Evidence
This page contains a snapshot of featured content which highlights evidence addressing key clinical questions including areas of uncertainty. Please see the main topic reference list for details of all sources underpinning this topic.
BMJ Best Practice evidence tables
Evidence tables provide easily navigated layers of evidence in the context of specific clinical questions, using GRADE and a BMJ Best Practice Effectiveness rating. Follow the links at the bottom of the table, which go to the related evidence score in the main topic text, providing additional context for the clinical question. Find out more about our evidence tables.
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is very low or low where GRADE has been performed and there may be no difference in effectiveness between the intervention and comparison for key outcomes. However, this is uncertain and new evidence could change this in the future.
Population: People aged ≥16 years with non-specific low back pain
Intervention: Soft tissue techniques such as massage
Comparison: Sham or usual care ᵃ
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Soft tissue technique versus sham in people with low back pain without sciatica | ||
Pain severity (Visual Analog Score [VAS]) ≤4 months | No statistically significant difference | Very Low |
Pain severity (McGill Questionnaire) ≤4 months | Favours intervention ᵇ | Very Low |
Function (Quebec Disability Score, 0-100) ≤4 months | Favours intervention ᵇ | Low |
Soft tissue technique versus usual care in people with low back pain without sciatica | ||
Pain severity (Von Korff scale) at both <4 months and >4 months | No statistically significant difference | Moderate |
Quality of life (SF-36 physical component) | No statistically significant difference | Low to Very Low ᶜ |
Quality of life (SF-36 mental component) ≤4 months | Favours intervention ᵇ | Very Low |
Quality of life (SF-36 mental component) >4 months | No statistically significant difference | Low |
Function (Roland Morris Disability Questionnaire [RMDQ]) ≤4 months | Favours intervention | Very Low |
Function (RMDQ) >4 months | No statistically significant difference | Very Low |
Recommendations as stated in the source guideline The National Institute for Health and Care Excellence (NICE) guideline on Low back pain and sciatica in over 16s makes the following recommendation: Consider manual therapy (spinal manipulation, mobilisation, or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy.
Note NICE looked at evidence for both acute/subacute and chronic pain. This table has therefore been added to both sections in the BMJ Best Practice topic. No serious adverse events attributable to manual therapy were reported by any of the studies reviewed. Overall the guideline committee felt the evidence for these therapies used alone was limited with little additional benefit, especially in the longer term, compared with usual care. Therefore, their recommendation was that these should only be considered as part of a “treatment package”. See guideline for more information. ᵃ Usual care as defined by individual included studies. NICE also considered evidence for the following comparisons: each other, any other non-invasive intervention for non-specific low back pain, and combination therapy (see guideline for more information). ᵇ The guideline committee agreed this difference was not clinically important (as a default an improvement of 10% was required to show clinical benefit). ᶜ Effectiveness was the same, but GRADE varied with time point (≤4 months versus >4 months).
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is moderate or low to moderate where GRADE has been performed and there may be no difference in effectiveness between the intervention and comparison for key outcomes.
Population: People aged ≥16 years with non-specific low back pain
Intervention: Spinal manipulation/mobilisation
Comparison: Sham or usual care ᵃ
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Manipulation/mobilisation versus sham in people with low back pain without sciatica | ||
Quality of life (Euroqol health state) | No statistically significant difference | High to Moderate ᵇ |
Quality of life (SF-12/SF36: physical composite score) ≤4 months | Favours intervention | Moderate |
Quality of life (SF-12/SF36: mental composite score, pain subscale, or physical function subscale) ≤4 months | No statistically significant difference | Moderate to Very Low ᶜ |
Quality of life (SF-12) >4 months (physical and mental composite scores) | No statistically significant difference | High |
Pain (VAS) ≤4 months | Favours intervention ᵈ | Moderate |
Pain (VAS) >4 months | No statistically significant difference | High |
Function (Oswestry Disability Index [ODI]) ≤4 months | Favours intervention ᵈ | Low |
Function (ODI) >4 months | No statistically significant difference | Moderate |
Function (Von Korff Scale) at both <4 months and >4 months | Favours intervention ᵈ | Moderate |
Manipulation/mobilisation versus usual care in people with low back pain without sciatica | ||
Pain severity (Numeric Rating Scale [NRS]) ≤4 months | Favours intervention | Low |
Pain severity (NRS) >4 months | No statistically significant difference | Low |
Function (ODI) ≤4 months | Favours intervention ᵈ | Very Low |
Function (ODI) >4 months | No statistically significant difference | Very Low |
Recommendations as stated in the source guideline The National Institute for Health and Care Excellence (NICE) guideline on Low back pain and sciatica in over 16s makes the following recommendation: Consider manual therapy (spinal manipulation, mobilisation, or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy.
