Introduction
Low back pain is one of the most common health conditions today. According to
some estimates, each year nearly 15 to 20 percent of the population of the United
States experiences low back problems, and as many as 80 percent of all adults
experience significant low back pain at some point during their lives.
Back
pain is the second most common reason why adults age
forty-five years and younger miss days from work (after the common cold). The cost
of back pain has been estimated to reach $25 billion per year in the United
States.
When back pain occurs suddenly (after lifting a heavy object, for example), it is called acute back pain or sprain. In most cases, acute back pain eventually improves by itself, but there may be weeks of discomfort, time lost from work, and impaired function at home.
When back pain persists over months or years, it is called chronic back pain.
In the majority of cases, the cause of chronic back pain is unknown. Identifiable
causes include osteoarthritis, fracture, or injury to the discs between the
vertebrae.
Conventional treatment of acute back pain involves anti-inflammatory
drugs, muscle relaxants, and the passage of time. Chronic
back pain requires a medical examination to make sure there are no serious
underlying causes. Evidence suggests that, in most cases, X rays are not
necessary.
Treatment may also include physical therapy and a graded exercise
program. However, there is little reliable evidence that these treatments actually
provide much benefit. Surgery may be recommended in certain cases, such as when
there are severe disc problems, but most forms of back surgery also lack reliable
supporting evidence.
Principal Proposed Natural Treatments
Extract of the herb white willow appears to be helpful for acute and chronic
back pain, presumably because of its similarity to aspirin. The
little-known injection technique known as prolotherapy also may be effective for
back pain. Lesser evidence supports the use of chiropractic and acupuncture.
White willow. Willow bark, which has been used as a treatment for pain and fever in China since 500 b.c.e., contains the substance salicin, which is chemically related to aspirin. Another ingredient of white willow, tremulacin, may also be important.
In a four-week, double-blind, placebo-controlled study of 210 persons with chronic back pain, two different doses of willow bark extract were compared with placebo. The higher-dose group received extract supplying 240 milligrams (mg) of salicin daily; in this group, 39 percent were pain-free for at least the last five days of the study. In the lower-dose group (120 mg of salicin daily), 21 percent became pain-free. In contrast, only 6 percent of those given placebo became pain-free. Stomach distress did not occur in this study. The only significant side effect seen was an allergic reaction in one participant given willow. White willow should not be combined with standard anti-inflammatory drugs, such as ibuprofen.
Chiropractic. Chiropractic spinal manipulation is one
of the most popular treatments for acute and chronic back pain in the United
States, and it may provide at least modest benefit; however, research evidence has
failed to find chiropractic manipulation convincingly more effective than standard
medical care.
Chiropractic does seem to be more effective than placebo, if not by a great
deal. For example, a single-blind controlled study of eighty-four people with low
back pain compared manipulation to treatment with a diathermy
machine (a physical therapy machine that uses microwaves to create heat beneath
the skin) that was not actually functioning. The researchers asked the
participants to assess their own pain levels within fifteen minutes of the first
treatment, then three and seven days after treatment. The only statistically
significant difference between the two groups was within fifteen minutes of the
manipulation. (Chiropractic had better results at that point.)
In another single-blind, placebo-controlled study, researchers assigned 209 persons to one of three groups: a high-velocity, low-amplitude spinal manipulation group; a sham manipulation group; or a back education-program group. Though this has been reported as a positive study, most of the differences seen between the groups were too small to be statistically significant.
Unimpressive results were also seen in a well-designed study of 321 people with back pain, comparing chiropractic manipulation, a special form of physical therapy (the Mackenzie method), and the provision of an educational booklet on treating low back pain. All groups improved to about the same extent. Several studies evaluated the effectiveness of chiropractic manipulation combined with a different kind of treatment called mobilization, but these studies too found little to no benefit.
On a positive note, one study of one hundred people with back pain and sciatica symptoms (pain down the leg caused by disc protrusion) found that chiropractic manipulation was significantly more effective at relieving symptoms than was sham chiropractic manipulation.
For low back pain, several studies have found that chiropractic is at least as helpful as other commonly used therapies, such as muscle relaxants, soft-tissue massage, and physical therapy. Furthermore, in one well-designed study, two months of chiropractic spinal manipulation produced somewhat greater pain relief than exercise therapy, and this relative superiority endured to the one-year follow-up point.
Acupuncture. The ancient technique of acupuncture
has become increasingly popular as a treatment for pain and other conditions.
However, research has not produced clear evidence of acupuncture’s effectiveness
for back pain. In a review of twenty-three randomized trials involving more than
six thousand persons with chronic low back pain, researchers concluded that
acupuncture is more effective than no treatment for short-term pain relief, but
there was no significant difference between the effects of genuine treatment and
sham treatment.
A six-month double-blind trial of 1,162 people with back pain compared real acupuncture, fake acupuncture, and conventional therapy. Both real and fake acupuncture were twice as effective as conventional therapy, according to the measures used. However, there was only a minimal difference between real and fake acupuncture. This result does not indicate that acupuncture is effective per se; rather, it shows the significant power of acupuncture as a placebo.
