Clinical Guidelines4 April 2017

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians

FREE
    Author, Article and Disclosure Information

    Abstract

    Description:

    The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.

    Methods:

    Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. Updated searches were performed through November 2016. Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.

    Target Audience and Patient Population:

    The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.

    Recommendation 1:

    Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

    Recommendation 2:

    For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)

    Recommendation 3:

    In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)

    Low back pain is one of the most common reasons for physician visits in the United States. Most Americans have experienced low back pain, and approximately one quarter of U.S. adults reported having low back pain lasting at least 1 day in the past 3 months (1). Low back pain is associated with high costs, including those related to health care and indirect costs from missed work or reduced productivity (2). The total costs attributable to low back pain in the United States were estimated at $100 billion in 2006, two thirds of which were indirect costs of lost wages and productivity (3).

    Low back pain is frequently classified and treated on the basis of symptom duration, potential cause, presence or absence of radicular symptoms, and corresponding anatomical or radiographic abnormalities. Acute back pain is defined as lasting less than 4 weeks, subacute back pain lasts 4 to 12 weeks, and chronic back pain lasts more than 12 weeks. Radicular low back pain results in lower extremity pain, paresthesia, and/or weakness and is a result of nerve root impingement. Most patients with acute back pain have self-limited episodes that resolve on their own; many do not seek medical care (4). For patients who do seek medical care, pain, disability, and return to work typically improve rapidly in the first month (5). However, up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode, and 1 in 5 report substantial limitations in activity (6). Many noninvasive treatment options are available for radicular and nonradicular low back pain, including pharmacologic and nonpharmacologic interventions.

    Guideline Focus and Target Population

    The purpose of this American College of Physicians (ACP) guideline is to provide treatment guidance based on the efficacy, comparative effectiveness, and safety of noninvasive pharmacologic and nonpharmacologic treatments for acute (<4 weeks), subacute (4 to 12 weeks), and chronic (>12 weeks) low back pain in primary care. This guideline does not address topical pharmacologic therapies or epidural injection therapies. It serves as a partial update of the 2007 ACP guideline (it excludes evidence on diagnosis). These recommendations are based on 2 background evidence reviews (7, 8) and a systematic review sponsored by the Agency for Healthcare Research and Quality (AHRQ) (9). The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.

    Methods
    Systematic Review of the Evidence

    The evidence review was conducted by the AHRQ's Pacific Northwest Evidence-based Practice Center. Additional methodological details can be found in the Appendix as well as in the accompanying articles (7, 8) and full report (9). Reviewers searched several databases for studies published in English from January 2008 through April 2015 and updated the search through November 2016. Studies published before 2007 were identified using the 2007 ACP/American Pain Society (APS) systematic reviews (10, 11). Reviewers combined data when possible using meta-analysis and assessed risk of bias and study quality according to established methods. The study population included adults (aged ≥18 years) with acute, subacute, or chronic nonradicular low back pain, radicular low back pain, or symptomatic spinal stenosis.

    The review evaluated pharmacologic (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], opioids, skeletal muscle relaxants [SMRs], benzodiazepines, antidepressants, antiseizure medications, and systemic corticosteroids) and nonpharmacologic (psychological therapies, multidisciplinary rehabilitation, spinal manipulation, acupuncture, massage, exercise and related therapies, and various physical modalities) treatments for low back pain. Evaluated outcomes included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability, return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.

    The magnitude of effect (small, moderate, or large) was determined as previously described (10, 11). A small effect on pain was defined as a mean between-group difference after treatment of 5 to 10 points on a visual analogue scale of 0 to 100 or equivalent, a mean between-group difference of 0.5 to 1.0 point on a numerical rating scale of 0 to 10, or a standardized mean difference of 0.2 to 0.5. A moderate effect was defined as a mean between-group difference of greater than 10 to no more than 20 points on a visual analogue scale of 0 to 100 or equivalent, a mean between-group difference of greater than 1.0 to no more than 2.0 points on a numerical rating scale of 0 to 10 or equivalent, or a standardized mean difference greater than 0.5 but no more than 0.8. For function, a small effect was defined as a mean between-group difference of 5 to 10 points on the Oswestry Disability Index (ODI), a mean between-group difference of 1 to 2 points on the Roland Morris Disability Questionnaire (RDQ), or a standardized mean difference of 0.2 to 0.5. A moderate effect on function was defined as a mean between-group difference of greater than 10 to no more than 20 points on the ODI, a mean between-group difference of greater than 2 to no more than 5 points on the RDQ, or a standardized mean difference greater than 0.5 but no more than 0.8. No large effects were found with any intervention.

    Grading the Evidence and Developing Recommendations

    This guideline was developed by ACP's Clinical Guidelines Committee (CGC) according to ACP's guideline development process, details of which can be found in the methods paper (12). The CGC used the evidence tables in the accompanying evidence reviews (7, 8) and full report (9) when reporting the evidence and graded the recommendations using the ACP's guideline grading system (Table).

    Table. The American College of Physicians Guideline Grading System*
    Peer Review

    The AHRQ systematic review was sent to invited peer reviewers and posted on the AHRQ Web site for public comments. The accompanying evidence reviews (7, 8) also underwent a peer review process through the journal. The guideline underwent a peer review process through the journal and was posted online for comments from ACP Regents and ACP Governors, who represent ACP members at the regional level.

    Benefits and Comparative Benefits of Pharmacologic Therapies
    Acute or Subacute Low Back Pain

    Appendix Table 1 summarizes the findings for all therapies for acute or subacute low back pain.

    Appendix Table 1. Pharmacologic and Nonpharmacologic Treatments for Acute or Subacute Low Back Pain
    Acetaminophen

    Low-quality evidence showed no difference between acetaminophen and placebo for pain intensity or function through 4 weeks or between acetaminophen and NSAIDs for pain intensity or likelihood of experiencing global improvement at 3 weeks or earlier (13, 14).

    NSAIDs

    Moderate-quality evidence showed that NSAIDs were associated with a small improvement in pain intensity compared with placebo (14, 15), although several randomized, controlled trials (RCTs) showed no difference in likelihood of achieving pain relief with NSAIDs compared with placebo (16–18). Low-quality evidence showed a small increase in function with NSAIDs compared with placebo (19). Moderate-quality evidence showed that most head-to-head trials of one NSAID versus another showed no differences in pain relief in patients with acute low back pain (14). Low-quality evidence showed no differences in pain between cyclooxygenase (COX)-2–selective NSAIDs versus traditional NSAIDs (14).

    SMRs

    Moderate-quality evidence showed that SMRs improved short-term pain relief compared with placebo after 2 to 4 and 5 to 7 days (20, 21). Low-quality evidence showed no differences between different SMRs for any outcomes in patients with acute pain (20). Low-quality evidence showed inconsistent findings for the effect on pain intensity with a combination of SMRs plus NSAIDs compared with NSAIDs alone (20, 22, 23).

    Systemic Corticosteroids

    Low-quality evidence showed no difference in pain or function between a single intramuscular injection of methylprednisolone or a 5-day course of prednisolone compared with placebo in patients with acute low back pain (24, 25).

    Other Therapies

    Evidence was insufficient to determine effectiveness of antidepressants, benzodiazepines (26, 27), antiseizure medications, or opioids versus placebo in patients with acute or subacute low back pain.

    Chronic Low Back Pain

    Appendix Table 2 summarizes the findings for all therapies for chronic low back pain.

    Appendix Table 2. Pharmacologic and Nonpharmacologic Treatments for Chronic Low Back Pain
    Appendix Table 2. Continued
    NSAIDs

    Moderate-quality evidence showed that NSAIDs were associated with small to moderate pain improvement compared with placebo (14, 28, 29). Low-quality evidence showed that NSAIDs were associated with no to small improvement in function (28–31). Moderate-quality evidence showed that most head-to-head trials of one NSAID versus another showed no differences in pain relief in patients with chronic low back pain (14). There were no data on COX-2–selective NSAIDs.

    Opioids

    Moderate-quality evidence showed that strong opioids (tapentadol, morphine, hydromorphone, and oxymorphone) were associated with a small short-term improvement in pain scores (about 1 point on a pain scale of 0 to 10) and function compared with placebo (32–36). Low-quality evidence showed that buprenorphine patches improved short-term pain more than placebo in patients with chronic low back pain; however, the improvement corresponded to less than 1 point on a pain scale of 0 to 10 (37–40). Moderate-quality evidence showed no differences among different long-acting opioids for pain or function (33, 41–44), and low-quality evidence showed no clear differences in pain relief between long- and short-acting opioids (45–50). Moderate-quality evidence showed that tramadol achieved moderate short-term pain relief and a small improvement in function compared with placebo (32, 51, 52).

    SMRs

    Evidence comparing SMRs versus placebo was insufficient (53–55). Low-quality evidence showed no differences in any outcome between different SMRs for treatment of chronic low back pain (20).

    Benzodiazepines

    Low-quality evidence showed that tetrazepam improved pain relief at 5 to 7 days and resulted in overall improvement at 10 to 14 days compared with placebo (20).

    Antidepressants

    Moderate-quality evidence showed no difference in pain between tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) versus placebo, and low-quality evidence showed no differences in function for antidepressants (56). Moderate-quality evidence showed that duloxetine was associated with a small improvement in pain intensity and function compared with placebo (57–59).

    Other Therapies

    Evidence was insufficient to determine the effect of acetaminophen, systemic corticosteroids, or antiseizure medications on chronic low back pain.

    Radicular Low Back Pain

    Appendix Table 3 summarizes the findings for all treatments for radicular low back pain.

    Appendix Table 3. Pharmacologic and Nonpharmacologic Treatments for Radicular Low Back Pain
    Benzodiazepines

    Low-quality evidence showed no difference between diazepam and placebo for function at 1 week through 1 year and analgesic use, return to work, or likelihood of surgery through 1 year of follow-up in patients with acute or subacute radicular pain (60). Diazepam resulted in a lower likelihood of pain improvement at 1 week compared with placebo.

    Systemic Corticosteroids

    Moderate-quality evidence showed no differences in pain between systemic corticosteroids and placebo and no to small effect on function in patients with radicular low back pain (61–66).

    Other Therapies

    No RCTs evaluated acetaminophen, SMRs, antidepressants, or opioids for radicular low back pain. Results for NSAIDs were inconsistent for pain, and evidence was therefore insufficient (22). There was insufficient evidence to determine the effect of antiseizure medications on radicular low back pain (67–71).

    Harms of Pharmacologic Therapies

    Harms were derived from the identified systematic reviews. Adverse effects generally associated with the drugs can be found in Appendix Table 4.

    Appendix Table 4. Adverse Events for Treatments for Acute, Chronic, and Radicular Low Back Pain

    Moderate-quality evidence showed no difference among scheduled acetaminophen, acetaminophen taken as needed, or placebo for serious adverse events (13). Moderate-quality evidence showed that more adverse effects occurred with NSAIDs than placebo, COX-2–selective NSAIDs were associated with a decreased risk for adverse effects compared with traditional NSAIDs, and acetaminophen was associated with a lower risk for adverse effects than NSAIDs (14). Moderate-quality evidence showed that short-term use of opioids increased nausea, dizziness, constipation, vomiting, somnolence, and dry mouth compared with placebo, and SMRs increased risk for any adverse event and central nervous system adverse events (mostly sedation) compared with placebo (20). Moderate-quality evidence showed that antidepressants increased risk for any adverse event compared with placebo, although rates of specific adverse events did not differ (72). The risk for serious adverse events did not differ between duloxetine and placebo, although duloxetine was associated with increased risk for withdrawal due to adverse events (57–59). Low-quality evidence showed no clear differences in adverse effects for gabapentin versus placebo (67, 68). Low-quality evidence showed that benzodiazepines caused more frequent somnolence, fatigue, and lightheadedness than placebo (20). Harms were not well-reported, and no RCTs assessed long-term use of benzodiazepines or risks for addiction, abuse, or overdose. Adverse events for systemic corticosteroids were not well-reported in RCTs, but the largest trial found that oral prednisone was associated with increased risk for any adverse event, insomnia, nervousness, and increased appetite (66). However, low-quality evidence showed no cases of hyperglycemia that required medical attention (24, 61, 64).

    Comparative Benefits of Nonpharmacologic Therapies
    Acute or Subacute Low Back Pain
    Exercise

    Low-quality evidence showed no difference between exercise therapy and usual care for pain or function in patients with acute or subacute pain (11); additional trials reported inconsistent results (73–75). Moderate-quality evidence showed no clear differences between different exercise regimens in more than 20 head-to-head RCTs in patients with acute low back pain.

    Acupuncture

    Low-quality evidence showed that acupuncture resulted in a small decrease in pain intensity compared with sham acupuncture with nonpenetrating needles, but there were no clear effects on function (76–78). Low-quality evidence showed that acupuncture slightly increased the likelihood of overall improvement compared with NSAIDs (76, 79–83).

    Massage

    Low-quality evidence showed that massage moderately improved short-term (1 week) pain and function compared with sham therapy for subacute low back pain (84), although 1 trial (85) showed no difference in pain or function at 5 weeks. Moderate-quality evidence showed that massage improved short-term pain relief and function compared with other interventions (manipulation, exercise therapy, relaxation therapy, acupuncture, or physiotherapy) for patients with subacute to chronic low back pain, but effects were small (84, 86). Low-quality evidence showed that a combination of massage plus another intervention (exercise, exercise and education, or usual care) was superior to the other intervention alone for short-term pain in patients with subacute to chronic low back pain (84).

    Spinal Manipulation

    Low-quality evidence showed that spinal manipulation was associated with a small effect on function compared with sham manipulation; evidence was insufficient to determine the effect on pain (87, 88). Low-quality evidence showed no difference in pain relief at 1 week between spinal manipulation and inert treatment (educational booklet, detuned ultrasound, detuned or actual short-wave diathermy, antiedema gel, or bed rest), although 1 trial showed better longer-term pain relief (3 months) with spinal manipulation (89). Function did not differ between spinal manipulation and inert treatment at 1 week or 3 months (89). Moderate-quality evidence showed no difference between spinal manipulation and other active interventions for pain relief at 1 week through 1 year or function (analyses included exercise, physical therapy, or back school as the comparator) (89, 90). Low-quality evidence showed that a combination of spinal manipulation plus exercise or advice slightly improved function at 1 week compared with exercise or advice alone, but these differences were not present at 1 or 3 months (89).

