|No. of trials|
(no. of participants*)Review quality
|Dosages; durations of treatment||Overall trial quality†||Safety and comments|
|Treatment sessions ranged from 3 to 13 weeks (median=4), with needle retention ranging from 20 to 30 min. Only one study provided journal references for the acupuncture point selection, and the description of the type of needle stimulation/manipulation was clear in only three studies.||Moderate||One in six people who had acupuncture, and one in three controls, reported adverse events. Such events were minor and lasted less than one day. No serious adverse events were reported in any trials.|
Individual sessions varied between 45 and 180 min, and the number of sessions varied between 6 and 16.
20–22 sessions of (where reported) 30 min duration.
|Poor||Only two‡ trials reported adverse event data. 4% of patients in one trial receiving EMG biofeedback reported stress. And 74% of patients in another, receiving EEG biofeedback reported a variety of side effects, including: headache, fatigue and sleep problems.|
|Topical application of Capsicum annuum L. cream, either|
0.025% capsaicin for 4 weeks or 0.075% for 12 weeks.
|Not reported||Patients reported moderate, transient, burning or stinging.|
|Little detail is given for any trials, but treatment elements included massage, stretching, spinal manipulation, education and resistance training.||Low||Around 50% of patients experience mild-to-moderate transient adverse effects after spinal manipulation.§|
|Median duration of therapy=10 weeks, with a median number of 10 sessions, and median total hours=18 hours. All but two studies delivered therapy face to face. Median follow-up (where this was performed 17/23 studies)=6 months.||Low||The assessment of safety in most studies was insufficient.|
Two studies reported dropout due to worsening of comorbid mental disorders. However, CBT is generally considered safe.
|Exercise programmes lasting 2.5–24 weeks. Aerobic exercise for ≥20 min, once a day (or twice for ≥10 min), 2–3 days a week. Strength training with ≥8 repetitions per exercise, 2–3 times a week.||Moderate||Although patients may initially notice a deterioration in symptoms, exercise is generally considered safe, especially when practised under supervision.|
|Hydrotherapy/spa therapy76||10 (446)|
|Wide variation in precise treatment strategy between trials. Most consisted of water or mud baths at body temperature 36–37°C, or slightly above (40–45°C), with a median treatment time of 240 min (range 200–300), over several weeks.||Low||Three studies reported no side effects of treatment; one reported slight flashes in 10% of the patients. The remaining trials did not explicitly mention safety.|
|Some variation between trials ranging (where reported) from 300 to 420 min, delivered over 10–26 weeks.||Good||Adverse events were not reported in any of the trials.|
|Massage therapy time lasted 25–90 min, with between 1 and 20 massage sessions in total.||Low to moderate||No adverse events were reported in any of the trials.|
|Meditative movement80||7 (362)|
|Wide variation in treatments between trials, and included yoga, tai chi, qigong or body awareness therapy. Median (range) duration of treatment=16 (6–24) hours, over 4–12 weeks.||Moderate||Although no serious adverse events were reported, six participants (3.1%) withdrew from the trials because of adverse events (increase of pain; muscle inflammation; chlorine hypersensitivity). The review authors concluded that the acceptance and safety of all types of meditative movement therapies were high.|
|Mindfulness/mind–body therapy84||6 (674)|
|Some variation between trials. Single 2–3.5 hours session per week, for 8–10 weeks. Four out of six programmes also included daily home practice (30–45 min) plus a single all-day retreat.||Low||Safety was assessed and reported in none of the trials.|
|Multicomponent therapy60||9 (1119)|
|Enormous variation in treatment strategies between trials. Most included different combinations of exercise (land and/or water based); education; relaxation; and/or some other specific therapeutic component (eg, Tai Chi; or massage).||Moderate||No adverse events were reported in any of the trials.|
|400 mg tablet, twice a day, for 6 weeks.||Moderate||Mild adverse effects such as stomach upset and dizziness were reported.|
|Other: guided imagery91||1 (48)|
|Audiotape-led, individual, guided imagery: 30 min daily for 6 weeks recommended. Median of 44 exercises (range 37–136).||Good||Adverse events were not reported.|
|Other: homeopathy98||4 (163)|
|Variation between trials. Two studied individualised homeopathic treatment, consisting of an initial consultation (and treatment), plus follow-up interviews every 4–8 weeks. Two studied Arnica montana, Bryonia alba or Rhus toxicodendron (potency 6c) daily for between 1 and 3 months.||Low to moderate||No information was provided on safety.|
*Total number of persons randomised.
†According to the method of quality evaluation used in the review.
‡Elsewhere in the review, it reports that three studies reported on adverse events. However, in the table where these data are presented, it is only clear for two. However, in a third trial, there were no dropouts due to side effects.
§These data were not contained in this review. The initial recommendation for chiropractic was weak against. However, after discussion, this was downgraded to strong against due to potential safety concerns.
CBT, cognitive behavioural therapy; EMG, electromyographic; SAMe, S-adenosyl methionine.