Forty-one studies met the inclusion criteria.
The quality of the included studies ranged from 0 to 5 points. The recommendations were graded by their level of evidence (I or II) and by the strength of evidence (A, B or C). Grade A recommendations indicated that a clinically important benefit was shown in one or more RCTs.
Acute LBP.
Therapeutic exercises (4 RCTs, n=1,035): the exercises included McKenzie, back extension, Kendall flexion, and strengthening exercises. Therapeutic exercises were no better then control therapy at improving function, ability to work, or reducing pain at 1 or 12 months.
Continuation of normal activities versus enforced bed rest (1 RCT, n=186): a clinically important benefit was found for return to work. The continuation of normal activities resulted in 49% fewer sick days after 3 weeks relative to the enforced bed rest group, with an absolute difference of 3.4 sick days (95% confidence interval, CI: 1.6, 5.2).
Mechanical traction (3 RCTs, n=176): no benefit of mechanical traction was demonstrated in comparison with placebo.
Therapeutic ultrasound (1 CCT, n=73): there was no clinically important difference between continuous ultrasound and placebo.
TENS (1 RCT, n=58): there was no difference in pain measured on a self-rated visual analogue scale, functional status, strength or range of motion at 1 month compared with placebo.
Acceptable evidence was not identified for thermotherapy, electrical stimulation, therapeutic massage, or EMG biofeedback.
Subacute LBP.
Therapeutic exercises (3 RCTs, n=405): the exercises consisted of McKenzie, Kendall, and strengthening exercises. Therapeutic exercises provided more pain relief relative to control at 1 month (SMD not reported; p<0.05), but not at 6 months (SMD not reported). Improvement in functional status at 1 month (1 RCT) was not statistically significant in comparison with the control.
Mechanical traction (2 RCTs, n=212): there was no clinically important benefit for patient global assessment at 1 month or return to work at 12 months.
Chronic LBP.
Therapeutic exercises (8 RCTs, n = unknown): the exercises included flexion, extension, stretching, circuit training and strength exercises with progressive increases in resistance. A clinically important benefit was demonstrated for pain relief and functional status. Five RCTs (n=361) demonstrated reductions in pain relative to the control group at 1 month (SMD not reported). Two RCTs of nursing aides with back pain showed no difference in the number of patients with pain improvement after 1 month (relative risk 1.45, 95% CI: 0.59, 3.56). Functional status (function) was improved in 3 RCTs (n=209) relative to the control group (SMD 0.36, 95% CI: 0.1, 0.6). There was no difference in range of motion, strength or return to work. One RCT (n=56) found no difference between flexion and extension exercises for pain or patient global assessment at 1 month. Two RCTs showed no difference in sick days compared to control over 12 months (WMD 0.5 days, 95% CI: -1.5, 2.5).
Mechanical traction (4 RCTS, n=176): there was no difference in pain, function, or patient global assessment compared to placebo or an untreated control group.
Therapeutic ultrasound (1 RCT, n=36): there was no difference in pain improvement between continuous therapeutic ultrasound and placebo after 1 month of therapy.
TENS (4 CCTs, n=235; 1 observational study, n=78): there was no difference in patient-rated pain at 1 month post-therapy (SMD -0.2, 95% CI: -0.4, 0.1) or at 3 to 6 months post-therapy. In addition, there were no differences between TENS and placebo for functional status, range of motion or strength at 1 month and 3 to 6 months post-therapy.
EMG biofeedback (5 RCTs, n=162): there was no difference in pain relief, functional status, or range of motion compared to control after 1 month of therapy (SMDs not reported).
Acceptable evidence was not identified for thermotherapy, massage or electrical stimulation.
Postsurgery back pain.
Therapeutic exercises (1 RCT, n=200): strengthening and McKenzie exercises improved function status by 51% relative to the control group. The exercise groups improved more on range of motion and strength at 2 months.