Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline

Chou, Roger; Deyo, Richard A.; Friedly, Janna; Skelly, Andrea C.; Hashimoto, Robin; Weimer, Melissa; Fu, Rochelle; Dana, Tracy; Kraegel, Paul; Griffin, Jessica; Grusing, Sara; Brodt, Erika D.

doi:10.7326/m16-2459

Cited by 671 publications

(565 citation statements)

References 219 publications

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“…This is consistent with other reviews including a recent Institute for Clinical and Economic Review (ICER) review on chronic low back pain and neck pain, 16 an AHRQ report on knee osteoarthritis treatment 17 and with recent reviews that included a variety of chronic pain conditions which examined exercise, 18 acupuncture, 19 and complementary health approaches 20 for chronic pain management, as well as a review of chronic pain treatment guidelines on the use of manual and physical therapies.…”

Section: Findings In Relationship To What Is Already Knownsupporting

confidence: 84%

“…Further, guidelines from the American College of Physicians recommend nonpharmacological therapies over medications for chronic back pain. 16 Our findings support the feasibility of implementing these guideline recommendations by showing that there are some nonpharmacological treatments for chronic pain that have evidence of sustained effectiveness after the completion of therapy. Importantly, some interventions, such as exercise, CBT, multidisciplinary rehabilitation, mindbody interventions, and some complementary and integrative medicine therapies, such as acupuncture and spinal manipulation, also were associated with some sustained effects on function, although evidence beyond 12 months is sparse.…”

Section: 14supporting

confidence: 71%

“…Our previous reviews found opioids associated with small to moderate effects on pain during treatment (effects would not be expected to persist) with evidence almost exclusively from short-term (≤3 month) trials. 11,16,25,247 Information on adherence to interventions was not well-reported; poor adherence may have impacted some of our findings. Harms were poorly reported across interventions.…”

Section: Discussion Key Findings and Strength Of Evidencementioning

confidence: 92%

“…16,25 In general we classified effects for measures with a 0 to 100 scale for pain or function as small/slight (5 to 10 points), moderate (>10 to 20 points), or large/substantial (>20 points) (see additional information in Assessing Applicability).…”

Section: Data Analysis and Synthesismentioning

confidence: 99%

“…Unilateral or bilateral W estern needle acupuncture (n=70) at locations depending on pain distribution and tenderness, using the following points: Primary local neck: GB 20, 21; GV 14; secondary local neck: SI 12, 13 14; BL 9, 10; ST 11; SI 15,16;BL 11,41,15,17;GB 29;TE 16,17;GV 15,16,17; Primary distal points: LI 4, SI 3, GB 34, TE 5; secondary distal points: LI 11; SI 8; TE 10, 36, 39, 40; BL 60; extra Luozhen deqi obtained B. Sham electroacupuncture (n=65) with audio and visual signals and up to 8 electrodes placed over acupuncture points simultaneously, but no current through severed cables.…”

Section: D-57mentioning

confidence: 99%

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Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review

Skelly¹,

Chou²,

Dettori³

et al. 2018

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ii Key Messages Purpose of ReviewTo assess which noninvasive nonpharmacological treatments for common chronic pain conditions improve function and pain for at least 1 month after treatment. Key Messages• Interventions that improved function and/or pain for at least 1 month when used foro Chronic low back pain: Exercise, psychological therapies (primarily cognitive behavioral therapy [CBT]), spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, multidisciplinary rehabilitation (MDR). o Chronic neck pain: Exercise, low-level laser, Alexander Technique, acupuncture. o Knee osteoarthritis: Exercise, ultrasound. o Hip osteoarthritis: Exercise, manual therapies. o Fibromyalgia: Exercise, CBT, myofascial release massage, tai chi, qigong, acupuncture, MDR. o Chronic tension headache: Spinal manipulation.• Most effects were small. Long-term evidence was sparse.• There was no evidence suggesting serious harms from any of the interventions studied; data on harms were limited.iii This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00009-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.The information in this report is intended to help health care decisionmakers-patients and clinicians, health system leaders, and policymakers, among others-make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders.AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.This report may periodically be assessed f...

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Section: Findings In Relationship To What Is Already Knownsupporting

confidence: 84%

Section: 14supporting

confidence: 71%

Section: Discussion Key Findings and Strength Of Evidencementioning

confidence: 92%

Section: Data Analysis and Synthesismentioning

confidence: 99%

Section: D-57mentioning

confidence: 99%

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Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review

Skelly¹,

Chou²,

Dettori³

et al. 2018

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Treatment of Low Back Pain

Wenger

Cifu

2017

JAMA

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Low back pain is among the most common symptoms seen in primary care clinics. 1 The management of LBP depends on its etiology, duration, presence of radiculopathy, and radiologic or physical examination findings. 2 Most episodes of LBP are acute (lasting <4 weeks), with no clearly identifiable underlying cause. 3 Low back pain is considered subacute if it persists for 4 to 12 weeks and chronic if it lasts longer than 12 weeks. 2 Because non-evidence-based management of LBP is associated with medical overuse and high health care expenditures, clinical practice guidelines have the potential to reduce costs and encourage value-based medical care. 4,5

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US Health Care Spending by Payer and Health Condition, 1996-2016

Dieleman

Cao

Chapin

et al. 2020

JAMA

797

527

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IMPORTANCE US health care spending has continued to increase and now accounts for 18% of the US economy, although little is known about how spending on each health condition varies by payer, and how these amounts have changed over time. OBJECTIVE To estimate US spending on health care according to 3 types of payers (public insurance [including Medicare, Medicaid, and other government programs], private insurance, or out-of-pocket payments) and by health condition, age group, sex, and type of care for 1996 through 2016. DESIGN AND SETTING Government budgets, insurance claims, facility records, household surveys, and official US records from 1996 through 2016 were collected to estimate spending for 154 health conditions. Spending growth rates (standardized by population size and age group) were calculated for each type of payer and health condition. EXPOSURES Ambulatory care, inpatient care, nursing care facility stay, emergency department care, dental care, and purchase of prescribed pharmaceuticals in a retail setting. MAIN OUTCOMES AND MEASURES National spending estimates stratified by health condition, age group, sex, type of care, and type of payer and modeled for each year from 1996 through 2016. RESULTS Total health care spending increased from an estimated $1.4 trillion in 1996 (13.3% of gross domestic product [GDP]; $5259 per person) to an estimated $3.1 trillion in 2016 (17.9% of GDP; $9655 per person); 85.2% of that spending was included in this study. In 2016, an estimated 48.0% (95% CI, 48.0%-48.0%) of health care spending was paid by private insurance, 42.6% (95% CI, 42.5%-42.6%) by public insurance, and 9.4% (95% CI, 9.4%-9.4%) by out-of-pocket payments. In 2016, among the 154 conditions, low back and neck pain had the highest amount of health care spending with an estimated $134.5 billion (95% CI, $122.4-$146.9 billion) in spending, of which 57.2% (95% CI, 52.2%-61.2%) was paid by private insurance, 33.7% (95% CI, 30.0%-38.4%) by public insurance, and 9.2% (95% CI, 8.3%-10.4%) by out-of-pocket payments. Other musculoskeletal disorders accounted for the second highest amount of health care spending

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Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline

Abstract: Agency for Healthcare Research and Quality. (PROSPERO: CRD42014014735).

Cited by 671 publications

References 219 publications

Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review

Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review

Treatment of Low Back Pain

US Health Care Spending by Payer and Health Condition, 1996-2016

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