Article Text

Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis
  1. Silvia Gianola1,
  2. Silvia Bargeri1,
  3. Gabriele Del Castillo2,
  4. Davide Corbetta3,4,
  5. Andrea Turolla5,
  6. Anita Andreano6,
  7. Lorenzo Moja2,
  8. Greta Castellini1
  1. 1 Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milano, Lombardia, Italy
  2. 2 Department of Biomedical Sciences for Health, University of Milan, Milano, Lombardia, Italy
  3. 3 Physiotherapy Degree Course, Universita Vita-Salute San Raffaele, Milano, Lombardia, Italy
  4. 4 Rehabilitation and Functional Recovery Department, IRCCS Ospedale San Raffaele, Milano, Lombardia, Italy
  5. 5 Laboratory of Rehabilitation Technologies, IRCCS San Camillo Hospital, Venezia, Veneto, Italy
  6. 6 Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, School of Medicine and Surgery, University of Milan–Bicocca, Milano, Lombardia, Italy
  1. Correspondence to Dr Silvia Bargeri, IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy Milano, Lombardia, IT, IRCCS Istituto Ortopedico Galeazzi, Milano 20161, Italy; bargeri.silvia{at}


Objective To assess the effectiveness of interventions for acute and subacute non-specific low back pain (NS-LBP) based on pain and disability outcomes.

Design A systematic review of the literature with network meta-analysis.

Data sources Medline, Embase and CENTRAL databases were searched from inception until 17 October 2020.

Eligibility criteria for selecting studies Randomised clinical trials (RCTs) involving adults with NS-LBP who experienced pain for less than 6 weeks (acute) or between 6 and 12 weeks (subacute).

Results Forty-six RCTs (n=8765) were included; risk of bias was low in 9 trials (19.6%), unclear in 20 (43.5%), and high in 17 (36.9%). At immediate-term follow-up, for pain decrease, the most efficacious treatments against an inert therapy were: exercise (standardised mean difference (SMD) −1.40; 95% confidence interval (CI) −2.41 to –0.40), heat wrap (SMD −1.38; 95% CI −2.60 to –0.17), opioids (SMD −0.86; 95% CI −1.62 to –0.10), manual therapy (SMD −0.72; 95% CI −1.40 to –0.04) and non-steroidal anti-inflammatory drugs (NSAIDs) (SMD −0.53; 95% CI −0.97 to –0.09). Similar findings were confirmed for disability reduction in non-pharmacological and pharmacological networks, including muscle relaxants (SMD -0.24; 95% CI -0.43 to -0.04). Mild or moderate adverse events were reported in the opioids (65.7%), NSAIDs (54.3%) and steroids (46.9%) trial arms.

Conclusion With uncertainty of evidence, NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate-term. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best harm–benefit balance.

  • lower back
  • rehabilitation
  • pharmacology
  • disability
  • evidence based review

Data availability statement

Data are available in a public, open access repository:

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Data are available in a public, open access repository:

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  • LM and GC are joint last authors.

  • Correction notice This article has been corrected since it published Online First. Affiliation 5 has been updated.

  • Contributors SG and GC designed the study, developed the search strategies and wrote the first draft of the manuscript. SG, SB, GC and GDC extracted the data. SG, SB and GC performed the analyses. All authors provided feedback on early and advanced drafts of the manuscript and approved the final version.

  • Funding The work was supported by the Italian Ministry of Health (L3026).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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