Note This table only includes outcomes defined by the Guideline Development Group as being critical to decision making; see the guideline for more information on those outcomes defined as important. NICE looked at evidence for both acute/subacute and chronic pain. This table has therefore been added to both sections in the BMJ Best Practice topic. No serious adverse events attributable to manual therapy were reported by any of the studies reviewed. However, the guideline committee were aware of possible serious very rare adverse events that may be related to spinal manipulation and took this into account when making their recommendation. Overall the guideline committee felt the evidence for these therapies used alone was limited with little additional benefit, especially in the longer term, compared with usual care. Therefore, their recommendation was that these should only be considered as part of a “treatment package”. See guideline for more information. ᵃ Usual care as defined by individual included studies. NICE also considered evidence for the following comparisons: each other, any other non-invasive intervention for non-specific low back pain, and combination therapy (see guideline for more information). ᵇ Effectiveness was the same, but GRADE varied with time point (≤4 months versus >4 months). ᶜ Effectiveness was the same, but GRADE varied with modality. ᵈ The guideline committee agreed this difference was not clinically important (as a default an improvement of 10% was required to show clinical benefit).
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is very low or low where GRADE has been performed and the intervention may be more effective/beneficial than the comparison for key outcomes. However, this is uncertain and new evidence could change this in the future.
Population: People aged ≥16 years with non-specific low back pain
Intervention: Group exercise programme ᵃ
Comparison: Usual care ᵇ
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Group biomechanical exercise versus usual care in people with low back pain without sciatica | ||
Quality of life composite scores (SF-36) <4 months: mental or physical component | Favours intervention | Moderate |
Quality of life individual scores (SF-12) <4 months: general health, physical functioning, physical role limitation, bodily pain, social functioning, or health perception | No statistically significant difference | Very Low |
Pain (Visual Analogue Scale [VAS]) <4 months | Favours intervention | Very Low |
Function (Oswestry Disability Index [ODI]) <4 months | Favours intervention | Very Low |
Group aerobic exercise versus usual care in people with low back pain without sciatica | ||
Quality of life (SF-36 mental or physical component) <4 months | Favours intervention | Very Low |
Quality of life (SF-36 physical functioning or physical role limitation) <4 months | No statistically significant difference | Very Low |
Pain (VAS or McGill Questionnaire) <4 months | No statistically significant difference | Very Low |
Pain (VAS) >4 months | No statistically significant difference | Low |
Function (ODI) <4 months | Favours intervention | Very Low |
Function (ODI) > 4 months | No statistically significant difference | Very Low |
Psychological distress (Radloff's Center for Epidemiologic Studies Depression Scale) <4 months | No statistically significant difference | Very Low |
Group mind-body exercise versus usual care in people with low back pain without sciatica | ||
Pain (VAS) at both <4 months and >4 months | Favours intervention | Very Low |
Group mixed exercise versus usual care in people with low back pain without sciatica | ||
Quality of life (SF-36) at <4 months | No statistically significant difference | Low to Very Low ᶜ |
Pain (VAS) <4 months | Favours intervention | Low |
Pain (VAS, change scores) <4 months | No statistically significant difference | Very Low |
Function (ODI/Roland Morris Disability Questionnaire, change score) <4 months | Favours intervention | Very Low |
Psychological distress (Hospital Anxiety and Depression Scale) <4 month | No statistically significant difference | Very Low |
Recommendations as stated in the source guideline The National Institute for Health and Care Excellence (NICE) guideline on Low back pain and sciatica in over 16s makes the following recommendation: Consider a group exercise programme (biomechanical, aerobic, mind–body, or a combination of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica. Take people’s specific needs, preferences, and capabilities into account when choosing the type of exercise.
