PEER systematic review of randomized controlled trials: Management of chronic low back pain in primary care

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Figure 1.
Comparison of overall efficacy between A) exercise; B) oral NSAIDs; and C) SNRIs (duloxetine): Treatments receiving a GRADE moderate certainty of evidence. Trials that are reported as a or b have ≥ 2 active interventions.
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Figure 2.
Exercise by time points of outcome measured: A) Outcome measured at ≤ 4 wk; B) outcome measured at > 4 and < 12 wk; C) outcome measured at ≥ 12 wk; D) outcome measured at longest follow-up after intervention completed. If a trial reported multiple time points within the specified time points, the trial only contributed once to the time point. For A), we routinely chose the midpoint of 2 wk unless only 1- and 4-wk data were reported; in which case, we chose the 4-wk data. For B), we chose the time closest to the midpoint of the time frame (ie, 8 wk). For C), we chose the longest point patients were receiving either intervention or control.

Table 1.

Overall proportion of patients with meaningful response to treatment: Ordered by certainty of evidence and then highest to lowest risk ratios.

GRADE CERTAINTY OF EVIDENCE	INTERVENTION TYPE	NO. OF RCTS^{^*}	INTERVENTION EVENT RATE, % (n/N)	CONTROL EVENT RATE, % (n/N)	TIME FRAME	RISK RATIO (95% CI)
Moderate	Exercise	18	50 (734/1472)	35 (386/1089)	6 to 52 wk	1.71 (1.37 to 2.15)
	Oral NSAIDs	4	55 (543/993)	37 (237/644)	4 to 16 wk	1.44 (1.17 to 1.78)
	SNRIs (duloxetine)	4	58 (482/832)	47 (314/667)	12 to 13 wk	1.25 (1.13 to 1.38)
Low	Spinal manipulation therapy	5	57 (199/349)	39 (132/337)	2 to 12 wk	1.54 (1.11 to 2.12)
	Rubefacients	3	64 (195/304)	46 (142/307)	3 wk	1.39 (1.20 to 1.61)
Very low	Acupuncture	8	54 (1320/2457)	35 (754/2161)	4 to 24 wk	1.58 (1.13 to 2.21)
	Opioids	6	39 (660/1712)	32 (318/996)	4 to 12 wk	1.26 (1.02 to 1.55)
	Corticosteroid injections	10	48 (276/581)	45 (257/571)	4 to 104 wk	1.07 (0.87 to 1.30)

GRADE—Grading of Recommendations Assessment, Development and Evaluation; NSAID—nonsteroidal anti-inflammatory drug; RCT—randomized controlled trial; SNRI—serotonin-norepinephrine reuptake inhibitor.
↵* Total number of RCTs is 63. Exercise and acupuncture have additional trials that do not report responder outcome data during the intervention period. Additionally, topical NSAIDs and anticonvulsants each have 1 study. Event rates for intervention and controls were calculated by meta-analyzing the responder outcome for the longest time frame in which the intervention was given.

Table 2.

Withdrawals due to adverse effects

INTERVENTION TYPE	NO. OF RCTS	INTERVENTION EVENT RATE, % (n/N)	CONTROL EVENT RATE, % (n/N)	RISK RATIO (95% CI)
Opioids	6	27 (461/1726)	5 (50/1011)	4.41 (3.30 to 5.91)
SNRIs (duloxetine)	1	18 (53/287)	9 (10/117)	2.02 (1.06 to 3.87)
Oral NSAIDs	4	4 (37/993)	3 (20/644)	1.36 (0.53 to 3.51)
Anticonvulsants	1	13 (7/55)	9 (5/53)	1.35 (0.46 to 3.99)
Acupuncture	1	3 (1/40)	0 (0/40)	3.00 (0.13 to 71.51)
Exercise, rubefacients, spinal manipulation therapy, corticosteroid injections, topical NSAIDs	Not reported in any trials	NA	NA	NA