page contents });

Noninvasive Treatments Chronic Low Back Pain

Low Back Pain affects %50-%60 Of The Population Each Year

We find this article of interest because it validates the concept that low back pain is an extremely common malady.

via Annals Of Internal Medicine

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*

Image: M162367tt1_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

Image: M162367tt2_Appendix_Table_1_Pharmacologic_and_Nonpharmacologic_Treatments_for_Acute_or_Subacute

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

Image: M162367tt3_Appendix_Table_2_Pharmacologic_and_Nonpharmacologic_Treatments_for_Chronic_Low_Back_P

Appendix Table 2. Continued

Image: M162367tt6_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

Image: M162367tt4_Appendix_Table_3_Pharmacologic_and_Nonpharmacologic_Treatments_for_Radicular_Low_Back

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

Image: M162367tt5_Appendix_Table_4_Adverse_Events_for_Treatments_for_Acute_Chronic_and_Radicular_Low_Ba

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.

Image: M162367ff1a_Figure_Summary_of_the_American_College_of_Physicians_guideline_on_noninvasive_treatm

FIGURE.

Continued

Image: M162367ff1b_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
    RA
    Mirza
    SK
    Martin
    BI
    Back pain prevalence and visit rates: estimates from U.S.
    national surveys, 2002. Spine (Phila Pa 1976)
    2006
    31
    2724
    7
  2. Andersson
    GB
    Epidemiological features of chronic low-back pain.
    Lancet
    1999
    354
    581
    5
  3. Katz
    JN
    Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.
    J Bone Joint Surg Am
    2006
    88 Suppl 2
    21
    4
  4. Carey
    TS
    Evans
    AT
    Hadler
    NM
    Lieberman
    G
    Kalsbeek
    WD
    Jackman
    AM
    et al
    Acute severe low back pain. A population-based study of prevalence and care-seeking.
    Spine (Phila Pa 1976)
    1996
    21
    339
    44
  5. Pengel
    LH
    Herbert
    RD
    Maher
    CG
    Refshauge
    KM
    Acute low back pain: systematic review of its prognosis.
    BMJ
    2003
    327
    323

    .

  6. Von Korff
    M
    Saunders
    K
    The course of back pain in primary care.
    Spine (Phila Pa 1976)
    1996
    21
    2833
    7
  7. 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
    2017
    166
    493
    505
  8. Chou
    R
    Deyo
    R
    Friedly
    J
    Skelly
    A
    Weimer
    M
    et al
    Systemic pharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline.
    Ann Intern Med
    2017
    166
    480
    92
  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.
  10. Chou
    R
    Huffman
    LH
    American Pain Society
    Medications 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 Med
    2007
    147
    505
    14
  11. Chou
    R
    Huffman
    LH
    American Pain Society
    Nonpharmacologic 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 Med
    2007
    147
    492
    504
  12. Qaseem
    A
    Snow
    V
    Owens
    DK
    Shekelle
    P
    Clinical Guidelines Committee of the American College of Physicians
    The development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods.
    Ann Intern Med
    2010
    153
    194
    9
  13. Williams
    CM
    Maher
    CG
    Latimer
    J
    McLachlan
    AJ
    Hancock
    MJ
    Day
    RO
    et al
    Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial.
    Lancet
    2014
    384
    1586
    96
  14. Roelofs
    PD
    Deyo
    RA
    Koes
    BW
    Scholten
    RJ
    van Tulder
    MW
    Non-steroidal anti-inflammatory drugs for low back pain.
    Cochrane Database Syst Rev.
    2008
    CD000396

    .

  15. Herrmann
    WA
    Geertsen
    MS
    Efficacy 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 Pract
    2009
    63
    1613
    21
  16. Basmajian
    JV
    Acute back pain and spasm. A controlled multicenter trial of combined analgesic and antispasm agents.
    Spine (Phila Pa 1976)
    1989
    14
    438
    9
  17. Goldie
    I
    A clinical trial with indomethacin (indomee®) in low back pain and sciatica.
    Acta Orthop Scand
    1968
    39
    117
    28
  18. Weber
    H
    Comparison of the effect of diazepam and levomepromazine on pain in patients with acute lumbago-sciatica.
    J Oslo City Hosp
    1980
    30
    65
    8
  19. Dreiser
    RL
    Marty
    M
    Ionescu
    E
    Gold
    M
    Liu
    JH
    Relief 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 Ther
    2003
    41
    375
    85
  20. van Tulder
    MW
    Touray
    T
    Furlan
    AD
    Solway
    S
    Bouter
    LM
    Muscle relaxants for non-specific low back pain.
    Cochrane Database Syst Rev.
    2003
    CD004252

    .