    Superficial Heat

    Moderate-quality evidence showed that a heat wrap moderately improved pain relief (at 5 days) and disability (at 4 days) compared with placebo (91). Low-quality evidence showed that a combination of heat plus exercise provided greater pain relief and improved RDQ scores at 7 days compared with exercise alone in patients with acute pain (92). Low-quality evidence showed that a heat wrap provided more effective pain relief and improved RDQ scores compared with acetaminophen or ibuprofen after 1 to 2 days (93). Low-quality evidence showed no clear differences between a heat wrap and exercise in pain relief or function (92).

    Low-Level Laser Therapy

    Low-quality evidence showed that a combination of low-level laser therapy (LLLT) and NSAIDs largely decreased pain intensity and resulted in a moderate improvement in function (as measured by the ODI) compared with sham laser therapy plus NSAIDs in patients with acute or subacute pain (94).

    Lumbar Supports

    Low-quality evidence showed no difference in pain or function between lumbar supports added to an educational program compared with an educational program alone or other active interventions in patients with acute or subacute low back pain (95).

    Other Therapies

    Evidence was insufficient to determine the effectiveness of transcutaneous electrical nerve stimulation (TENS), electrical muscle stimulation, inferential therapy, short-wave diathermy, traction, superficial cold, motor control exercise (MCE), Pilates, tai chi, yoga, psychological therapies, multidisciplinary rehabilitation, ultrasound, and taping.

    Chronic Low Back Pain
    Exercise

    Moderate-quality evidence showed that exercise resulted in a small improvement in pain relief and function compared with no exercise (11, 96). Moderate-quality evidence showed that compared with usual care, exercise resulted in small improvements in pain intensity and function at the end of treatment, although effects were smaller at long-term follow-up (96). Moderate-quality evidence showed no clear differences between different exercise regimens in more than 20 head-to-head RCTs in patients with chronic low back pain.

    MCE

    Motor control exercise focuses on restoring coordination, control, and strength of the muscles that control and support the spine. Low-quality evidence showed that MCE moderately decreased pain scores and slightly improved function in short- to long-term follow-up compared with a minimal intervention (97). Low-quality evidence showed that MCE resulted in small improvements in pain intensity at short-term (≥6 weeks to <4 months) and intermediate-term (≥4 to <8 months) follow-up compared with general exercise, although improvements were small and no longer significant at long-term follow-up (97). Motor control exercise also resulted in small improvements in function in the short and long term (97). Low-quality evidence showed that MCE resulted in a moderate improvement in pain intensity and function compared with multimodal physical therapy at intermediate follow-up (97). Low-quality evidence showed no clear differences in pain with a combination of MCE plus exercise versus exercise alone (98, 99).

    Pilates

    Low-quality evidence showed that Pilates resulted in small or no clear effects on pain and no clear effects on function compared with usual care plus physical activity (100–107). Low-quality evidence showed no clear differences between Pilates and other types of exercise for pain or function (108–110).

    Tai Chi

    Low-quality evidence showed that tai chi resulted in moderate pain improvement compared with wait-list controls or no tai chi (111, 112), and 1 study showed a small increase in function (111). Moderate-quality evidence showed that tai chi moderately decreased pain intensity at 3 and 6 months compared with backward walking or jogging but not versus swimming (112).

    Yoga

    Low-quality evidence showed that Iyengar yoga resulted in moderately lower pain scores and improved function compared with usual care at 24 weeks (113). Low-quality evidence showed that yoga resulted in a small decrease in pain intensity compared with exercise (114–118). Low-quality evidence showed that, compared with education, yoga resulted in a small decrease in short-term (≤12 weeks) but not long-term (about 1 year) pain intensity and a small increase in short- and long-term function (119).

    Psychological Therapies

    Low-quality evidence showed that progressive relaxation therapy moderately improved pain intensity and functional status compared with wait-list controls (120). Low-quality evidence showed that electromyography biofeedback training moderately decreased pain intensity (reduction of 5 to 13 points on a 100-point pain scale) compared with wait-list controls, but there was no effect on function (120). Low-quality evidence showed that operant therapy (behavioral therapy involving reinforcement) slightly improved pain intensity compared with wait-list control, although there was no difference for function (120). Low-quality evidence showed that cognitive behavioral therapy (CBT) and other combined psychological therapies (involving education, problem-solving training, coping techniques, imagery, relaxation, goal setting, cognitive pain control, and exercises) were associated with moderately improved pain intensity compared with wait-list controls, but there was no difference in function (120). Moderate-quality evidence showed that mindfulness-based stress reduction is an effective treatment for chronic low back pain. One study showed a small improvement in pain at 26 and 52 weeks and in function at 26 weeks compared with usual care (121). The same study showed no difference between mindfulness-based stress reduction and CBT for improvements in pain or function. Two other studies showed improvement in pain and function compared with education (122, 123). Low-quality evidence showed no difference between psychological therapies and exercise or physical therapy for pain intensity (120). Low-quality evidence showed no differences in pain or function between a combination of psychological therapy plus exercise or physiotherapy compared with exercise or physiotherapy alone (120). Moderate-quality evidence showed no differences between different psychological therapies for pain or function outcomes (120).

    Multidisciplinary Rehabilitation

    Moderate-quality evidence showed that multidisciplinary rehabilitation moderately reduced short-term (<3 months) and slightly reduced long-term pain intensity and disability compared with usual care, although there was no difference in return to work (124). Low-quality evidence showed that multidisciplinary rehabilitation was associated with moderately lower short-term pain intensity and slightly lower disability than no rehabilitation (124). Moderate-quality evidence showed that multidisciplinary rehabilitation was associated with slightly lower short-term pain intensity and disability, moderately lower long-term pain intensity, and improved function compared with physical therapy and a greater likelihood of returning to work compared with nonmultidisciplinary rehabilitation (124).

    Acupuncture

    Low-quality evidence showed that acupuncture was associated with moderate improvement in pain relief immediately after treatment and up to 12 weeks later compared with sham acupuncture, but there was no improvement in function (125–130). Moderate-quality evidence showed that acupuncture was associated with moderately lower pain intensity and improved function compared with no acupuncture at the end of treatment (125). Low-quality evidence showed a small improvement in pain relief and function compared with medications (NSAIDs, muscle relaxants, or analgesics) (125).

    Massage

    Low-quality evidence showed no difference in pain between foot reflexology and usual care for patients with chronic low back pain (131–133). Moderate-quality evidence showed that massage improved short-term pain relief and function compared with other interventions (manipulation, exercise therapy, relaxation therapy, acupuncture, physiotherapy, or TENS) for patients with subacute to chronic low back pain, although effects were small (84, 86). Low-quality evidence showed that a combination of massage plus another intervention (exercise, exercise and education, or usual care) was superior to the other intervention alone for short-term pain in patients with subacute to chronic low back pain (84).

    Spinal Manipulation

    Low-quality evidence showed no difference in pain with spinal manipulation versus sham manipulation at 1 month (134, 135). Low-quality evidence showed that spinal manipulation slightly improved pain compared with an inert treatment (136–142). Moderate-quality evidence showed no clear differences in pain or function compared with another active intervention. Low-quality evidence showed that a combination of spinal manipulation with another active treatment resulted in greater pain relief and improved function at 1, 3, and 12 months compared with the other treatment alone (134, 143–147).

    Ultrasound

    Low-quality evidence showed no difference between ultrasound and sham ultrasound for pain at the end of treatment or 4 weeks after treatment (148–150). Low-quality evidence showed no difference between ultrasound and no ultrasound for pain or function (151, 152).

    TENS

    Low-quality evidence showed no difference between TENS and sham TENS for pain intensity or function at short-term follow-up (153). Low-quality evidence showed no difference between TENS and acupuncture in short- or long-term pain (154).

    LLLT

    Low-quality evidence showed that LLLT slightly improved pain compared with sham laser (155–157), and 1 RCT (155) showed that LLLT slightly improved function compared with sham laser.

    Lumbar Support

    Evidence was insufficient to compare lumbar support versus no lumbar support. Low-quality evidence showed no difference between a lumbar support plus exercise (muscle strengthening) versus exercise alone for pain or function at 8 weeks or 6 months (158). Low-quality evidence showed no clear differences between lumbar supports and other active treatments (traction, spinal manipulation, exercise, physiotherapy, or TENS) for pain or function (159–161).

    Taping

    Low-quality evidence showed no differences between Kinesio taping and sham taping for back-specific function after 5 or 12 weeks, although effects on pain were inconsistent between the 2 trials (162, 163). Low-quality evidence showed no differences between Kinesio taping and exercise for pain or function (164, 165).

    Other Therapies

    Evidence was insufficient to determine the effectiveness of electrical muscle stimulation, interferential therapy, short-wave diathermy, traction, or superficial heat or cold.

    Radicular Low Back Pain
    Exercise

    Low-quality evidence showed that exercise resulted in small improvements in pain and function compared with usual care or no exercise (166–168).

    Traction

    Low-quality evidence showed no clear differences between traction and other active treatments, between traction plus physiotherapy versus physiotherapy alone, or between different types of traction in patients with low back pain with or without radiculopathy (169).

    Other Therapies

    Evidence was insufficient for ultrasound, MCE, Pilates, tai chi, yoga, psychological therapies, multidisciplinary rehabilitation, acupuncture, massage, spinal manipulation, LLLT, electrical muscle stimulation, short-wave diathermy, TENS, interferential therapy, superficial heat or cold, lumbar support, and taping.

    Harms of Nonpharmacologic Therapies

    Evidence on adverse events from the included RCTs and systematic reviews was limited, and the quality of evidence for all available harms data is low. Harms were poorly reported (if they were reported at all) for most of the interventions.

    Low-quality evidence showed no reported harms or serious adverse events associated with tai chi, psychological interventions, multidisciplinary rehabilitation, ultrasound, acupuncture, lumbar support, or traction (9, 95, 150, 170–174). Low-quality evidence showed that when harms were reported for exercise, they were often related to muscle soreness and increased pain, and no serious harms were reported. All reported harms associated with yoga were mild to moderate (119). Low-quality evidence showed that none of the RCTs reported any serious adverse events with massage, although 2 RCTs reported soreness during or after massage therapy (175, 176). Adverse events associated with spinal manipulation included muscle soreness or transient increases in pain (134). There were few adverse events reported and no clear differences between MCE and controls. Transcutaneous electrical nerve stimulation was associated with an increased risk for skin site reaction but not serious adverse events (177). Two RCTs (178, 179) showed an increased risk for skin flushing with heat compared with no heat or placebo, and no serious adverse events were reported. There were no data on cold therapy. Evidence was insufficient to determine harms of electrical muscle stimulation, LLLT, percutaneous electrical nerve stimulation, interferential therapy, short-wave diathermy, and taping.

    Comparison of Conclusions With Those of the 2007 Guideline

    Some evidence has changed since the 2007 ACP guideline and supporting evidence review. The 2007 review concluded that acetaminophen was effective for acute low back pain, based on indirect evidence from trials of acetaminophen for other conditions and trials of acetaminophen versus other analgesics. However, this update included a placebo-controlled RCT in patients with low back pain that showed no difference in effectiveness between acetaminophen and placebo (low-quality evidence). In addition, contrary to the 2007 review, current moderate-quality evidence showed that TCAs were not effective for chronic low back pain compared with placebo. Additional pharmacologic treatments addressed in the current review included duloxetine and the antiseizure medication pregabalin. Many conclusions about nonpharmacologic interventions are similar between the 2007 review and the update. Additional modalities assessed (with at least low-quality evidence) include mindfulness-based stress reduction, MCE, taping, and tai chi. Additional evidence or changes from the updated review include that superficial heat was found to be more effective for acute or subacute low back pain (moderate-quality evidence) and neither ultrasound nor TENS was shown to be effective compared with controls (low-quality evidence).

    The Figure summarizes the recommendations and clinical considerations. Additional details on the evidence are available in Appendix Tables 1, 2, 3 and 4 and the accompanying evidence reviews (7, 8).

    Figure. Summary of the American College of Physicians guideline on noninvasive treatments for acute, subacute, or chronic low back pain.

    COX-2 = cyclooxygenase-2; LLLT = low-level laser therapy; NSAID = nonsteroidal anti-inflammatory drug; SMR = skeletal muscle relaxant.

    Figure. Continued
    Recommendations

    Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

    Clinicians should inform all patients of the generally favorable prognosis of acute low back pain with or without sciatica, including a high likelihood for substantial improvement in the first month (5, 180). Clinicians should also provide patients with evidence-based information with regard to their expected course, advise them to remain active as tolerated, and provide information about effective self-care options. Clinicians and patients should use a shared decision-making approach to select the most appropriate treatment based on patient preferences, availability, harms, and costs of the interventions. Nonpharmacologic interventions shown to be effective for improving pain and function in patients with acute or subacute low back pain include superficial heat (moderate-quality evidence and moderate improvement in pain and function) and massage (low-quality evidence and small to moderate improvement in pain and function). Low-quality evidence showed that acupuncture had a small effect on improving pain and spinal manipulation had a small effect on improving function compared with sham manipulation but not inert treatment. Harms of nonpharmacologic interventions were sparsely reported, and no serious adverse events were reported. Superficial heat was associated with increased risk for skin flushing, and massage and spinal manipulation were associated with muscle soreness.

    We recommend that the choice between NSAIDs and SMRs be individualized on the basis of patient preferences and likely individual medication risk profile. Treatment with NSAIDs resulted in a small improvement in both pain intensity (moderate-quality evidence) and function (low-quality evidence), and treatment with SMRs resulted in a small improvement in pain relief (moderate-quality evidence). There was no evidence for the effect of SMRs on function. Nonsteroidal anti-inflammatory drugs are associated with gastrointestinal and renal risks. Clinicians should therefore assess renovascular and gastrointestinal risk factors before prescribing NSAIDs and recommend the lowest effective doses for the shortest periods necessary. Although they are associated with lower risk for adverse effects than nonselective NSAIDs, COX-2–selective NSAIDs were not assessed for improvement in pain or function. Skeletal muscle relaxants are associated with central nervous system adverse effects, especially sedation.

    The updated evidence showed that acetaminophen was not effective at improving pain outcomes versus placebo. However, this study assessed pain at 3 weeks after the intervention, and evidence from head-to-head trials showed no difference between acetaminophen and NSAIDs. Low-quality evidence showed that systemic steroids were not effective in treating acute or subacute low back pain, and we recommend against these drugs for treatment of acute low back pain.

    Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)

    Nonpharmacologic interventions are considered as first-line options in patients with chronic low back pain because fewer harms are associated with these types of therapies than with pharmacologic options. It is important that physical therapies be administered by providers with appropriate training. Moderate-quality evidence showed that exercise therapy resulted in small improvements in pain and function. Specific components associated with greater effects on pain included individually designed programs, supervised home exercise, and group exercise; regimens that included stretching and strength training were most effective. Moderate-quality evidence showed that, compared with usual care, multidisciplinary rehabilitation resulted in moderate pain improvement in the short term (<3 months), small pain improvement in the long term, and small improvement in function in both the short and long term. Low-quality evidence showed that multidisciplinary rehabilitation resulted in a moderate improvement in pain and a small improvement in function compared with no multidisciplinary rehabilitation. Acupuncture had a moderate effect on pain and function compared with no acupuncture (moderate-quality evidence) and a moderate effect on pain with no clear effect on function compared with sham acupuncture (low-quality evidence). Moderate-quality evidence showed that mindfulness-based stress reduction resulted in small improvements in pain and function (small effect), and 1 study showed that it was equivalent to CBT for improving back pain and function.

    Low-quality evidence showed that tai chi had a moderate effect on pain and a small effect on function. Tai chi sessions in included studies lasted 40 to 45 minutes and were done 2 to 5 times per week for 10 to 24 weeks. Low-quality evidence showed that yoga improved pain and function by a moderate amount compared with usual care and by a small amount compared with education. Low-quality evidence showed that MCE had a moderate effect on pain and a small effect on function. Motor control exercise, tai chi, and yoga were favored over general exercise (low-quality evidence).

    Low-quality evidence showed that progressive relaxation had a moderate effect on pain and function, electromyography biofeedback and CBT each had a moderate effect on pain and no effect on function, and operant therapy had a small effect on pain and no effect on function. Low-quality evidence showed that LLLT had a small effect on pain and function. Low-quality evidence showed that spinal manipulation had a small effect on pain compared with inert treatment but no effect compared with sham manipulation. There were no clear differences between spinal manipulation and other active interventions (moderate-quality evidence).

    Harms were poorly reported for nonpharmacologic therapies, although no serious harms were reported for any of the recommended interventions. Muscle soreness was reported for exercise, massage, and spinal manipulation.

    Ultrasound, TENS, and Kinesio taping had no effect on pain or function compared with control treatments (low-quality evidence).

    Recommendation 3: In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)

    Pharmacologic therapy should be considered for patients with chronic low back pain who do not improve with nonpharmacologic interventions. Nonsteroidal anti-inflammatory drugs had a small to moderate effect on pain (moderate-quality evidence) and no to small effect on function (low-quality evidence) and should be the first option considered. Moderate-quality evidence showed no difference in pain improvement when different NSAIDs were compared with one another. Nonsteroidal anti-inflammatory drugs are associated with gastrointestinal and renal risks. Clinicians should therefore assess renovascular and gastrointestinal risk factors before prescribing NSAIDs and should recommend the lowest effective doses for the shortest periods necessary. COX-2–selective NSAIDs were not assessed for improvement in pain or function, although they are associated with lower risk for adverse effects than nonselective NSAIDs.

    For second-line therapies, moderate-quality evidence showed that tramadol had a moderate effect on pain and a small effect on function in the short term. Of note, tramadol is a narcotic and, like other opioids, is associated with the risk for abuse (181). Moderate-quality evidence showed that duloxetine had a small effect on pain and function.

    Moderate-quality evidence showed that opioids (morphine, oxymorphone, hydromorphone, and tapentadol) had a small effect on short-term pain and function. Low-quality evidence showed that buprenorphine (patch or sublingual) resulted in a small improvement in pain. Opioids should be the last treatment option considered and should be considered only in patients for whom other therapies have failed because they are associated with substantial harms. Moderate-quality evidence showed no difference in pain or function when different long-acting opioids were compared with one another. Harms of short-term use of opioids include increased nausea, dizziness, constipation, vomiting, somnolence, and dry mouth compared with placebo. Studies assessing opioids for the treatment of chronic low back pain did not address the risk for addiction, abuse, or overdose, although observational studies have shown a dose-dependent relationship between opioid use for chronic pain and serious harms (182).

    Moderate-quality evidence showed that TCAs did not effectively improve pain or function (low-quality evidence) in patients with chronic low back pain, which is contrary to the 2007 guideline. In addition, moderate-quality evidence showed that SSRIs did not improve pain.

    Areas of Inconclusive Evidence

    Evidence is insufficient or lacking to determine treatments for radicular low back pain. Most RCTs enrolled a mixture of patients with acute, subacute, and chronic low back pain, so it is difficult to extrapolate the benefits of treatment compared with its duration. Use of opioids for chronic pain is an important area that requires further research to compare benefits and harms of therapy. The evidence is also insufficient for most physical modalities. Evidence is insufficient on which patients are likely to benefit from which specific therapy. Evidence on patient-important outcomes, such as disability or return to work, was largely unavailable, and available evidence showed no clear connection with improvements in pain.

    High-Value Care

    Clinicians should reassure patients that acute or subacute low back pain usually improves over time, regardless of treatment. Thus, clinicians should avoid prescribing costly and potentially harmful treatments for these patients, especially narcotics. In addition, systemic steroids were not shown to provide benefit and should not be prescribed for patients with acute or subacute low back pain, even with radicular symptoms. For treatment of chronic low back pain, clinicians should select therapies that have the fewest harms and lowest costs because there were no clear comparative advantages for most treatments compared with one another. Clinicians should avoid prescribing costly therapies; those with substantial potential harms, such as long-term opioids (which can be associated with addiction and accidental overdose); and pharmacologic therapies that were not shown to be effective, such as TCAs and SSRIs.

    Appendix: Detailed Methods

    The evidence review was conducted by the AHRQ's Pacific Northwest Evidence-based Practice Center. Details of the ACP guideline development process can be found in ACP's methods paper (12). Disclosures of interests and management of any conflicts can be found at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.

    Key Questions Addressed

    1. What are the comparative benefits and harms of different pharmacologic therapies for acute or chronic nonradicular low back pain, radicular low back pain, or spinal stenosis, including NSAIDs, acetaminophen, opioids, muscle relaxants, antiseizure medications, antidepressants, corticosteroids, and topical or patch-delivered medications?

    2. What are the comparative benefits and harms of different nonpharmacologic, noninvasive therapies for acute or chronic nonradicular low back pain, radicular low back pain, or spinal stenosis, including but not limited to interdisciplinary rehabilitation, exercise (various types), physical modalities (ultrasound, TENS, electrical muscle stimulation, interferential therapy, heat [various forms], and ice), traction tables/devices, back supports/bracing, spinal manipulation, various psychological therapies, acupuncture, massage therapy (various types), yoga, magnets, and low-level lasers?

    Search Strategy

    Reviewers searched MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews for trials published from January 2008 through April 2015. Searches were updated through November 2016. Studies published before 2008 were identified using the 2007 ACP/APS systematic reviews (10, 11).

    Quality Assessment

    Randomized trials were evaluated using methods developed by the Cochrane Back Review Group and the AHRQ (183), and systematic reviews were assessed using AMSTAR (A Measurement Tool to Assess Systematic Reviews) (184).

    Population Studied

    Adults with acute, subacute, or chronic nonradicular low back pain, radicular low back pain, or symptomatic spinal stenosis.

    Interventions Evaluated

    Oral or topical pharmacologic therapies included NSAIDs, acetaminophen, opioids, tramadol and tapentadol, antidepressants, SMRs, benzodiazepines, corticosteroids, antiepileptic medications, capsaicin, and lidocaine.

    Noninvasive, nonpharmacologic therapies included interdisciplinary or multicomponent rehabilitation (physical therapy plus psychological therapy with some coordination), psychological therapies, exercise and related interventions (such as yoga or tai chi), complementary and alternative medicine therapies (spinal manipulation, acupuncture, and massage), passive physical modalities (such as heat, cold, ultrasound, TENS, electrical muscle stimulation, interferential therapy, short-wave diathermy, traction, LLLT, and lumbar supports/braces), and taping.

    Comparators

    Interventions were compared with each other or with placebo (drug trials), sham (functionally inert) treatments, or no treatment.

    Outcomes

    Outcomes included reduction or elimination of low back pain (including related leg symptoms), improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects of interventions.

    Timing

    Timing of outcomes was stratified as long-term (≥1 year) and short-term (≤6 months).

    Setting

    Settings included inpatient and outpatient.

    Target Audience

    The target audience includes all clinicians.

    Target Patient Population

    The target patient population includes adults with acute (<4 weeks), subacute (4 to 12 weeks), or chronic (>12 weeks) nonradicular low back pain, radicular low back pain, or symptomatic spinal stenosis. Children or adolescents with low back pain; pregnant women; and patients with low back pain from sources outside the back (nonspinal low back pain), fibromyalgia or other myofascial pain syndromes, and thoracic or cervical back pain are not included.

    Peer Review

    The AHRQ systematic review was sent to invited peer reviewers and posted on the AHRQ Web site for public comments. The accompanying evidence reviews (7, 8) also underwent a peer review process through the journal. The guideline underwent a peer review process through the journal and was posted online for comments from ACP Regents and ACP Governors, who represent ACP members at the regional level.

