Effectiveness of interventions for non-specific low back pain in older adults. A systematic review and meta-analysis

Published:November 15, 2018DOI:



      Systematically review the literature about all available interventions to manage non-specific low back pain (NSLBP) in older adults (≥60 years).


      We searched the Medline, EMBASE, CINAHL, LILACS, PEDro, and Cochrane CENTRAL databases reference lists for randomized controlled trials (RCTs) testing interventions for NSLBP. Two independent reviewers extracted data, assessed the risk of bias and completeness of the description of interventions.


      Eighteen (RCTs) fulfilled the eligibility criteria. Evidence about interventions to manage NSLBP in older adults is weak. Very low to moderate quality evidence showed that complementary health approach (i.e., manual therapy, acupuncture, mindfulness, yoga), percutaneous electrical nerve stimulation (PENS), education, exercise or pharmacological agents were not effective to produce a clinically significant reduction in pain and disability at short-term and intermediate-term compared to sham, usual care or minimal intervention. Interventions were moderately well-described according to the template for intervention description and replication (TIDieR) and the risk of bias was moderate 6.4 points on the 10-point PEDro Scale (SD = 1.44).


      Evidence about interventions for NSLP in older adults is limited and new studies are highly likely to change these results. This result may impact healthcare providers due to the lack of effective evidence based interventions, patients, and policy makers that will expend financial resources with interventions that provide in the best scenario a not significant improvement of the clinical symptoms. Researchers need to consider the importance of designing clinical trials targeting older adults and examine possible outcome modifiers present in this population allowing the recommendation of more efficacious evidence-based interventions.

      Systematic Review Registration Number

      PROSPERO (CRD42016036686).


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        • Hoy D.
        • March L.
        • Brooks P.
        • Blyth F.
        • Woolf A.
        • Bain C.
        • et al.
        The global burden of low back pain: estimates from the Global Burden of Disease 2010 study.
        Ann Rheum Dis. 2014; 73: 968-974
        • Deyo R.A.
        • Bryan M.
        • Comstock B.A.
        • Turner J.A.
        • Heagerty P.
        • Friedly J.
        • et al.
        Trajectories of symptoms and function in older adults with low back disorders.
        Spine. 2015;
        • Scheele J.
        • Luijsterburg P.A.
        • Bierma-Zeinstra S.M.
        • Koes B.W.
        Course of back complaints in older adults: a systematic literature review.
        Eur J Phys Rehabil Med. 2012; 48: 379-386
        • Donelson R.
        • McIntosh G.
        • Hall H.
        Is it time to rethink the typical course of low back pain?.
        PM R. 2012; 4 (quiz 400): 394-401
        • Macfarlane G.J.
        • Beasley M.
        • Jones E.A.
        • Prescott G.J.
        • Docking R.
        • Keeley P.
        • et al.
        The prevalence and management of low back pain across adulthood: results from a population-based cross-sectional study (the MUSICIAN study).
        Pain. 2012; 153: 27-32
        • Delitto A.
        • George S.Z.
        • Van Dillen L.
        • Whitman J.M.
        • Sowa G.A.
        • Shekelle P.
        • et al.
        Low back pain: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the american physical therapy association.
        J Orthop Sports Phys Ther. 2012; 42: A1-A57
        • Dziechciaz M.
        • Filip R.
        Biological psychological and social determinants of old age: bio-psycho-social aspects of human aging.
        Ann Agric Environ Med. 2014; 21: 835-838
        • Teixeira L.F.
        • Pereira L.S.M.
        • Silva S.L.A.
        • Dias J.M.D.
        • Dias R.C.
        Factors associated with attitudes and beliefs of elders with acute low back pain: data from the study Back Complaints in the Elders (BACE).
        Braz J Phys Ther. 2016; 20: 553-560
        • Lautenbacher S.
        • Peters J.H.
        • Heesen M.
        • Scheel J.
        • Kunz M.
        Age changes in pain perception: a systematic-review and meta-analysis of age effects on pain and tolerance thresholds.
        Neurosci Biobehav Rev. 2017; 75: 104-113
        • Paeck T.
        • Ferreira M.L.
        • Sun C.
        • Lin C.W.
        • Tiedemann A.
        • Maher C.G.
        Are older adults missing from low back pain clinical trials? A systematic review and meta-analysis.
        Arthritis Care Res. 2014; 66: 1220-1226
        • Anderson E.Z.
        Complementary therapies and older adults.
        Top Geriatr Rehabil. 2009; 25: 320-328
        • Wang H.
        • Naghavi M.
        • Allen C.
        • Barber R.M.
        • Bhutta Z.A.
        • Carter A.
        • et al.
        Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015.
        Lancet. 2016; 388: 1459-1544
        • Vos T.
        • Allen C.
        • Arora M.
        • Barber R.M.
        • Bhutta Z.A.
        • Brown A.
        • et al.
        Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.
        Lancet. 2016; 388: 1545-1602
        • Bergen G.
        • Stevens M.R.
        • Burns E.R.
        Falls and fall injuries among adults aged ≥65 years – United States, 2014.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 1-998
        • Rosa N.M.B.
        • Queiroz B.Z.
        • Lopes R.A.
        • Sampaio N.R.
        • Pereira D.S.
        • Pereira L.S.M.
        Risk of falls in Brazilian elders with and without low back pain assessed using the Physiological Profile Assessment: BACE study.
        Braz J Phys Ther. 2016; 20: 502-509
        • Ehrenbrusthoff K.
        • Ryan C.G.
        • Schofield P.
        • Martin D.J.
        Physical therapy management of older adults with chronic low back pain: a systematic review.
        J Pain Manag. 2012; 5: 317-329
        • Kuss K.
        • Becker A.
        • Quint S.
        • Leonhardt C.
        Activating therapy modalities in older individuals with chronic non-specific low back pain: a systematic review.
        Physiotherapy. 2015; 101: 310-318
        • United Nations, Department of Economic and Social Affairs, Population Division
        World population ageing 2015 (ST/ESA/SER.A/390).
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • Mulrow C.
        • Gotzsche P.C.
        • Ioannidis J.P.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
        BMJ. 2009; 339: b2700
        • Riva J.J.
        • Malik K.M.P.
        • Burnie S.J.
        • Endicott A.R.
        • Busse J.W.
        What is your research question? An introduction to the PICOT format for clinicians.
        J Can Chiropr Assoc. 2012; 56: 167-171
        • Maher C.
        • Underwood M.
        • Buchbinder R.
        Non-specific low back pain.
        Lancet. 2016; 389: 736-747
      1. 2013 CBRG. [Available fom:].