  21. Ralph
    L
    Look
    M
    Wheeler
    W
    Sacks
    H
    Double-blind, placebo-controlled trial of carisoprodol 250-mg tablets in the treatment of acute lower-back spasm.
    Curr Med Res Opin
    2008
    24
    551
    8
  22. Pareek
    A
    Chandurkar
    N
    Chandanwale
    AS
    Ambade
    R
    Gupta
    A
    Bartakke
    G
    Aceclofenac-tizanidine in the treatment of acute low back pain: a double-blind, double-dummy, randomized, multicentric, comparative study against aceclofenac alone.
    Eur Spine J
    2009
    18
    1836
    42
  23. Friedman
    BW
    Dym
    AA
    Davitt
    M
    Holden
    L
    Solorzano
    C
    Esses
    D
    et al
    Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial.
    JAMA
    2015
    314
    1572
    80
  24. Friedman
    BW
    Holden
    L
    Esses
    D
    Bijur
    PE
    Choi
    HK
    Solorzano
    C
    et al
    Parenteral corticosteroids for emergency department patients with non-radicular low back pain.
    J Emerg Med
    2006
    31
    365
    70
  25. Eskin
    B
    Shih
    RD
    Fiesseler
    FW
    Walsh
    BW
    Allegra
    JR
    Silverman
    ME
    et al
    Prednisone for emergency department low back pain: a randomized controlled trial.
    J Emerg Med
    2014
    47
    65
    70
  26. Hingorani
    K
    Diazepam in backache. A double-blind controlled trial.
    Ann Phys Med
    1966
    8
    303
    6
  27. Moll
    W
    [Therapy of acute lumbovertebral syndromes through optimal muscle relaxation using diazepam. Results of a double-blind study on 68 cases].
    Med Welt
    1973
    24
    1747
    51
  28. Katz
    N
    Borenstein
    DG
    Birbara
    C
    Bramson
    C
    Nemeth
    MA
    Smith
    MD
    et al
    Efficacy and safety of tanezumab in the treatment of chronic low back pain.
    Pain
    2011
    152
    2248
    58
  29. Kivitz
    AJ
    Gimbel
    JS
    Bramson
    C
    Nemeth
    MA
    Keller
    DS
    Brown
    MT
    et al
    Efficacy and safety of tanezumab versus naproxen in the treatment of chronic low back pain.
    Pain
    2013
    154
    1009
    21
  30. Birbara
    CA
    Puopolo
    AD
    Munoz
    DR
    Sheldon
    EA
    Mangione
    A
    Bohidar
    NR
    et al
    Etoricoxib Protocol 042 Study Group
    Treatment 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 Pain
    2003
    4
    307
    15
  31. Katz
    N
    Ju
    WD
    Krupa
    DA
    Sperling
    RS
    BozalisRodgers
    D
    Gertz
    BJ
    et al
    Vioxx Chronic Low Back Pain Study Group
    Efficacy 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
  32. 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
    CD004959

    .

  33. Hale
    ME
    Dvergsten
    C
    Gimbel
    J
    Efficacy 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 Pain
    2005
    6
    21
    8
  34. Cloutier
    C
    Taliano
    J
    O’Mahony
    W
    Csanadi
    M
    Cohen
    G
    Sutton
    I
    et al
    Controlled-release oxycodone and naloxone in the treatment of chronic low back pain: a placebo-controlled, randomized study.
    Pain Res Manag
    2013
    18
    75
    82
  35. Rauck
    RL
    Nalamachu
    S
    Wild
    JE
    Walker
    GS
    Robinson
    CY
    Davis
    CS
    et al
    Single-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 Med
    2014
    15
    975
    85
  36. Wen
    W
    Sitar
    S
    Lynch
    SY
    He
    E
    Ripa
    SR
    A 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 Pharmacother
    2015
    16
    1593
    606
  37. Steiner
    DJ
    Sitar
    S
    Wen
    W
    Sawyerr
    G
    Munera
    C
    Ripa
    SR
    et al
    Efficacy 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 Manage
    2011
    42
    903
    17
  38. Gordon
    A
    Callaghan
    D
    Spink
    D
    Cloutier
    C
    Dzongowski
    P
    O’Mahony
    W
    et al
    Buprenorphine 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 Ther
    2010
    32
    844
    60
  39. Miller
    K
    Yarlas
    A
    Wen
    W
    Dain
    B
    Lynch
    SY
    Ripa
    SR
    et al
    The 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 Pain
    2014
    30
    1015
    22
  40. Yarlas
    A
    Miller
    K
    Wen
    W
    Lynch
    SY
    Munera
    C
    Pergolizzi
    JV
    Jr
    et al
    Buprenorphine transdermal system compared with placebo reduces interference in functioning for chronic low back pain.
    Postgrad Med
    2015
    127
    38
    45
  41. Allan
    L
    Richarz
    U
    Simpson
    K
    Slappendel
    R
    Transdermal fentanyl versus sustained release oral morphine in strong-opioid naïve patients with chronic low back pain.
    Spine (Phila Pa 1976)
    2005
    30
    2484
    90
  42. Rauck
    RL
    Bookbinder
    SA
    Bunker
    TR
    Alftine
    CD
    Ghalie
    R
    Negro-Vilar
    A
    et al
    The 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 Manag
    2006
    2
    155
    66
  43. Nicholson
    B
    Ross
    E
    Sasaki
    J
    Weil
    A
    Randomized trial comparing polymer-coated extended-release morphine sulfate to controlled-release oxycodone HCl in moderate to severe nonmalignant pain.
    Curr Med Res Opin
    2006
    22
    1503
    14
  44. Ueberall
    MA
    Mueller-Schwefe
    GH
    Safety 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 Opin
    2015
    31
    1413
    29
  45. Jamison
    RN
    Raymond
    SA
    Slawsby
    EA
    Nedeljkovic
    SS
    Katz
    NP
    Opioid therapy for chronic noncancer back pain. A randomized prospective study.
    Spine (Phila Pa 1976)
    1998
    23
    2591
    600
  46. Hale
    ME
    Fleischmann
    R
    Salzman
    R
    Wild
    J
    Iwan
    T
    Swanton
    RE
    et al
    Efficacy and safety of controlled-release versus immediate-release oxycodone: randomized, double-blind evaluation in patients with chronic back pain.
    Clin J Pain
    1999
    15
    179
    83
  47. Salzman
    RT
    Roberts
    MS
    Wild
    J
    Fabian
    C
    Reder
    RF
    Goldenheim
    PD
    Can 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 Manage
    1999
    18
    271
    9
  48. Hale
    ME
    Speight
    KL
    Harsanyi
    Z
    Iwan
    T
    Slagle
    NS
    Lacouture
    PG
    et al
    Efficacy of 12 hourly controlled-release codeine compared with as required dosing of acetaminophen plus codeine in patients with chronic low back pain.
    Pain Res Manag
    1997
    2
    33
    8
  49. Gostick
    N
    Allen
    J
    Cranfield
    R
    Currie
    J
    Grillage
    M
    Hildebrand
    P
    et al
    A 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 Education
    1989
    137
    43
  50. Beaulieu
    AD
    Peloso
    P
    Bensen
    W
    Clark
    AJ
    Watson
    CP
    Gardner-Nix
    J
    et al
    A 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 Ther
    2007
    29
    49
    60
  51. 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
    35
    1830
    40
  52. Schiphorst Preuper
    HR
    Geertzen
    JHB
    van Wijhe
    M
    Boonstra
    AM
    Molmans
    BHW
    Dijkstra
    PU
    et al
    Do analgesics improve functioning in patients with chronic low back pain? An explorative triple-blinded RCT.
    Eur Spine J
    2014
    23
    800
    6
  53. Casale
    R
    Acute low back pain: symptomatic treatment with a muscle relaxing drug.
    Clin J Pain
    1988
    4
    81
    8
  54. Basmajian
    JV
    Cyclobenzaprine hydrochloride effect on skeletal muscle spasm in the lumbar region and neck: two double-blind controlled clinical and laboratory studies.
    Arch Phys Med Rehabil
    1978
    59
    58
    63
  55. Pratzel
    HG
    Alken
    RG
    Ramm
    S
    Efficacy 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.
    Pain
    1996
    67
    417
    25
  56. Urquhart
    DM
    Hoving
    JL
    Assendelft
    WW
    Roland
    M
    van Tulder
    MW
    Antidepressants for non-specific low back pain.
    Cochrane Database Syst Rev.
    2008
    CD001703