    References

    • 1. Deyo RAMirza SKMartin BIBack pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976)2006;31:2724-7. [PMID: 17077742] MedlineGoogle Scholar
    • 2. Andersson GBEpidemiological features of chronic low-back pain. Lancet1999;354:581-5. [PMID: 10470716] CrossrefMedlineGoogle Scholar
    • 3. Katz JNLumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am2006;88 Suppl 2:21-4. [PMID: 16595438] MedlineGoogle Scholar
    • 4. Carey TSEvans ATHadler NMLieberman GKalsbeek WDJackman AMet alAcute severe low back pain. A population-based study of prevalence and care-seeking. Spine (Phila Pa 1976)1996;21:339-44. [PMID: 8742211] CrossrefMedlineGoogle Scholar
    • 5. Pengel LHHerbert RDMaher CGRefshauge KMAcute low back pain: systematic review of its prognosis. BMJ2003;327:323. [PMID: 12907487] CrossrefMedlineGoogle Scholar
    • 6. Von Korff MSaunders KThe course of back pain in primary care. Spine (Phila Pa 1976)1996;21:2833-7. [PMID: 9112707] CrossrefMedlineGoogle Scholar
    • 7. Chou RDeyo RFriedly JSkelly AHashimoto RWeimer Met alNonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med2017;166:493-505. doi:10.7326/M16-2459 LinkGoogle Scholar
    • 8. Chou RDeyo RFriedly JSkelly AWeimer Met alSystemic pharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med2017;166:480-92. doi:10.7326/M16-2458 LinkGoogle Scholar
    • 9. Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. Noninvasive Treatments for Low Back Pain. Comparative Effectiveness Review no. 169. (Prepared by the Pacific Northwest Evidence-based Practice Center under contract no. 290-2012-00014-I.) AHRQ publication no. 16-EHC004-EF. Rockville: Agency for Healthcare Research and Quality; February 2016. Accessed at www.effectivehealthcare.ahrq.gov/reports/final.cfm on 19 January 2017. Google Scholar
    • 10. Chou RHuffman LHAmerican Pain SocietyMedications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med2007;147:505-14. [PMID: 17909211]. doi:10.7326/0003-4819-147-7-200710020-00008 LinkGoogle Scholar
    • 11. Chou RHuffman LHAmerican Pain SocietyNonpharmacologic 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. Ann Intern Med2007;147:492-504. [PMID: 17909210]. doi:10.7326/0003-4819-147-7-200710020-00007 LinkGoogle Scholar
    • 12. Qaseem ASnow VOwens DKShekelle PClinical Guidelines Committee of the American College of PhysiciansThe development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods. Ann Intern Med2010;153:194-9. [PMID: 20679562]. doi:10.7326/0003-4819-153-3-201008030-00010 LinkGoogle Scholar
    • 13. Williams CMMaher CGLatimer JMcLachlan AJHancock MJDay ROet alEfficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet2014;384:1586-96. [PMID: 25064594] doi:10.1016/S0140-6736(14)60805-9 CrossrefMedlineGoogle Scholar
    • 14. Roelofs PDDeyo RAKoes BWScholten RJvan Tulder MWNon-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev2008:CD000396. [PMID: 18253976] doi:10.1002/14651858.CD000396.pub3 CrossrefMedlineGoogle Scholar
    • 15. Herrmann WAGeertsen MSEfficacy and safety of lornoxicam compared with placebo and diclofenac in acute sciatica/lumbo-sciatica: an analysis from a randomised, double-blind, multicentre, parallel-group study. Int J Clin Pract2009;63:1613-21. [PMID: 19832818] doi:10.1111/j.1742-1241.2009.02187.x CrossrefMedlineGoogle Scholar
    • 16. Basmajian JVAcute back pain and spasm. A controlled multicenter trial of combined analgesic and antispasm agents. Spine (Phila Pa 1976)1989;14:438-9. [PMID: 2524114] CrossrefMedlineGoogle Scholar
    • 17. Goldie IA clinical trial with indomethacin (indomee®) in low back pain and sciatica. Acta Orthop Scand1968;39:117-28. [PMID: 4239771] CrossrefMedlineGoogle Scholar
    • 18. Weber HComparison of the effect of diazepam and levomepromazine on pain in patients with acute lumbago-sciatica. J Oslo City Hosp1980;30:65-8. [PMID: 6446597] MedlineGoogle Scholar
    • 19. Dreiser RLMarty MIonescu EGold MLiu JHRelief of acute low back pain with diclofenac-K 12.5 mg tablets: a flexible dose, ibuprofen 200 mg and placebo-controlled clinical trial. Int J Clin Pharmacol Ther2003;41:375-85. [PMID: 14518597] CrossrefMedlineGoogle Scholar
    • 20. van Tulder MWTouray TFurlan ADSolway SBouter LMMuscle relaxants for non-specific low back pain. Cochrane Database Syst Rev2003:CD004252. [PMID: 12804507] MedlineGoogle Scholar
    • 21. Ralph LLook MWheeler WSacks HDouble-blind, placebo-controlled trial of carisoprodol 250-mg tablets in the treatment of acute lower-back spasm. Curr Med Res Opin2008;24:551-8. [PMID: 18194591] doi:10.1185/030079908X261014 CrossrefMedlineGoogle Scholar
    • 22. Pareek AChandurkar NChandanwale ASAmbade RGupta ABartakke GAceclofenac-tizanidine in the treatment of acute low back pain: a double-blind, double-dummy, randomized, multicentric, comparative study against aceclofenac alone. Eur Spine J2009;18:1836-42. [PMID: 19421791] doi:10.1007/s00586-009-1019-4 CrossrefMedlineGoogle Scholar
    • 23. Friedman BWDym AADavitt MHolden LSolorzano CEsses Det alNaproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA2015;314:1572-80. [PMID: 26501533] doi:10.1001/jama.2015.13043 CrossrefMedlineGoogle Scholar
    • 24. Friedman BWHolden LEsses DBijur PEChoi HKSolorzano Cet alParenteral corticosteroids for emergency department patients with non-radicular low back pain. J Emerg Med2006;31:365-70. [PMID: 17046475] CrossrefMedlineGoogle Scholar
    • 25. Eskin BShih RDFiesseler FWWalsh BWAllegra JRSilverman MEet alPrednisone for emergency department low back pain: a randomized controlled trial. J Emerg Med2014;47:65-70. [PMID: 24739318] doi:10.1016/j.jemermed.2014.02.010 CrossrefMedlineGoogle Scholar
    • 26. Hingorani KDiazepam in backache. A double-blind controlled trial. Ann Phys Med1966;8:303-6. [PMID: 4224750] MedlineGoogle Scholar
    • 27. Moll W[Therapy of acute lumbovertebral syndromes through optimal muscle relaxation using diazepam. Results of a double-blind study on 68 cases]. Med Welt1973;24:1747-51. [PMID: 4272092] MedlineGoogle Scholar
    • 28. Katz NBorenstein DGBirbara CBramson CNemeth MASmith MDet alEfficacy and safety of tanezumab in the treatment of chronic low back pain. Pain2011;152:2248-58. [PMID: 21696889] doi:10.1016/j.pain.2011.05.003 CrossrefMedlineGoogle Scholar
    • 29. Kivitz AJGimbel JSBramson CNemeth MAKeller DSBrown MTet alEfficacy and safety of tanezumab versus naproxen in the treatment of chronic low back pain. Pain2013;154:1009-21. [PMID: 23628600] doi:10.1016/j.pain.2013.03.006 CrossrefMedlineGoogle Scholar
    • 30. Birbara CAPuopolo ADMunoz DRSheldon EAMangione ABohidar NRet alEtoricoxib Protocol 042 Study GroupTreatment of chronic low back pain with etoricoxib, a new cyclo-oxygenase-2 selective inhibitor: improvement in pain and disability—a randomized, placebo-controlled, 3-month trial. J Pain2003;4:307-15. [PMID: 14622687] CrossrefMedlineGoogle Scholar
    • 31. Katz NJu WDKrupa DASperling RSBozalisRodgers DGertz BJet alVioxx Chronic Low Back Pain Study GroupEfficacy and safety of rofecoxib in patients with chronic low back pain: results from two 4-week, randomized, placebo-controlled, parallel-group, double-blind trials. Spine (Phila Pa 1976)2003;28:851-8. [PMID: 12941996] CrossrefMedlineGoogle Scholar
    • 32. Chaparro LEFurlan ADDeshpande AMailis-Gagnon AAtlas STurk DCOpioids compared to placebo or other treatments for chronic low-back pain. Cochrane Database Syst Rev2013:CD004959. [PMID: 23983011] doi:10.1002/14651858.CD004959.pub4(5) CrossrefMedlineGoogle Scholar
    • 33. Hale MEDvergsten CGimbel JEfficacy and safety of oxymorphone extended release in chronic low back pain: results of a randomized, double-blind, placebo- and active-controlled phase III study. J Pain2005;6:21-8. [PMID: 15629415] CrossrefMedlineGoogle Scholar
    • 34. Cloutier CTaliano JO'Mahony WCsanadi MCohen GSutton Iet alControlled-release oxycodone and naloxone in the treatment of chronic low back pain: a placebo-controlled, randomized study. Pain Res Manag2013;18:75-82. [PMID: 23662289] CrossrefMedlineGoogle Scholar
    • 35. Rauck RLNalamachu SWild JEWalker GSRobinson CYDavis CSet alSingle-entity hydrocodone extended-release capsules in opioid-tolerant subjects with moderate-to-severe chronic low back pain: a randomized double-blind, placebo-controlled study. Pain Med2014;15:975-85. [PMID: 24517082] doi:10.1111/pme.12377 CrossrefMedlineGoogle Scholar
    • 36. Wen WSitar SLynch SYHe ERipa SRA multicenter, randomized, double-blind, placebo-controlled trial to assess the efficacy and safety of single-entity, once-daily hydrocodone tablets in patients with uncontrolled moderate to severe chronic low back pain. Expert Opin Pharmacother2015;16:1593-606. [PMID: 26111544] doi:10.1517/14656566.2015.1060221 CrossrefMedlineGoogle Scholar
    • 37. Steiner DJSitar SWen WSawyerr GMunera CRipa SRet alEfficacy and safety of the seven-day buprenorphine transdermal system in opioid-naïve patients with moderate to severe chronic low back pain: an enriched, randomized, double-blind, placebo-controlled study. J Pain Symptom Manage2011;42:903-17. [PMID: 21945130] doi:10.1016/j.jpainsymman.2011.04.006 CrossrefMedlineGoogle Scholar
    • 38. Gordon ACallaghan DSpink DCloutier CDzongowski PO'Mahony Wet alBuprenorphine transdermal system in adults with chronic low back pain: a randomized, double-blind, placebo-controlled crossover study, followed by an open-label extension phase. Clin Ther2010;32:844-60. [PMID: 20685494] doi:10.1016/j.clinthera.2010.04.018 CrossrefMedlineGoogle Scholar
    • 39. Miller KYarlas AWen WDain BLynch SYRipa SRet alThe impact of buprenorphine transdermal delivery system on activities of daily living among patients with chronic low back pain: an application of the International Classification of Functioning, Disability and Health. Clin J Pain2014;30:1015-22. [PMID: 24394747] doi:10.1097/AJP.0000000000000068 CrossrefMedlineGoogle Scholar
    • 40. Yarlas AMiller KWen WLynch SYMunera CPergolizzi JVet alBuprenorphine transdermal system compared with placebo reduces interference in functioning for chronic low back pain. Postgrad Med2015;127:38-45. [PMID: 25526229] CrossrefMedlineGoogle Scholar
    • 41. Allan LRicharz USimpson KSlappendel RTransdermal fentanyl versus sustained release oral morphine in strong-opioid naïve patients with chronic low back pain. Spine (Phila Pa 1976)2005;30:2484-90. [PMID: 16284584] CrossrefMedlineGoogle Scholar
    • 42. Rauck RLBookbinder SABunker TRAlftine CDGhalie RNegro-Vilar Aet alThe ACTION study: a randomized, open-label, multicenter trial comparing once-a-day extended-release morphine sulfate capsules (AVINZA) to twice-a-day controlled-release oxycodone hydrochloride tablets (OxyContin) for the treatment of chronic, moderate to severe low back pain. J Opioid Manag2006;2:155-66. [PMID: 17319449] MedlineGoogle Scholar
    • 43. Nicholson BRoss ESasaki JWeil ARandomized trial comparing polymer-coated extended-release morphine sulfate to controlled-release oxycodone HCl in moderate to severe nonmalignant pain. Curr Med Res Opin2006;22:1503-14. [PMID: 16870075] CrossrefMedlineGoogle Scholar
    • 44. Ueberall MAMueller-Schwefe GHSafety and efficacy of oxycodone/naloxone vs. oxycodone vs. morphine for the treatment of chronic low back pain: results of a 12 week prospective, randomized, open-label blinded endpoint streamlined study with prolonged-release preparations. Curr Med Res Opin2015;31:1413-29. [PMID: 25942606] doi:10.1185/03007995.2015.1047747 CrossrefMedlineGoogle Scholar
    • 45. Jamison RNRaymond SASlawsby EANedeljkovic SSKatz NPOpioid therapy for chronic noncancer back pain. A randomized prospective study. Spine (Phila Pa 1976)1998;23:2591-600. [PMID: 9854758] CrossrefMedlineGoogle Scholar
    • 46. Hale MEFleischmann RSalzman RWild JIwan TSwanton REet alEfficacy and safety of controlled-release versus immediate-release oxycodone: randomized, double-blind evaluation in patients with chronic back pain. Clin J Pain1999;15:179-83. [PMID: 10524470] CrossrefMedlineGoogle Scholar
    • 47. Salzman RTRoberts MSWild JFabian CReder RFGoldenheim PDCan a controlled-release oral dose form of oxycodone be used as readily as an immediate-release form for the purpose of titrating to stable pain control? J Pain Symptom Manage1999;18:271-9. [PMID: 10534967] CrossrefMedlineGoogle Scholar
    • 48. Hale MESpeight KLHarsanyi ZIwan TSlagle NSLacouture PGet alEfficacy of 12 hourly controlled-release codeine compared with as required dosing of acetaminophen plus codeine in patients with chronic low back pain. Pain Res Manag1997;2:33-8. CrossrefGoogle Scholar
    • 49. Gostick NAllen JCranfield RCurrie JGrillage MHildebrand Pet alA comparison of the efficacy and adverse effects of controlled-release dihydrocodeine and immediate-release dihydrocodeine in the treatment of pain in osteoarthritis and chronic back pain. Proceedings of The Edinburgh Symposium on Pain Control and Medical Education1989:137-43. Google Scholar
    • 50. Beaulieu ADPeloso PBensen WClark AJWatson CPGardner-Nix Jet alA randomized, double-blind, 8-week crossover study of once-daily controlled-release tramadol versus immediate-release tramadol taken as needed for chronic noncancer pain. Clin Ther2007;29:49-60. [PMID: 17379046] CrossrefMedlineGoogle Scholar
    • 51. Lee JHLee CSUltracet ER Study GroupA randomized, double-blind, placebo-controlled, parallel-group study to evaluate the efficacy and safety of the extended-release tramadol hydrochloride/acetaminophen fixed-dose combination tablet for the treatment of chronic low back pain. Clin Ther2013;35:1830-40. [PMID: 24183364] doi:10.1016/j.clinthera.2013.09.017 CrossrefMedlineGoogle Scholar
    • 52. Schiphorst Preuper HRGeertzen JHBvan Wijhe MBoonstra AMMolmans BHWDijkstra PUet alDo analgesics improve functioning in patients with chronic low back pain? An explorative triple-blinded RCT. Eur Spine J2014;23:800-6. CrossrefMedlineGoogle Scholar
    • 53. Casale RAcute low back pain: symptomatic treatment with a muscle relaxing drug. Clin J Pain1988;4:81-8. CrossrefGoogle Scholar
    • 54. Basmajian JVCyclobenzaprine hydrochloride effect on skeletal muscle spasm in the lumbar region and neck: two double-blind controlled clinical and laboratory studies. Arch Phys Med Rehabil1978;59:58-63. [PMID: 623512] MedlineGoogle Scholar
    • 55. Pratzel HGAlken RGRamm SEfficacy and tolerance of repeated oral doses of tolperisone hydrochloride in the treatment of painful reflex muscle spasm: results of a prospective placebo-controlled double-blind trial. Pain1996;67:417-25. [PMID: 8951937] CrossrefMedlineGoogle Scholar
    • 56. Urquhart DMHoving JLAssendelft WWRoland Mvan Tulder MWAntidepressants for non-specific low back pain. Cochrane Database Syst Rev2008:CD001703. [PMID: 18253994] doi:10.1002/14651858.CD001703.pub3 CrossrefMedlineGoogle Scholar
    • 57. Skljarevski VOssanna MLiu-Seifert HZhang QChappell AIyengar Set alA double-blind, randomized trial of duloxetine versus placebo in the management of chronic low back pain. Eur J Neurol2009;16:1041-8. [PMID: 19469829] doi:10.1111/j.1468-1331.2009.02648.x CrossrefMedlineGoogle Scholar
    • 58. Skljarevski VZhang SDesaiah DAlaka KJPalacios SMiazgowski Tet alDuloxetine versus placebo in patients with chronic low back pain: a 12-week, fixed-dose, randomized, double-blind trial. J Pain2010;11:1282-90. [PMID: 20472510] doi:10.1016/j.jpain.2010.03.002 CrossrefMedlineGoogle Scholar
