Physician characteristics and variation in treatment outcomes: are better qualified and experienced physicians more successful in treating patients with chronic pain with acupuncture? Assessing the quality of randomized controlled trials published in neurourology and urodynamics from 1993 to 2012. A Systematic Evaluation of the Impact of STRICTA and CONSORT Recommendations on Quality of Reporting for Acupuncture Trials CONSORT 2010 Statement: Updated Guidelines for Reporting Parallel Group Randomized Trials Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. [Observation on short-term and long-term therapeutic effects of electroacupuncture at Houxi (SI 3) on acute lumbar sprain]. Assessing the utility of the standards for reporting trials of acupuncture (STRICTA): a survey of authors. Two Styles of Acupuncture for Treating Painful Diabetic Neuropathy – a Pilot Randomised Control Trial Acupuncture for acute non-specific low back pain: a pilot randomised non-penetrating sham controlled trial. Massage for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Back Review Group [Immediate analgesic effect of wrist-ankle acupuncture for acute lumbago: a randomized controlled trial]. Acupuncture for postchemotherapy fatigue: a phase II study. Randomised Controlled Trial Comparing the Effectiveness of Electroacupuncture and Tens for Low Back Pain: A Preliminary Study for a Pragmatic Trial Assessing the quality of randomized controlled trials: an annotated bibliography of scales and checklists. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Language of publication restrictions in systematic reviews gave different results depending on whether the intervention was conventional or complementary.
UNLABELLED The aim of this paper was to quantify the influence of the physician 's training and experience in the field of acupuncture on the outcome in patients with chronic pain . Patients visiting their physician because of chronic low back pain , headache , pain due to osteoarthritis of the knee or hip , or neck pain , were included in 4 multicenter , r and omized , controlled studies . All patients received routine care ; patients in the acupuncture groups received additional acupuncture treatment ( on average 10 sessions ) . The data was pooled , and the 3-month change from baseline of the SF-36 bodily pain subscale as the main outcome defined . A total of 9,990 patients ( mean age 49.6 + /- 13.6 years , 68 % female ) treated by 2,781 physicians ( mean age 46.3 + /- 7 years , 37 % female ) were analyzed . The physicians had 7.3 + /- 5.2 ( mean + /- sd ) years of experience in acupuncture  and their mean duration of formal acupuncture training had been 287 + /- 321 hours . The outcome was markedly improved in the acupuncture group . We identified only 1 physician characteristic with a significant influence on the outcome : Internists performed better ( odds ratio OR = 1.49 , confidence interval CI : 1.01;2.18 ; P = .043 ) ; orthopedists worse ( OR = .79 , CI : .62;1 ; P = .043 ) than the average physician . Neither the duration of training nor the duration of experience had any impact on the extent of the  acupuncture effect . PERSPECTIVE In this analysis , physician characteristics such as training did not influence patients ' outcome after acupuncture , suggesting that formal training parameters have only a limited influence on treatment effect . Other skills such as the therapeutic relationship , which are difficult to measure , may probably play a more important role and should be taken into consideration AIMS To assess the quality of r and omized controlled trials ( RCTs ) published in Neurourology and Urodynamics ( NAU ) by using three types of analytical tools . METHODS MEDLINE was used to extract RCTs from original articles published in the NAU from 1993 to 2012 . The relationship between the number of articles and RCTs with time and that between various factors and the quality of RCTs were analyzed . To analyze the quality of the RCTs , the time period was divided into four sections and three tools were applied ( e.g. , the Jadad scale , van Tulder scale , and Cochrane Collaboration Risk of Bias Tool [ CCRBT ] ) . RESULTS Among the 1,957 original articles , 93 ( 4.75 % ) were RCTs . The ratio between the number of NAU and RCTs over time increased . The Jadad score for years 1993 - 1997 was 3.25 ± 1.71 , 1998 - 2002 was 2.10 ± 0.74 , 2003 - 2007 was 2.09 ± 1.12 , and 2008 - 2012 was 2.80 ± 1.09 ( P = 0.014 ) . The van Tulder scales were 6.25 ± 3.10 , 4.40 ± 1.65 , 4.97 ± 1.99 , and 5.93 ± 1.98 , respectively ( P = 0.055 ) . The CCRBT identified a low risk of bias in 1 ( 25 % ) , 0 ( 0 % ) , 1 ( 2.86 % ) , and 5 ( 11.36 % ) articles , respectively . Trials with allocation concealment , Institutional review board ( IRB ) approval , and blinded studies had significantly higher quality than others . CONCLUSIONS The quantitative increase of RCT presented in NAU over time was observed but there was no definite qualitative improvement . Effort is required to improve the quality of RCTs published in NAU from the design step Background We investigated whether there had been an improvement in quality of reporting for r and omised controlled trials of acupuncture since the publication of the STRICTA and CONSORT statements . We conducted a before- and -after study , comparing ratings for quality of reporting following the publication of both STRICTA and CONSORT recommendations . Methodology and Principal Findings Ninety peer review ed journal articles reporting the results of acupuncture trials were selected at r and om from a wider sample frame of 266 papers . Papers published in three distinct time periods ( 1994–1995 , 1999–2000 and 2004–2005 ) were compared . Assessment criteria were developed directly from CONSORT and STRICTA checklists . Papers were independently assessed for quality of reporting by two assessors , one of whom was blind to information which could have introduced systematic bias ( e.g. date of publication ) . We detected a statistically significant increase in the reporting of CONSORT items for papers published in each time period measured . We did not , however , find a difference between the number of STRICTA items reported in journal articles published before and 3 to 4 years following the introduction of STRICTA recommendations . Conclusions and Significance The results of this study suggest that general st and ards of reporting for acupuncture trials have significantly improved since the introduction of the CONSORT statement in 1996 , but that quality in reporting details specific to acupuncture interventions has yet to change following the more recent introduction of STRICTA recommendations . Wider targeting and revision of the guidelines is recommended The CONSORT ( Consoli date d St and ards of Reporting Trials ) statement is used worldwide to improve the reporting of r and omized , controlled trials . Schulz and colleagues describe the latest version , CONSORT 2010 , which up date s the reporting guideline based on new method ological evidence and accumulating experience . BACKGROUND Despite growing popularity of complementary and alternative medical ( CAM ) therapies , little is known about the patients seen by CAM practitioners .  Our objective was to describe the patients and problems seen by CAM practitioners .  METHODS We collected data on 20 consecutive visits to r and omly sample d licensed acupuncturists , chiropractors , massage therapists , and naturopathic physicians practicing in Arizona , Connecticut , Massachusetts , and Washington . Data were collected on patient demographics , smoking status , referral source , reasons for visit , concurrent medical care , payment source , and visit duration . Comparative data for conventional physicians were drawn from the National Ambulatory Medical Care Survey . RESULTS In each profession , at least 99 practitioners collected data on more than 1,800 visits . More than 80 % of visits to CAM providers were by young and middle-aged adults , and roughly two thirds were by women . Children comprised 10 % of visits to naturopathic physicians but only 1 % to 4 % of all visits to other CAM providers . At least two thirds of visits result ed from self-referrals , and only 4 % to 12 % of visits were from conventional physician referrals . Chiropractors and massage therapists primarily saw musculoskeletal problems , while acupuncturists and naturopathic physicians saw a broader range of conditions . Visits to acupuncturists and massage therapists lasted about 60 minutes compared with 40 minutes for naturopathic physicians and less than 20 minutes for chiropractors . Most visits to chiropractors and naturopathic physicians , but less than one third of visits to acupuncturists and massage therapists , were covered by insurance . CONCLUSIONS This information will help inform discussion s of the roles CAM practitioners will play in the health care system of the future OBJECTIVE To compare therapeutic effects of electroacupuncture at Houxi ( SI 3 ) and medicine on acute lumbar sprain . METHODS Three hundred cases of acute lumbar sprain were r and omly divided into two groups , a electroacupuncture ( EA ) group and a medication group , 150 cases in each group . The EA group were treated with EA at Houxi ( SI 3 ) , once each day , 3 sessions constituting one course , and the medication group with Mobike , once daily , 7 . 5 mg each time . Their therapeutic effects were evaluated after treatment for 7 days and one month respectively . RESULTS For the short-term therapeutic effect , the effective rate was 97 . 3 % in the EA group and 89 . 2 % in the medication group with a very significant difference between the two groups ( P<0 . 01 ) ; for the long-term therapeutic effect , the effective rate was 99 . 3 % in the EA group and 93 . 2 % in the medication group with a very significant difference between the two groups ( P<0 . 01 ) . CONCLUSION Both the short-term and the long-term therapeutic effects of EA at Houxi ( SI 3 ) on acute lumbar sprain are better than those in the medication group OBJECTIVE To inform the potential revision of St and ards for Reporting Interventions in Controlled Trials of Acupuncture ( STRICTA ) , we sought the opinion of acupuncture trial authors and systematic review ers to rank the utility of the guidelines and asked trial authors about their experiences using them . DESIGN Question naires ranking STRICTA items and qualitative responses about experience using the guidelines . SAMPLE The authors of 38 r and omized controlled acupuncture trials r and omly selected from a systematic search of those published in 2004 and 2005 were contacted with a question naire . Authors of 14 Cochrane acupuncture systematic review s or protocol s published in the same time frame were also sent a question naire . RESULTS Fifty-four percent ( 54 % ) ( 28/52 ) of