        • Sherrington C.
        • Herbert R.D.
        • Maher C.G.
        • Moseley A.M.
        PEDro: a database of randomized trials and systematic reviews in physiotherapy.
        Man Ther. 2000; 5: 223-226
        • Macedo L.G.
        • Elkins M.R.
        • Maher C.G.
        • Moseley A.M.
        • Herbert R.D.
        • Sherrington C.
        There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials.
        J Clin Epidemiol. 2010; 63: 920-925
        • de Morton N.A.
        The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study.
        Aust J Physiother. 2009; 55: 129-133
        • Hoffmann T.C.
        • Glasziou P.P.
        • Boutron I.
        • Milne R.
        • Perera R.
        • Moher D.
        • et al.
        Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide.
        BMJ. 2014; : 348
        • Higgins J.
        • Green S.
        Cochrane handbook for systematic reviews of interventions version 5.1.0.
        2011 (Available fom:)
        • Guyatt G.H.
        • Oxman A.D.
        • Kunz R.
        • Brozek J.
        • Alonso-Coello P.
        • Rind D.
        • et al.
        GRADE guidelines 6. Rating the quality of evidence–imprecision.
        J Clin Epidemiol. 2011; 64: 1283-1293
        • Herbert R.D.
        How to estimate treatment effects from reports of clinical trials: I: continuous outcomes.
        Aust J Physiother. 2000; 46: 229-235
        • Rubinstein S.M.
        • Terwee C.B.
        • Assendelft W.J.J.
        • Boer M.R.D.
        • Tulder M.W.V.
        Spinal manipulative therapy for acute low-back pain.
        The Cochrane Library, 2012
        • van der Roer N.
        • Ostelo R.W.
        • Bekkering G.E.
        • van Tulder M.W.
        • de Vet H.C.
        Minimal clinically important change for pain intensity, functional status, and general health status in patients with nonspecific low back pain.
        Spine. 2006; 31 (Phila Pa 1976): 578-582
        • Inoue M.
        • Kitakoji H.
        • Ishizaki N.
        • Tawa M.
        • Yano T.
        • Katsumi Y.
        • et al.
        Relief of low back pain immediately after acupuncture treatment – a randomised, placebo controlled trial.
        Acupunct Med. 2006; 24: 103-108
        • Giemza C.
        • Matczak-Giemza M.
        • De Nardi M.
        • Ostrowska B.
        • Czech P.
        Effect of frequent WBC treatments on the back pain therapy in elderly men.
        Aging Male. 2015; 18: 135-142
        • Dougherty P.E.
        • Karuza J.
        • Dunn A.S.
        • Savino D.
        • Katz P.
        Spinal manipulative therapy for chronic lower back pain in older veterans: a prospective, randomized, placebo-controlled trial.
        Geriatr Orthop Surg Rehabil. 2014; 5: 157-164
        • Grant D.J.
        • Bishop-Miller J.
        • Winchester D.M.
        • Anderson M.
        • Faulkner S.
        A randomized comparative trial of acupuncture versus transcutaneous electrical nerve stimulation for chronic back pain in the elderly.
        Pain. 1999; 82: 9-13
        • Meng C.F.
        • Wang D.
        • Ngeow J.
        • Lao L.
        • Peterson M.
        • Paget S.
        Acupuncture for chronic low back pain in older patients: a randomized, controlled trial.
        Rheumatology. 2003; 42: 1508-1517
        • Morone N.E.
        • Greco C.M.
        • Moore C.G.
        • Rollman B.L.
        • Lane B.
        • Morrow L.A.
        • et al.
        A mind-body program for older adults with chronic low back pain: a randomized clinical trial [with consumer summary].
        JAMA Intern Med. 2016; 176: 329-337
        • Soriano F.
        • Rios R.
        Gallium arsenide laser treatment of chronic low back pain: a prospective, randomized and double blind study.
        Laser Ther. 1998; 10: 175-180
        • Sritoomma N.
        • Moyle W.
        • Cooke M.
        • O’Dwyer S.
        The effectiveness of Swedish massage with aromatic ginger oil in treating chronic low back pain in older adults: a randomized controlled trial.
        Complement Ther Med. 2014; 22: 26-33
