Evaluation of treatment of patients with chronic low back pain in primary care

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Created On: 15/12/2022

Determination of the percentage of persistent low back pain patients who have a statistically significant response to various non-pharmacological and pharmaceutical therapy was the aim of this systematic review.

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Key take away

Exercise, oral NSAIDs, and serotonin-norepinephrine reuptake inhibitors (Duloxetine) offer remarkable improvements in chronic low back pain.

Background

Method

For finding out relevant literature, data sources such as gray literature search, Cochrane Library, EMBASE, and MEDLINE were explored. Randomized controlled trials (RCTs) that included a responder analysis of individuals with low back pain managed with any of the following fifteen therapies were incorporated: topical rubefacients, oral muscle relaxants, cannabinoids, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, anticonvulsants, oral opioids, corticosteroid injections, acetaminophen, spinal manipulation therapy, acupuncture, exercise, topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs).

Result

Overall, 63 RCTs were incorporated. There was moderate certainty evidence that oral NSAIDs (risk ratio [RR] = 1.44; number needed to treat [NNT] = 6), SNRIs (Duloxetine; RR = 1.25; NNT = 10) and exercise (RR of 1.71; NNT of 7) provide statistically significant benefits to people with chronic low back pain. The only approach that provided long-term benefits was exercise (up to 48 weeks). The likelihood that patients will benefit from topical rubefacients and spinal manipulation treatment was low.

Higher-quality, longer-term (more than 4 weeks) research revealed no longer benefit from acupuncture. The ineffectiveness of corticosteroid injections was proven by very low-quality data. While those managed with SNRIs (Duloxetine) had a comparable probability of continuing to achieve benefit (NNT = 10) as those discontinuing the medicine due to side effects (number need to harm of 11), participants receiving opioids had a higher probability of discontinuing intervention due to a side effect (number needed to harm of 5) than continuing intervention to derive any statistically significant benefit (NNT = 16). Anticonvulsants and topical NSAIDs both showed comparable benefits to placebo in one experiment each. The inclusion criteria were not satisfied for RCTs with acetaminophen, tricyclic antidepressants, cannabinoids, muscle relaxants, or SSRIs.

Conclusion

In patients diagnosed with chronic low back pain in primary care, there was a profound decrease in pain with SNRIs (Duloxetine), oral NSAIDs, and exercise, with exercise being the only intervention that illustrated persistent effects even after treatment cessation.