENP), Jacarezinho campus -PR. All data collection took place in person at the university's physiotherapy clinic. Initially, the intensity of low back pain was measured using the Numerical Pain Scale (NDS) and later the Pain Catastrophizing Scale(PCS) was applied, which would evaluate catastrophizing of university students with the presence of nonspecific chronic low back pain (CLBP). The study included 40 university students with a mean age of 21 years, 70% of whom were women. Previous studies have shown that psychological aspects influence pain intensity and disability more than anatomical factors, corroborating the data found in our study, since there was a significant (moderate) correlation (p≤0.05) between pain intensity andthe B-PCS questionnaire score, suggesting that the higher the pain intensity, the higher the level of catastrophizing of university students. Thus, it is concluded that catastrophizing is related to pain intensity in university students with chronic nonspecific low back pain. These findings highlight the importance of addressing psychosocial factors in the treatment of patients with low back pain

Study Design.Prospective study.Objective.To compare the burden between chronic nonspecific low back pain (LBP) and axial spondyloarthropathy (SpA).Summary of Background Data.Chronic nonspecific LBP and SpA are two debilitating yet different chronic musculoskeletal disorders. To compare their burden, propensity score matching is used to control for potential confounders and match the study subjects.Materials and Methods.Two prospectively collected cohorts of LBP (n=269) and SpA (n=218) patients were studied. Outcomes included current LBP, 36-item Short Form Questionnaire, Oswestry Disability Index, EuroQol 5-dimension 5-level Questionnaire, and EuroQol Visual Analog Scale. With the inherent differences between the two types of patients, propensity score matching was performed for comparing the two groups. Baseline covariates of age, sex, education level, occupation, smoking, and drinking history were selected for the estimation of propensity scores for each subject with the logistic regression model. Significant independent variables for the outcome of current back pain were included in the multivariate logistic regressions.Results.A total of 127 matched pairs were identified, with 254 patients. In the matched cohort, more patients with chronic LBP had current back pain (95.3%) as compared with SpA (71.7%). Patients with SpA were younger (P<0.001), with more males (P<0.001), and better educated (P=0.001). There was less current back pain and higher nonsteroidal anti-inflammatory drug use (P<0.001). Most SpA patients had lower Oswestry Disability Index than LBP patients and with low disease activity. Patients with LBP had worse outcome scores as compared with SpA patients given the same Visual Analog Scale. LBP patients had 8.6 times the odds (95% CI: 3.341–20.671; P<0.001) of experiencing current back pain compared with SpA patients.Conclusions.The disease activity of SpA patients is well controlled. However, patients with chronic LBP have worse pain severity, disability, and health-related quality of life. This has implications on resource utilization and the necessity of advancing LBP understanding and management.Level of Evidence.Type I prognostic study.

Background and Objectives Non-specific chronic low back pain is common and complex and has a large impact on individuals and society. Inculcating physical exercise to promote healthy lifestyle has played an important role in the prevention and management of chronic health conditions. The purpose of this study is to review the published literature on lifestyle factors mainly physical exercise to combat nonspecific chronic low back pain. Material and Methods PubMed database was reviewed from 2000 and November 2018 and searched for ‘exercise and non-specific chronic low back pain’, ‘lifestyle and non-specific chronic low back pain’ and individual exercise interventions and non-specific chronic low back pain. Articles which fulfilled the criteria were included in the final review. Results The available evidences from existing systematic reviews and articles suggested that physical exercise does improve pain severity and physical function in chronic nonspecific low back pain. Regarding the type of exercises, strengthening or resistance exercises seem to be effective but no specific type of exercise is superior to others. Conclusion Incorporating physical exercise such as strengthening exercises as part of the lifestyle change could combat non-specific chronic low back pain.