        • Weiner D.K.
        • Perera S.
        • Rudy T.E.
        • Glick R.M.
        • Shenoy S.
        • Delitto A.
        Efficacy of percutaneous electrical nerve stimulation and therapeutic exercise for older adults with chronic low back pain: a randomized controlled trial.
        Pain. 2008; 30: 344-357
        • Weiner D.K.
        • Rudy T.E.
        • Glick R.M.
        • Boston J.R.
        • Lieber S.J.
        • Morrow L.A.
        • et al.
        Efficacy of percutaneous electrical nerve stimulation for the treatment of chronic low back pain in older adults.
        J Am Geriatr Soc. 2003; 51: 599-608
        • Costantino C.
        • Romiti D.
        Effectiveness of back school program versus hydrotherapy in elderly patients with chronic non-specific low back pain: a randomized clinical trial.
        Acta BioMed. 2014; 85: 52-61
        • Hondras M.A.
        • Long C.R.
        • Cao Y.
        • Rowell R.M.
        • Meeker W.C.
        A randomized controlled trial comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain [with consumer summary].
        J Manipulative Physiol Ther. 2009; 32: 330-343
        • Learman K.E.
        • Showalter C.
        • O’Halloran B.
        • Cook C.E.
        Thrust and nonthrust manipulation for older adults with low back pain: an evaluation of pain and disability [with consumer summary].
        J Manipulative Physiol Ther. 2013; 36: 284-291
        • Teut M.
        • Knilli J.
        • Daus D.
        • Roll S.
        • Witt C.M.
        Qigong or yoga versus no intervention in older adults with chronic low back pain – a randomized controlled trial.
        J Pain. 2016; 17: 796-805
        • Cruz-Diaz D.
        • Martinez-Amat A.
        • de la Torre-Cruz M.J.
        • Casuso R.A.
        • de Guevara N.M.L.
        • Hita-Contreras F.
        Effects of a six-week Pilates intervention on balance and fear of falling in women aged over 65 with chronic low-back pain: a randomized controlled trial.
        Maturitas. 2015; 82: 371-376
        • Vincent H.K.
        • George S.Z.
        • Seay A.N.
        • Vincent K.R.
        • Hurley R.W.
        Resistance exercise, disability, and pain catastrophizing in obese adults with back pain.
        Med Sci Sports Exerc. 2014; 46: 1693-1701
        • Haas M.
        • Groupp E.
        • Muench J.
        • Kraemer D.
        • Brummel-Smith K.
        • Sharma R.
        • et al.
        Chronic disease self-management program for low back pain in the elderly.
        J Manipulative Physiol Ther. 2005; 28: 228-237
        • Miki K.
        • Ikemoto T.
        • Hayashi K.
        • Arai Y.C.
        • Sekiguchi M.
        • Shi K.
        • et al.
        Randomized open-labbel non-inferiority trial of acetaminophen or loxoprofen for patients with acute low back pain.
        J Orthop Sci. 2018; 23: 483-487
        • Furlan A.D.
        • Yazdi F.
        • Tsertsvadze A.
        • Gross A.
        • Van Tulder M.
        • Santaguida L.
        • et al.
        A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain.
        Evid Based Complement Altern Med. 2012; 2012 (eCAM 953139)
        • Rubinstein S.M.
        • van Middelkoop M.
        • Kuijpers T.
        • Ostelo R.
        • Verhagen A.P.
        • de Boer M.R.
        • et al.
        A systematic review on the effectiveness of complementary and alternative medicine for chronic non-specific low-back pain.
        Eur Spine J. 2010; 19: 1213-1228
        • Shea B.J.
        • Hamel C.
        • Wells G.A.
        • Bouter L.M.
        • Kristjansson E.
        • Grimshaw J.
        • et al.
        AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews.
        J Clin Epidemiol. 2009; 62: 1013-1020
        • Ghoname E.A.
        • Craig W.F.
        • White P.F.
        • Ahmed H.E.
        • Hamza M.A.
        • Henderson B.N.
        • et al.
        Percutaneous electrical nerve stimulation for low back pain: a randomized crossover study.
        JAMA. 1999; 281: 818-823
        • Yokoyama M.
        • Sun X.
        • Oku S.
