Antidepressants. Older RCTs demonstrated no statistically significant effect on LBP, and a few newer RCTs have shown a small effect. Again, caution is wise given a 20% risk of adverse effects.
Narcotic analgesics. These drugs afford short-term moderate symptomatic relief. However, tolerance, adverse effects, and the potential to negatively influence long-term outcome have led to a considerable pendulum swing away from using these medications for chronic LBP.
SUMMARY: The medications frequently used for chronic LBP have less effect and greater risks than commonly appreciated. Their use should be considered with care and should be short term.
Exercise. The results of more than 20 RCTs suggest that exercise provides a moderate reduction in pain and a moderate increase in function in patients with chronic LBP. They also suggest that the specific type of exercise (eg, McKenzie, usual physical therapy, chiropractic, aerobics, or machine training) is unimportant—all appear to be effective to some degree.
Back schools. Intensive classroom-style education for patients with chronic LBP appears to have a minor benefit for return to work.
Behavioral therapy. Operant conditioning, cognitive treatments, and progressive relaxation have been studied in a handful of RCTs. The results have been conflicting.
Manual therapy. This intervention, often undertaken within chiropractic, appears to offer reasonable short-term relief but limited long-term effect. Because the adverse effects are minimal, however, manual therapy is a reasonable alternative.
Biofeedback. About 10 RCTs have been performed. The evidence suggests no effect on chronic LBP.