Gianola S1, Castellini G1,2, Andreano A3, Corbetta D4,5, Frigerio P6, Pecoraro V7, Redaelli V8, Tettamanti A4,5, Turolla A9, Moja L1,2, Valsecchi MG3
1IRCCS Istituto Ortopedico Galeazzi, Milano, Italy, 2University of Milano, Milano, Italy, 3University of Milano-Bicocca, Monza, Italy, 4IRCCS San Raffaele Hospital, Milano, Italy, 5Vita-Salute San Raffaele University, Milano, Italy, 6ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy, 7Azienda USL of Modena, Modena, Italy, 8Casa di Cura del Policlinico di Milano, Milano, Italy, 9IRCCS San Hospital Camillo Foundation, Venezia, Italy
Background: Which kind of treatment is most suitable to treat a person with acute and sub-acute low back pain (LBP) is still discussed and pairwise meta-analyses cannot get hierarchies of these treatments.
Purpose: Our aim is to use a network meta-analysis (NMA) design to integrate the evidence providing hierarchies of the comparative efficacy of treatments measured by the change of pain.
Methods: Comprehensive searches in Pubmed, Embase and CENTRAL were undertaken up to 29 November 2017 to identify randomized controlled trials (RCT) focused on pharmacological and rehabilitation interventions for acute and sub-acute LBP. The primary outcomes was pain investigated at one month of follow-up. Risk of bias of included studies was assessed using the Cochrane Collaboration´s tool. Assessment of transitivity and consistency was made. We performed the network meta-analyses (NMA) within a frequentist setting, assuming equal heterogeneity across all treatment comparisons, and accounting for correlations induced by multi-arm. We used a multivariate normal model with random-effects.
Results: Overall, 36 RCT met our inclusion criteria accounting for 7111 participants. Seven trials were at low RoB (19.5%), 20 at unclear RoB (55.5%) and 9 at high RoB (25%). However, only 21 RCTs reported the outcome data for quantitative analysis. The following treatments were identified as nodes of the network: usual care, non-steroids anti-inflammatory drugs, acupuncture, exercise, heat wrap, manual therapy, muscle relaxant, opioid, paracetamol, inert treatment. No inconsistency was found (p=0.42, χ2=8.16 on 8 df). Thus, assuming consistency we performed the NMA showing that the best efficacious treatments to reduce pain are muscle relaxant drugs (SMD -0.98, 95% IC -1.52,-0.43) and manual therapy (SMD -0.84, 95% IC -1.61,-0.08) with the probability of 83% and 76% to be the first treatment, respectively.
Conclusion(s): This study addressed the uncertainties in the use of pharmacological or rehabilitation treatments, and their relative efficacy, for acute and subacute LBP. Muscle relaxant drugs and manual therapy are the most efficacious options.
Implications: Network meta-analysis can be useful for clinical guidelines. Based on our findings, the actual guideline recommendations on acute and subacute LBP might be in need of revision. These results are clinically relevant for patients, healthcare providers and policy-makers.
Keywords: low back pain, network meta-analysis, interventions
Funding acknowledgements: The work was supported by the Italian Ministry of Health (L3026) and by Italian Ministry of Health (Giovani Ricercatori GR-2011-02348048).
Purpose: Our aim is to use a network meta-analysis (NMA) design to integrate the evidence providing hierarchies of the comparative efficacy of treatments measured by the change of pain.
Methods: Comprehensive searches in Pubmed, Embase and CENTRAL were undertaken up to 29 November 2017 to identify randomized controlled trials (RCT) focused on pharmacological and rehabilitation interventions for acute and sub-acute LBP. The primary outcomes was pain investigated at one month of follow-up. Risk of bias of included studies was assessed using the Cochrane Collaboration´s tool. Assessment of transitivity and consistency was made. We performed the network meta-analyses (NMA) within a frequentist setting, assuming equal heterogeneity across all treatment comparisons, and accounting for correlations induced by multi-arm. We used a multivariate normal model with random-effects.
Results: Overall, 36 RCT met our inclusion criteria accounting for 7111 participants. Seven trials were at low RoB (19.5%), 20 at unclear RoB (55.5%) and 9 at high RoB (25%). However, only 21 RCTs reported the outcome data for quantitative analysis. The following treatments were identified as nodes of the network: usual care, non-steroids anti-inflammatory drugs, acupuncture, exercise, heat wrap, manual therapy, muscle relaxant, opioid, paracetamol, inert treatment. No inconsistency was found (p=0.42, χ2=8.16 on 8 df). Thus, assuming consistency we performed the NMA showing that the best efficacious treatments to reduce pain are muscle relaxant drugs (SMD -0.98, 95% IC -1.52,-0.43) and manual therapy (SMD -0.84, 95% IC -1.61,-0.08) with the probability of 83% and 76% to be the first treatment, respectively.
Conclusion(s): This study addressed the uncertainties in the use of pharmacological or rehabilitation treatments, and their relative efficacy, for acute and subacute LBP. Muscle relaxant drugs and manual therapy are the most efficacious options.
Implications: Network meta-analysis can be useful for clinical guidelines. Based on our findings, the actual guideline recommendations on acute and subacute LBP might be in need of revision. These results are clinically relevant for patients, healthcare providers and policy-makers.
Keywords: low back pain, network meta-analysis, interventions
Funding acknowledgements: The work was supported by the Italian Ministry of Health (L3026) and by Italian Ministry of Health (Giovani Ricercatori GR-2011-02348048).
Topic: Musculoskeletal: spine; Musculoskeletal: spine; Disability & rehabilitation
Ethics approval required: No
Institution: none
Ethics committee: none
Reason not required: methodological research (systematic review) did not recruite participants and not perform prospective interventions
All authors, affiliations and abstracts have been published as submitted.
