Key messages
- Compared to usual care, alternative care models probably do not appreciably improve the quality of care for people with low back pain in terms of referrals to or use of any lumbar spine imaging and prescription or use of opioids.
- Alternative care models do not make an important difference to the level of pain or back-related function.
- We are less certain of the effects on lumbar spine surgery, hospitalisation, and total adverse (unwanted or harmful) events.
What is non-specific low back pain, and how is it treated?
Low back pain (situated between the bottom of the ribs and top of the buttocks) is a common problem and can be disabling. In most people, it is not possible to identify a specific cause of the problem.
Much of the care given to people with low back pain does not fully follow evidence-based guidelines. When this occurs, people may not benefit, and healthcare resources are wasted. Alternative care models deliver the same care but change how it is delivered or co-ordinated with the hope of improving adherence to evidence-based guidelines and patient health outcomes. Examples include telemedicine compared to in-person care or care delivered to groups compared to individual patients.
What did we want to find out?
We wanted to find out if delivering the same care but in a different way improved quality of care and patient health outcomes in people with non-specific low back pain.
What did we do?
We searched for studies that investigated alternative care models compared to usual care in people with non-specific low back pain. We compared and summarised the results and rated our confidence in the evidence, based on factors such as trial methods and size.
What did we find?
We included 57 studies (29,578 people). Most were set in primary care, either general practice or physiotherapy, in high-income countries.
Main results
Compared with usual care, 19 fewer people out of 1000 were referred to, or received, lumbar spine imaging (e.g. x-ray, computed tomography (CT), magnetic resonance imaging (MRI)) with alternative care models.
- 213 out of 1000 people were referred to/received lumbar spine imaging with alternative care models.
- 232 out of 1000 people were referred to/received lumbar spine imaging with usual care.
Compared with usual care, 17 fewer people out of 1000 were prescribed or used opioid medication (e.g. morphine, codeine) with alternative care models.
- 332 out of 1000 people were prescribed/used opioid medication with alternative care models.
- 349 out of 1000 people were prescribed/used opioid medication with usual care.
Compared with usual care, 2 more people out of 1000 were referred to, or underwent, lumbar spine surgery with alternative care models.
- 76 out of 1000 people were referred to a surgeon or had lumbar spine surgery with alternative care models.
- 74 out of 1000 people were referred to a surgeon or had lumbar spine surgery with usual care.
Compared to usual care, 23 fewer people out of 1000 were admitted to hospital with alternative care models.
- 176 out of 1000 people were admitted to hospital with alternative care models.
- 199 out of 1000 people were admitted to hospital with usual care.
Pain was measured on a 0 to 10-point scale (lower scores mean less pain), and was 0.24 points better with alternative care models.
- People who received alternative care models rated their pain as 2.2 points.
- People who received usual care rated their pain as 2.4 points.
Back-related function was measured on a 0 to 24-point scale (lower score means less disability), and was 0.7 points better with alternative models of care compared with usual care.
- People who received alternative care models rated their back-related function as 5.7 points.
- People who received usual care rated their back-related function as 6.4 points.
Compared to usual care, 10 fewer people out of 1000 reported adverse events with alternative care models.
- 45 out of 1000 people reported an adverse event with alternative care models.
- 55 out of 1000 people reported an adverse event with usual care.
What are the limitations of the evidence?
Compared to usual care, we are confident that alternative care models:
- do not make an important difference to the level of pain;
- do not make an important difference to back-related function.
Compared to usual care, we are moderately confident that alternative care models:
- do not make an important difference to the likelihood of referral for or receipt of lumbar spine imaging;
- do not make a difference to the likelihood of prescription or use of opioid medication.
Compared to usual care, we are not confident that alternative care models:
- change the likelihood of being referred to a surgeon or undergoing lumbar spine surgery;
- change the likelihood of being admitted to the hospital for low back pain;
- change the likelihood of suffering an adverse event.
How up-to-date is this evidence?
The evidence is up-to-date to June 2024.
Compared to usual care, alternative care models for non-specific low back pain probably lead to little or no difference in the quality of care and result in small but clinically unimportant improvements in pain and back-related function. Whether alternative care models result in a difference in total adverse events compared to usual care remains unresolved.
Alternative care models seek to improve the quality or efficiency of care, or both, and thus optimise patient health outcomes. They provide the same health care but change how, when, where, or by whom health care is delivered and co-ordinated. Examples include care delivered via telemedicine versus in-person care or care delivered to groups versus individual patients.
