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Conservative Treatment of Acute and Chronic Nonspecific Low Back Pain: A Systematic Review of Randomized Controlled Trials of the Most Common Interventions

van Tulder, Maurits W., PhD; Koes, Bart W., PhD; Bouter, Lex M., PhD

Literature Review

Study Design. A systematic review of randomized controlled trials.

Objectives. To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic nonspecific low back pain.

Summary of Background Data. Many treatment options for acute and chronic low back pain are available, but little is known about the optimal treatment strategy.

Methods. A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results.

Results. The number of randomized controlled trials identified varied widely with regard to the interventions involved. The scores ranged from 20 to 79 points for acute low back pain and from 19 to 79 points for chronic low back pain on a 100-point scale, indicating the overall poor quality of the trials. Overall, only 28 (35%) randomized controlled trials on acute low back pain and 20 (25%) on chronic low back pain had a methodologic score of 50 or more points, and were considered to be of high quality. Various methodologic flaws were identified. Strong evidence was found for the effectiveness of muscle relaxants and nonsteroidal anti-inflammatory drugs and the ineffectiveness of exercise therapy for acute low back pain; strong evidence also was found for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short-term effects.

Conclusions. The quality of the design, execution, and reporting of randomized controlled trials should be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain.

From the Institute for Research in Extramural Medicine, Vrije Universiteit, Amsterdam, The Netherlands.

Supported by a grant from the Dutch Health Insurance Board.

Acknowledgment date: May 30, 1996.

First revision date: September 9, 1996.

Second revision date: December 13, 1996.

Acceptance date: December 23, 1996.

Device status category: 1.

Address reprint requests to: Maurits W. van Tulder, PhD; Institute for Research in Extramural Medicine; Faculty of Medicine; Vrije Universiteit; Van der Boechorststraat 7; 1081 BT Amsterdam, The Netherlands; E-mail:

© Lippincott-Raven Publishers.