the sample responded . Among the trial authors , 58 % ( 11/19 ) used STRICTA to help guide their writing , but more than half of these reported that the editing process had removed some or all of the STRICTA-specific items . STRICTA was seen as a helpful reference , but authors requested that some items be clarified . Respondents tended to rank the utility of STRICTA  highly overall , but five items in particular were not highly valued ; three of these pertained to details on the trial acupuncturists ' background . Authors flagged potential difficulties of reporting unusual trial design s in the current format of STRICTA . CONCLUSIONS Authors of acupuncture trials and systematic review s believe that STRICTA contributes to the reporting of acupuncture interventions and rate it highly . Because very few acupuncture studies are published in STRICTA-adopting journals , the editing process for journals unaware of the guidelines may be responsible for deleting acupuncture intervention-specific items . Several items remain unclear , and the relevance of STRICTA to some trial design s is question ed . A review of STRICTA is warranted to clarify and reconsider items , and targeted promotion to non-complementary and alternative medicine journals should be considered In a pilot study , we evaluated the clinical and mechanistic effects of two styles of acupuncture , Traditional Chinese Medicine ( TCM ) and Japanese acupuncture , for the treatment of painful diabetic neuropathy . Out of seven patients enrolled , three received Traditional Chinese acupuncture while four received Japanese style acupuncture . Treatments were delivered once a week for 10 weeks . Acupuncturists were permitted to select the needle interventions . Substantial differences in diagnostic techniques , choice of acupuncture points , and needle manipulation were observed between TCM and Japanese acupuncturists . Clinical ly , patients allocated to Japanese acupuncture reported decreased neuropathy-associated pain according to the daily pain severity score , while the group allocated to the TCM acupuncture reported minimal effects . Both acupuncture styles , however , lowered pain according to the McGill Short Form Pain Score . The TCM style improved nerve sensation according to quantitative sensory testing while the Japanese style had a more equivocal effect . No evident changes were observed in glucose control or heart rate variability in either group OBJECTIVE A pilot study to assess the feasibility of a trial to investigate the efficacy of acupuncture compared to placebo needling for the treatment of acute low back pain ( LBP ) . As part of this , the study was design ed to establish the credibility of the placebo control , and to provide data to inform a power analysis to determine numbers for a future trial . STUDY DESIGN A pilot patient and assessor blinded r and omized controlled trial . SETTING Primary care health centre facility , South and East Belfast Trust , Northern Irel and . PATIENTS Patients from the physiotherapy waiting list ( n=48 ) with LBP of less than 12 weeks duration . OUTCOME MEASURES Rol and and Morris Disability Question naire ( RMDQ ) , Visual Analogue Scale ( VAS ) , medication use and an exit question naire were completed at baseline , end of treatment , and at 3 months follow up . RESULTS Ninety-four percent ( 45/48 ) of patients completed assigned treatment , 83 % ( 40/48 ) completed 3 months follow-up . The sham needle used here proved to be credible : 91.7 % in the placebo group believed they had received acupuncture , compared to 95.8 % in the verum acupuncture group . Differences in baseline characteristics were accounted for using ANCOVA . There was no significant difference between groups on the RMDQ over time . For pain , the only statistically significant difference was at the 3 months follow up ( worst VAS , point estimate , 18.7 , 95 % CI 1.5 - 36.0 , p=0.034 ) . The majority of patients were taking some form of analgesic medication for LBP at the start of treatment ( n=44 ; 92 % ) , and at the end of treatment the verum acupuncture group were taking significantly fewer tablets of pain control medication ( mean ( S.D. ) : 1.0+/-0.3 ) than the placebo group ( mean ( S.D. ) : 4.2+/-0.6 , p<0.05 ) . Based upon these data , power analysis ( power=90 % , alpha=0.05 , minimal clinical ly important difference ( MCID ) for RMDQ=2.5 points ) indicated that 120 participants ( 60 per group ) would be needed to complete an adequately powered r and omized controlled trial . CONCLUSIONS This study has demonstrated the feasibility of a r and omized controlled trial of penetrating needle acupuncture compared to a non-penetrating sham for the treatment of acute LBP in primary care ; 120 participants would be required in a fully powered trial . The placebo needle used in this study proved to be a credible form of control Study Design . Systematic Review . Objectives . To assess the effects of massage therapy for nonspecific low back pain . Summary of Background Data . Low back pain is one of the most common and costly musculoskeletal problems in modern society . Proponents of massage therapy cl aim it can minimize pain and disability , and speed return to normal function . Methods . We search ed MEDLINE , EMBASE , CINAHL from their beginning to May 2008 . We also search ed the Cochrane Central Register of Controlled Trials ( The Cochrane Library 2006 , issue 3 ) , HealthSTAR and