    .

  57. Skljarevski
    V
    Ossanna
    M
    Liu-Seifert
    H
    Zhang
    Q
    Chappell
    A
    Iyengar
    S
    et al
    A double-blind, randomized trial of duloxetine versus placebo in the management of chronic low back pain.
    Eur J Neurol
    2009
    16
    1041
    8
  58. Skljarevski
    V
    Zhang
    S
    Desaiah
    D
    Alaka
    KJ
    Palacios
    S
    Miazgowski
    T
    et al
    Duloxetine versus placebo in patients with chronic low back pain: a 12-week, fixed-dose, randomized, double-blind trial.
    J Pain
    2010
    11
    1282
    90
  59. Skljarevski
    V
    Desaiah
    D
    Liu-Seifert
    H
    Zhang
    Q
    Chappell
    AS
    Detke
    MJ
    et al
    Efficacy and safety of duloxetine in patients with chronic low back pain.
    Spine (Phila Pa 1976)
    2010
    35
    E578
    85
  60. Brötz
    D
    Maschke
    E
    Burkard
    S
    Engel
    C
    Mänz
    C
    Ernemann
    U
    et al
    Is there a role for benzodiazepines in the management of lumbar disc prolapse with acute sciatica?
    Pain
    2010
    149
    470
    5
  61. Finckh
    A
    Zufferey
    P
    Schurch
    MA
    Balagué
    F
    Waldburger
    M
    So
    AK
    Short-term efficacy of intravenous pulse glucocorticoids in acute discogenic sciatica. A randomized controlled trial.
    Spine (Phila Pa 1976)
    2006
    31
    377
    81
  62. Haimovic
    IC
    Beresford
    HR
    Dexamethasone is not superior to placebo for treating lumbosacral radicular pain.
    Neurology
    1986
    36
    1593
    4
  63. Porsman
    O
    Friis
    H
    Prolapsed lumbar disc treated with intramuscularly administered dexamethasonephosphate. A prospectively planned, double-blind, controlled clinical trial in 52 patients.
    Scand J Rheumatol
    1979
    8
    142
    4
  64. Friedman
    BW
    Esses
    D
    Solorzano
    C
    Choi
    HK
    Cole
    M
    Davitt
    M
    et al
    A randomized placebo-controlled trial of single-dose IM corticosteroid for radicular low back pain.
    Spine (Phila Pa 1976)
    2008
    33
    E624
    9
  65. Holve
    RL
    Barkan
    H
    Oral steroids in initial treatment of acute sciatica.
    J Am Board Fam Med
    2008
    21
    469
    74
  66. Goldberg
    H
    Firtch
    W
    Tyburski
    M
    Pressman
    A
    Ackerson
    L
    Hamilton
    L
    et al
    Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial.
    JAMA
    2015
    313
    1915
    23
  67. McCleane
    GJ
    Does gabapentin have an analgesic effect on background, movement and referred pain? A randomised, double-blind, placebo controlled study.
    The Pain Clinic
    2001
    13
    103
    7
  68. Yildirim
    K
    Sişecioğlu
    M
    Karatay
    S
    Erdal
    A
    Levent
    A
    Uğur
    M
    et al
    The effectiveness of gabapentin in patients with chronic radiculopathy.
    The Pain Clinic
    2003
    15
    213
    8
  69. Yaksi
    A
    Ozgönenel
    L
    Ozgönenel
    B
    The efficiency of gabapentin therapy in patients with lumbar spinal stenosis.
    Spine (Phila Pa 1976)
    2007
    32
    939
    42
  70. Khoromi
    S
    Patsalides
    A
    Parada
    S
    Salehi
    V
    Meegan
    JM
    Max
    MB
    Topiramate in chronic lumbar radicular pain.
    J Pain
    2005
    6
    829
    36
  71. Muehlbacher
    M
    Nickel
    MK
    Kettler
    C
    Tritt
    K
    Lahmann
    C
    Leiberich
    PK
    et al
    Topiramate in treatment of patients with chronic low back pain: a randomized, double-blind, placebo-controlled study.
    Clin J Pain
    2006
    22
    526
    31
  72. Salerno
    SM
    Browning
    R
    Jackson
    JL
    The effect of antidepressant treatment on chronic back pain: a meta-analysis.
    Arch Intern Med
    2002
    162
    19
    24
  73. Hagen
    EM
    Ødelien
    KH
    Lie
    SA
    Eriksen
    HR
    Adding a physical exercise programme to brief intervention for low back pain patients did not increase return to work.
    Scand J Public Health
    2010
    38
    731
    8
  74. Machado
    LA
    Maher
    CG
    Herbert
    RD
    Clare
    H
    McAuley
    JH
    The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial.
    BMC Med
    2010
    8
    10

