Placebo effects in low back pain: A systematic review and meta‐analysis of the literature

Lennep, Johan Hans Peter Alexander van; Trossèl, Faye; Perez, Roberto Silvio Giovanni Maria; Otten, René; Middendorp, Henriët van; Evers, Andrea; Szadek, Karolina M.

doi:10.1002/ejp.1811

Cited by 24 publications

(10 citation statements)

References 56 publications

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“…Anyhow, we consider (based on the confidence intervals) most effects on pain as probably clinically relevant when individualised exercises are compared to passive measures or other exercises. The clinical relevance may be strengthened due to the following reasons: i) adding a stratification and /or personalisation to the exercise intervention is simple and almost time and cost neutral, ii) at 12 weeks pain intensity was reduced by individualised exercise by 40% and at 26 weeks by 38%, which from a patient's perspective is of clear benefit, iii) all results are at least consistent in the point that there is a trend (or, even, mostly a significant betweengroup difference leading to a probable relevant effect) towards individualised treatments that becomes larger when not comparing to active but passive controls, iv) taking into account the strong known placebo effects in low back pain 43 emphasizes the small effects retrieved in our study. As all studies were patient-examiner blinded -what hands-on trials cannot be blamed for-this observation seems robust.…”

Section: Discussionmentioning

confidence: 62%

Individualized exercise in chronic non-specific low back pain: a systematic review with meta-analysis on the effects of exercise alone or in combination with psychological interventions on pain and disability

Fleckenstein

Floessel

Engel

et al. 2021

Preprint

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ObjectiveTo investigate the effects of individualised exercise interventions consisting with or without combined psychological intervention on pain intensity and disability in patients with chronic non-specific low back pain.DesignSystematic review with meta-analysis and meta-regression.Data sourcesFive databases (PubMed, Cochrane Central, EMBASE, Clarivate Web of Science, and Google Scholar) were searched up to 31 March 2021.Selection criteriaRandomised controlled trials were eligible if they included participants with chronic non-specific low back pain, compared at least one individualised/personalised/stratified exercise intervention with or without psychological treatment to any control / comparator group, and if they assessed at least pain intensity or disability as outcome measure.ResultsFifty-eight studies (n = 9099 patients, 44.3 years, 56% female) compared individualised to other types of exercise (n = 44; 62%), usual care (n = 16; 23%), advice to stay active, or true controls. The remaining studies had passive controls.At short-term follow-up, low-certainty evidence for pain intensity (SMD -0.33 [95%CI -0.47 to -0.18]) and very low-certainty evidence for disability (−0.16 [-0.30 to -0.02]) indicates effects of individualised exercise compared to other exercises. Very low-certainty evidence for pain intensity (−0.35; [-0.53 to - 0.17])) and low-certainty evidence for disability (−0.12; [-0.22 to -0.02]) indicates effects compared to passive controls.At long-term follow-up, moderate-certainty evidence for pain intensity (−0.14 [-0.23 to -0.06]) and disability (−0.23 [-0.33 to -0.12]) indicates effects compared to passive controls exercises.All findings stayed below the threshold for minimal clinically important difference (MCID). Certainty of evidence was downgraded mainly due to evidence of risk of bias, publication bias and inconsistency that could not be explained. Sensitivity analyses indicated that the effects on pain, but not on disability (always short-term and versus active treatments) were robust. Sub-group analysis of pain outcomes suggested that individualised exercise treatment is probably more effective in combination with psychological interventions (−0.32 [-0.51 to -0.14]), a clinically important differenceConclusionWe found very low to moderate-certainty evidence that individualised exercise is effective for treatment of chronic non-specific low back pain. Individualised exercise seems superior to other active treatments and sub-group analysis suggests that some forms of individualised exercise (especially motor-control based treatments) combined with behavioural therapy interventions enhances the treatment effect. Certainty of evidence was higher for long-term follow-up. In summary, individualised exercise can be recommended from a clinical point of view.

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Section: Discussionmentioning

confidence: 62%

Individualized exercise in chronic non-specific low back pain: a systematic review with meta-analysis on the effects of exercise alone or in combination with psychological interventions on pain and disability

Fleckenstein

Floessel

Engel

et al. 2021

Preprint

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“…Hence, the effects of SMT against placebo or sham SM remain uncertain. This parallels the state of research on most interventions for spine pain, as no treatment has been demonstrated to be superior to any other or to placebo (126)(127)(128). It could be argued that effective treatments for LBP and NP have a large share of non-specific effects.…”

Section: Discussion and Future Perspectivesmentioning

confidence: 88%

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain

et al. 2021

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Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.

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“…Through altering expectations, shifting mood, and providing social support, placebo treatments have been shown to decrease perceptions of pain [ 43 ]. A recent meta-analysis of patients with LBP also showed significant placebo effects for pain intensity and LBP-related disability [ 44 ]. Future studies should further investigate the expectation of improvement based on interventions.…”

Section: Discussionmentioning

confidence: 99%

Stratification of spine patients based on self-reported clinical symptom classes: Evaluation of long-term outcomes and subsequent interventions

Lapin

Davin

Stilphen

et al. 2023

North American Spine Society Journal (NASSJ)

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Placebo effects in low back pain: A systematic review and meta‐analysis of the literature

Abstract: This is an open access article under the terms of the Creat ive Commo ns Attri bution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Cited by 24 publications

References 56 publications

Individualized exercise in chronic non-specific low back pain: a systematic review with meta-analysis on the effects of exercise alone or in combination with psychological interventions on pain and disability

Individualized exercise in chronic non-specific low back pain: a systematic review with meta-analysis on the effects of exercise alone or in combination with psychological interventions on pain and disability

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain

Stratification of spine patients based on self-reported clinical symptom classes: Evaluation of long-term outcomes and subsequent interventions

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