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Chou R, Deyo R, Friedly J, et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166:493-505.
In people with low back pain, do non-drug treatments improve pain and functioning?
Low back pain is very common and may be experienced as dull or sharp and can be specific to one area or over a larger area, usually between the ribs and legs. It may also cause leg symptoms. There are many causes of low back pain, including injury or strain, aging, illness, fractures, and problems existing since birth.
Low back pain often lasts less than 4 weeks (acute), though it may be subacute (4 to 12 weeks) or chronic (lasting longer than 12 weeks).
Treatment of low back pain is difficult and often not very effective at improving pain or functioning.
The researchers did a systematic review based on studies available up to November 2016.
They found more than 120 randomized controlled trials.
The key features of the studies were:
Based on the results of this review, the American College of Physicians made 2 strong recommendations (the benefits of treatment clearly outweigh the risk or burden of treatment).
The first choice for treatment of acute or subacute low back pain in most adults should be non-drug options such as superficial heat, massage, acupuncture, or spinal manipulation for small to moderate improvements.
Treatment for chronic back pain should begin with non-drug treatments, including exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, yoga, tai chi, progressive relaxation, motor control exercise, electromyography biofeedback, low-level laser therapy, operant therapy (behavioral therapy involving a reward system), cognitive-behavioral therapy (psychological treatment that helps patients to change their emotional and behavioral reactions), or spinal manipulation for small to moderate improvements.
In people with acute or chronic low back pain, some non-drug treatments can provide small to moderate improvements pain and functioning.
Evidence (effect size)
Low back pain for up to 12 weeks (acute or subacute)
First choice for treatment in most patients should be
Heat wrap improved pain and function (moderate).
Massage improved pain and function at 1 week (moderate).
Acupuncture improved pain (small).
Spinal manipulation improved function (small).
Low back pain for more than 12 weeks (chronic)
Treatment should begin with non-drug treatment, including
Exercise improved pain and function (small).
Multidisciplinary rehabilitation improved pain at less than 3 months (moderate) or longer (small).
Acupuncture improved pain and function (moderate).
Mindfulness-based stress reduction improved pain and function (small).
Yoga improved pain and function at 24 weeks (moderate).
Tai chi improved pain (moderate) and function (small).
Progressive relaxation improved pain and function (moderate).
Motor control exercise improved pain (moderate) and function (small).
Electromyography feedback training improved pain (moderate).
Low-level laser therapy improved pain and function (small).
Operant therapy improved pain (small).
Cognitive-behavioral therapy improved pain (moderate).
Spinal manipulation improved pain (small).