    .

  75. Pengel
    LH
    Refshauge
    KM
    Maher
    CG
    Nicholas
    MK
    Herbert
    RD
    McNair
    P
    Physiotherapist-directed exercise, advice, or both for subacute low back pain: a randomized trial.
    Ann Intern Med
    2007
    146
    787
    96
  76. Lee
    JH
    Choi
    TY
    Lee
    MS
    Lee
    H
    Shin
    BC
    Lee
    H
    Acupuncture for acute low back pain: a systematic review.
    Clin J Pain
    2013
    29
    172
    85
  77. Hasegawa
    TM
    Baptista
    AS
    de Souza
    MC
    Yoshizumi
    AM
    Natour
    J
    Acupuncture for acute non-specific low back pain: a randomised, controlled, double-blind, placebo trial.
    Acupunct Med
    2014
    32
    109
    15
  78. Vas
    J
    Aranda
    JM
    Modesto
    M
    Benítez-Parejo
    N
    Herrera
    A
    Martínez-Barquín
    DM
    et al
    Acupuncture in patients with acute low back pain: a multicentre randomised controlled clinical trial.
    Pain
    2012
    153
    1883
    9
  79. Gao
    H
    Wei
    C
    Extrapoint acupuncture treatement of 36 cases of acute lumbar sprain [in Chinese].
    Journal of Gansu College of Traditional Chinese Medicine
    2006
    2006
    49
    50
  80. Jin
    M
    Chen
    J
    Acupuncture treatment for 40 cases of acute lumbar sprain [in Chinese].
    Journal of Gansu College of Traditional Chinese Medicine
    2008
    2006
    49
    50
  81. Lan
    J
    Analysis of application of acupuncture analgesia in acute lumbar sprain [in Chinese].
    Journal of Community Medicine
    2009
    68
    9
  82. Yao-chi
    W
    Bi-meng
    Z
    Chong-miao
    W
    Jun-feng
    Z
    Ping
    S
    Liu
    GZ
    [Observation on short-term and long-term therapeutic effects of electroacupuncture at Houxi (SI 3) on acute lumbar sprain].
    Zhongguo Zhen Jiu
    2007
    27
    3
    5
  83. Chen
    Y
    Clinical observation of electroacupuncture at SI3 in addition to drug therapy in acute lumbar sprain [in Chinese].
    Journal of Community Medicine
    2010
    39

    .

  84. Furlan
    AD
    Imamura
    M
    Dryden
    T
    Irvin
    E
    Massage for low-back pain.
    Cochrane Database Syst Rev.
    2008
    CD001929

    .

  85. Farasyn
    A
    Meeusen
    R
    Nijs
    J
    A pilot randomized placebo-controlled trial of roptrotherapy in patients with subacute non-specific low back pain.
    J Back Musculoskelet Rehabil
    2006
    19
    111
    7
  86. Yoon
    YS
    Yu
    KP
    Lee
    KJ
    Kwak
    SH
    Kim
    JY
    Development and application of a newly designed massage instrument for deep cross-friction massage in chronic non-specific low back pain.
    Ann Rehabil Med
    2012
    36
    55
    65
  87. von Heymann
    WJ
    Schloemer
    P
    Timm
    J
    Muehlbauer
    B
    Spinal 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
  88. Hoiriis
    KT
    Pfleger
    B
    McDuffie
    FC
    Cotsonis
    G
    Elsangak
    O
    Hinson
    R
    et al
    A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain.
    J Manipulative Physiol Ther
    2004
    27
    388
    98
  89. Rubinstein
    SM
    Terwee
    CB
    Assendelft
    WJ
    de Boer
    MR
    van Tulder
    MW
    Spinal manipulative therapy for acute low-back pain.
    Cochrane Database Syst Rev.
    2012
    CD008880

    .

  90. Schneider
    M
    Haas
    M
    Glick
    R
    Stevans
    J
    Landsittel
    D
    Comparison 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
  91. French
    SD
    Cameron
    M
    Walker
    BF
    Reggars
    JW
    Esterman
    AJ
    Superficial heat or cold for low back pain.
    Cochrane Database Syst Rev.
    2006
    CD004750

    .

