Rizzo Rodrigo Rn, Cashin Aidan G, Wand Benedict M, Ferraro Michael C, Sharma Saurab, Lee Hopin, O'Hagan Edel, Maher Christopher G, Furlan Andrea D, van Tulder Maurits W, McAuley James H
School of Health Sciences, Faculty of Medicine and Health, The University of New South Wales, Sydney, Australia.
Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia.
Cochrane Database Syst Rev. 2025 Mar 27;3(3):CD014691. doi: 10.1002/14651858.CD014691.pub2.
Low back pain (LBP) is a significant public health issue due to its high prevalence and associated disability burden. Clinical practice guidelines recommend non-pharmacological/non-surgical interventions for managing pain and function in people with LBP.
To provide accessible, high-quality evidence on the effects of non-pharmacological and non-surgical interventions for people with LBP and to highlight areas of remaining uncertainty and gaps in the evidence regarding the effects of these interventions for people with LBP.
We searched the Cochrane Database of Systematic Reviews from inception to 15 April 2023, to identify Cochrane reviews of randomised controlled trials testing the effect of non-pharmacological/non-surgical interventions, unrestricted by language. Major outcomes were pain intensity, function and safety. Two authors independently assessed eligibility, extracted data and assessed the quality of the reviews using AMSTAR 2 (A MeaSurement Tool to Assess Systematic Reviews) and the certainty of the evidence using GRADE. The primary comparison was placebo/sham.
We included 31 Cochrane reviews of 644 trials that randomised 97,183 adults with LBP. We have high confidence in the findings of 19 reviews, moderate confidence in the findings of two reviews, and low confidence in the findings of 10 reviews. We present results for non-pharmacological/non-surgical interventions compared to placebo/sham or no treatment/usual care at short-term (≤ three months) follow-up. Placebo/sham comparisons Acute/subacute LBP Compared to placebo, there is probably no difference in function (at one-week follow-up) for spinal manipulation (standardised mean difference (SMD) -0.08, 95% confidence interval (CI) -0.37 to 0.21; 2 trials, 205 participants; moderate-certainty evidence). Data for safety were reported only for heated back wrap. Compared to placebo, heated back wrap may result in skin pinkness (6/128 participants versus 1/130; 2 trials; low-certainty evidence). Chronic LBP Compared to sham acupuncture, acupuncture probably provides a small improvement in function (SMD -0.38, 95% CI -0.69 to -0.07; 3 trials, 957 participants; moderate-certainty evidence). Compared to sham traction, there is probably no difference in pain intensity for traction (0 to 100 scale, mean difference (MD) -4, 95% CI -17.7 to 9.7; 1 trial, 60 participants; moderate-certainty evidence). Data for safety were reported only for acupuncture. There may be no difference between acupuncture and sham acupuncture for safety outcomes (risk ratio (RR) 0.68, 95% CI 0.42 to 1.10; I = 0%; 4 trials, 465 participants; low-certainty evidence). No treatment/usual