Back pain ranks as the second most common reason for visiting the doctor's office (1). In fact, more than 70% of the population suffers from back pain at some point with an annual incidence of 15% (1). Conventional medicine offers treatment options that typically include analgesics, physical therapy, exercise and "back school" education programs. In severe cases, patients may also seek surgery or the services of a pain management center.

Despite this range of interventions, large numbers of patients turn to complementary/alternative medicine (CAM) treatments for back pain (2,3). These can include spinal manipulation, acupuncture, massage, yoga and stress reduction programs.

Here is a brief overview of some of the most common CAM practices and what is known about their efficacy in the treatment of chronic back pain.

Massage

Massage is popular in the United States - 5% to 10% of the population use massage therapy for a total of 32 million visits annually (2,3). The underlying theory of massage is that the application of pressure through the hands is thought to reduce muscular tone and mental tension while improving blood flow and lymph drainage.

The procedure is generally considered safe, although patients occasionally experience discomfort during or immediately after treatment. Possible contraindications include allergies to oils used by therapists or deep vein thrombosis, burns, skin infections and wounds.

There have been few trials of massage for back pain, but those that have been conducted have shown promising results. Although the studies have been small, the data they have generated are compelling enough to warrant a large multicenter clinical trial of this form of therapy. In a small Canadian study (4) involving 107 participants with subacute lower back pain randomized to one of four treatment arms, those who received a comprehensive program involving stretching, massage, exercise, and posture or soft tissue manipulation reported less disability and pain than those performing exercise alone or those receiving sham laser. In a larger 10-week study, Cherkin randomized 262 patients with chronic low back pain to receive either acupuncture, massage or educational materials. At the conclusion of the study, subjects receiving massage had better function than those receiving acupuncture or self-care educational materials. At one-year follow-up, massage was superior to acupuncture but no different than educational materials (5).

Spinal Manipulation

Ninety percent of spinal manipulations are performed by the nation's 60,000 chiropractors. Over 7% of the population undergoes this procedure each year. Chiropractic guidelines generally support the use of spinal manipulative therapy for acute and chronic low back pain.

Treatment for an episode of back pain typically requires up to 10 visits to the chiropractor. Serious complications from the procedure are rare; however, a recent review suggests manipulation of the cervical spine may put patients at risk for a rare complication - vertebral artery dissection (see Commentary in this issue). A recent meta-analysis (6) found that spinal manipulation for low back pain was beneficial compared to sham manipulation or ineffective therapies, such as bed rest. It did not, however, find spinal manipulation to be superior to other standard treatments such as analgesics, physical therapy, exercises and back school. The analysis concluded that spinal manipulation is one of several options of modest effectiveness for patients with low back pain. Previous systematic reviews reported favorable outcomes with spinal manipulation, but this more recent meta-analysis included newer randomized controlled clinical trials comparing active and control arms.

Acupuncture

Research has found mixed results for the efficacy of acupuncture over sham acupuncture or other active control interventions such as massage or spinal manipulation. There does seem to be evidence of benefit when acupuncture is compared to inert placebo or usual care, such as analgesics.

Acupuncture, a component of Traditional Chinese Medicine, is thought to improve health by correcting imbalances in the flow of energy (Qi) through the body. Needles are placed at acupuncture points along meridians (virtual superficial channels) that are believed to regulate the flow of Qi to affect specific functions of the body. When an acupuncture point is stimulated, research shows that endorphins, enkephalins and cortisol are released. Patients typically undergo multiple treatments over a period of time and may be asked to take herbs as part of their therapy. Acupuncture is very safe. All licensed practitioners are certified in using clean needle technique to prevent the spread of infection.

Studies of the efficacy of acupuncture for the treatment of acute and chronic back pain are mixed. A meta-analysis by Ernst encompassing nine studies among 377 patients with acute and chronic back pain found that acupuncture appeared to be superior to control treatments but noted that larger studies were needed to examine the effect of the location of needle placement (7). A study of 131 Germans with chronic low back pain randomized to 12 weeks of physiotherapy alone (the control treatment), physiotherapy and real acupuncture, or physiotherapy and sham acupuncture found that at the end of treatment, reductions in pain, disability and psychological distress were superior in the acupuncture as compared to the control group. Acupuncture was superior to sham acupuncture, however, only for psychological distress. At nine-month follow-up, there were no differences between the sham and acupuncture groups (8).

