Non-Pharmacological Interventions for Chronic Low Back Pain: What Works Best? A Network Meta-Analysis

Abstract

Background: Several non-pharmacological strategies are widely-used in patients with chronic low back pain. However, which of these strategies is more effective remain undetermined. We conducted this network meta-analysis to assess and compare the effectiveness of various non-pharmacological strategies for managing chronic low back pain. Methods: We searched Medline, Scopus, Web of Science, Embase and Cochrane-Central through February 2018. We included randomized trials that enrolled >100 patients and compared different non-pharmacological interventions to each other or standard care. A network meta-analysis with frequentist approach was performed using R software. We used the P-score to rank the efficacy of treatments and the net-split function to assess the consistency between direct and indirect evidence. The main outcomes included visual analogue scale (VAS) and Rolland-Morris Disability Questionnaire (RMDQ). The outcomes were analyzes as mean difference (MD) with 95% confidence interval (CI). Findings: Seventy-seven trials randomizing 14850 patients into nine treatment groups were included. For VAS, massage (MD=-4.51, 95%CI [-7.76, -1.26]) and spinal manipulation (MD=-2.11, 95%CI [-3.63, -0.60]) were associated with significant reductions than standard care. In terms of RMDQ, massage (MD=-2.12, 95%CI [-3.73, -0.50]) and yoga (MD=-1.84, 95%CI [-3.45, -0.22]) were associated with significant reductions than standard care. Moreover, massage was associated with a significant reduction in healthcare utilization at 12 months (MD=-0.90, 95%CI [-1.78, -0.02]) than acupuncture. The P-score ranking indicated that massage ranked the highest in terms of reducing VAS (P-score=0.94), RMDQ (P-score=0.92) and Oswestry disability scale (P-score=0.76). Spinal manipulation (P-score=0.79) ranked the highest in reducing health care utilization at 12 months, while exercise (P-score= 0.76) ranked the highest in reducing sick leaves' duration. Interpretation: Our network meta-analysis showed significantly higher efficacy for most assessed non-pharmacological strategies than standard care, with message achieving the highest rank in reducing back pain and associated disability. Funding Statement: This work was supported by the National Natural Science Foundation of China (grant nos.31300137). Declaration of Interests: The authors state: None to declare. Ethics Approval Statement: All steps of this network meta-analysis were performed following the guidelines of the PRISMA checklist.