care comparisons Acute/subacute LBP Compared to advice to rest, advice to stay active probably provides a small reduction in pain intensity (SMD -0.22, 95% CI -0.02 to -0.41; 2 trials, 401 participants; moderate-certainty evidence). Compared to advice to rest, advice to stay active probably provides a small improvement in function (SMD -0.29, 95% CI -0.09 to -0.49; 2 trials, 400 participants; moderate-certainty evidence). Data for safety were reported only for massage. There may be no difference between massage and usual care for safety (risk difference 0, 95% CI -0.07 to 0.07; 1 trial, 51 participants; low-certainty evidence). Chronic LBP Compared to no treatment, acupuncture probably provides a medium reduction in pain intensity (0 to 100 scale, mean difference (MD) -10.1, 95% CI -16.8 to -3.4; 3 trials, 144 participants; moderate-certainty evidence), and a small improvement in function (SMD -0.39, 95% CI -0.72 to -0.06; 3 trials, 144 participants; moderate-certainty evidence). Compared to usual care, acupuncture probably provides a small improvement in function (MD 9.4, 95% CI 6.15 to 12.65; 1 trial, 734 participants; moderate-certainty evidence). Compared to no treatment/usual care, exercise therapies probably provide a small to medium reduction in pain intensity (0 to 100 scale, MD -15.2, 95% CI -18.3 to -12.2; 35 trials, 2746 participants; moderate-certainty evidence), and probably provide a small improvement in function (0 to 100 scale, MD -6.8, 95% CI -8.3 to -5.3; 38 trials, 2942 participants; moderate-certainty evidence). Compared to usual care, multidisciplinary therapies probably provide a medium reduction in pain intensity (SMD -0.55, 95% CI -0.83 to -0.28; 9 trials, 879 participants; moderate-certainty evidence), and probably provide a small improvement in function (SMD -0.41, 95% CI -0.62 to -0.19; 9 trials, 939 participants; moderate-certainty evidence). Compared to no treatment, psychological therapies using operant approaches probably provide a small reduction in pain intensity (SMD -0.43, 95% CI -0.75 to -0.11; 3 trials, 153 participants; moderate-certainty evidence). Compared to usual care, psychological therapies (including progressive muscle relaxation and behavioural approaches) probably provide a small reduction in pain intensity (0 to 100 scale, MD -5.18, 95% CI -9.79 to -0.57; 2 trials, 330 participants; moderate-certainty evidence), but there is probably no difference in function (SMD -0.2, 95% CI -0.41 to 0.02; 2 trials, 330 participants; moderate-certainty evidence). It is uncertain whether there is a difference between non-pharmacological/non-surgical interventions and no treatment/usual care for safety (very low-certainty evidence).