    • 59. Skljarevski VDesaiah DLiu-Seifert HZhang QChappell ASDetke MJet alEfficacy and safety of duloxetine in patients with chronic low back pain. Spine (Phila Pa 1976)2010;35:E578-85. [PMID: 20461028] doi:10.1097/BRS.0b013e3181d3cef6 CrossrefMedlineGoogle Scholar
    • 60. Brötz DMaschke EBurkard SEngel CMänz CErnemann Uet alIs there a role for benzodiazepines in the management of lumbar disc prolapse with acute sciatica? Pain2010;149:470-5. [PMID: 20362397] doi:10.1016/j.pain.2010.02.015 CrossrefMedlineGoogle Scholar
    • 61. Finckh AZufferey PSchurch MABalagué FWaldburger MSo AKShort-term efficacy of intravenous pulse glucocorticoids in acute discogenic sciatica. A randomized controlled trial. Spine (Phila Pa 1976)2006;31:377-81. [PMID: 16481946] CrossrefMedlineGoogle Scholar
    • 62. Haimovic ICBeresford HRDexamethasone is not superior to placebo for treating lumbosacral radicular pain. Neurology1986;36:1593-4. [PMID: 2946981] CrossrefMedlineGoogle Scholar
    • 63. Porsman OFriis HProlapsed lumbar disc treated with intramuscularly administered dexamethasonephosphate. A prospectively planned, double-blind, controlled clinical trial in 52 patients. Scand J Rheumatol1979;8:142-4. [PMID: 386492] CrossrefMedlineGoogle Scholar
    • 64. Friedman BWEsses DSolorzano CChoi HKCole MDavitt Met alA randomized placebo-controlled trial of single-dose IM corticosteroid for radicular low back pain. Spine (Phila Pa 1976)2008;33:E624-9. [PMID: 18665021] doi:10.1097/BRS.0b013e3181822711 CrossrefMedlineGoogle Scholar
    • 65. Holve RLBarkan HOral steroids in initial treatment of acute sciatica. J Am Board Fam Med2008;21:469-74. [PMID: 18772303] doi:10.3122/jabfm.2008.05.070220 CrossrefMedlineGoogle Scholar
    • 66. Goldberg HFirtch WTyburski MPressman AAckerson LHamilton Let alOral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA2015;313:1915-23. [PMID: 25988461] doi:10.1001/jama.2015.4468 CrossrefMedlineGoogle Scholar
    • 67. McCleane GJDoes gabapentin have an analgesic effect on background, movement and referred pain? A randomised, double-blind, placebo controlled study. The Pain Clinic2001;13:103-7. CrossrefGoogle Scholar
    • 68. Yildirim KSişecioğlu MKaratay SErdal ALevent AUğur Met alThe effectiveness of gabapentin in patients with chronic radiculopathy. The Pain Clinic2003;15:213-8. CrossrefGoogle Scholar
    • 69. Yaksi AOzgönenel LOzgönenel BThe efficiency of gabapentin therapy in patients with lumbar spinal stenosis. Spine (Phila Pa 1976)2007;32:939-42. [PMID: 17450066] CrossrefMedlineGoogle Scholar
    • 70. Khoromi SPatsalides AParada SSalehi VMeegan JMMax MBTopiramate in chronic lumbar radicular pain. J Pain2005;6:829-36. [PMID: 16326371] CrossrefMedlineGoogle Scholar
    • 71. Muehlbacher MNickel MKKettler CTritt KLahmann CLeiberich PKet alTopiramate in treatment of patients with chronic low back pain: a randomized, double-blind, placebo-controlled study. Clin J Pain2006;22:526-31. [PMID: 16788338] CrossrefMedlineGoogle Scholar
    • 72. Salerno SMBrowning RJackson JLThe effect of antidepressant treatment on chronic back pain: a meta-analysis. Arch Intern Med2002;162:19-24. [PMID: 11784215] CrossrefMedlineGoogle Scholar
    • 73. Hagen EMØdelien KHLie SAEriksen HRAdding a physical exercise programme to brief intervention for low back pain patients did not increase return to work. Scand J Public Health2010;38:731-8. [PMID: 20817653] doi:10.1177/1403494810382472 CrossrefMedlineGoogle Scholar
    • 74. Machado LAMaher CGHerbert RDClare HMcAuley JHThe effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Med2010;8:10. [PMID: 20102596] doi:10.1186/1741-7015-8-10 CrossrefMedlineGoogle Scholar
    • 75. Pengel LHRefshauge KMMaher CGNicholas MKHerbert RDMcNair PPhysiotherapist-directed exercise, advice, or both for subacute low back pain: a randomized trial. Ann Intern Med2007;146:787-96. [PMID: 17548410]. doi:10.7326/0003-4819-146-11-200706050-00007 LinkGoogle Scholar
    • 76. Lee JHChoi TYLee MSLee HShin BCLee HAcupuncture for acute low back pain: a systematic review. Clin J Pain2013;29:172-85. [PMID: 23269281] doi:10.1097/AJP.0b013e31824909f9 CrossrefMedlineGoogle Scholar
    • 77. Hasegawa TMBaptista ASde Souza MCYoshizumi AMNatour JAcupuncture for acute non-specific low back pain: a randomised, controlled, double-blind, placebo trial. Acupunct Med2014;32:109-15. [PMID: 24316509] doi:10.1136/acupmed-2013-010333 CrossrefMedlineGoogle Scholar
    • 78. Vas JAranda JMModesto MBenítez-Parejo NHerrera AMartínez-Barquín DMet alAcupuncture in patients with acute low back pain: a multicentre randomised controlled clinical trial. Pain2012;153:1883-9. [PMID: 22770838] doi:10.1016/j.pain.2012.05.033 CrossrefMedlineGoogle Scholar
    • 79. Gao HWei CExtrapoint acupuncture treatement of 36 cases of acute lumbar sprain [in Chinese]. Journal of Gansu College of Traditional Chinese Medicine2006;2006:49-50. Google Scholar
    • 80. Jin MChen JAcupuncture treatment for 40 cases of acute lumbar sprain [in Chinese]. Journal of Gansu College of Traditional Chinese Medicine2008;2006:49-50. Google Scholar
    • 81. Lan JAnalysis of application of acupuncture analgesia in acute lumbar sprain [in Chinese]. Journal of Community Medicine2009:68-9. Google Scholar
    • 82. Yao-chi WBi-meng ZChong-miao WJun-feng ZPing SLiu GZ[Observation on short-term and long-term therapeutic effects of electroacupuncture at Houxi (SI 3) on acute lumbar sprain]. Zhongguo Zhen Jiu2007;27:3-5. [PMID: 17378192] MedlineGoogle Scholar
    • 83. Chen YClinical observation of electroacupuncture at SI3 in addition to drug therapy in acute lumbar sprain [in Chinese]. Journal of Community Medicine2010:39. Google Scholar
    • 84. Furlan ADImamura MDryden TIrvin EMassage for low-back pain. Cochrane Database Syst Rev2008:CD001929. [PMID: 18843627] doi:10.1002/14651858.CD001929.pub2 CrossrefMedlineGoogle Scholar
    • 85. Farasyn AMeeusen RNijs JA pilot randomized placebo-controlled trial of roptrotherapy in patients with subacute non-specific low back pain. J Back Musculoskelet Rehabil2006;19:111-7. CrossrefGoogle Scholar
    • 86. Yoon YSYu KPLee KJKwak SHKim JYDevelopment and application of a newly designed massage instrument for deep cross-friction massage in chronic non-specific low back pain. Ann Rehabil Med2012;36:55-65. [PMID: 22506236] doi:10.5535/arm.2012.36.1.55 CrossrefMedlineGoogle Scholar
    • 87. von Heymann WJSchloemer PTimm JMuehlbauer BSpinal high-velocity low amplitude manipulation in acute nonspecific low back pain: a double-blinded randomized controlled trial in comparison with diclofenac and placebo. Spine (Phila Pa 1976)2013;38:540-8. [PMID: 23026869] doi:10.1097/BRS.0b013e318275d09c CrossrefMedlineGoogle Scholar
    • 88. Hoiriis KTPfleger BMcDuffie FCCotsonis GElsangak OHinson Ret alA randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. J Manipulative Physiol Ther2004;27:388-98. [PMID: 15319761] CrossrefMedlineGoogle Scholar
    • 89. Rubinstein SMTerwee CBAssendelft WJde Boer MRvan Tulder MWSpinal manipulative therapy for acute low-back pain. Cochrane Database Syst Rev2012:CD008880. [PMID: 22972127] doi:10.1002/14651858.CD008880.pub2 CrossrefMedlineGoogle Scholar
    • 90. Schneider MHaas MGlick RStevans JLandsittel DComparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: a randomized clinical trial. Spine (Phila Pa 1976)2015;40:209-17. [PMID: 25423308] doi:10.1097/BRS.0000000000000724 CrossrefMedlineGoogle Scholar
    • 91. French SDCameron MWalker BFReggars JWEsterman AJSuperficial heat or cold for low back pain. Cochrane Database Syst Rev2006:CD004750. [PMID: 16437495] MedlineGoogle Scholar
    • 92. Mayer JMRalph LLook MErasala GNVerna JLMatheson LNet alTreating acute low back pain with continuous low-level heat wrap therapy and/or exercise: a randomized controlled trial. Spine J2005;5:395-403. [PMID: 15996609] CrossrefMedlineGoogle Scholar
    • 93. Nadler SFSteiner DJErasala GNHengehold DAHinkle RTBeth Goodale Met alContinuous low-level heat wrap therapy provides more efficacy than ibuprofen and acetaminophen for acute low back pain. Spine (Phila Pa 1976)2002;27:1012-7. [PMID: 12004166] CrossrefMedlineGoogle Scholar
    • 94. Konstantinovic LMCutovic MRMilovanovic ANJovic SJDragin ASLetic MDjet alLow-level laser therapy for acute neck pain with radiculopathy: a double-blind placebo-controlled randomized study. Pain Med2010;11:1169-78. [PMID: 20704667] doi:10.1111/j.1526-4637.2010.00907.x CrossrefMedlineGoogle Scholar
    • 95. Oleske DMLavender SAAndersson GBKwasny MMAre back supports plus education more effective than education alone in promoting recovery from low back pain?: Results from a randomized clinical trial. Spine (Phila Pa 1976)2007;32:2050-7. [PMID: 17762804] CrossrefMedlineGoogle Scholar
    • 96. van Middelkoop MRubinstein SMVerhagen APOstelo RWKoes BWvan Tulder MWExercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol2010;24:193-204. [PMID: 20227641] doi:10.1016/j.berh.2010.01.002 CrossrefMedlineGoogle Scholar
    • 97. Byström MGRasmussen-Barr EGrooten WJMotor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis. Spine (Phila Pa 1976)2013;38:E350-8. [PMID: 23492976] doi:10.1097/BRS.0b013e31828435fb CrossrefMedlineGoogle Scholar
    • 98. Koumantakis GAWatson PJOldham JATrunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Phys Ther2005;85:209-25. [PMID: 15733046] CrossrefMedlineGoogle Scholar
    • 99. Cairns MCFoster NEWright CRandomized controlled trial of specific spinal stabilization exercises and conventional physiotherapy for recurrent low back pain. Spine (Phila Pa 1976)2006;31:E670-81. [PMID: 16946640] CrossrefMedlineGoogle Scholar
    • 100. Wells CKolt GSMarshall PHill BBialocerkowski AThe effectiveness of Pilates exercise in people with chronic low back pain: a systematic review. PLoS One2014;9:e100402. [PMID: 24984069] doi:10.1371/journal.pone.0100402 CrossrefMedlineGoogle Scholar
    • 101. Gladwell VHead SHaggar MBeneke RDoes a program of Pilates improve chronic non-specific low back pain? J Sport Rehabil2006;15:338-50. CrossrefGoogle Scholar
    • 102. Borges JBaptista AFSantana NSouza IKruschewsky RAGalvão-Castro Bet alPilates exercises improve low back pain and quality of life in patients with HTLV-1 virus: a randomized crossover clinical trial. J Bodyw Mov Ther2014;18:68-74. [PMID: 24411152] doi:10.1016/j.jbmt.2013.05.010 CrossrefMedlineGoogle Scholar
    • 103. da Fonseca JLMagini Mde Freitas THLaboratory gait analysis in patients with low back pain before and after a Pilates intervention. J Sport Rehabil2009;18:269-82. [PMID: 19561369] CrossrefMedlineGoogle Scholar
    • 104. MacIntyre LThe Effect of Pilates on Patients' Chronic Low Back Pain: A Pilot Study [dissertation]. Johannesburg, South Africa: University of the Witwatersrand; 2006. Google Scholar
    • 105. Miyamoto GCCosta LOGalvanin TCabral CMEfficacy of the addition of modified Pilates exercises to a minimal intervention in patients with chronic low back pain: a randomized controlled trial. Phys Ther2013;93:310-20. [PMID: 23064732] doi:10.2522/ptj.20120190 CrossrefMedlineGoogle Scholar
    • 106. Quinn KBarry SBarry LDo patients with chronic low back pain benefit from attending Pilates classes after completing conventional physiotherapy treatment? Physiother Pract Res2011;32:5-12. CrossrefGoogle Scholar
    • 107. Rydeard REvaluation of a Targeted Exercise Rehabilitation Approach and Its Effectiveness in the Treatment of Pain, Functional Disability and Muscle Function in a Population with Longstanding Unresolved Low Back Pain [dissertation]. Kingston, ON, Canada: Queen's University; 2001. Google Scholar
    • 108. Gagnon LEfficacy of Pilates Exercises as Therapeutic Intervention in Treating Patients with Low Back Pain [dissertation]. Knoxville, TN: University of Tennessee; 2005. Google Scholar
    • 109. Rajpal NArora MChauhan VThe study on efficacy of Pilates and McKenzie exercise in postural low back pain—a rehabilitative protocol. Physiotherapy and Occupational Therapy Journal2008;1:33-56. Google Scholar
    • 110. Wajswelner HMetcalf BBennell KClinical Pilates versus general exercise for chronic low back pain: randomized trial. Med Sci Sports Exerc2012;44:1197-205. [PMID: 22246216] doi:10.1249/MSS.0b013e318248f665 CrossrefMedlineGoogle Scholar
    • 111. Hall AMMaher CGLam PFerreira MLatimer JTai chi exercise for treatment of pain and disability in people with persistent low back pain: a randomized controlled trial. Arthritis Care Res (Hoboken)2011;63:1576-83. [PMID: 22034119] doi:10.1002/acr.20594 CrossrefMedlineGoogle Scholar
    • 112. Weifen WMuheremu AChaohui CWenge LLei SEffectiveness of tai chi practice for non-specific chronic low back pain on retired athletes: a randomized controlled study. J Musculoskelet Pain2013;21:37-45. CrossrefGoogle Scholar
    • 113. Williams KAbildso CSteinberg LDoyle EEpstein BSmith Det alEvaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine (Phila Pa 1976)2009;34:2066-76. [PMID: 19701112] doi:10.1097/BRS.0b013e3181b315cc CrossrefMedlineGoogle Scholar
    • 114. Sherman KJCherkin DCErro JMiglioretti DLDeyo RAComparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial. Ann Intern Med2005;143:849-56. [PMID: 16365466]. doi:10.7326/0003-4819-143-12-200512200-00003 LinkGoogle Scholar
    • 115. Sherman KJCherkin DCWellman RDCook AJHawkes RJDelaney Ket alA randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med2011;171:2019-26. [PMID: 22025101] doi:10.1001/archinternmed.2011.524 CrossrefMedlineGoogle Scholar
    • 116. Nambi GSInbasekaran DKhuman RDevi SShanmugananth,Jagannathan KChanges in pain intensity and health related quality of life with Iyengar yoga in nonspecific chronic low back pain: a randomized controlled study. Int J Yoga2014;7:48-53. [PMID: 25035607] doi:10.4103/0973-6131.123481 CrossrefMedlineGoogle Scholar
    • 117. Tekur PNagarathna RChametcha SHankey ANagendra HRA comprehensive yoga programs improves pain, anxiety and depression in chronic low back pain patients more than exercise: an RCT. Complement Ther Med2012;20:107-18. [PMID: 22500659] doi:10.1016/j.ctim.2011.12.009 CrossrefMedlineGoogle Scholar
    • 118. Aboagye EKarlsson MLHagberg JJensen ICost-effectiveness of early interventions for non-specific low back pain: a randomized controlled study investigating medical yoga, exercise therapy and self-care advice. J Rehabil Med2015;47:167-73. [PMID: 25403347] doi:10.2340/16501977-1910 CrossrefMedlineGoogle Scholar
    • 119. Cramer HLauche RHaller HDobos GA systematic review and meta-analysis of yoga for low back pain. Clin J Pain2013;29:450-60. [PMID: 23246998] doi:10.1097/AJP.0b013e31825e1492 CrossrefMedlineGoogle Scholar
    • 120. Henschke NOstelo RWvan Tulder MWVlaeyen JWMorley SAssendelft WJet alBehavioural treatment for chronic low-back pain. Cochrane Database Syst Rev2010:CD002014. [PMID: 20614428] doi:10.1002/14651858.CD002014.pub3 CrossrefMedlineGoogle Scholar
    • 121. Cherkin DCSherman KJBalderson BHCook AJAnderson MLHawkes RJet alEffect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA2016;315:1240-9. [PMID: 27002445] doi:10.1001/jama.2016.2323 CrossrefMedlineGoogle Scholar
    • 122. Morone NEGreco CMMoore CGRollman BLLane BMorrow LAet alA mind-body program for older adults with chronic low back pain: a randomized clinical trial. JAMA Intern Med2016;176:329-37. [PMID: 26903081] doi:10.1001/jamainternmed.2015.8033 CrossrefMedlineGoogle Scholar
