title: A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain.
abstract: BACKGROUND
  Few treatments for back pain are supported by strong scientific evidence. Conventional treatments, although widely used, have had limited success. Dissatisfied patients have, therefore, turned to complementary and alternative medical therapies and providers for care for back pain.
  
  
  OBJECTIVE
  To provide a rigorous and balanced summary of the best available evidence about the effectiveness, safety, and costs of the most popular complementary and alternative medical therapies used to treat back pain.
  
  
  METHODS
  MEDLINE, EMBASE, and the Cochrane Controlled Trials Register.
  
  
  METHODS
  Systematic reviews of randomized, controlled trials (RCTs) that were published since 1995 and that evaluated acupuncture, massage therapy, or spinal manipulation for nonspecific back pain and RCTs published since the reviews were conducted.
  
  
  METHODS
  Two authors independently extracted data from the reviews (including number of RCTs, type of back pain, quality assessment, and conclusions) and original articles (including type of pain, comparison treatments, sample size, outcomes, follow-up intervals, loss to follow-up, and authors' conclusions).
  
  
  RESULTS
  Because the quality of the 20 RCTs that evaluated acupuncture was generally poor, the effectiveness of acupuncture for treating acute or chronic back pain is unclear. The three RCTs that evaluated massage reported that this therapy is effective for subacute and chronic back pain. A meta-regression analysis of the results of 26 RCTs evaluating spinal manipulation for acute and chronic back pain reported that spinal manipulation was superior to sham therapies and therapies judged to have no evidence of a benefit but was not superior to effective conventional treatments.
  
  
  CONCLUSIONS
  Initial studies have found massage to be effective for persistent back pain. Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. The effectiveness of acupuncture remains unclear. All of these treatments seem to be relatively safe. Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy.
authors.affiliation: Group Health Cooperative and University of Washington, Seattle, Washington 98101, USA.
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Cherkin
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Sherman
authors.forename: Richard A
authors.initials: RA
authors.lastname: Deyo
authors.forename: Paul G
authors.initials: PG
authors.lastname: Shekelle
mesh_terms: D015670:Acupuncture Therapy / Q000009:adverse effects / Q000191:economics / Q000592:standards*; D000208:Acute Disease; D001416:Back Pain / Q000628:therapy*; D002908:Chronic Disease; D003365:Costs and Cost Analysis; D019317:Evidence-Based Medicine; D006801:Humans; D020393:Manipulation, Spinal / Q000009:adverse effects / Q000191:economics / Q000592:standards*; D008405:Massage / Q000009:adverse effects / Q000191:economics / Q000592:standards*; D012449:Safety