Letters to the Editor

The Role of Nonpharmacologic Therapies for Back Pain


Am Fam Physician. 2012 Nov 1;86(9):online.

Original Article: Diagnosis and Treatment of Acute Low Back Pain

Issue Date: February 15, 2012

Available at: https://www.aafp.org/afp/2012/0215/p343.html

to the editor: Dr. Casazza does not provide an accurate picture of the potential role of nonpharmacologic approaches in the treatment of back pain. A guideline from the American Pain Society/American College of Physicians specifically recommends that physicians consider the addition of nonpharmacologic therapies with proven benefits (spinal manipulation for acute back pain; intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive behavioral therapy, or progressive relaxation for chronic or subacute low back pain) if symptoms do not improve with self-care options.1

Although the evidence supporting the use of these nonpharmacologic therapies may not be as strong as we would like, this is largely because the methodology we consider strongest—the double-blind, randomized, placebo-controlled trial—is not easily applied to the study of these approaches. Designing an appropriate placebo for a manual therapy and then blinding to that placebo can be difficult; therefore, many excellent studies of these therapies have used comparative effectiveness and other methodologies, which do not meet the strict standards that would produce a strong evidence rating. We should not confuse this methodologic challenge with the lack of effectiveness of therapies that are extremely safe and potentially helpful to patients.

Author disclosure: No relevant financial affiliations to disclose.


1. Chou R, Huffman LH. 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 [published correction appears in Ann Intern Med. 2008;148(3):247–248]. Ann Intern Med. 2007;147(7):492–504.

in reply: I thank Dr. Kligler for his comments. As he states, there have been many methodologic difficulties with completing high-quality research on spine-based pain. However, it is the goal of physicians and scientists to evaluate and apply the present data, despite their shortcomings. In my article, I evaluated extensive, up-to-date research and evidence-based analyses on acute low back pain. Because of restrictions on the length of the article, it was not feasible to describe my full, in-depth analysis. I refer readers to the reference list as it is an excellent resource of research on acute low back pain through May 2011 and strongly supports why certain treatments were recommended, unsupported, or not recommended in my article. Although the American Pain Society/American College of Physicians clinical practice guideline is informative, readers should understand that the guideline is more than four years old, and acute low back pain research has moved forward since then. For us to provide our patients the best evidence-based treatments, we must stay up-to-date.

E-mail: brian_casazza@med.unc.edu

Author disclosure: No relevant financial affiliations to disclose.

Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



Copyright © 2012 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

More in AFP

Editor's Collections

Related Content


Sep 2021

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article