  92. Mayer
    JM
    Ralph
    L
    Look
    M
    Erasala
    GN
    Verna
    JL
    Matheson
    LN
    et al
    Treating acute low back pain with continuous low-level heat wrap therapy and/or exercise: a randomized controlled trial.
    Spine J
    2005
    5
    395
    403
  93. Nadler
    SF
    Steiner
    DJ
    Erasala
    GN
    Hengehold
    DA
    Hinkle
    RT
    Beth Goodale
    M
    et al
    Continuous 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
  94. Konstantinovic
    LM
    Cutovic
    MR
    Milovanovic
    AN
    Jovic
    SJ
    Dragin
    AS
    Letic
    MDj
    et al
    Low-level laser therapy for acute neck pain with radiculopathy: a double-blind placebo-controlled randomized study.
    Pain Med
    2010
    11
    1169
    78
  95. Oleske
    DM
    Lavender
    SA
    Andersson
    GB
    Kwasny
    MM
    Are 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
  96. van Middelkoop
    M
    Rubinstein
    SM
    Verhagen
    AP
    Ostelo
    RW
    Koes
    BW
    van Tulder
    MW
    Exercise therapy for chronic nonspecific low-back pain.
    Best Pract Res Clin Rheumatol
    2010
    24
    193
    204
  97. Byström
    MG
    Rasmussen-Barr
    E
    Grooten
    WJ
    Motor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis.
    Spine (Phila Pa 1976)
    2013
    38
    E350
    8
  98. Koumantakis
    GA
    Watson
    PJ
    Oldham
    JA
    Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain.
    Phys Ther
    2005
    85
    209
    25
  99. Cairns
    MC
    Foster
    NE
    Wright
    C
    Randomized controlled trial of specific spinal stabilization exercises and conventional physiotherapy for recurrent low back pain.
    Spine (Phila Pa 1976)
    2006
    31
    E670
    81
  100. Wells
    C
    Kolt
    GS
    Marshall
    P
    Hill
    B
    Bialocerkowski
    A
    The effectiveness of Pilates exercise in people with chronic low back pain: a systematic review.
    PLoS One
    2014
    9
    e100402

    .

  101. Gladwell
    V
    Head
    S
    Haggar
    M
    Beneke
    R
    Does a program of Pilates improve chronic non-specific low back pain?
    J Sport Rehabil
    2006
    15
    338
    50
  102. Borges
    J
    Baptista
    AF
    Santana
    N
    Souza
    I
    Kruschewsky
    RA
    Galvão-Castro
    B
    et al
    Pilates exercises improve low back pain and quality of life in patients with HTLV-1 virus: a randomized crossover clinical trial.
    J Bodyw Mov Ther
    2014
    18
    68
    74
  103. da Fonseca
    JL
    Magini
    M
    de Freitas
    TH
    Laboratory gait analysis in patients with low back pain before and after a Pilates intervention.
    J Sport Rehabil
    2009
    18
    269
    82
  104. MacIntyre
    L
    The Effect of Pilates on Patients’ Chronic Low Back Pain: A Pilot Study [dissertation].
    Johannesburg, South Africa
    University of the Witwatersrand
    2006
  105. Miyamoto
    GC
    Costa
    LO
    Galvanin
    T
    Cabral
    CM
    Efficacy of the addition of modified Pilates exercises to a minimal intervention in patients with chronic low back pain: a randomized controlled trial.
    Phys Ther
    2013
    93
    310
    20
  106. Quinn
    K
    Barry
    S
    Barry
    L
    Do patients with chronic low back pain benefit from attending Pilates classes after completing conventional physiotherapy treatment?
    Physiother Pract Res
    2011
    32
    5
    12
  107. Rydeard
    R
    Evaluation 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
  108. Gagnon
    L
    Efficacy of Pilates Exercises as Therapeutic Intervention in Treating Patients with Low Back Pain [dissertation].
    Knoxville, TN
    University of Tennessee
    2005
  109. Rajpal
    N
    Arora
    M
    Chauhan
    V
    The study on efficacy of Pilates and McKenzie exercise in postural low back pain—a rehabilitative protocol.
    Physiotherapy and Occupational Therapy Journal
    2008
    1
    33
    56
  110. Wajswelner
    H
    Metcalf
    B
    Bennell
    K
    Clinical Pilates versus general exercise for chronic low back pain: randomized trial.
    Med Sci Sports Exerc
    2012
    44
    1197
    205
  111. Hall
    AM
    Maher
    CG
    Lam
    P
    Ferreira
    M
    Latimer
    J
    Tai 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
  112. Weifen
    W
    Muheremu
    A
    Chaohui
    C
    Wenge
    L
    Lei
    S
    Effectiveness of tai chi practice for non-specific chronic low back pain on retired athletes: a randomized controlled study.
    J Musculoskelet Pain
    2013
    21
    37
    45
  113. Williams
    K
    Abildso
    C
    Steinberg
    L
    Doyle
    E
    Epstein
    B
    Smith
    D
    et al
    Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain.
    Spine (Phila Pa 1976)
    2009
    34
    2066
    76
  114. Sherman
    KJ
    Cherkin
    DC
    Erro
    J
    Miglioretti
    DL
    Deyo
    RA
    Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial.
    Ann Intern Med
    2005
    143
    849
    56
  115. Sherman
    KJ
    Cherkin
    DC
    Wellman
    RD
    Cook
    AJ
    Hawkes
    RJ
    Delaney
    K
    et al
    A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain.
    Arch Intern Med
    2011
    171
    2019
    26
  116. Nambi
    GS
    Inbasekaran
    D
    Khuman
    R
    Devi
    S
    Shanmugananth,Jagannathan
    K
    Changes in pain intensity and health related quality of life with Iyengar yoga in nonspecific chronic low back pain: a randomized controlled study.
    Int J Yoga
    2014
    7
    48
    53
  117. Tekur
    P
    Nagarathna
    R
    Chametcha
    S
    Hankey
    A
    Nagendra
    HR
    A comprehensive yoga programs improves pain, anxiety and depression in chronic low back pain patients more than exercise: an RCT.
    Complement Ther Med
    2012
    20
    107
    18
  118. Aboagye
    E
    Karlsson
    ML
    Hagberg
    J
    Jensen
    I
    Cost-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 Med
    2015
    47
    167
    73
  119. Cramer
    H
    Lauche
    R
    Haller
    H
    Dobos
    G
    A systematic review and meta-analysis of yoga for low back pain.
    Clin J Pain
    2013
    29
    450
    60
  120. Henschke
    N
    Ostelo
    RW
    van Tulder
    MW
    Vlaeyen
    JW
    Morley
    S
    Assendelft
    WJ
    et al
    Behavioural treatment for chronic low-back pain.
    Cochrane Database Syst Rev.
    2010
    CD002014