Note NICE looked at evidence for both acute/subacute and chronic pain. This table has been added to both sections in the Best Practice topic. ᵃ The guideline also considered individual exercise programmes, but as the evidence better supported group exercise (and this was the recommendation made), only the evidence for group programmes has been included in this table. ᵇ Usual care as defined by individual included studies. NICE also considered evidence for the following comparisons: placebo, sham, attention control, waiting list, any other non-invasive intervention for non-specific low back pain, different exercise programmes versus each other, and combination therapy (with exercise therapy as the adjunct). See the guideline for more information. ᶜ GRADE rating is very low for all quality of life (SF-36) scores as listed in the guideline for this comparison group except for emotional role limitation, which is low.
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is moderate or low to moderate where GRADE has been performed and the intervention may be more effective/beneficial than the comparison for key outcomes.
Population: People aged 16 years or above with non-specific low back pain
Intervention: Combined physical and psychological programme
Comparison: Placebo/Sham or attention control; usual care or waiting list; or psychological intervention or physical programme alone
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Psychological intervention (behavioural therapy) plus exercise (aerobic) compared with waiting list for people with low back pain without sciatica | ||
Pain severity (McGill Questionnaire) ≤4 months | No statistically significant difference | Very Low |
Psychological intervention (behavioural therapy) plus exercise (aerobic) compared with exercise (aerobic) alone for people with low back pain without sciatica | ||
Pain severity (McGill Questionnaire) ≤4 months | No statistically significant difference | Very Low |
Psychological intervention (cognitive behavioural approaches) plus exercise compared with exercise alone for people with low back pain with or without sciatica | ||
Pain severity (Numeric Rating Scale [NRS]) ≤4 months | No statistically significant difference | Low |
Pain severity (NRS) >4 months | Favours intervention | Low |
Function (Low back outcome scale questionnaire) ≤4 months | No statistically significant difference | Low |
Function (Low back outcome scale questionnaire) >4 months | Favours intervention | Low |
Psychological intervention (cognitive behavioural approaches) plus self management compared with self management alone for people with low back pain with or without sciatica (mixed population) | ||
Pain severity (Von Korff scale) | Favours intervention ᵃ | Moderate to Low ᵇ |
Function (Roland Morris Disability Questionnaire or Von Korff scale) | Favours intervention ᵃ | Moderate to Low ᵇ |
Quality of life (EQ-5D) | Favours intervention | Moderate to Low ᵇ |
Quality of life (SF-12) ≤4 months | No statistically significant difference | Low |
Quality of life (SF-12 physical component) >4 months | No statistically significant difference | Moderate |
Quality of life (SF-12 mental component) >4 months | Favours intervention | Moderate |
Recommendations as stated in the source guideline The National Institute for Health and Care Excellence (NICE) guideline on Low back pain and sciatica in over 16s makes the following recommendation: Consider a combined physical and psychological programme, incorporating a cognitive behavioural approach (preferably in a group context that takes into account a person's specific needs and capabilities), for people with persistent low back pain or sciatica: when they have significant psychosocial obstacles to recovery (for example, avoiding normal activities based on inappropriate beliefs about their condition) or when previous treatments have not been effective.
Note The overall evidence rating in this table is based upon the results for combinations including cognitive behavioural therapy which is explicitly mentioned in the guideline recommendation. The guideline committee felt that the evidence indicated some potentially longer term benefits from a combined physical and psychological programme which incorporated cognitive behavioural approaches. The guideline committee also reviewed the evidence for psychological therapies in isolation but agreed that there was not enough evidence to make any recommendations for their use. ᵃ The guideline committee agreed this difference was not clinically important (as a default an improvement of 10% was required to show clinical benefit). ᵇ Effectiveness was the same, but GRADE varied with time point (≤4 months versus >4 months).
This evidence table is related to the following section/s:
Cochrane Clinical Answers
Cochrane Clinical Answers (CCAs) provide a readable, digestible, clinically focused entry point to rigorous research from Cochrane systematic reviews. They are designed to be actionable and to inform decision making at the point of care and have been added to relevant sections of the main Best Practice text.
- What are the effects of topical NSAIDS in adults with acute musculoskeletal pain?
- What are the effects of paracetamol in people with acute low back pain?
- In people with chronic low-back pain, is there randomized controlled trial evidence to support the use of therapeutic ultrasound?
- What are the risks and benefits of massage for low-back pain?
- What are the benefits and harms of multidisciplinary biopsychosocial rehabilitation in people with chronic low back pain?
- For adults with chronic pain, what are the benefits and harms of antidepressants?
- What are the effects of opioids compared with placebo or other treatments in people with chronic low-back pain?
Use of this content is subject to our disclaimer