Yoga

Yoga is rapidly entering American culture as a form of exercise and a way to alleviate stress. Over 20 million people practice this discipline in the United States today, and an increasing percentage of people with back pain are turning to yoga. At this time there are no published studies evaluating its safety or effectiveness.

The Osher Center for Integrative Medicine recently conducted a pilot study on 50 subjects with chronic benign mechanical lower back pain who participated in a 3-month yoga intervention with 6-month follow-up. Participants were randomly assigned to an Iyengar yoga class or to a wait-list control group, which received educational materials and yoga classes that began 3 months after enrollment in the study. Preliminary results (unpublished) suggest clinically significant improvements in function and disability for the yoga group compared to the wait-list group. (Methodology published: (9).)

Other Modalities

Many back pain patients use other alternative treatments that have not been studied. These include supplements such as willow bark, a salicylate-based compound that may have bioactivity as an analgesic. Glucosamine, a popular over-the-counter supplement, is frequently taken by patients with back pain. A 3-year clinical trial showed efficacy for knee osteoarthritis; however, there are no studies to support its use for chronic back pain.

Studies have shown that mindfulness-based stress reduction (MBSR) can be helpful in the management of chronic back pain. (See Spotlight in this issue.) Many other practices, such as Pilates or Feldenkrais, are used by people with back pain, although they have not been well studied. Pilates is a systematic practice of gentle exercises coupled with focused breathing, often designed to improve flexibility and core body strength. Feldenkrais is an educational system that helps patients improve physical functioning through gentle movements. It teaches awareness of habitual neuromuscular patterns and identifies ways to expand options for moving with increased sensitivity and efficiency. Although their efficacy has not been documented, these practices are quite safe when taught under the direction of an experienced, certified instructor.

The following table highlights research on the safety and efficacy of selected CAM treatments for chronic back pain. Please note that this table does NOT address safety and efficacy for neck pain.

Take Home Message

Over 60% of U.S. adults have used some form of complementary and alternative medicine in the past year (Barnes PM). Back pain has been reported as the most frequent indication for accessing these therapies. (Barnes PM). Clinical research has not identified effective conventional or alternative medicine therapies for the treatment of chronic back pain. Patient preference and expectation should be considered when evaluating treatment options. Massage, manipulation, and acupuncture should be considered generally safe when performed by an experienced and credentialed practitioner.

1. Frymoyer JW, et al. An overview of the incidences and costs of low back pain. Orthop Clin North Am. 1991 Apr;22(2):263-71. Review.

2. Wolsko PM, et al. Patterns and perceptions of care for treatment of back and neck pain: results of a national survey. Spine. 2003 Feb 1;28(3):292-7; discussion 298.

3. Barnes PM, et al. Complementary and alternative medicine use among adults: United States, 2002. Adv Data. 2004 May 27(343):1-19.

4. Preyde M. Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. CMAJ. 2000 Jun 27;162(13):1815-20.

5. Cherkin DC, et al. Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Arch Intern Med. 2001 Apr 23;161(8):1081-8.Ernst E, White AR. Acupuncture for back pain: a meta-analysis of randomized controlled trials. Arch Intern Med. 1998 Nov 9;158(20):2235-41.

6. Assendelft WJ, et al. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med. 2003 Jun 3;138(11):871-81.

7. Ernst E, et al. Acupuncture for back pain: a meta-analysis of randomized controlled trials. Arch Intern Med. 1998 Nov 9;158(20):2235-41.

8. Leibing E, et al. Acupuncture treatment of chronic low-back pain-a randomized, blinded, placebo-controlled trial with 9-month follow-up. Pain. 2002 Mar;96(1-2):189-96.

9. Jacobs BP, et al. Feasibility of conducting a clinical trial on Hatha yoga for chronic low back pain: methodological lessons. Altern Ther Health Med. 2004 Mar-Apr;10(2):80-3.