    .

  121. Cherkin
    DC
    Sherman
    KJ
    Balderson
    BH
    Cook
    AJ
    Anderson
    ML
    Hawkes
    RJ
    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
  122. Morone
    NE
    Greco
    CM
    Moore
    CG
    Rollman
    BL
    Lane
    B
    Morrow
    LA
    et al
    A mind-body program for older adults with chronic low back pain: a randomized clinical trial.
    JAMA Intern Med
    2016
    176
    329
    37
  123. Morone
    NE
    Rollman
    BL
    Moore
    CG
    Li
    Q
    Weiner
    DK
    A mind-body program for older adults with chronic low back pain: results of a pilot study.
    Pain Med
    2009
    10
    1395
    407
  124. Kamper
    SJ
    Apeldoorn
    AT
    Chiarotto
    A
    Smeets
    RJ
    Ostelo
    RW
    Guzman
    J
    et al
    Multidisciplinary biopsychosocial rehabilitation for chronic low back pain.
    Cochrane Database Syst Rev.
    2014
    CD000963

    .

  125. Lam
    M
    Galvin
    R
    Curry
    P
    Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis.
    Spine (Phila Pa 1976)
    2013
    38
    2124
    38
  126. Cho
    YJ
    Song
    YK
    Cha
    YY
    Shin
    BC
    Shin
    IH
    Park
    HJ
    et al
    Acupuncture for chronic low back pain: a multicenter, randomized, patient-assessor blind, sham-controlled clinical trial.
    Spine (Phila Pa 1976)
    2013
    38
    549
    57
  127. Haake
    M
    Müller
    HH
    Schade-Brittinger
    C
    Basler
    HD
    Schäfer
    H
    Maier
    C
    et al
    German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups.
    Arch Intern Med
    2007
    167
    1892
    8
  128. Leibing
    E
    Leonhardt
    U
    Köster
    G
    Goerlitz
    A
    Rosenfeldt
    JA
    Hilgers
    R
    et al
    Acupuncture treatment of chronic low-back pain—a randomized, blinded, placebo-controlled trial with 9-month follow-up.
    Pain
    2002
    96
    189
    96
  129. Sator-Katzenschlager
    SM
    Scharbert
    G
    Kozek-Langenecker
    SA
    Szeles
    JC
    Finster
    G
    Schiesser
    AW
    et al
    The short- and long-term benefit in chronic low back pain through adjuvant electrical versus manual auricular acupuncture.
    Anesth Analg
    2004
    98
    1359
    64
  130. Yeh
    CH
    Suen
    LK
    Shen
    J
    Chien
    LC
    Liang
    Z
    Glick
    RM
    et al
    Changes in sleep with auricular point acupressure for chronic low back pain.
    Behav Sleep Med
    2016
    14
    279
    94
  131. Eghbali
    M
    Safari
    R
    Nazari
    F
    Abdoli
    S
    The 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 Res
    2012
    17
    239
    43
  132. Quinn
    F
    Hughes
    CM
    Baxter
    GD
    Reflexology in the management of low back pain: a pilot randomised controlled trial.
    Complement Ther Med
    2008
    16
    3
    8
  133. Poole
    H
    Glenn
    S
    Murphy
    P
    A randomised controlled study of reflexology for the management of chronic low back pain.
    Eur J Pain
    2007
    11
    878
    87
  134. Rubinstein
    SM
    van Middelkoop
    M
    Assendelft
    WJ
    de Boer
    MR
    van Tulder
    MW
    Spinal manipulative therapy for chronic low-back pain.
    Cochrane Database Syst Rev.
    2011
    CD008112

    .

  135. Senna
    MK
    Machaly
    SA
    Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?
    Spine (Phila Pa 1976)
    2011
    36
    1427
    37
  136. Postacchini
    F
    Facchini
    M
    Palieri
    P
    Efficacy of various forms of conservative treatment in low back pain. A comparative study.
    Neuro-orthopedics
    1988
    6
    28
    35
  137. Koes
    BW
    Bouter
    LM
    van Mameren
    H
    Essers
    AH
    Verstegen
    GM
    Hofhuizen
    DM
    et al
    Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up.
    BMJ
    1992
    304
    601
    5
  138. Gibson
    T
    Grahame
    R
    Harkness
    J
    Woo
    P
    Blagrave
    P
    Hills
    R
    Controlled comparison of short-wave diathermy treatment with osteopathic treatment in non-specific low back pain.
    Lancet
    1985
    1
    1258
    61
  139. Pope
    MH
    Phillips
    RB
    Haugh
    LD
    Hsieh
    CY
    MacDonald
    L
    Haldeman
    S
    A 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
  140. Balthazard
    P
    de Goumoens
    P
    Rivier
    G
    Demeulenaere
    P
    Ballabeni
    P
    Dériaz
    O
    Manual 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 Disord
    2012
    13
    162

    .

