The history of treatments for back and neck pain is generally one of small increments in benefit. For patients with acute pain, the natural history is favorable, and it is hard to prove that most treatments result in greater improvement than the nonspecific effects of natural history, placebo, and regression to the mean. The treatments that appear better than placebo, such as nonsteroidal anti-inflammatory drugs, muscle relaxants, and spinal manipulation, generally have modest effects (1 - 3). For chronic pain, the natural history is less favorable, but it is similarly difficult to prove that most treatments are better than nonspecific effects alone. The literature is replete with conflicting results, modest effects, and weak studies. The treatments that may be better than placebo, such as exercise programs, tricyclic antidepressants, and cognitive behavioral therapy, often require substantial patient commitment or lifestyle changes. In both clinical practice and clinical trials, many patients decline these treatments or find adherence difficult.