    • 123. Morone NERollman BLMoore CGLi QWeiner DKA mind-body program for older adults with chronic low back pain: results of a pilot study. Pain Med2009;10:1395-407. [PMID: 20021599] doi:10.1111/j.1526-4637.2009.00746.x CrossrefMedlineGoogle Scholar
    • 124. Kamper SJApeldoorn ATChiarotto ASmeets RJOstelo RWGuzman Jet alMultidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev2014:CD000963. [PMID: 25180773] doi:10.1002/14651858.CD000963.pub3 CrossrefMedlineGoogle Scholar
    • 125. Lam MGalvin RCurry PEffectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis. Spine (Phila Pa 1976)2013;38:2124-38. [PMID: 24026151] doi:10.1097/01.brs.0000435025.65564.b7 CrossrefMedlineGoogle Scholar
    • 126. Cho YJSong YKCha YYShin BCShin IHPark HJet alAcupuncture for chronic low back pain: a multicenter, randomized, patient-assessor blind, sham-controlled clinical trial. Spine (Phila Pa 1976)2013;38:549-57. [PMID: 23026870] doi:10.1097/BRS.0b013e318275e601 CrossrefMedlineGoogle Scholar
    • 127. Haake MMüller HHSchade-Brittinger CBasler HDSchäfer HMaier Cet alGerman Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med2007;167:1892-8. [PMID: 17893311] CrossrefMedlineGoogle Scholar
    • 128. Leibing ELeonhardt UKöster GGoerlitz ARosenfeldt JAHilgers Ret alAcupuncture treatment of chronic low-back pain—a randomized, blinded, placebo-controlled trial with 9-month follow-up. Pain2002;96:189-96. [PMID: 11932074] CrossrefMedlineGoogle Scholar
    • 129. Sator-Katzenschlager SMScharbert GKozek-Langenecker SASzeles JCFinster GSchiesser AWet alThe short- and long-term benefit in chronic low back pain through adjuvant electrical versus manual auricular acupuncture. Anesth Analg2004;98:1359-64. [PMID: 15105215] CrossrefMedlineGoogle Scholar
    • 130. Yeh CHSuen LKShen JChien LCLiang ZGlick RMet alChanges in sleep with auricular point acupressure for chronic low back pain. Behav Sleep Med2016;14:279-94. [PMID: 26244591] doi:10.1080/15402002.2014.981820 CrossrefMedlineGoogle Scholar
    • 131. Eghbali MSafari RNazari FAbdoli SThe effects of reflexology on chronic low back pain intensity in nurses employed in hospitals affiliated with Isfahan University of Medical Sciences. Iran J Nurs Midwifery Res2012;17:239-43. [PMID: 23833620] MedlineGoogle Scholar
    • 132. Quinn FHughes CMBaxter GDReflexology in the management of low back pain: a pilot randomised controlled trial. Complement Ther Med2008;16:3-8. [PMID: 18346622] doi:10.1016/j.ctim.2007.05.001 CrossrefMedlineGoogle Scholar
    • 133. Poole HGlenn SMurphy PA randomised controlled study of reflexology for the management of chronic low back pain. Eur J Pain2007;11:878-87. [PMID: 17459741] CrossrefMedlineGoogle Scholar
    • 134. Rubinstein SMvan Middelkoop MAssendelft WJde Boer MRvan Tulder MWSpinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev2011:CD008112. [PMID: 21328304] doi:10.1002/14651858.CD008112.pub2 CrossrefMedlineGoogle Scholar
    • 135. Senna MKMachaly SADoes maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome? Spine (Phila Pa 1976)2011;36:1427-37. [PMID: 21245790] doi:10.1097/BRS.0b013e3181f5dfe0 CrossrefMedlineGoogle Scholar
    • 136. Postacchini FFacchini MPalieri PEfficacy of various forms of conservative treatment in low back pain. A comparative study. Neuro-orthopedics1988;6:28-35. Google Scholar
    • 137. Koes BWBouter LMvan Mameren HEssers AHVerstegen GMHofhuizen DMet alRandomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up. BMJ1992;304:601-5. [PMID: 1532760] CrossrefMedlineGoogle Scholar
    • 138. Gibson TGrahame RHarkness JWoo PBlagrave PHills RControlled comparison of short-wave diathermy treatment with osteopathic treatment in non-specific low back pain. Lancet1985;1:1258-61. [PMID: 2860453] CrossrefMedlineGoogle Scholar
    • 139. Pope MHPhillips RBHaugh LDHsieh CYMacDonald LHaldeman SA prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain. Spine (Phila Pa 1976)1994;19:2571-7. [PMID: 7855683] CrossrefMedlineGoogle Scholar
    • 140. Balthazard Pde Goumoens PRivier GDemeulenaere PBallabeni PDériaz OManual therapy followed by specific active exercises versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain: a randomized controlled trial. BMC Musculoskelet Disord2012;13:162. [PMID: 22925609] doi:10.1186/1471-2474-13-162 CrossrefMedlineGoogle Scholar
    • 141. Bicalho ESetti JAMacagnan JCano JLManffra EFImmediate effects of a high-velocity spine manipulation in paraspinal muscles activity of nonspecific chronic low-back pain subjects. Man Ther2010;15:469-75. [PMID: 20447857] doi:10.1016/j.math.2010.03.012 CrossrefMedlineGoogle Scholar
    • 142. Haas MVavrek DPeterson DPolissar NNeradilek MBDose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial. Spine J2014;14:1106-16. [PMID: 24139233] doi:10.1016/j.spinee.2013.07.468 CrossrefMedlineGoogle Scholar
    • 143. UK BEAM Trial TeamUnited Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ2004;329:1377. [PMID: 15556955] CrossrefMedlineGoogle Scholar
    • 144. Hsieh CYAdams AHTobis JHong CZDanielson CPlatt Ket alEffectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial. Spine (Phila Pa 1976)2002;27:1142-8. [PMID: 12045509] CrossrefMedlineGoogle Scholar
    • 145. Licciardone JCStoll STFulda KGRusso DPSiu JWinn Wet alOsteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine (Phila Pa 1976)2003;28:1355-62. [PMID: 12838090] CrossrefMedlineGoogle Scholar
    • 146. Rasmussen JLaetgaard JLindecrona ALQvistgaard EBliddal HManipulation does not add to the effect of extension exercises in chronic low-back pain (LBP). A randomized, controlled, double blind study. Joint Bone Spine2008;75:708-13. [PMID: 19028434] doi:10.1016/j.jbspin.2007.12.011 CrossrefMedlineGoogle Scholar
    • 147. Evans DPBurke MSLloyd KNRoberts EERoberts GMLumbar spinal manipulation on trial. Part I—clinical assessment. Rheumatol Rehabil1978;17:46-53. [PMID: 153574] CrossrefMedlineGoogle Scholar
    • 148. Ebadi SHenschke NNakhostin Ansari NFallah Evan Tulder MWTherapeutic ultrasound for chronic low-back pain. Cochrane Database Syst Rev2014:CD009169. [PMID: 24627326] doi:10.1002/14651858.CD009169.pub2 CrossrefMedlineGoogle Scholar
    • 149. Ebadi SAnsari NNNaghdi SJalaei SSadat MBagheri Het alThe effect of continuous ultrasound on chronic non-specific low back pain: a single blind placebo-controlled randomized trial. BMC Musculoskelet Disord2012;13:192. [PMID: 23031570] doi:10.1186/1471-2474-13-192 CrossrefMedlineGoogle Scholar
    • 150. Mohseni-Bandpei MACritchley JStaunton TRichardson BA prospective randomised controlled trial of spinal manipulation and ultrasound in the treatment of chronic low back pain. Physiotherapy2006;92:34-42. doi:10.1016/j.physio.2005.05.005 CrossrefGoogle Scholar
    • 151. Durmus DDurmaz YCanturk FEffects of therapeutic ultrasound and electrical stimulation program on pain, trunk muscle strength, disability, walking performance, quality of life, and depression in patients with low back pain: a randomized-controlled trial. Rheumatol Int2010;30:901-10. [PMID: 19644691] doi:10.1007/s00296-009-1072-7 CrossrefMedlineGoogle Scholar
    • 152. Durmus DAlayli GGoktepe ASTaskaynatan MABilgici AKuru OIs phonophoresis effective in the treatment of chronic low back pain? A single-blind randomized controlled trial. Rheumatol Int2013;33:1737-44. [PMID: 23283539] doi:10.1007/s00296-012-2634-7 CrossrefMedlineGoogle Scholar
    • 153. van Middelkoop MRubinstein SMKuijpers TVerhagen APOstelo RKoes BWet alA systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J2011;20:19-39. [PMID: 20640863] doi:10.1007/s00586-010-1518-3 CrossrefMedlineGoogle Scholar
    • 154. Manheimer EWhite ABerman BForys KErnst EMeta-analysis: acupuncture for low back pain. Ann Intern Med2005;142:651-63. [PMID: 15838072]. doi:10.7326/0003-4819-142-8-200504190-00014 LinkGoogle Scholar
    • 155. Basford JRSheffield CGHarmsen WSLaser therapy: a randomized, controlled trial of the effects of low-intensity Nd:YAG laser irradiation on musculoskeletal back pain. Arch Phys Med Rehabil1999;80:647-52. [PMID: 10378490] CrossrefMedlineGoogle Scholar
    • 156. Soriano FRios RGallium arsenide laser treatment of chronic low back pain: a prospective, randomized and double blind study. Laser Therapy1998;10:175-80. CrossrefGoogle Scholar
    • 157. Toya SMotegi MInomata KOhshiro TReport on a computer-randomized double blind clinical trial to determine the effectiveness of the GaAlAs (830 nm) diode laser for pain attenuation in selected pain groups. Laser Therapy1994;6:143-8. CrossrefGoogle Scholar
    • 158. Dalichau SScheele K[Effects of elastic lumbar belts on the effect of a muscle training program for patients with chronic back pain]. Z Orthop Ihre Grenzgeb2000;138:8-16. [PMID: 10730357] CrossrefMedlineGoogle Scholar
    • 159. Hsieh CYPhillips RBAdams AHPope MHFunctional outcomes of low back pain: comparison of four treatment groups in a randomized controlled trial. J Manipulative Physiol Ther1992;15:4-9. [PMID: 1531488] MedlineGoogle Scholar
    • 160. Doran DMNewell DJManipulation in treatment of low back pain: a multicentre study. Br Med J1975;2:161-4. [PMID: 123815] CrossrefMedlineGoogle Scholar
    • 161. Coxhead CEInskip HMeade TWNorth WRTroup JDMulticentre trial of physiotherapy in the management of sciatic symptoms. Lancet1981;1:1065-8. [PMID: 6112444] CrossrefMedlineGoogle Scholar
    • 162. Castro-Sánchez AMLara-Palomo ICMatarán-Peñarrocha GAFernández-Sánchez MSánchez-Labraca NArroyo-Morales MKinesio taping reduces disability and pain slightly in chronic non-specific low back pain: a randomised trial. J Physiother2012;58:89-95. [PMID: 22613238] doi:10.1016/S1836-9553(12)70088-7 CrossrefMedlineGoogle Scholar
    • 163. Parreira Pdo CCosta Lda CTakahashi RHespanholJunior LCLuz Junior MASilva TMet alKinesio taping to generate skin convolutions is not better than sham taping for people with chronic non-specic low back pain: a randomised trial. J Physiother2014;60:90-6. [PMID: 24952836] doi:10.1016/j.jphys.2014.05.003 CrossrefMedlineGoogle Scholar
    • 164. Paoloni MBernetti AFratocchi GMangone MParrinello LDel Pilar Cooper Met alKinesio taping applied to lumbar muscles influences clinical and electromyographic characteristics in chronic low back pain patients. Eur J Phys Rehabil Med2011;47:237-44. [PMID: 21430611] MedlineGoogle Scholar
    • 165. Kachanathu SJAlenazi AMSeif HEHafez ARAlroumim MAComparison between Kinesio taping and a traditional physical therapy program in treatment of nonspecific low back pain. J Phys Ther Sci2014;26:1185-8. [PMID: 25202177] doi:10.1589/jpts.26.1185 CrossrefMedlineGoogle Scholar
    • 166. Albaladejo CKovacs FMRoyuela Adel Pino RZamora JSpanish Back Pain Research NetworkThe efficacy of a short education program and a short physiotherapy program for treating low back pain in primary care: a cluster randomized trial. Spine (Phila Pa 1976)2010;35:483-96. [PMID: 20147875] doi:10.1097/BRS.0b013e3181b9c9a7 CrossrefMedlineGoogle Scholar
    • 167. Albert HBManniche CThe efficacy of systematic active conservative treatment for patients with severe sciatica: a single-blind, randomized, clinical, controlled trial. Spine (Phila Pa 1976)2012;37:531-42. [PMID: 21494193] doi:10.1097/BRS.0b013e31821ace7f CrossrefMedlineGoogle Scholar
    • 168. Hofstee DJGijtenbeek JMHoogland PHvan Houwelingen HCKloet ALötters Fet alWesteinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica. J Neurosurg2002;96:45-9. [PMID: 11797655] MedlineGoogle Scholar
    • 169. Wegner IWidyahening ISvan Tulder MWBlomberg SEde Vet HCBrønfort Get alTraction for low-back pain with or without sciatica. Cochrane Database Syst Rev2013:CD003010. [PMID: 23959683] doi:10.1002/14651858.CD003010.pub5 CrossrefMedlineGoogle Scholar
    • 170. Calmels PQueneau PHamonet CLe Pen CMaurel FLerouvreur Cet alEffectiveness of a lumbar belt in subacute low back pain: an open, multicentric, and randomized clinical study. Spine (Phila Pa 1976)2009;34:215-20. [PMID: 19179915] doi:10.1097/BRS.0b013e31819577dc CrossrefMedlineGoogle Scholar
    • 171. Sato NSekiguchi MKikuchi SShishido HSato KKonno SEffects of long-term corset wearing on chronic low back pain. Fukushima J Med Sci2012;58:60-5. [PMID: 22790893] CrossrefMedlineGoogle Scholar
    • 172. Diab AAMoustafa IMLumbar lordosis rehabilitation for pain and lumbar segmental motion in chronic mechanical low back pain: a randomized trial. J Manipulative Physiol Ther2012;35:246-53. [PMID: 22632584] doi:10.1016/j.jmpt.2012.04.021 CrossrefMedlineGoogle Scholar
    • 173. Diab AAMoustafa IMThe efficacy of lumbar extension traction for sagittal alignment in mechanical low back pain: a randomized trial. J Back Musculoskelet Rehabil2013;26:213-20. [PMID: 23640324] doi:10.3233/BMR-130372 CrossrefMedlineGoogle Scholar
    • 174. Moustafa IMDiab AAExtension traction treatment for patients with discogenic lumbosacral radiculopathy: a randomized controlled trial. Clin Rehabil2013;27:51-62. [PMID: 22684211] doi:10.1177/0269215512446093 CrossrefMedlineGoogle Scholar
    • 175. Hsieh LLKuo CHYen MFChen THA randomized controlled clinical trial for low back pain treated by acupressure and physical therapy. Prev Med2004;39:168-76. [PMID: 15207999] CrossrefMedlineGoogle Scholar
    • 176. Chatchawan UThinkhamrop BKharmwan SKnowles JEungpinichpong WEffectiveness of traditional Thai massage versus Swedish massage among patients with back pain associated with myofascial trigger points. J Bodyw Mov Ther2005;9:298-309. CrossrefGoogle Scholar
    • 177. Buchmuller ANavez MMilletre-Bernardin MPouplin SPresles ELantéri-Minet Met alLombotens Trial GroupValue of TENS for relief of chronic low back pain with or without radicular pain. Eur J Pain2012;16:656-65. [PMID: 22337531] doi:10.1002/j.1532-2149.2011.00061.x CrossrefMedlineGoogle Scholar
    • 178. Nadler SFSteiner DJErasala GNHengehold DAAbeln SBWeingand KWContinuous low-level heatwrap therapy for treating acute nonspecific low back pain. Arch Phys Med Rehabil2003;84:329-34. [PMID: 12638099] CrossrefMedlineGoogle Scholar
    • 179. Nadler SFSteiner DJPetty SRErasala GNHengehold DAWeingand KWOvernight use of continuous low-level heatwrap therapy for relief of low back pain. Arch Phys Med Rehabil2003;84:335-42. [PMID: 12638100] CrossrefMedlineGoogle Scholar
    • 180. Hestbaek LLeboeuf-Yde CManniche CLow back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J2003;12:149-65. [PMID: 12709853] CrossrefMedlineGoogle Scholar
    • 181. Drug Enforcement Administration, Departmentof JusticeSchedule of controlled substances: placement of tramadol into schedule IV. Final rule. Fed Regist2014;79:37623-30. [PMID: 25016619] MedlineGoogle Scholar
    • 182. Chou RDeyo RDevine BHansen RSullivan SJarvik JGet alThe Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. Evidence Report/Technology Assessment no. 218. (Prepared by the Pacific Northwest Evidence-based Practice Center under contract no. 290-212-00014-I.) AHRQ publication no. 14-E005-EF. Rockville: Agency for Healthcare Research and Quality; 2014. Google Scholar
    • 183. Agency for Healthcare Research and QualityMethods Guide for Effectiveness and Comparative Effectiveness Reviews. AHRQ publication no. 10(13)-EHC063-EF. Rockville: Agency for Healthcare Research and Quality; 2014. Google Scholar
    • 184. Shea BJHamel CWells GABouter LMKristjansson EGrimshaw Jet alAMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. J Clin Epidemiol2009;62:1013-20. [PMID: 19230606] doi:10.1016/j.jclinepi.2008.10.009 CrossrefMedlineGoogle Scholar

