Manipulation, which is defined as manual loading of the spine using short- or long-leverage methods, is safe and effective for patients in the first month of acute low back symptoms without radiculopathy. For patients with symptoms lasting longer than 1 month, manipulation is probably safe, but its efficacy is unproved. If manipulation has not resulted in symptomatic and functional improvement after 4 weeks, it should be stopped and the patient reevaluated. —I6
Other interventions, including traction, massage, diathermy, ultrasound, cutaneous laser application, biofeedback, application of shoe lifts, and transcutaneous electrical nerve stimulation (TENS), have not yet been found to provide any lasting benefit. Instruction in self-application of heat or cold may be provided for temporary symptom relief. Additionally, invasive techniques such as needle acupuncture and injection procedures (injection of trigger points in the back; injection of facet joints; injection of steroids, lidocaine, or opioids in the epidural space) have no proven benefit. 15
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