Roger Chou, MD; Richard Deyo, MD, MPH; Janna Friedly, MD; Andrea Skelly, PhD, MPH; Robin Hashimoto, PhD; Melissa Weimer, DO, MCR; Rochelle Fu, PhD; Tracy Dana, MLS; Paul Kraegel, MSW; Jessica Griffin, MS; Sara Grusing, BA; Erika D. Brodt, BS
Disclaimer: The authors of this manuscript are responsible for its content. A representative from the Agency for Healthcare Research and Quality (AHRQ) served as a Contracting Officer's Technical Representative and provided technical assistance during the conduct of the full evidence report and provided comments on draft versions of the full evidence report. The AHRQ did not directly participate in the literature search, determination of study eligibility criteria, data analysis or interpretation, or preparation, review, or approval of the manuscript for publication. Statements in the report should not be construed as endorsement by AHRQ or the U.S. Department of Health and Human Services. The AHRQ retains a license to display, reproduce, and distribute the data and the report from which this manuscript was derived under the terms of the agency's contract with the author.
Grant Support: By contract HHSA290201200014I from AHRQ, U.S. Department of Health and Human Services.
Disclosures: Dr. Chou reports grants from AHRQ and funds for manuscript preparation from ACP during the conduct of this study. Dr. Deyo reports grants from AHRQ during the conduct of the study; grants from the National Institutes of Health (NIH), AHRQ, Centers for Disease Control and Prevention, and Patient-Centered Outcomes Research Institute (PCORI) outside the submitted work; personal fees from UpToDate and other support from Kaiser Permanente outside the submitted work; and a financial gift from NuVasive as part of a lifetime achievement award from the International Society for Study of the Lumbar Spine. Dr. Friedly reports grants from AHRQ during the conduct of the study and grants from PCORI and NIH outside the submitted work. Dr. Skelly reports grants from AHRQ during the conduct of the study and other support from the Washington State Health Technology Assessment (HTA) Program and AOSpine North America outside the submitted work. Dr. Hashimoto reports grants from AHRQ during the conduct of the study, other support from the Washington State HTA Program, and personal fees from Amgen, which were received after the submitted work was prepared. Dr. Weimer, Ms. Dana, Ms. Grusing, and Ms. Brodt report grants from AHRQ during the conduct of the study. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2459.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Available at www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014014735. Statistical code: Not applicable. Data set: See the Supplement (available at Annals.org) and full report at www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=2178.
Requests for Single Reprints: Roger Chou, MD, 3181 Southwest Sam Jackson Park Road, Mail Code: BICC, Portland, OR 97239; e-mail, email@example.com.
Current Author Addresses: Drs. Chou and Fu, Ms. Dana, Ms. Griffin, and Ms. Grusing: 3181 Southwest Sam Jackson Park Road, Mail Code: BICC, Portland, OR 97239.
Dr. Deyo: 3181 Southwest Sam Jackson Park Road, Mail Code: FM, Portland, OR 97239.
Dr. Friedly: 325 Ninth Avenue, Box 359612, Seattle, WA 98104.
Drs. Skelly and Hashimoto and Ms. Brodt: 705 South 9th Street, Suite 203, Tacoma, WA 98405.
Dr. Weimer: 3181 Southwest Sam Jackson Park Road, Mail Code: L-475, Portland, OR 97239.
Mr. Kraegel: University of Washington, Department of Pharmacy, Box 357630, Seattle, WA 98195.
Author Contributions: Conception and design: R. Chou, J. Friedly, M. Weimer.
Analysis and interpretation of the data: R. Chou, R. Deyo, J. Friedly, A. Skelly, R. Hashimoto, M. Weimer, R. Fu, T. Dana, J. Griffin, E. Brodt.
Drafting of the article: R. Chou, A. Skelly, R. Hashimoto, M. Weimer, R. Fu, J. Griffin, S. Grusing, E. Brodt.
Critical revision for important intellectual content: R. Chou, R. Deyo, J. Friedly, M. Weimer, J. Griffin.
Final approval of the article: R. Chou, R. Deyo, J. Friedly, A. Skelly, R. Hashimoto, M. Weimer, R. Fu, T. Dana, P. Kraegel, J. Griffin, S. Grusing, E. Brodt.
Statistical expertise: R. Chou, R. Fu.
Obtaining of funding: R. Chou.
Administrative, technical, or logistic support: T. Dana, P. Kraegel, J. Griffin, S. Grusing, E. Brodt.
Collection and assembly of data: R. Chou, R. Deyo, A. Skelly, R. Hashimoto, M. Weimer, T. Dana, P. Kraegel, J. Griffin, S. Grusing, E. Brodt.
Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. [Epub ahead of print 14 February 2017]:. doi: 10.7326/M16-2459
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Published: Ann Intern Med. 2017.
A 2007 American College of Physicians guideline addressed nonpharmacologic treatment options for low back pain. New evidence is now available.
To systematically review the current evidence on nonpharmacologic therapies for acute or chronic nonradicular or radicular low back pain.
Ovid MEDLINE (January 2008 through February 2016), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and reference lists.
Randomized trials of 9 nonpharmacologic options versus sham treatment, wait list, or usual care, or of 1 nonpharmacologic option versus another.
One investigator abstracted data, and a second checked abstractions for accuracy; 2 investigators independently assessed study quality.
The number of trials evaluating nonpharmacologic therapies ranged from 2 (tai chi) to 121 (exercise). New evidence indicates that tai chi (strength of evidence [SOE], low) and mindfulness-based stress reduction (SOE, moderate) are effective for chronic low back pain and strengthens previous findings regarding the effectiveness of yoga (SOE, moderate). Evidence continues to support the effectiveness of exercise, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture for chronic low back pain (SOE, low to moderate). Limited evidence shows that acupuncture is modestly effective for acute low back pain (SOE, low). The magnitude of pain benefits was small to moderate and generally short term; effects on function generally were smaller than effects on pain.
Qualitatively synthesized new trials with prior meta-analyses, restricted to English-language studies; heterogeneity in treatment techniques; and inability to exclude placebo effects.
Several nonpharmacologic therapies for primarily chronic low back pain are associated with small to moderate, usually short-term effects on pain; findings include new evidence on mind–body interventions.
Agency for Healthcare Research and Quality. (PROSPERO: CRD42014014735)
Table 1. Definitions for Magnitude of Effects, Based on Mean Between-Group Differences
Literature search and selection.
ACP = American College of Physicians; AHRQ = Agency for Healthcare Research and Quality; APS = American Pain Society; KQ = key question; RCT = randomized, controlled trial; SR = systematic review.
* Cochrane databases include the Cochrane Register of Controlled Trials and the Cochrane Database of Systematic Reviews.
† Other sources include prior reports, reference lists of relevant articles, systematic reviews, and others.
‡ Publications may be included or excluded for several interventions.
Table 2. Nonpharmacologic Treatments Versus Sham, No Treatment, or Usual Care for Chronic Low Back Pain
Table 3. Nonpharmacologic Treatments Versus Sham, No Treatment, or Usual Care for Acute Low Back Pain
Table 4. Nonpharmacologic Treatments for Radicular Low Back Pain
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Back Pain, Neurology, Neuropathy, Rheumatology.
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