    Comments

    Andrea MacGregor17 May 2017
    Comment
    Previous acupuncture recommendations are now being reconsidered by many prominent institutions. The NICE guideline for NHS patients in the U.K. now recommends against the use of acupuncture for low-back pain, following a high-quality review that critically examined the existing evidence regarding the use of acupuncture and found it to be no more effective than a placebo. The Toronto Hospital for Sick Children has also recently removed references on their website that suggested the efficacy of acupuncture in managing specific chronic pain conditions. The WHO has done the same, no longer suggesting that acupuncture is effective for low-back pain and sciatica. A review by the Friends of Science in Medicine association describing a lack of evidence of a therapeutic effect has been endorsed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

    As someone about to enter a field that is frequently associated with, or considered a part of, complementary healthcare, I know first-hand how misguided and overblown the claims and hopes of acupuncture’s efficacy can be. Such claims are generally based on small and probably unmeaningful effects taken selectively from the total evidence. I have often seen my own mentors and peers pushing for the use of acupuncture for many chronic and serious conditions for which there is no basis of evidence at all of acupuncture’s efficacy, including systemic, neurological, and developmental conditions. When questioned, they will usually refer to authorities perceived as “legitimate”, including the ACP, to say that claims of acupuncture “working” are backed by experts.

    We see a similar situation (as touched on in one of the comments above), with advertisers and media using the guise of “expert-backed” legitimization to recommend acupuncture in misleading ways, often to an audience of vulnerable people who could be making better-informed and more effective treatment and management choices for their conditions. Many of these entities specifically mention the ACP as lending credence to their claims, sometimes somewhat out of context.

    I hope that you will reconsider your recommendation of a practice that is simply not supported by the majority of the research evidence that exists to date. Patients with complex conditions, including low-back pain, deserve accurate and realistic information regarding their treatment options, especially from such trusted and reputable sources as the ACP.

    This comment is condensed from a longer open letter to the ACP that can be accessed, with further sourcing, via the reference below.

    MacGregor, A. (14 May 2017). Acupuncture for back pain: an open letter by a Canadian therapist. Retrieved from http://edzardernst.com/2017/05/acupuncture-for-back-pain-an-open-letter-by-a-canadian-therapist/
    Amir Qaseem, MD, PhD, Scott Manaker, MD, PhD, Sandeep Vijan, MD4 April 2017
    Author's Response
    IN RESPONSE: We disagree with the comment from Dr. Braillon and Dr. Marcus questioning the efficacy of acupuncture. Although not all trials showed benefit (1), acupuncture versus sham needles showed a small beneficial effect on pain, with no evidence of an effect on function in acute low back pain and improvement in both pain an function in chronic low back pain; similar findings were shown even when compared to NSAIDs. However, we agree with the commenters that sustained benefit has not been demonstrated with acupuncture. We agree with Dr. Braillon regarding evidence of benefit with the use of cognitive behavioral therapy, and we recommend CBT in our guideline.

    We concur with Mr. Collen that there is both observational and meta-analytic evidence that suggests that NSAIDs may increase CV risk; however, as our review process is focused specifically on the setting of low back pain, we did not conduct independent evidence searches for the side effects of medications outside of the trials. This is an admitted limitation of our process and one that we will need to consider in future reviews. Mr. Collen also notes that psychosocial support is essential to throughout the recovery process and it likely might be the case, but the evidence review did not identify any such studies to support the recommendations.

    Dr. Vucina notes that low back pain has heterogeneous causes, and that treatment may vary. We agree this is likely, but rarely addressed by current trials; further, there is no agreement on clear methods to define the source of low back pain, as symptoms and imaging findings are rarely determinative.

    Dr. Murphy and colleagues advocate for “Primary Spine Practitioners (PSP)” to manage back pain. While we concur that the array of treatment options and the lack of head-to-head comparisons of these options makes choices difficult for physicians and patients, we would also comment that low back pain is so ubiquitous that training enough PSPs to care for back pain would be an undertaking of massive proportion. Ideally the options laid out in our guideline (2), along with the fact that most back pain is self-limited, would suffice for many patients, and rare referral would occur for more refractory cases.

    We appreciate the updated review conducted by Drs. Le and Badgett. Given their findings, we would agree that tramadol would likely not have been recommended as a treatment option for chronic low back pain.








    Sandeep Vijan, MD, MS
    Ann Arbor VA HSR&D CCMR, Ann Arbor, MI

    Scott Manaker, MD, PhD
    Hospital of the University of Pennsylvania, Philadelphia, PA 19104

    Amir Qaseem, MD, PhD, MHA
    American College of Physicians, Philadelphia, Pennsylvania


    References
    1. Chou R, Deyo R, Friedly J, et al. Systemic pharmacologic therapies for low back pain: A systematic review for an American College of Physicians clinical practice guideline. Annals of Internal Medicine. 2017.

    2. Qaseem A, Wilt TJ, McLean RM, Forciea M, for the Clinical Guidelines Committee of the American College of P. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2017.
    Donald M. Marcus, M.D.1 March 2017
    Comment
    The Guideline (1) appropriately emphasizes the importance of nonpharmacologic therapies for back pain, which are underutilized, but the recommendation of a multiplicity of therapies supported by low to moderate evidence is confusing, Moreover, I disagree with the claim of moderate-quality of evidence for acupuncture. Placebos are very effective for relief of pain, and a number of sham procedures have been used as controls for traditional acupuncture. The preponderance of evidence from high-quality controlled trials is that there is there is no clinically relevant difference between sham and traditional acupuncture for relief of pain of knee osteoarthritis or back pain (2). The Guideline is based in part on the systematic review of Chou et al. (3), which states that five trials that were consistent with the efficacy of acupuncture could not be included in the review. However, two of those trial, references 66 and 67, found no specific efficacy for acupuncture beyond the sham procedure, as did two other trials that were not included in review, references 10 and 12 in (2). The control in the latter large trial was toothpicks in a plastic tube.
    The recommendation of acupuncture in the Guideline was cited by several medical websites that aggregate news and by the media, which may mislead healthcare providers and the public. Endorsing a placebo therapy violates professionalism standards requiring use of the best evidence in guiding practice, and in enabling patients to make informed decisions about therapy. The lack of rigor in evaluating acupuncture raises concerns about other therapies listed in Recommendation 2.
    The lack of truly effective pharmacologic or nonpharmacologic treatments for chronic low back pain is widely acknowledged. The compilation of many weakly effective, disparate therapies in the Guideline will do little to assist healthcare providers in making informed decisions, or for other purposes, including informing insurance coverage, quality of care evaluations, and medicolegal liability standards (4).
    References
    (1) Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2017 doi:10.7326/M16-2367.
    (2) Marcus DM. Is acupuncture for pain a placebo treatment? An examination of the evidence. The Rheumatologist 2010; 4: 1, 28-35.
    (3) Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, et al. Nonpharmacologic theerrapies for low back pain: A systematic review for an American College of Physicians clinical practice guideline. Ann Int Med 2017: 166 doi10.7326/M16-2459.
    (4) Greenfield S. Clinical practice guidelines. Expanded use and misuse. JAMA 2017; 317: 594-5.
    IVAN VUCINA MD22 February 2017
    ABOUT GUIDELINE LOW BACK PAIN

    Don't you believe that low back pain will have different treatments according to the cause can go since a muscular problem until osteoporotic fracture of the spine. 

    Daniel Pomerantz MD MPH FACP6 June 2017
    Treatment failure is a treatment issue, not a patient issue
    The guideline is generally useful and helpful; however, I wish the third recommendation had been phrase just a little differently.
    The language we use to talk about whether and how our treatment has, or has not, helped our patient can shape our thinking. Many authors have written about how the language we use can change the way we think. No one has written more trenchantly about this issue than George Orwell in his novel, 1984, and in his essay, 'Politics and the English Language.'
    The third recommendation from Qaseem, et al reads:
    Recommendation 3: In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).
    Right in the middle is the phrase, "in patients who have failed the aforementioned treatments." This phrase confuses the subject and predicate. The treatment has failed to help the patient. We should not blame the patient for "failing" to improve, but rather accept our responsibility for recommending, with good reason, a treatment which was intended to be helpful, but which has failed to improve our patient's condition. Our desire to linguistically offload responsibility to the patient is understandable, but pernicious, especially when we are considering whether to prescribe opioids for chronic pain. While the evidence for benefit is weak, there are some patients who do well with them, provided that we prescribe opioids responsibly, and continue to provide other forms of treatment and support for chronic back pain. If we label our patients as "failures," will we be less likely to consider prescribing opioids for them? I suspect that this habit of thinking of the patient having failed the treatment makes us less willing to consider opioids, even when other evidence might suggest a benefit. We should accept responsibility for our treatment failures, by clearly and consistently labeling the treatment, rather than the patient, as the failure.
    Jeremy D. Whyman MD, Rosanne M. Leipzig MD, PhD 26 April 2017
    Age Matters
    We were pleased to see the ACP guideline on noninvasive treatments for low back pain in the April 4th, 2017 issue, however we were surprised there were no caveats on treatment of older adults nor discussion of the age of patients in the evidentiary trials.
    The stakes of improperly treated back pain may be high in older adults. Each year back pain is experienced by nearly 17 million people 65 years and older. Age > 75 years and osteoporosis are ‘red flags’ that can indicate a serious underlying pathology such as a vertebral fracture. Older adults with chronic low back pain have more difficulty performing everyday tasks and more depressive symptoms. They are also at greater risk of adverse effects from some of the first line medications recommended in the guideline.
    The use of NSAIDs in the elderly increases the risk of acute GI bleeds by a factor of 4. Although Proton Pump Inhibitors (PPIs) reduce this risk, PPIs are associated with increased bone loss, pneumonia and Clostridium Difficile in this population. Skeletal muscle relaxants are a ‘drug to avoid’ in the elderly (American Geriatrics Society 2015 Updated Beers Criteria) and have been associated with increased ED visits and hospitalization.
    Our challenge as clinicians caring for these adults is to alleviate their pain without causing more harm, including greater functional decline. In the future, we hope that ACP will consider a focus in their guidelines that helps clinicians address the complexity of low back pain in aging adults.

    Jeremy D. Whyman, MD
    Palliative Medicine and Geriatrics Fellow
    Brookdale Dept. of Geriatrics and Palliative Medicine
    Icahn School of Medicine at Mount Sinai

    Rosanne M. Leipzig MD, PhD
    Gerald and May Ellen Ritter Professor
    Vice Chair, Education
    Brookdale Dept. of Geriatrics and Palliative Medicine
    Icahn School of Medicine at Mount Sinai

    Enthoven WTM Geuze J, Scheele J et al. Prevalence and “Red Flags” regarding specific causes of back pain in older adults presenting in general practice. Physical Therapy 2016:96(3):305-312.

