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2 October 2007 | Volume 147 Issue 7 | Pages 492-504
Background: Many nonpharmacologic therapies are available for treatment of low back pain.
Purpose: To assess benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain).
Data Sources: English-language studies were identified through searches of MEDLINE (through November 2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4). These electronic searches were supplemented by hand searching of reference lists and additional citations suggested by experts.
Study Selection: Systematic reviews and randomized trials of 1 or more of the preceding therapies for acute or chronic low back pain (with or without leg pain) that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction.
Data Extraction: We abstracted information about study design, population characteristics, interventions, outcomes, and adverse events. To grade methodological quality, we used the Oxman criteria for systematic reviews and the Cochrane Back Review Group criteria for individual trials.
Data Synthesis: We found good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks' duration) low back pain. Benefits over placebo, sham therapy, or no treatment averaged 10 to 20 points on a 100-point visual analogue pain scale, 2 to 4 points on the Roland–Morris Disability Questionnaire, or a standardized mean difference of 0.5 to 0.8. We found fair evidence that acupuncture, massage, yoga (Viniyoga), and functional restoration are also effective for chronic low back pain. For acute low back pain (<4 weeks' duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat (good evidence for moderate benefits) and spinal manipulation (fair evidence for small to moderate benefits). Although serious harms seemed to be rare, data on harms were poorly reported. No trials addressed optimal sequencing of therapies, and methods for tailoring therapy to individual patients are still in early stages of development. Evidence is insufficient to evaluate the efficacy of therapies for sciatica.
Limitations: Our primary source of data was systematic reviews. We included non–English-language trials only if they were included in English-language systematic reviews.
Conclusions: Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. For acute low back pain, the only therapy with good evidence of efficacy is superficial heat.
Author and Article Information
From the Oregon Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon.
Disclaimer: No statement in this article should be construed as an official position of the American Pain Society.
Acknowledgments: The authors thank Jayne Schablaske and Michelle Pappas for administrative support.
Grant Support: This article is based on research conducted at the Oregon Evidence-based Practice Center, with funding from the American Pain Society.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Roger Chou, MD, Oregon Evidence-based Practice Center, 3181 SW Sam Jackson Park Road, Mailcode BICC, Portland, OR 97239; e-mail, chour{at}ohsu.edu.
Current Author Addresses: Dr. Chou and Ms. Huffman: Oregon Evidence-based Practice Center, 3181 SW Sam Jackson Park Road, Mailcode BICC, Portland, OR 97239. CLINICAL GUIDELINES
Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline
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  R. Chou, P. Shekelle, A. Qaseem, and D. K. Owens Correction: Diagnosis and Treatment of Low Back Pain Ann Intern Med, February 5, 2008; 148(3): 247 - 248. [Full Text] [PDF]
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 Diagnosis and Treatment of Low Back Pain Journal Watch (General), October 25, 2007; 2007(1025): 1 - 1. [Full Text]
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R. Chou, A. Qaseem, V. Snow, D. Casey, J. T. Cross Jr, P. Shekelle, D. K. Owens, and for the Clinical Efficacy Assessment Subcommittee Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Ann Intern Med, October 2, 2007; 147(7): 478 - 491. [Abstract] [Full Text] [PDF]
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