Dissertation abstract s up to 2006 . There were no language restrictions . References in the included studies and in review s of the literature were screened . The studies had to be r and omized or quasi-r and omized trials investigating the use of any type of massage ( using the h and s or a mechanical device ) as a treatment for nonspecific low back pain . Two review authors selected the studies , assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group , and extracted the data using st and ardized forms . Both qualitative and meta-analyses were performed . Results . Thirteen r and omized trials were included . Eight had a high risk and 5 had a low risk of bias . One study was published in German and the rest in English . Massage was compared to an inert therapy ( sham treatment ) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups . In 8 studies , massage was compared to other active treatments . They showed that massage was similar to exercises , and massage was superior to joint mobilization , relaxation therapy , physical therapy , acupuncture , and self-care education . One study showed that reflexology on the feet had no effect on pain and functioning . The beneficial effects of massage in patients with chronic low back pain  lasted at least 1 year after the end of the treatment . Two studies compared 2 different techniques of massage . One concluded that acupuncture massage produces better results than classic ( Swedish ) massage and another concluded that Thai massage produces similar results to classic ( Swedish ) massage . Conclusion . Massage might be beneficial for patients with subacute and chronic nonspecific low back pain , especially when combined with exercises and education . The evidence suggests that acupuncture massage is more effective than classic massage , but this need confirmation . More studies are needed to confirm these conclusions , to assess the impact of massage on return-to-work , and to determine cost-effectiveness of massage  as an intervention for low back pain OBJECTIVE To assess the immediate analgesic effect of wrist-ankle acupuncture on acute lumbago and the relationship between the analgesic effect and the expectation of patients . METHODS A r and omized , single-blind , sham-controlled trial was design ed . Sixty cases of acute lumbago were r and omly divided into two groups , 30 cases in each one . In observation group , wrist-ankle acupuncture was adopted to the Lower 5 and Lower 6 bilaterally , no requirement of Deqi ( arrival of qi ) . In control group , sham acupuncture was adopted . The treatment was applied once in either group , with the needles retained for 30 min . The Short-form McGill Pain Question naire  ( SF-MPQ ) and the  Modified-Modified Schober ( MMS ) test were used to assess the motion related pain and the situation of spinal flexion in 3 min before treatment and 5 min , 10 min , 15 min , during treatment and 30 min ( needle removed ) , respectively . The  Expectation and Treatment Credibility Scale ( ETCS ) was applied to analyze the relationship between the expectation of patients and the analgesic effect . The adverse reaction was recorded . RESULTS There were no statistically significant differences in SF-MPQ , MMS and ETCS before treatment between two groups ( all P>0.05 ) . In 5 min after needles insertion , the scores of the items in SF-MPQ in observation group were lower than those in control group ( P<0.05 , P<0.01 ) . In 10 min after needles insertion , the scores of SF-MPQ in observation group were lower than those in control group and the scores of MMS were higher than those in control group ( P<0.05 ) . In 15 min after needles insertion , except the sensory pain rating index , the scores of the rest items in SF-MPQ in observation group were all lower than those in control group ( P<0.05 , P<0.01 ) . In 30 min ( needles removed ) , the scores of affective pain rating index of SF-MPQ and Visual Analogue Scale ( VAS ) in observation group were lower than those in control group ( P<0.05 , P<0.01 ) . The expectation before treatment was negatively correlated with VAS scores in 5 min , 10 min , 15 min and 30 min after needle insertion separately in observation group ( P<0.05 ) , while the correlation was not found in control group ( P>0.05 ) . No adverse reaction was reported . CONCLUSION Wrist-ankle acupuncture can reduce acute lumbago immediately and significantly . The higher the expectation on the analgesic effect of wrist-ankle acupuncture the patients have , the better the analgesic effect will be . This therapy is highly safe in the treatment PURPOSE To determine whether improvement in postchemotherapy fatigue following acupuncture treatment is substantial enough to warrant a controlled trial . PATIENTS AND METHODS We accrued patients at Memorial Sloan-Kettering Cancer Center who had completed cytotoxic chemotherapy but experienced persisting fatigue . Patients with severe anemia , clinical depression , or Karnofsky performance status score less than 70 were excluded . Thirty-seven patients were registered in two cohorts ; 31 provided follow-up data . Patients received acupuncture either twice per week for 4 weeks ( 25 patients ) or once per week for 6 weeks ( 12 patients ) . The primary end point was change in score on the Brief Fatigue Inventory between baseline and 2 weeks after the final treatment . A baseline Brief Fatigue Inventory score of four or greater was an eligibility requirement for the trial . RESULTS Patients had completed cytotoxic chemotherapy an average of more than 2 years previously .  