Many nonpharmacologic therapies are available for treatment of low back pain.
To assess benefits and harms of acupuncture, back schools, psychological therapies,
exercise therapy, functional restoration, interdisciplinary therapy, massage, physical
therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave
diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation,
and ultrasonography), spinal manipulation, and yoga for acute or chronic low back
pain (with or without leg pain).
English-language studies were identified through searches of MEDLINE (through November
2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4). These electronic
searches were supplemented by hand searching of reference lists and additional citations
suggested by experts.
Systematic reviews and randomized trials of 1 or more of the preceding therapies for
acute or chronic low back pain (with or without leg pain) that reported pain outcomes,
back-specific function, general health status, work disability, or patient satisfaction.
We abstracted information about study design, population characteristics, interventions,
outcomes, and adverse events. To grade methodological quality, we used the Oxman criteria
for systematic reviews and the Cochrane Back Review Group criteria for individual
trials.
We found good evidence that cognitive-behavioral therapy, exercise, spinal manipulation,
and interdisciplinary rehabilitation are all moderately effective for chronic or subacute
(>4 weeks' duration) low back pain. Benefits over placebo, sham therapy, or no treatment
averaged 10 to 20 points on a 100-point visual analogue pain scale, 2 to 4 points
on the Roland-Morris Disability Questionnaire, or a standardized mean difference of
0.5 to 0.8. We found fair evidence that acupuncture, massage, yoga (Viniyoga), and
functional restoration are also effective for chronic low back pain. For acute low
back pain (<4 weeks' duration), the only nonpharmacologic therapies with evidence
of efficacy are superficial heat (good evidence for moderate benefits) and spinal
manipulation (fair evidence for small to moderate benefits). Although serious harms
seemed to be rare, data on harms were poorly reported. No trials addressed optimal
sequencing of therapies, and methods for tailoring therapy to individual patients
are still in early stages of development. Evidence is insufficient to evaluate the
efficacy of therapies for sciatica.
Our primary source of data was systematic reviews. We included non-English-language
trials only if they were included in English-language systematic reviews.
Therapies with good evidence of moderate efficacy for chronic or subacute low back
pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary
rehabilitation. For acute low back pain, the only therapy with good evidence of efficacy
is superficial heat.