AUTHORS' CONCLUSIONS: Spinal manipulation probably makes no difference to function compared to placebo for people with acute/subacute LBP. Acupuncture probably improves function slightly for people with chronic LBP, compared to sham acupuncture. There is probably no difference between traction and sham traction for pain intensity in people with chronic LBP. Compared to advice to rest, advice to stay active probably reduces pain intensity slightly and improves function slightly for people with acute LBP. Acupuncture probably reduces pain intensity, and improves function slightly for people with chronic LBP, compared to no treatment. Acupuncture probably improves function slightly for people with chronic LBP, compared to usual care. Exercise therapies probably reduce pain intensity, and improve function slightly for people with chronic LBP, compared to no treatment/usual care. Multidisciplinary therapies probably reduce pain intensity, and improve function slightly for people with chronic LBP, compared to usual care. Compared to usual care, psychological therapies probably reduce pain intensity slightly, but probably make no difference to function for people with chronic LBP.
腰痛（LBP）因其高患病率和相关的残疾负担，是一个重大的公共卫生问题。临床实践指南推荐采用非药物/非手术干预措施来管理腰痛患者的疼痛和功能。
为腰痛患者提供关于非药物和非手术干预措施效果的可获取的高质量证据，并突出这些干预措施效果方面仍存在不确定性的领域和证据空白。
我们检索了Cochrane系统评价数据库，从创建至2023年4月15日，以识别对测试非药物/非手术干预措施效果的随机对照试验的Cochrane系统评价，不受语言限制。主要结局为疼痛强度、功能和安全性。两位作者独立评估纳入标准、提取数据，并使用AMSTAR 2（一种评估系统评价的测量工具）评估系统评价的质量，以及使用GRADE评估证据的确定性。主要比较为安慰剂/假干预。
我们纳入了31篇Cochrane系统评价，涉及644项试验，这些试验将97183名成年腰痛患者随机分组。我们对19篇系统评价的结果有高置信度，对2篇系统评价的结果有中等置信度，对10篇系统评价的结果有低置信度。我们呈现了与安慰剂/假干预或无治疗/常规护理相比，非药物/非手术干预措施在短期（≤3个月）随访时的结果。安慰剂/假干预比较 急性/亚急性腰痛 与安慰剂相比，脊柱推拿在功能方面（在1周随访时）可能与安慰剂无差异（标准化均数差（SMD）-0.08，95%置信区间（CI）-0.37至0.21；2项试验，205名参与者；中等确定性证据）。仅报告了加热背部包裹的安全性数据。与安慰剂相比，加热背部包裹可能导致皮肤发红（128名参与者中有6名，而130名参与者中有1名；2项试验；低确定性证据）。慢性腰痛 与假针灸相比，针灸可能在功能上有小幅改善（SMD -0.38，95%CI -0.69至-0.07；3项试验，957名参与者；中等确定性证据）。与假牵引相比，牵引在疼痛强度方面可能与假牵引无差异（0至100分制，均数差（MD）-4，95%CI -17.7至9.7；1项试验，60名参与者；中等确定性证据）。仅报告了针灸的安全性数据。针灸与假针灸在安全性结局方面可能无差异（风险比（RR）0.68，95%CI 0.42至1.10；I² = 0%；4项试验，465名参与者；低确定性证据）。无治疗/常规护理比较 急性/亚急性腰痛 与建议休息相比，建议保持活动可能在疼痛强度上有小幅降低（SMD -0.22，95%CI -0.02至-0.41；2项试验，401名参与者；中等确定性证据）。与建议休息相比，建议保持活动可能在功能上有小幅改善（SMD -0.29，95%CI -0.09至-0.49；2项试验，400名参与者；中等确定性证据）。仅报告了按摩的安全性数据。按摩与常规护理在安全性方面可能无差异（风险差0，95%CI -0.07至0.07；1项试验，51名参与者；低确定性证据）。慢性腰痛 与无治疗相比，针灸可能在疼痛强度上有中度降低（0至100分制，均数差（MD）-10.1，95%CI -16.8至-3.4；3项试验，144名参与者；中等确定性证据），在功能上有小幅改善（SMD -0.39，95%CI -0.72至-0.06；3项试验，144名参与者；中等确定性证据）。与常规护理相比，针灸可能在功能上有小幅改善（MD 9.4，95%CI 6.15至12.65；1项试验，734名参与者；中等确定性证据）。与无治疗/常规护理相比，运动疗法可能在疼痛强度上有小幅至中度降低（0至100分制，MD -15.2，95%CI -18.3至-12.2；35项试验，2746名参与者；中等确定性证据），可能在功能上有小幅改善（0至100分制，MD -6.8，95%CI -8.3至-5.3；38项试验，2942名参与者；中等确定性证据）。与常规护理相比，多学科疗法可能在疼痛强度上有中度降低（SMD -0.55，95%CI -0.83至-0.28；9项试验；879名参与者；中等确定性证据）。可能在功能上有小幅改善（SMD -0.41，95%CI -0.62至-0.19；9项试验，939名参与者；中等确定性证据）。与无治疗相比，采用操作性方法的心理疗法可能在疼痛强度上有小幅降低（SMD -0.43，95%CI -0.75至-0.11；3项试验，153名参与者；中等确定性证据）。与常规护理相比，心理疗法（包括渐进性肌肉松弛和行为方法）可能在疼痛强度上有小幅降低（0至100分制，MD -5.18，95%CI -9.79至-0.57；2项试验，330名参与者；中等确定性证据），但在功能上可能无差异（SMD -0.2，95%CI -0.41至0.02；2项试验，33名参与者；中等确定性证据）。非药物/非手术干预措施与无治疗/常规护理在安全性方面是否存在差异尚不确定（极低确定性证据）。
对于急性/亚急性腰痛患者，与安慰剂相比，脊柱推拿可能对功能无差异。对于慢性腰痛患者，与假针灸相比，针灸可能在功能上有轻微改善。对于慢性腰痛患者，牵引与假牵引在疼痛强度方面可能无差异。对于急性腰痛患者，与建议休息相比，建议保持活动可能会轻微降低疼痛强度并轻微改善功能。对于慢性腰痛患者，与无治疗相比，针灸可能会降低疼痛强度并轻微改善功能。对于慢性腰痛患者，与常规护理相比，针灸可能会轻微改善功能。对于慢性腰痛患者，与无治疗/常规护理相比，运动疗法可能会降低疼痛强度并轻微改善功能。对于慢性腰痛患者，与常规护理相比，多学科疗法可能会降低疼痛强度并轻微改善功能。与常规护理相比，心理疗法可能会轻微降低疼痛强度，但对于慢性腰痛患者，可能对功能无差异。
