The contemporary management of non-specific low back pain: treatment, mechanisms and outcomes

Abstract

The broad aim of this thesis was to contribute to a better understanding of the contemporary management of non-specific low back pain (LBP) by investigating treatment options, mechanisms and outcomes. Chapter Two investigated the effectiveness of paracetamol for LBP in a Cochrane systematic review revealing high-quality evidence that there is no difference between paracetamol and placebo for acute LBP. Chapter Three and Chapter Four are two Cochrane reviews investigating the effectiveness of motor control exercise (MCE) for acute and chronic LBP. For acute, there is low to moderate quality evidence indicating no clinically important differences between MCE and manual therapy or other exercises. For chronic, there is low to high quality evidence that MCE is effective for pain and function compared with minimal intervention, but not clinically different from other exercises or manual therapy. Chapter Five evaluated the clinimetric properties of the Lumbar Spine Instability Questionnaire (LSIQ) in 107 people with LBP. The LSIQ seemed a unidimensional measure and had adequate reliability. However, it had poor internal consistency and did not function as an interval-level measure. Chapter Six investigated the credibility of subgroup claims in LBP trials using a 10-item checklist addressing design, analysis, and context. The credibility of subgroup claims was typically low and overstated by authors. Chapter Seven is a viewpoint exploring the advantages and disadvantages of subgroup analyses, considering the progress made to date, and the relevant literature in adjacent fields. Chapter Eight, a secondary analysis of Cochrane reviews, showed that LBP treatments usually provide larger effects for pain than for disability. The studies in this thesis have provided an important contribution to the contemporary management of LBP. The main implications are: i) paracetamol should not be endorsed in guidelines; ii) MCE is effective for chronic LBP, although it is not superior to other exercises; iii) subgroups in LBP have low credibility and lack validation, but a simple checklist can help improve research in this area; iv) the LSIQ needs more studies to understand its use and construct measured; and v) pain intensity should still be the primary measure of treatment success in chronic pain.