    Weiner DK, Haggerty CL., et al. How does low back pain impact physical function in independent, well-functioning older adults? Evidence from the Health ABC Cohort and implications for the future. Pain Med. 2003 Dec;4(4):311-20.
    Pilotto, Alberto, Franceschi, Marilisa, et al. The risk of upper gastrointestinal bleeding in elderly users of aspirin and other non-steroidal antiinflammatory drugs: The role of gastroprotective drugs. Aging Clinical and Experimental Research December 2003, Volume 15, Issue 6, pp 494–499.
    Kapadia A, Wynn Daisy, Salzman B, Potential Adverse Effects of Proton Pump Inhibitors in the Elderly. Clinical Geriatrics, July/August 2010.
    Alvarez, Carlos A., et al. Association of skeletal muscle relaxers and antihistamines on mortality, hospitalizations, and emergency department visits in elderly patients: a nationwide retrospective cohort study. BMC Geriatrics 2015.
    Lisa H Le, Robert G Badgett8 March 2017
    Reassessment of benefit from tramadol
    We are concerned about the Guideline’s recommendation of tramadol to be secondary line pharmacotherapy of chronic back pain. We acknowledge that the Guideline labels this recommendation as ‘weak’ and supported by ‘moderate’ evidence; however, we suggest tramadol should not be a recommendation at all as the underlying evidence rests on unregistered and short duration trials.

    We updated the Cochrane meta-analysis that the guideline’s recommendation is based on.(1) We completed the search for newer trials with a mix of methods. We subgrouped the trials based on whether they were registered prior to execution. Results are online at https://openMetaAnalysis.github.io/tramadol.

    Our findings suggest several biases. While there are insufficient trials to test for publication bias with a funnel plot, we found significant differences in results between registered and unregistered trials with benefit confined to unregistered trials. Unregistered trials may lead to inflated results due to both publication bias and selective reporting bias.(2,3) Two of the four unregistered trials reported selecting patients after an open-label run-in phase - which may also inflate results.(4) In addition, the short duration of these trials (the longest lasting 13 weeks) does not seem relevant to the treatment of a chronic disease. Finally, heterogeneity of overall results was substantial at 90%.

    Focusing on the subgroup of registered trials, we found no benefit from tramadol with 17% heterogeneity. Although the Guidelines describe the registered trial by Lee as showing benefit, this study is problematic.(5) According to the registration archives at ClinicalTrials.gov, the trial was registered after completion. The primary outcome according to ClinicalTrials.gov was “difference in pain intensity as measured on the Visual Analog Scale”. If this is interpreted as the mean change, that result is insignificant. If this interpreted as proportion responding, the authors omitted the randomized patients who dropped out. When we recalculate with an intention to treat analysis, the results are insignificant.

    We encourage others to use the data from this review to help evolve the assessment of tramadol for chronic therapy of back pain.

    References:

    1.Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC. Opioids compared to placebo or other treatments for chronic low-back pain. Cochrane Database Syst Rev. 2013 Aug 27;(8):CD004959. PMID: 23983011

    2.Kaplan RM, Irvin VL. Likelihood of Null Effects of Large NHLBI Clinical Trials Has Increased over Time. PLoS One. 2015 Aug 5;10(8):e0132382. PMID: 26244868

    3.Chan AW, Hróbjartsson A, Haahr MT, Gøtzsche PC, Altman DG. Empirical evidence for selective reporting of outcomes in randomized trials: comparison of protocols to published articles. JAMA. 2004 May 26;291(20):2457-65. PMID: 15161896

    4.Prasad V, Berger VW. Hard-Wired Bias: How Even Double-Blind, Randomized Controlled Trials Can Be Skewed From the Start. Mayo Clin Proc. 2015 Sep;90(9):1171-5. PMID: 26277702

    5.Lee JH, Lee CS; Ultracet ER Study Group.. A randomized, double-blind, placebo-controlled, parallel-group study to evaluate the efficacy and safety of the extended-release tramadol hydrochloride/acetaminophen fixed-dose combination tablet for the treatment of chronic low back pain. Clin Ther. 2013 Nov;35(11):1830-40. PMID: 24183364.
    Donald R. Murphy, DC, FCC, Michael J. Schneider, DC, PhD, Christopher G. Bise, PT, MS, DPT, Brian Justice, DC24 February 2017
    Low Back Pain Guideline: What is the Next Step?
    Congratulations to the ACP on a job well done in synthesizing the literature on noninvasive treatments for low back pain (LBP). Several treatment approaches are identified for which evidence suggests effectiveness. As Atlas points out in his editorial (1), the next question becomes “what does the clinician do with this information?” We would like provide input from a clinical, operational and translational viewpoint.

    How does the primary care practitioner (PCP) use the information from the guideline when seeing a patient with LBP? Do they refer the patient for all recommended treatments? Do they refer the patient for each treatment one at a time until they land on one that helps? Do they provide a list of recommended treatments and allow the patient to choose?

    None of these are efficient options, in our view. We think this illustrates the need in spine care for a designated professional who is specially trained, skilled and experienced in evidence-based clinical reasoning to determine the best course of action for each individual patient. A professional who can, based on the unique clinical features in each patient, provide differential diagnosis, manage the majority without the need for referral and, when necessary, provide guidance regarding other noninvasive or invasive options. As the guideline points out, medications are not recommended as a first-line approach, so this professional need not be a medical physician. This role can be played by specially-trained chiropractors and physical therapists. We refer to this professional as the Primary Spine Practitioner (PSP) (2).

    An appropriately trained PSP can provide a clear, evidence-based explanation of the problem (the most important factor in patient satisfaction (3)) as well as evidence-based management that is tailored to each patient’s individual needs (2). The PSP can go beyond the general recommendations of a guideline to individualized care for each patient in a way that most PCPs are not well trained to do (4).

    PSP services have been implemented in several environments. Preliminary data suggest that these services are efficient and provide good outcomes and patient satisfaction at low cost (5). Provider satisfaction, particularly for the PCP, is high. A formal training and certification program for PSPs has been developed at the University of Pittsburgh. We anticipate that wide implementation of PSP services, particularly within an integrated spine care pathway (5), will be of great benefit to PCPs and, most important, to patients and the health care system.

    1. Atlas SJ. Management of Low Back Pain: Getting From Evidence-Based Recommendations to High-Value Care. Annals of internal medicine. 2017. doi: 10.7326/M17-0293. PubMed PMID: 28192792.
    2. Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ. The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States. Chiropractic & manual therapies. 2011;19(1):17. PubMed PMID: 21777444.
    3. Verbeek J, Sengers M, Riemens L, Haafkens J. Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine. 2004;29(20):2309-17.
    4. Goff I, Wise EM, Coady D, Walker D. Musculoskeletal training: are GP trainees exposed to the right case mix for independent practice? Clinical rheumatology. 2014. doi: 10.1007/s10067-014-2767-z. PubMed PMID: 25190366.
    5. Paskowski I, Schneider M, Stevans J, Ventura JM, Justice BD. A hospital-based standardized spine care pathway: report of a multidisciplinary, evidence-based process. Journal of manipulative and physiological therapeutics. 2011;34(2):98-106. PubMed PMID: 21334541.

    The authors declare no conflicts

    Donald R. Murphy, DC, FRCC
    Medical Director of Spine Program
    Care New England Health System
    Clinical Assistant Professor, Department of Family Medicine
    Alpert Medical School of Brown University
    600 Pawtucket Avenue
    Pawtucket, RI 02860 USA
    [email protected]

    Michael J. Schneider, DC, PhD
    Associate Professor, Department of Physical Therapy
    University of Pittsburgh
    Bridgeside Point 1
    100 Technology Drive, Suite 210
    Pittsburgh, PA 15219-3130 USA
    [email protected]

    Christopher G. Bise PT, MS, DPT, OCS
    Assistant Professor, Department of Physical Therapy
    University of Pittsburgh
    School of Health and Rehabilitation Science
    Bridgeside Point 1
    100 Technology Drive, Suite 210
    Pittsburgh, PA 15219-3130 USA
    [email protected]

    Brian Justice, DC
    Medical Director Pathway Development and Spine Care
    Excellus BlueCross BlueShield
    165 Court Street, Rochester, NY 14647
    [email protected]
    Mark Collen22 February 2017
    Comment on ACP low back pain guideline
    The College of Physician’s guideline for noninvasive treatments of low back pain (1) is logical and makes total sense, but I have a number of comments.

    I believe that the authors should have mentioned the cardiovascular (CV) risk factors associated with NSAIDs.(2-4) In the same vein, on page 11, the paper reads, “COX-2–selective NSAIDs…are associated with lower risk for adverse effects than nonselective NSAIDs.” This statement is not necessarily true and adverse events are dependent upon many elements including the specific NSAID and risk factor.(4) Rofecoxib is one example of a COX-2 selective NSAID with intolerable side effects that was pulled from the market.(5)

    The paper states under “Harms of Pharmacological Therapies,” that the harms were obtained from the reviews and admittedly there were no NSAID CV adverse events in the articles, but the authors raise potential harms of opioids under “Recommendation 3,” including addiction, abuse and overdose, and those adverse effects are also absent in the reviews. It’s important to be consistent and thus the CV risk factor for NSAIDs should have been added, along with a suggestion that clinicians evaluate their patient’s cardiovascular health prior to prescribing non-steroidal anti-inflammatories.

    Furthermore, I have posited that the onset of pain may trigger the unconscious animal brain to believe there is a direct threat to survival.(6) In nature, injured animals get eaten. Under Recommendation 1, the authors suggest the clinician provides social support through educating the patient about the positive prognosis, course of healing and staying active—all while using patient-centered care. This is excellent advice and may help to disarm any potential threat in the patient’s mind, conscious or unconscious.

    However, I wish the guideline had recommended consistent social support until the patient has recovered. There are a couple of reasons for this with the most important being to help prevent short-term low back pain from turning into long-term chronic pain. Individuals that catastrophize and/or are afraid to move their bodies may be vulnerable to this negative conversion and consistent support may help prevent it.(7-10) In addition, psycho-social elements can worsen one’s pain (11) and staying in touch with the patient may mitigate these negative influences.

    Although some clinicians may not be accustomed to providing social support, my experience as a patient advocate has taught me that most people just need reassurance that everything is going to be fine, and that they are not alone in their recovery from back pain.

    Mark Collen
    Founder, PainExhibit.org
    Editorial Board Member, Journal of Pain & Palliative Care Pharmacotherapy

    The author declares no conflicts of interest.

    References

    (1) Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of PhysiciansNoninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain. Ann Intern Med. 2017. [Epub ahead of print]

    (2) McGettigan P, Henry D. Use of non-steroidal anti-inflammatory drugs that elevate cardiovascular risk: an examination of sales and essential medicines lists in low-, middle-, and high-income countries. PLoS Med. 2013;10:e1001388.

    (3) Bello AE, Holt RJ. Cardiovascular risk with non-steroidal anti-inflammatory drugs: clinical implications. Drug Saf. 2014;37:897-902.

    (4) Harirforoosh S, Asghar W, Jamali F. Adverse effects of nonsteroidal antiinflammatory drugs: an update of gastrointestinal, cardiovascular and renal complications. J Pharm Pharm Sci. 2014;16:821-847.

    (5) Berenson A, Gardiner H, Meier B, Pollack A. Despite warnings, drug giant took long path to Vioxx recall. New York Times. November 14, 2004. Available at: http://www.nytimes.com/2004/11/14/business/despite-warnings-drug-giant-took-long-path-to-vioxx-recall.html? Accessed February 21, 2017.

    (6) Collen M. Pain and treatment from a human primate perspective. J Pain Palliat Care Pharmacother. 2014;28:152-157.

    (7) Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9:745-758.

    (8) Smeets RJ, Vlaeyen JW, Kester AD, Knottnerus JA. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J Pain. 2006;7:261-271.

    (9) O’Sullivan P. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Man Ther. 2005;10:242-255.

    (10) Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2007;30:77-94.

    (11) Hoogendoorn WE, van Poppel MN, Bongers PM, Koes BW, Bouter LM. Systematic review of psychosocial factors at work and private life as risk factors for back pain. Spine. 2000;25:2114-2125.
    Alain Braillon M.D., Ph.D17 February 2017
    Acupuncture and low-back pain: an international bazar
    The American College of Physicians (ACP) guideline on non-invasive treatments for low back pain recommending “complementary and alternative medicine therapies” (massage, acupuncture, or spinal manipulation)” while mentioning the “low-quality evidence” deserves comment.(1)
    First, the correct term is “Complementary and Alternative Practices” (CAP): medicine should be based on evidence. Adding “therapies” to practices which enduringly failed to show evidence of relevant effects creates an oxymoron.(2) For low back pain, endpoints are a decrease in pharmacological treatment, an increase in the odds of being at work, improved functional limitations or quality of life …
    Second, the recommendation ignored several old robust trials published in core clinical journals showing effectiveness of Cognitive Behavioral Therapies.(e.g. 3,4) The trial cited as reference 121 was prolonged, confirming improvements in pain and functional limitations at 26 weeks.(5)
    Third, in England, the National Institute for Health and Care Excellence specifically recommended acupuncture NOT be used for managing low back pain as evidence is lacking.(https://www.nice.org.uk/guidance/ng59) In Australia, Friends of Science in Medicine warned “There is already enough evidence to confidently conclude that acupuncture doesn’t work. It is merely a theatrical placebo based on pre-scientific myths”(www.scienceinmedicine.org.au/images/pdf/acupuncturereview.pdf) and showed advertising claims are grossly misleading lay people.(http://www.scienceinmedicine.org.au/images/pdf/ukasaletter.pdf)
    Patients need explanations and reassurance to promote autonomy, not to be given faith in weird practices. Several skills in the doctor-patient encounter are pivotal (take time, remove barriers, let the patient explain…), CAP cannot replace them, they only strengthen medical arrogance. Voltaire at his time (1694-1778) stated "The art of medicine consists in amusing the patient while nature cures the disease." In 2017 AD, why amusing patients with weird practices from BC and non-existing meridians? Last, acupuncture was excluded from the Imperial Medical Institute by a decree of the Emperor of China in 1822, being regarded as superstitious and irrational.

    1 Qaseem A, Wilt TJ1, McLean RM et al. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2017. Online Feb 14. doi: 10.7326/M16-2367.
    2 Braillon A. Placebo and chronic low back pain: Too much in way of expectations, too little in terms of data. Pain 2017;158:535-536.
    3 Cherkin DC, Sherman KJ, Balderson BH et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial. JAMA 2016;315:1240-9.
    4 Lamb SE, Mistry D, Lall R et al. Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet 2010;375:916-23
    5 Cherkin DC, Sherman KJ, Balderson BH et al. Two-year follow-up of a randomized clinical trial
    of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care for chronic low back pain. JAMA 2017:317:642-3.