Baseline fatigue scores were high , with approximately half of the sample scoring in the " severe " range . Mean improvement following  acupuncture  was 31.1 % ( 95 % CI , 20.6 % to 41.5 % ) , meeting our prespecified criterion for declaring acupuncture worthy of further study . Increasing age was associated with poorer response and failure to complete the study . There was no important difference in improvement following once-weekly and twice-weekly treatments . CONCLUSION Acupuncture is worthy of further study in the treatment of postchemotherapy fatigue The objective of this study was to compare the effectiveness of electroacupuncture and TENS for low back pain when the electroacupuncture is applied in a clinical ly realistic manner . The study was design ed as an evaluator-blinded r and omised controlled trial ( RCT ) . The study was performed at the Tsukuba College of Technology Clinic in Japan . Twenty subjects , who suffered from low back pain ( LBP ) without sciatica , were recruited , using leaflets in Tsukuba city . Subjects were allocated to either an electroacupuncture ( EA ) group ( 10 patients ) or a transcutaneous electrical nerve stimulation ( TENS ) group ( 10 patients ) . The procedure for EA was in accordance with st and ard practice at our clinic . The main outcome measures were a pain relief scale ( 100 mm visual analogue scale : VAS ) and a LBP score recommended by the Japanese Orthopaedic Association ( JOA Score ) . Mean VAS value during the 2-weeks experimental period of the EA group was significantly smaller than that of the TENS group ( 65 mm vs 86 mm ; 95 % CI , 4.126 – 37.953 ) . JOA Score in the EA group improved significantly while that in the TENS group showed no change . Although some placebo effect may be included , EA appeared more useful than TENS in the short-term effect on low back pain . We suggest that more realistic acupuncture interventions based on st and ard practice should be employed in pragmatic RCTs Assessing the quality of r and omized controlled trials ( RCTs ) is important and relatively new . Quality gives us an estimate of the likelihood that the results are a valid estimate of the truth . We present an annotated bibliography of scales and checklists developed to assess quality . Twenty-five scales and nine checklists have been developed to assess quality . The checklists are most useful in providing investigators with guidelines as to what information should be included in reporting RCTs . The scales give readers a quantitative index of the likelihood that the reported methodology and results are free of bias . There are several shortcomings with these scales . Future scale development is likely to be most beneficial if questions common to all trials are assessed , if the scale is easy to use , and if it is developed with sufficient rigor Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . 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 ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . 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 . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain Recommendation 1 : Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy or spinal stenosis , or back pain potentially associated with another specific spinal cause . The history should include assessment of psychosocial risk factors , which predict risk for chronic disabling back pain ( strong recommendation , moderate- quality evidence ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied OBJECTIVE To assess whether language of publication restrictions impact the estimates of an intervention 's effectiveness , whether such impact is similar for conventional medicine and complementary medicine interventions , and whether the results are influenced by publication bias and statistical heterogeneity . STUDY DESIGN AND SETTING We set out to examine the extent to which including reports of r and omized  controlled trials ( RCTs ) in language s other than English ( LOE ) influences the results of systematic review s , using a broad data set of 42 language -inclusive systematic review s , involving 662 RCTs , including both conventional medicine ( CM ) and complementary and alternative medicine ( CAM ) interventions .  RESULTS For CM interventions , language -restricted systematic review s , compared with language -inclusive ones , did not introduce biased results , in terms of estimates of intervention effectiveness ( r and om effects ration of odds rations ROR=1.02 ; 95 % CI=0.83 - 1.26 ) . For CAM interventions , however , language -restricted systematic review s result ed in a 63 % smaller protective effect estimate than language -inclusive review s ( r and om effects ROR=1.63 ; 95 % CI=1.03 - 2.60 ) . CONCLUSION Language restrictions do not change the results of CM systematic review s but do substantially alter the results of CAM systematic review s. These findings are robust even after sensitivity analyses , and do not appear to be influenced by statistical heterogeneity and publication bias
OBJECTIVES Although acupuncture has been frequently used for acute nonspecific low back pain ( LBP ) , relevant systematic review s indicate sparse and inconclusive evidence .
This systematic review aim ed at critically evaluating the evidence for/against acupuncture for acute LBP .