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.

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.