To review the effectiveness of different physical therapies for acute and sub-acute low back pain supported by evidence, and create clinical recommendations and expert consensus for physiotherapists on clinical prescriptions.
Data sources
A systematic search was conducted in PubMed and the Cochrane Library for studies published within the previous 15 years.
Review methods
Systematic review and meta-analysis, randomized controlled trials assessing patients with acute and sub-acute low back pain were included. Two reviewers independently screened relevant studies using the same inclusion criteria. The Physiotherapy Evidence Database and the Assessment of Multiple Systematic Reviews tool were used to grade the quality assessment of randomized controlled trials and systematic reviews, respectively. The final recommendation grades were based on the consensus discussion results of the Delphi of 22 international experts.
Results
Twenty-one systematic reviews and 21 randomized controlled trials were included. Spinal manipulative therapy and low-level laser therapy are recommended for acute low back pain. Core stability exercise/motor control, spinal manipulative therapy, and massage can be used to treat sub-acute low back pain.
Conclusions
The consensus statements provided medical staff with appliable recommendations of physical therapy for acute and sub-acute low back pain. This consensus statement will require regular updates after 5–10 years.
MaherCUnderwoodMBuchbinderR. Non-specific low back pain. Lancet (London, England)2017; 389: 736–747.
2.
WilliamsCMMaherCGLatimerJ, et al.Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet (London, England)2014; 384: 1586–1596.
3.
BalagueFMannionAFPelliseF,et al.Non-specific low back pain. Lancet (London, England)2012; 379: 482–491.
4.
KnezevicNNCandidoKDVlaeyenJWS,et al.Low back pain. Lancet (London, England)2021; 398: 78–92.
5.
GarciaJBHernandez-CastroJJNunezRG, et al.Prevalence of low back pain in Latin America: a systematic literature review. Pain Physician2014; 17: 379–391.
6.
StevansJMDelittoAKhojaSS, et al.Risk factors associated with transition from acute to chronic low back pain in US patients seeking primary care. JAMA Netw Open2021; 4: e2037371.
7.
JagannathanHThotaAKumarappaAKB, et al.A comparative study of aceclofenac versus etoricoxib in the management of acute low back pain in a tertiary care hospital. J Drug Assess. 2020; 9: 60–65.
8.
DiseaseGBDInjuryIPrevalenceC. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the global burden of disease study 2016. Lancet2017; 390: 1211–1259.
9.
JuniperMLeTKMladsiD. The epidemiology, economic burden, and pharmacological treatment of chronic low back pain in France, Germany, Italy, Spain and the UK: a literature-based review. Expert Opin Pharmacother2009; 10: 2581–2592.
10.
DielemanJLCaoJChapinA, et al.US health care spending by payer and health condition, 1996–2016. Jama2020; 323: 863–884.
11.
QaseemAWiltTJMcLeanRM, et al.Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med2017; 166: 514–530.
12.
BernsteinIAMalikQCarvilleS,et al.Low back pain and sciatica: summary of NICE guidance. Br Med J2017; 356: i6748.
13.
DelittoAGeorgeSZVan DillenLR, et al.Low back pain. J Orthop Sports Phys Ther2012; 42: A1–57.
14.
PicelliABuzziMGCisariC, et al.Headache, low back pain, other nociceptive and mixed pain conditions in neurorehabilitation. Evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation. Eur J Phys Rehabil Med2016; 52: 867–880.
15.
LisiAJSalsburySAHawkC, et al.Chiropractic integrated care pathway for low back pain in veterans: results of a Delphi consensus process. J Manipulative Physiol Ther2018; 41: 137–148.
16.
Amescua-GarciaCColimonFGuerreroC, et al.Most relevant neuropathic pain treatment and chronic low back pain management guidelines: a change pain Latin America advisory panel consensus. Pain Med2018; 19: 460–470.
17.
ChouRDeyoRFriedlyJ, et al.Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med2017; 166: 493–505.
18.
GeorgeSZFritzJMSilfiesSP, et al.Interventions for the management of acute and chronic low back pain: revision 2021. J Orthop Sports Phys Ther2021; 51: Cpg1–cpg60.
