title: Comparative effectiveness of exercise, acupuncture, and spinal manipulation for low back pain.
abstract: METHODS
  Systematic review.
  
  
  OBJECTIVE
  We sought to answer the following clinical questions: (1) Is structured exercise more effective in the treatment of chronic low back pain (LBP) than spinal manipulative therapy (SMT)? (2) Is structured exercise more effective in the treatment of chronic LBP than acupuncture? (3) Is SMT more effective in the treatment of chronic LBP than acupuncture? (4) Do certain subgroups respond more favorably to specific treatments? (5) Are any of these treatments more cost-effective than the others?
  
  
  BACKGROUND
  Exercise, SMT, and acupuncture are widely used interventions in the treatment of chronic LBP. There is evidence that all of these approaches may offer some benefit for patients with chronic LBP when compared with usual care or no treatment. The relative benefits or cost-effectiveness of any one of these treatments when compared with the others are less well-defined, and it is difficult to identify specific subgroups of those with chronic LBP who may preferentially respond to a particular treatment modality.
  
  
  METHODS
  A systematic review of the literature was performed to identify randomized controlled trials comparing a structured exercise program, SMT, or acupuncture with one another in patients with chronic LBP.
  
  
  RESULTS
  Two studies were identified comparing the use of structured exercise with SMT that met our inclusion criteria. Although these studies utilized different approaches for the exercise and SMT treatment groups, patients in both groups improved in terms of pain and function in both studies. Using random-effects modeling, there was no difference between the exercise and SMT groups when the data from these studies were pooled. We identified no studies meeting our inclusion criteria that compared acupuncture with either structured exercise or SMT or that addressed the relative cost-effectiveness of these approaches in the treatment of patients with chronic LBP.
  
  
  CONCLUSIONS
  The studies identified indicate that structured exercise and SMT appear to offer equivalent benefits in terms of pain and functional improvement for those with chronic LBP with clinical benefits evident within 8 weeks of care. However, the level of evidence is low. There is insufficient evidence to comment on the relative benefit of acupuncture compared with either structured exercise or SMT or to address the differential effects of structured exercise, SMT, or acupuncture for specific subgroups of individuals with chronic LBP. There is also insufficient evidence regarding the relative cost-effectiveness of structured exercise, SMT, or acupuncture in the treatment of chronic LBP.
  
  
  CONCLUSIONS
  Structured exercise and SMT appear to offer equivalent benefits in the management of pain and function for patients with nonspecific chronic LBP. If no clinical benefit is appreciated after using one of these approaches for 8 weeks, then the treatment plan should be reevaluated and consideration should be given to modifying the treatment approach or using alternate forms of care. Strength of recommendation: Weak.There is insufficient evidence regarding the relative benefits of the acupuncture compared with either structured exercise or SMT in the treatment of chronic LBP.There is insufficient evidence to address differential effects of structured exercise, SMT, or acupuncture for specific subgroups of individuals with chronic LBP. There is insufficient evidence regarding the relative cost-effectiveness of structured exercise, SMT, or acupuncture in the treatment of chronic LBP.
authors.affiliation: Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98104, USA. cjs1@uw.edu
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Standaert
authors.forename: Janna
authors.initials: J
authors.lastname: Friedly
authors.forename: Mark W
authors.initials: MW
authors.lastname: Erwin
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Lee
authors.forename: Glenn
authors.initials: G
authors.lastname: Rechtine
authors.forename: Nora B
authors.initials: NB
authors.lastname: Henrikson
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Norvell
mesh_terms: D015670:Acupuncture Therapy / Q000191:economics; D059350:Chronic Pain / Q000175:diagnosis / Q000191:economics / Q000503:physiopathology / Q000628:therapy*; D003362:Cost-Benefit Analysis; D019317:Evidence-Based Medicine; D005081:Exercise Therapy / Q000191:economics; D017048:Health Care Costs; D006801:Humans; D017116:Low Back Pain / Q000175:diagnosis / Q000191:economics / Q000503:physiopathology / Q000628:therapy*; D020393:Manipulation, Spinal / Q000191:economics; D010147:Pain Measurement; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D020127:Recovery of Function; D013997:Time Factors; D016896:Treatment Outcome