Traction has been used to treat low-back pain (LBP), often in combination with other treatments. We included both manual and machine-delivered traction in this review. This is an update of a Cochrane review first published in 1995, and previously updated in 2006. To assess the effects of traction compared to placebo, sham traction, reference treatments and no treatment in people with LBP. We searched the Cochrane Back Review Group Specialized Register, the Cochrane Central Register of Controlled Trials (2012, Issue 8), MEDLINE (January 2006 to August 2012), EMBASE (January 2006 to August 2012), CINAHL (January 2006 to August 2012), and reference lists of articles and personal files. The review authors are not aware of any important new randomized controlled trial (RCTs) on this topic since the date of the last search. RCTs involving traction to treat acute (less than four weeks' duration), subacute (four to 12 weeks' duration) or chronic (more than 12 weeks' duration) non-specific LBP with or without sciatica. Two review authors independently performed study selection, risk of bias assessment and data extraction. As there were insufficient data for statistical pooling, we performed a descriptive analysis. We did not find any case series that identified adverse effects, therefore we evaluated adverse effects that were reported in the included studies. We included 32 RCTs involving 2762 participants in this review. We considered 16 trials, representing 57% of all participants, to have a low risk of bias based on the Cochrane Back Review Group's 'Risk of bias' tool.For people with mixed symptom patterns (acute, subacute and chronic LBP with and without sciatica), there was low- to moderate-quality evidence that traction may make little or no difference in pain intensity, functional status, global improvement or return to work when compared to placebo, sham traction or no treatment. Similarly, when comparing the combination of physiotherapy plus traction with physiotherapy alone or when comparing traction with other treatments, there was very-low- to moderate-quality evidence that traction may make little or no difference in pain intensity, functional status or global improvement.For people with LBP with sciatica and acute, subacute or chronic pain, there was low- to moderate-quality evidence that traction probably has no impact on pain intensity, functional status or global improvement. This was true when traction was compared with controls and other treatments, as well as when the combination of traction plus physiotherapy was compared with physiotherapy alone. No studies reported the effect of traction on return to work.For chronic LBP without sciatica, there was moderate-quality evidence that traction probably makes little or no difference in pain intensity when compared with sham treatment. No studies reported on the effect of traction on functional status, global improvement or return to work.Adverse effects were reported in seven of the 32 studies. These included increased pain, aggravation of neurological signs and subsequent surgery. Four studies reported that there were no adverse effects. The remaining studies did not mention adverse effects. These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP. There is only limited-quality evidence from studies with small sample sizes and moderate to high risk of bias. The effects shown by these studies are small and are not clinically relevant. Implications for practice To date, the use of traction as treatment for non-specific LBP cannot be motivated by the best available evidence. These conclusions are applicable to both manual and mechanical traction. Implications for research Only new, large, high-quality studies may change the point estimate and its accuracy, but it should be noted that such change may not necessarily favour traction. Therefore, little priority should be given to new studies on the effect of traction treatment alone or as part of a package.

Little is known about the effectiveness of placebo interventions in patients with nonspecific low back pain (LBP). This systematic review assessed the magnitude of the effects of placebo interventions as compared to no intervention in randomized controlled trials (RCTs) including patients with LBP. Embase, MEDLINE (Ovid), and Cochrane CENTRAL databases were searched from inception to December 5, 2019. Randomized controlled trials comparing placebo intervention vs no intervention in adult patients with nonspecific LBP were included. Pain intensity, physical functioning, and health-related quality of life measured at short-term, medium-term, and long-term follow-up were the outcomes of this review. Twenty-one randomized controlled trials were included; one concerning acute LBP and one subacute LBP, whereas 19 studies reported on chronic LBP. In chronic LBP, placebo interventions were more effective than no intervention at short-term follow-up for pain intensity (standardized mean difference = -0.37, 95% confidence interval [CI] = -0.55 to -0.18, moderate-quality evidence), physical functioning (standardized mean difference -0.19, 95% CI = -0.39-0.01, moderate-quality evidence), and physical quality of life (mean difference = -2.71, 95% CI = -4.71-0.71, high-quality evidence), respectively. These effects were not significant at medium-term follow-up, and no data were available at long-term follow-up. These results show placebo interventions are more effective than no intervention at short-term follow-up in patients with chronic LBP. However, the magnitude of the effects is probably not clinically relevant (approximately 8 points on a 0-100 pain scale). Future research should identify effect modifiers and causal mechanisms explaining the short-term effects of placebo interventions in patients with chronic LBP.