To assess the effects of alternative models of evidenced-based care for people with non-specific low back pain on the quality of care and patient self-reported outcomes and to summarise the availability and principal findings of economic evaluations of these alternative models.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries up to 14 June 2024, unrestricted by language.
We included randomised controlled trials comparing alternative care models to usual care or other care models. Eligible trials had to investigate care models that changed at least one domain of the Cochrane EPOC delivery arrangement taxonomy and provide the same care as the comparator arm. Participants were individuals with non-specific low back pain, regardless of symptom duration. Main outcomes were quality of care (referral for/receipt of lumbar spine imaging, prescription/use of opioids, referral to a surgeon/lumbar spine surgery, admission to hospital for back pain), patient health outcomes (pain, back-related function), and adverse events.
Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE. The primary comparison was alternative models of care versus usual care at closest follow-up to 12 months.
Fifty-seven trials (29,578 participants) met our inclusion criteria. Trials were primarily set within primary care (18 trials) or physiotherapy practices (15 trials) in high-income countries (51 trials). Forty-eight trials compared alternative models of care to usual care. There was substantial clinical diversity across alternative care models. Alternative care models most commonly differed from usual care by altering the co-ordination/management of care processes (18 trials), or by utilising information and communication technology (10 trials).
Moderate-certainty evidence indicates that alternative care models probably result in little difference in referral for or receipt of any lumbar spine imaging at follow-up closest to 12 months compared to usual care (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.86 to 0.98; I2 = 2%; 18 trials, 16,157 participants). In usual care, 232/1000 people received lumbar spine imaging compared to 213/1000 people who received alternative care models. We downgraded the certainty of the evidence by one level due to serious indirectness (diversity in outcome measurement).
Moderate-certainty evidence suggests that alternative care models probably result in little or no difference in the prescription or use of opioid medication at follow-up closest to 12 months compared to usual care (RR 0.95, 95% CI 0.89 to 1.03; I2 = 0%; 15 trials, 13,185 participants). In usual care, 349 out of 1000 people used opioid medication compared to 332 out of 1000 people in alternative care models. We downgraded the certainty of the evidence by one level due to serious indirectness (diversity in outcome measurement).
We are uncertain if alternative care models alter referral for or use of lumbar spine surgery at follow-up closest to 12 months compared to usual care as the certainty of the evidence was very low (odds ratio (OR) 1.04, 95% CI 0.79 to 1.37; I2 = 0%; 10 trials, 4189 participants). We downgraded the certainty of the evidence by three levels due to very serious imprecision (wide CIs) and serious indirectness (diversity in outcome measurement).
We are uncertain if alternative care models alter hospital admissions for non-specific low back pain at follow-up closest to 12 months compared to usual care as the certainty of evidence was very low (OR 0.86, 95% CI 0.67 to 1.11; I2 = 8%; 12 trials, 10,485 participants). We downgraded the certainty of the evidence by three levels due to serious indirectness (diversity in outcome measurement), serious publication bias (asymmetry of results), minor imprecision (wide CIs), and minor risk of bias (blinding of participants/personnel).
High-certainty evidence indicates that alternative care models result in a small but clinically unimportant improvement in pain on a 0 to 10 scale (mean difference -0.24, 95% CI -0.43 to -0.05; I2 = 68%; 36 trials, 9403 participants). Mean pain at follow-up closest to 12 months was 2.4 points on a 0 to 10 rating scale (lower score indicates less pain) with usual care compared to 2.2 points with alternative care models, a difference of 0.2 points better (95% CI 0.4 better to 0.0 better; minimal clinically important difference (MCID) 0.5 to 1.5 points).
High-certainty evidence indicates that alternative care models result in a small, clinically unimportant improvement in back-related function compared with usual care (standardised mean difference -0.12, 95% CI -0.20 to -0.04; I2 = 66%; 44 trials, 13,688 participants). Mean back-related function at follow-up closest to 12 months was 6.4 points on a 0 to 24 rating scale (lower score indicates less disability) with usual care compared to 5.7 points with alternative care models, a difference of 0.7 points better (95% CI 1.2 better to 0.2 better; MCID 1.5 to 2.5 points).
We are uncertain of the effect of alternative care models on adverse events compared to usual care as the certainty of the evidence was very low (OR 0.81, 95% CI 0.45 to 1.45; I2 = 43%; 10 trials, 2880 participants). We downgraded the certainty of the evidence by three levels due to serious risk of bias (blinding of participants/personnel), serious indirectness (variation in assumed risk), and serious inconsistency (substantial between-study heterogeneity).