        • Taga N.
        • Sato K.
        • Mizobuchi S.
        • et al.
        Comparison of percutaneous electrical nerve stimulation with transcutaneous electrical nerve stimulation for long-term pain relief in patients with chronic low back pain.
        Anesth Analg. 2004; 98: 1552-1556
        • National Guideline C
        National Institute for Health and Care Excellence: clinical guidelines. Low back pain and sciatica in over 16s: assessment and management.
        National Institute for Health and Care Excellence (UK) Copyright (c) NICE, 2016, London2016
        • Parreira P.
        • Heymans M.W.
        • van Tulder M.W.
        • Esmail R.
        • Koes B.W.
        • Poquet N.
        • et al.
        Back schools for chronic non-specific low back pain.
        Cochrane Database Syst Rev. 2017; 8Cd011674
        • Straube S.
        • Harden M.
        • Schröder H.
        • Arendacka B.
        • Fan X.
        • Moore R.A.
        • et al.
        Back schools for the treatment of chronic low back pain: possibility of benefit but no convincing evidence after 47 years of research—systematic review and meta-analysis.
        Pain. 2016; 157: 2160-2172
        • Oliveira V.C.
        • Ferreira P.H.
        • Maher C.G.
        • Pinto R.Z.
        • Refshauge K.M.
        • Ferreira M.L.
        Effectiveness of self-management of low back pain: systematic review with meta-analysis.
        Arthritis Care Res. 2012; 64: 1739-1748
        • Huang Z.
        • Ma J.
        • Chen J.
        • Shen B.
        • Pei F.
        • Kraus V.B.
        The effectiveness of low-level laser therapy for nonspecific chronic low back pain: a systematic review and meta-analysis.
        Arthritis Res Ther. 2015; 17: 360
        • Yousefi-Nooraie R.
        • Schonstein E.
        • Heidari K.
        • Rashidian A.
        • Pennick V.
        • Akbari-Kamrani M.
        • et al.
        Low level laser therapy for nonspecific low-back pain.
        Cochrane Database Syst Rev. 2008;
        • French S.D.
        • Cameron M.
        • Walker B.F.
        • Reggars J.W.
        • Esterman A.J.
        Superficial heat or cold for low back pain.
        The Cochrane Library, 2006
        • Poitras S.
        • Brosseau L.
        Evidence-informed management of chronic low back pain with transcutaneous electrical nerve stimulation, interferential current, electrical muscle stimulation, ultrasound, and thermotherapy.
        Spine J. 2008; 8: 226-233
        • Gutiérrez Espinoza H.J.
        • Lavado Bustamante I.P.
        • Méndez Pérez S.J.
        Revisión sistemática sobre el efecto analgésico de la crioterapia en el manejo del dolor de origen músculo esquelético.
        Revista de la Sociedad Española del Dolor. 2010; 17: 242-252
        • Saragiotto B.T.
        • Machado G.C.
        • Ferreira M.L.
        • Pinheiro M.B.
        • Abdel Shaheed C.
        • Maher C.G.
        Paracetamol for low back pain.
        Cochrane Database Syst Rev. 2016;
        • Stochkendahl M.J.
        • Kjaer P.
        • Hartvigsen J.
        • Kongsted A.
        • Aaboe J.
        • Andersen M.
        • et al.
        National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy.
        Eur Spine J. 2018; 27: 60-75
        • Hayden J.
        • van Tulder M.W.
        • Malmivaara A.
        • Koes B.W.
        Exercise therapy for treatment of non-specific low back pain.
        The Cochrane Library, 2005
        • Ferreira M.L.
        • Smeets R.J.E.M.
        • Kamper S.J.
        • Ferreira P.H.
        • Machado L.A.C.
        Can we explain heterogeneity among randomized clinical trials of exercise for chronic back pain? A meta- regression analysis of randomized controlled trials.
        Phys Ther. 2010; 90: 1383-1403
        • Yamato T.P.
        • Maher C.
        • Koes B.
        • Moseley A.
        The PEDro scale had acceptably high convergent validity, construct validity, and interrater reliability in evaluating methodological quality of pharmaceutical trials.
        J Clin Epidemiol. 2017; 86: 176-181