  141. Bicalho
    E
    Setti
    JA
    Macagnan
    J
    Cano
    JL
    Manffra
    EF
    Immediate effects of a high-velocity spine manipulation in paraspinal muscles activity of nonspecific chronic low-back pain subjects.
    Man Ther
    2010
    15
    469
    75
  142. Haas
    M
    Vavrek
    D
    Peterson
    D
    Polissar
    N
    Neradilek
    MB
    Dose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial.
    Spine J
    2014
    14
    1106
    16
  143. UK BEAM Trial
    Team
    United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care.
    BMJ
    2004
    329
    1377

    .

  144. Hsieh
    CY
    Adams
    AH
    Tobis
    J
    Hong
    CZ
    Danielson
    C
    Platt
    K
    et al
    Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial.
    Spine (Phila Pa 1976)
    2002
    27
    1142
    8
  145. Licciardone
    JC
    Stoll
    ST
    Fulda
    KG
    Russo
    DP
    Siu
    J
    Winn
    W
    et al
    Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial.
    Spine (Phila Pa 1976)
    2003
    28
    1355
    62
  146. Rasmussen
    J
    Laetgaard
    J
    Lindecrona
    AL
    Qvistgaard
    E
    Bliddal
    H
    Manipulation does not add to the effect of extension exercises in chronic low-back pain (LBP). A randomized, controlled, double blind study.
    Joint Bone Spine
    2008
    75
    708
    13
  147. Evans
    DP
    Burke
    MS
    Lloyd
    KN
    Roberts
    EE
    Roberts
    GM
    Lumbar spinal manipulation on trial. Part I—clinical assessment.
    Rheumatol Rehabil
    1978
    17
    46
    53
  148. Ebadi
    S
    Henschke
    N
    Nakhostin Ansari
    N
    Fallah
    E
    van Tulder
    MW
    Therapeutic ultrasound for chronic low-back pain.
    Cochrane Database Syst Rev.
    2014
    CD009169

    .

  149. Ebadi
    S
    Ansari
    NN
    Naghdi
    S
    Jalaei
    S
    Sadat
    M
    Bagheri
    H
    et al
    The effect of continuous ultrasound on chronic non-specific low back pain: a single blind placebo-controlled randomized trial.
    BMC Musculoskelet Disord
    2012
    13
    192

    .

  150. Mohseni-Bandpei
    MA
    Critchley
    J
    Staunton
    T
    Richardson
    B
    A prospective randomised controlled trial of spinal manipulation and ultrasound in the treatment of chronic low back pain.
    Physiotherapy
    2006
    92
    34
    42
  151. Durmus
    D
    Durmaz
    Y
    Canturk
    F
    Effects 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 Int
    2010
    30
    901
    10
  152. Durmus
    D
    Alayli
    G
    Goktepe
    AS
    Taskaynatan
    MA
    Bilgici
    A
    Kuru
    O
    Is phonophoresis effective in the treatment of chronic low back pain? A single-blind randomized controlled trial.
    Rheumatol Int
    2013
    33
    1737
    44
  153. van Middelkoop
    M
    Rubinstein
    SM
    Kuijpers
    T
    Verhagen
    AP
    Ostelo
    R
    Koes
    BW
    et al
    A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain.
    Eur Spine J
    2011
    20
    19
    39
  154. Manheimer
    E
    White
    A
    Berman
    B
    Forys
    K
    Ernst
    E
    Meta-analysis: acupuncture for low back pain.
    Ann Intern Med
    2005
    142
    651
    63
  155. Basford
    JR
    Sheffield
    CG
    Harmsen
    WS
    Laser therapy: a randomized, controlled trial of the effects of low-intensity Nd:YAG laser irradiation on musculoskeletal back pain.
    Arch Phys Med Rehabil
    1999
    80
    647
    52
  156. Soriano
    F
    Rios
    R
    Gallium arsenide laser treatment of chronic low back pain: a prospective, randomized and double blind study.
    Laser Therapy
    1998
    10
    175
    80
  157. Toya
    S
    Motegi
    M
    Inomata
    K
    Ohshiro
    T
    Report 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 Therapy
    1994
    6
    143
    8
  158. Dalichau
    S
    Scheele
    K
    [Effects of elastic lumbar belts on the effect of a muscle training program for patients with chronic back pain].
    Z Orthop Ihre Grenzgeb
    2000
    138
    8
    16
  159. Hsieh
    CY
    Phillips
    RB
    Adams
    AH
    Pope
    MH
    Functional outcomes of low back pain: comparison of four treatment groups in a randomized controlled trial.
    J Manipulative Physiol Ther
    1992
    15
    4
    9
  160. Doran
    DM
    Newell
    DJ
    Manipulation in treatment of low back pain: a multicentre study.
    Br Med J
    1975
    2
    161
    4
  161. Coxhead
    CE
    Inskip
    H
    Meade
    TW
    North
    WR
    Troup
    JD
    Multicentre trial of physiotherapy in the management of sciatic symptoms.
    Lancet
    1981
    1
    1065
    8
  162. Castro-Sánchez
    AM
    Lara-Palomo
    IC
    Matarán-Peñarrocha
    GA
    Fernández-Sánchez
    M
    Sánchez-Labraca
    N
    Arroyo-Morales
    M
    Kinesio taping reduces disability and pain slightly in chronic non-specific low back pain: a randomised trial.
    J Physiother
    2012
    58
    89
    95
  163. Parreira Pdo
    C
    Costa Lda
    C
    Takahashi
    R
    HespanholJunior
    LC
    Luz Junior
    MA
    Silva
    TM
    et al
    Kinesio taping to generate skin convolutions is not better than sham taping for people with chronic non-specic low back pain: a randomised trial.
    J Physiother
    2014
    60
    90
    6
  164. Paoloni
    M
    Bernetti
    A
    Fratocchi
    G
    Mangone
    M
    Parrinello
    L
    Del Pilar Cooper
    M
    et al
    Kinesio taping applied to lumbar muscles influences clinical and electromyographic characteristics in chronic low back pain patients.
    Eur J Phys Rehabil Med
    2011
    47
    237
    44
  165. Kachanathu
    SJ
    Alenazi
    AM
    Seif
    HE
    Hafez
    AR
    Alroumim
    MA
    Comparison between Kinesio taping and a traditional physical therapy program in treatment of nonspecific low back pain.
    J Phys Ther Sci
    2014
    26
    1185
    8
  166. Albaladejo
    C
    Kovacs
    FM
    Royuela
    A
    del Pino
    R
    Zamora
    J
    Spanish Back Pain Research Network
    The 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
  167. Albert
    HB
    Manniche
    C
    The 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
  168. Hofstee
    DJ
    Gijtenbeek
    JM
    Hoogland
    PH
    van Houwelingen
    HC
    Kloet
    A
    Lötters
    F
    et al
    Westeinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica.
    J Neurosurg
    2002
    96
    45
    9
  169. Wegner
    I
    Widyahening
    IS
    van Tulder
    MW
    Blomberg
    SE
    de Vet
    HC
    Brønfort
    G
    et al
    Traction for low-back pain with or without sciatica.
    Cochrane Database Syst Rev.
    2013
    CD003010