19.
MartinRLChimentiRCuddefordT, et al.Achilles pain, stiffness, and muscle power deficits: midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther2018; 48: A1–A38.
CollinsNJBartonCJvan MiddelkoopM, et al.2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med2018; 52: 1170–1178.
22.
SheaBJGrimshawJMWellsGA, et al.Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol2007; 7: 10.
23.
CrossleyKMvan MiddelkoopMCallaghanMJ,et al.2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). Br J Sports Med2016; 50: 844–852.
24.
JormAF. Using the Delphi expert consensus method in mental health research. Aust N Z J Psychiatry2015; 49: 887–897.
25.
BossardDSRemusADohertyC,et al.Developing consensus on clinical assessment of acute lateral ankle sprain injuries: protocol for an international and multidisciplinary modified Delphi process. Br J Sports Med2018; 52: 1539.
26.
Sanz-ParisAHernandezABallesteros-PomarJ, et al.Evidence-based recommendations and expert consensus on enteral nutrition in the adult patient with diabetes mellitus or hyperglycemia. Nutrition2017; 41: 58–67.
27.
SaragiottoBTMaherCGYamatoTP, et al.Motor control exercise for nonspecific low back pain: a Cochrane review. Spine2016; 41: 1284–1295.
28.
MacedoLGSaragiottoBTYamatoTP, et al.Motor control exercise for acute non-specific low back pain. Cochrane Database Syst Rev2016; 2: Cd012085.
29.
PintoSMBoghraSBMacedoLG, et al.Does motor control exercise restore normal morphology of lumbar multifidus muscle in people with low back pain? – a systematic review. J Pain Res2021; 14: 2543–2562.
30.
IjzelenbergWOosterhuisTHaydenJA, et al.Exercise therapy for treatment of acute non-specific low back pain. Cochrane Database Syst Rev2023; 8: CD009365.
31.
CasazzaBA. Diagnosis and treatment of acute low back pain. Am Fam Physician2012; 85: 343–350.
32.
MachadoLAMaherCGHerbertRD,et al.The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Med2010; 8: 10.
33.
LamOTStrengerDMChan-FeeM,et al.Effectiveness of the McKenzie method of mechanical diagnosis and therapy for treating low back pain: literature review with meta-analysis. J Orthop Sports Phys Ther2018; 48: 476–490.
34.
SheetsCMachadoLAHancockM,et al.Can we predict response to the McKenzie method in patients with acute low back pain? A secondary analysis of a randomized controlled trial. Eur Spine J2012; 21: 1250–1256.
35.
LohanaDKAhmadUSharifF,et al.Comparison of mulligan sustained natural apophyseal glides versus McKenzie extension exercises on disability and functional outcomes in patients with acute nonspecific low back pain. Rawal Med J2021; 46: 469–472.
36.
DayJMNitzAJ. The effect of muscle energy techniques on disability and pain scores in individuals with low back pain. J Sport Rehabil2012; 21: 194–198.
37.
PatelVDEapenCCeepeeZ,et al.Effect of muscle energy technique with and without strain-counterstrain technique in acute low back pain – a randomized clinical trial. Hong Kong Physiotherapy Journal: Official Publication of the Hong Kong Physiotherapy Association Limited=Wu li Chih Liao2018; 38: 41–51.
38.
FrankeHFryerGOsteloRW,et al.Muscle energy technique for non-specific low-back pain. Cochrane Database Syst Rev2015; 2: CD009852.
39.
HancockMJMaherCGLatimerJ. Spinal manipulative therapy for acute low back pain: a clinical perspective. J Man Manip Ther2008; 16: 198–203.
40.
PaigeNMMiake-LyeIMBoothMS, et al.Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain: systematic review and meta-analysis. Jama2017; 317: 1451–1460.
41.
RubinsteinSMTerweeCBAssendelftWJ,et al.Spinal manipulative therapy for acute low back pain: an update of the Cochrane review. Spine2013; 38: E158–E177.
FarberKWielandLS. Massage for low-back pain. Explore (New York, NY)2016; 12: 215–217.
44.
