Pharmacotherapy Versus Exercise for Management of Low Back Pain: a Network Meta-analysis

Abstract Background/aims: Use of pharmacological agents for low back pain (LBP) is more popular than physical exercises due to convenience, and administrative easiness. However, it is unclear whether pharmacotherapy is superior to exercises. The study aimed to examine efficacy of pharmacotherapy versus physical exercises for LBP. Materials/Methods: This is a network meta-analysis of randomized and non-randomised trials. We searched MEDLINE, PubMed, CINAHL, Academic Search Complete, and PsycINFO for articles published in English on use of pharmacotherapy and/or exercise in LBP management. Initial title, abstract screening and extraction were done following a predefined eligibility criteria. We used random-effect model of meta-analysis to estimate efficacy of pharmacotherapy and exercise, and network meta-analysis to compare their separate efficacies. We appraised quality of the included studies with aid of Cochrane Risk of Bias 1 and 2. Results: Relative to placebo, there were significant reductions in pain intensity with both pharmacotherapy (SMD = -0.769, 95% CI = -1.290-0.248, I2 = 96.634) and exercises (SMD = -1.563, CI = -2.784-0.342, I2 = 93.701). Direct comparison of pharmacotherapy and exercise showed insignificant reduction in pain intensity amongst individuals who received exercise compared to pharmacotherapy and exercise (SMD= -0.138, CI = -0.384 – 0.660). Indirect comparison showed no significant difference between pharmacotherapy and acupuncture (SMD = 0.023 (CI = -0.688 to 0.733). Overall, in favour of exercise, we obtained a combined estimate of SMD = -0.483 = (CI =-2.059 to 1.093). Conclusions: Exercise appears superior to pharmacotherapy for LBP, however exercise may not always be a preferred option.