    .

  170. Calmels
    P
    Queneau
    P
    Hamonet
    C
    Le Pen
    C
    Maurel
    F
    Lerouvreur
    C
    et al
    Effectiveness of a lumbar belt in subacute low back pain: an open, multicentric, and randomized clinical study.
    Spine (Phila Pa 1976)
    2009
    34
    215
    20
  171. Sato
    N
    Sekiguchi
    M
    Kikuchi
    S
    Shishido
    H
    Sato
    K
    Konno
    S
    Effects of long-term corset wearing on chronic low back pain.
    Fukushima J Med Sci
    2012
    58
    60
    5
  172. Diab
    AA
    Moustafa
    IM
    Lumbar lordosis rehabilitation for pain and lumbar segmental motion in chronic mechanical low back pain: a randomized trial.
    J Manipulative Physiol Ther
    2012
    35
    246
    53
  173. Diab
    AA
    Moustafa
    IM
    The efficacy of lumbar extension traction for sagittal alignment in mechanical low back pain: a randomized trial.
    J Back Musculoskelet Rehabil
    2013
    26
    213
    20
  174. Moustafa
    IM
    Diab
    AA
    Extension traction treatment for patients with discogenic lumbosacral radiculopathy: a randomized controlled trial.
    Clin Rehabil
    2013
    27
    51
    62
  175. Hsieh
    LL
    Kuo
    CH
    Yen
    MF
    Chen
    TH
    A randomized controlled clinical trial for low back pain treated by acupressure and physical therapy.
    Prev Med
    2004
    39
    168
    76
  176. Chatchawan
    U
    Thinkhamrop
    B
    Kharmwan
    S
    Knowles
    J
    Eungpinichpong
    W
    Effectiveness of traditional Thai massage versus Swedish massage among patients with back pain associated with myofascial trigger points.
    J Bodyw Mov Ther
    2005
    9
    298
    309
  177. Buchmuller
    A
    Navez
    M
    Milletre-Bernardin
    M
    Pouplin
    S
    Presles
    E
    Lantéri-Minet
    M
    et al
    Lombotens Trial Group
    Value of TENS for relief of chronic low back pain with or without radicular pain.
    Eur J Pain
    2012
    16
    656
    65
  178. Nadler
    SF
    Steiner
    DJ
    Erasala
    GN
    Hengehold
    DA
    Abeln
    SB
    Weingand
    KW
    Continuous low-level heatwrap therapy for treating acute nonspecific low back pain.
    Arch Phys Med Rehabil
    2003
    84
    329
    34
  179. Nadler
    SF
    Steiner
    DJ
    Petty
    SR
    Erasala
    GN
    Hengehold
    DA
    Weingand
    KW
    Overnight use of continuous low-level heatwrap therapy for relief of low back pain.
    Arch Phys Med Rehabil
    2003
    84
    335
    42
  180. Hestbaek
    L
    Leboeuf-Yde
    C
    Manniche
    C
    Low back pain: what is the long-term course? A review of studies of general patient populations.
    Eur Spine J
    2003
    12
    149
    65
  181. Drug Enforcement Administration, Departmentof Justice
    Schedule of controlled substances: placement of tramadol into schedule IV. Final rule.
    Fed Regist
    2014
    79
    37623
    30
  182. Chou
    R
    Deyo
    R
    Devine
    B
    Hansen
    R
    Sullivan
    S
    Jarvik
    JG
    et al
    The 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
  183. Agency for Healthcare Research and Quality
    Methods Guide for Effectiveness and Comparative Effectiveness Reviews. AHRQ publication no. 10(13)-EHC063-EF.
    Rockville
    Agency for Healthcare Research and Quality
    2014
  184. Shea
    BJ
    Hamel
    C
    Wells
    GA
    Bouter
    LM
    Kristjansson
    E
    Grimshaw
    J
    et al
    AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews.
    J Clin Epidemiol
    2009
    62
    1013
    20