KamaliFPanahiFEbrahimiS,et al.Comparison between massage and routine physical therapy in women with sub-acute and chronic nonspecific low back pain. J Back Musculoskelet Rehabil2014; 27: 475–480.
45.
FurlanADImamuraMDrydenT,et al.Massage for low back pain: an updated systematic review within the framework of the Cochrane back review group. Spine2009; 34: 1669–1684.
YipYBTseSHM. The effectiveness of relaxation acupoint stimulation and acupressure with aromatic lavender essential oil for non-specific low back pain in Hong Kong: a randomised controlled trial. Complement Ther Med2004; 12: 28–37.
48.
GladwellPWCrampFPalmerS. Matching the perceived benefits of Transcutaneous Electrical Nerve Stimulation (TENS) for chronic musculoskeletal pain against Patient Reported Outcome Measures using the International Classification of Functioning, Disability and Health (ICF). Physiotherapy 2020; 106: 128–135.
49.
BinnyJJoshua WongNLGargaS, et al.Transcutaneous electric nerve stimulation (TENS) for acute low back pain: systematic review. Scand J Pain2019; 19: 225–233.
50.
CotlerHBChowRTHamblinMR,et al.The use of low level laser therapy (LLLT) for musculoskeletal pain. MOJ Orthop Rheumatol2015; 2: 00068.
51.
KonstantinovicLMKanjuhZMMilovanovicAN, et al.Acute low back pain with radiculopathy: a double-blind, randomized, placebo-controlled study. Photomed Laser Surg2010; 28: 553–560.
52.
PanahHMAbbasiMYazdiZ,et al.Comparative study of combination therapy with non-steroidal anti-inflammatory drugs and different doses of low level laser therapy in acute low back pain. J Bodyw Mov Ther2021; 27: 705–709.
53.
SongGChenCZhangJ,et al.Association of traditional Chinese exercises with glycemic responses in people with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. J Sport Health Sci2018; 7: 442–452.
54.
MillerSTaylor-PiliaeRE. The association between Tai Chi exercise and safe driving performance among older adults: an observational study. J Sport Health Sci2018; 7: 83–94.
55.
JangJHChoTYChoYH. The effects of t’ai chi on muscle activity, pain, and balance in females in their 20s with acute low back pain. J Phys Ther Sci2015; 27: 725–727.
56.
ChoY. Effects of tai chi on pain and muscle activity in young males with acute low back pain. J Phys Ther Sci2014; 26: 679–681.
57.
WhiteAErnstE. A brief history of acupuncture. Rheumatology (Oxford, England)2004; 43: 662–663.
58.
PearlDSchrollingerE. Acupuncture: its use in medicine. West J Med1999; 171: 176–180.
59.
WuBYangLFuC, et al.Efficacy and safety of acupuncture in treating acute low back pain: a systematic review and Bayesian network meta-analysis. Ann Palliat Med2021; 10: 6156–6167.
60.
LeeJHChoiTYLeeMS,et al.Acupuncture for acute low back pain: a systematic review. Clin J Pain2013; 29: 172–185.
61.
LiTWangSChengK, et al.Comparing the efficacy of two different temperature stimulation in warm acupuncture on acute low back pain: a randomized controlled trial. Integr Med Res2022; 11: 100748.
62.
GianolaSBargeriSDel CastilloG, et al.Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis. Br J Sports Med2022; 56: 41–50.
63.
LiuLSkinnerMMcDonoughS,et al.Acupuncture for low back pain: an overview of systematic reviews. Evid-based Complementary Altern Med: ECAM2015; 2015: 328196.
64.
MostafavifarMWertzJBorchersJ. A systematic review of the effectiveness of Kinesio taping for musculoskeletal injury. Phys Sportsmed2012; 40: 33–40.
65.
KelleBGüzelRSakallıH. The effect of Kinesio taping application for acute non-specific low back pain: a randomized controlled clinical trial. Clin Rehabil2016; 30: 997–1003.
66.
PuntumetakulRChalermsanRHlaingSS,et al.The effect of core stabilization exercise on lumbar joint position sense in patients with subacute non-specific low back pain: a randomized controlled trial. J Phys Ther Sci2018; 30: 1390–1395.
67.
LehtolaVLuomajokiHLeinonenV,et al.Sub-classification based specific movement control exercises are superior to general exercise in sub-acute low back pain when both are combined with manual therapy: a randomized controlled trial. BMC Musculoskelet Disord2016; 17: 135.
68.
HlaingSSPuntumetakulRKhineEE,et al.Effects of core stabilization exercise and strengthening exercise on proprioception, balance, muscle thickness and pain related outcomes in patients with subacute nonspecific low back pain: a randomized controlled trial. BMC Musculoskelet Disord2021; 22: 998.
69.
del Pozo-CruzBGusiNdel Pozo-CruzJ,et al.Clinical effects of a nine-month web-based intervention in subacute non-specific low back pain patients: a randomized controlled trial. Clin Rehabil2013; 27: 28–39.
70.
del Pozo-CruzBdel Pozo-CruzJAdsuarJC,et al.Reanalysis of a tailored web-based exercise programme for office workers with sub-acute low back pain: assessing the stage of change in behaviour. Psychol Health Med2013; 18: 687–697.
71.
del Pozo-CruzBParracaJAdel Pozo-CruzJ,et al.An occupational, internet-based intervention to prevent chronicity in subacute lower back pain: a randomised controlled trial. J Rehabil Med2012; 44: 581–587.
72.
GaneshGSMohantyPPattnaikM,et al.Effectiveness of mobilization therapy and exercises in mechanical neck pain. Physiother Theory Pract2015; 31: 99–106.
73.
SatputeKHallTBisenR,et al.The effect of spinal mobilization with leg movement in patients with lumbar radiculopathy—a double-blind randomized controlled trial. Arch Phys Med Rehabil2019; 100: 828–836.
74.
SchneiderMHaasMGlickR,et al.Comparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: a randomized clinical trial. Spine2015; 40: 209–217.
75.
XiaTLongCRGudavalliMR, et al.Similar effects of thrust and nonthrust spinal manipulation found in adults with subacute and chronic low back pain: a controlled trial with adaptive allocation. Spine2016; 41: E702–E709.
76.
HondrasMALongCRCaoY,et al.A randomized controlled trial comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain. J Manipulative Physiol Ther2009; 32: 330–343.
77.
NguyenCBoutronIZegarra-ParodiR, et al.Effect of osteopathic manipulative treatment vs sham treatment on activity limitations in patients with nonspecific subacute and chronic low back pain: a randomized clinical trial. JAMA Intern Med2021; 181: 620–630.
NooriSARasheedAAiyerR, et al.Therapeutic ultrasound for pain management in chronic low back pain and chronic neck pain: a systematic review. Pain Med 2020; 21: 1482–1493.
80.
LauferYDarG. Effectiveness of thermal and athermal short-wave diathermy for the management of knee osteoarthritis: a systematic review and meta-analysis. Osteoarthritis Cartilage2012; 20: 957–966.
81.
EhdeDMDillworthTMTurnerJA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol2014; 69: 153–166.
82.
MarianoTYUrmanRDHutchisonCA,et al.Cognitive behavioral therapy (CBT) for subacute low back pain: a systematic review. Curr Pain Headache Rep2018; 22: 15.
83.
MonticoneMAmbrosiniEPortogheseI,et al.Multidisciplinary program based on early management of psychological factors reduces disability of patients with subacute low back pain: one-year results of a randomized controlled study. Eur J Phys Rehabil Med2021; 57: 959–967.
84.
GuyattGOxmanADAklEA, et al.GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol2011; 64: 383–394.
85.
GuyattGHOxmanADVistGE, et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ (Clinical Research Ed)2008; 336: 924–926.
86.
AlrwailyMTimkoMSchneiderM, et al.Treatment-based classification system for patients with low back pain: the movement control approach. Phys Ther2017; 97: 1147–1157.
87.
AlrwailyMTimkoMSchneiderM, et al.Treatment-based classification system for low back pain: revision and update. Phys Ther2016; 96: 1057–1066.
88.
OliveiraCBMaherCGPintoRZ, et al.Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J2018; 27: 2791–2803.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