Similarly, in a single-blind, sham-acupuncture, and no-treatment controlled study of 298 people with chronic back pain, the use of real acupuncture failed to prove significantly more effective than sham acupuncture. Also, in a fairly large randomized trial involving 638 adults with chronic back pain, there was no difference in pain at one year in persons receiving real versus fake acupuncture (with neither group improving significantly over standard care). Both real and simulated acupuncture were, however, associated with improved function at one year. Other studies have failed to find benefit; in several controlled studies enrolling more than three hundred people, real acupuncture again failed to prove more effective than sham acupuncture or other placebo treatments.
One study compared the effects of acupuncture, massage, and education (such as videotapes on back care) for 262 people with chronic back pain over a ten-week period. The exact type of acupuncture and massage was left to practitioners, but only ten visits were permitted. At the ten-week point, evaluations showed benefit with massage but not with acupuncture. One year later, massage and education were nearly equivalent, and both were superior to acupuncture.
Low level laser therapy (LLLT) is a technique similar to electro-acupuncture that uses precision laser energy instead of electricity conducted through a needle. In a detailed review of seven randomized trials, researchers were unable to draw any conclusions regarding the effectiveness of LLLT for nonspecific low back pain.
Many other studies have compared acupuncture to such treatments as transcutaneous electrical nerve stimulation (TENS), physical therapy, chiropractic care, and massage. In many of these trials, acupuncture provided benefits comparable to the other options tested. However, because TENS, physical therapy, and so forth have not been proven effective for back pain, studies of this type cannot be taken as evidence that acupuncture is effective. One study did find acupressure massage more effective than standard physical therapy; however, it was performed in a Chinese population that may have had more faith in this traditional approach than in physical therapy.
Other Proposed Natural Treatments
Herbal treatments. In a double-blind, placebo-controlled study enrolling 215 people with back pain, the use of a topical cream made from the herb comfrey produced statistically significant benefits compared with placebo. The herb devil’s claw, which is used for the treatment of osteoarthritis, has been tried for back pain too. However, the results have been less than impressive. A double-blind, placebo-controlled study of 197 persons with chronic back pain found devil’s claw only marginally effective at best. Similarly poor results were seen in an earlier four-week, double-blind, placebo-controlled study of 118 persons with acute back pain. However, a four-week, double-blind, placebo-controlled study of 63 people with mild to moderate chronic muscular tension in the neck, back, and shoulders did find some benefit.
The herb cayenne contains capsaicin, a substance that produces an immediate burning sensation but later reduces pain. One double-blind study found a topical cayenne treatment more effective than placebo in 320 people with low back pain. However, upon closer inspection, one finds it difficult to believe that this study was truly double-blind. When cayenne is applied to the skin, it causes such an intense sensation that participants would hardly fail to notice it. When people in a study know whether they are getting real treatment or placebo treatment, the validity of the study’s results is greatly decreased.
Other herbs and supplements sometimes recommended for back pain, but with no real supporting evidence, include boswellia, butterbur, chondroitin, ginger, glucosamine, and turmeric.
Manual therapies. Osteopathic manipulation (OM) is a form
of treatment related to chiropractic manipulation, but it tends to use gentle,
extended movements (low velocity, high amplitude) rather than the quick, short,
cracking movements of chiropractic. Although OM has shown some promise for the
treatment of back pain, one of the best-designed trials failed to find it a
superior alternative to conventional medical care. In this twelve-week study of
178 persons, osteopathic manipulation proved no more effective than standard
treatment for back pain. Another study failed to find OM more effective than sham
manipulation.
In a review of thirteen randomized trials, researchers concluded that massage may be effective for nonspecific low back pain, and the beneficial effects can last for up to one year in persons with chronic pain. The researchers also noted that exercise and education appear to enhance the effectiveness of massage.
The Alexander
technique (AT) is a special method of postural training
popular among dancers and other performers. A review of the literature found no
more than weak preliminary evidence that AT may help with back pain, but it
concluded that further research is warranted. A subsequent controlled trial
involving 579 persons with chronic or recurrent low back pain found that AT
lessons, particularly when combined with exercise, were more effective than normal
care or massage after one year.
Prolotherapy. The use of prolotherapy
to treat back pain has had mixed results in clinical studies.
Invented in the 1950s by George Hackett, prolotherapy is based on the theory that chronic pain is often caused by laxness of the ligaments that are responsible for keeping a joint stable. When ligaments and associated tendons are loose, the body is said to compensate by using muscles to hold the joint stable. The net result, according to prolotherapy theory, is muscle spasms and pain.
Prolotherapy treatment involves injections of chemical irritant solutions into the area around such ligaments. These solutions are believed to cause tissue to proliferate (grow), increasing the strength and thickness of ligaments. This presumably serves to tighten up the joint and allow the associated muscles to stop having spasms. In the case of arthritic joints, increased ligament strength would allow the joint to function more efficiently, reducing pain.
Although two studies have suggested prolotherapy may be effective, two more recent studies found prolotherapy to be ineffective. In a review of five studies, three found prolotherapy to be no more effective than control treatments for treating low back pain. The other two studies suggested that prolotherapy was more effective than control treatments when used with therapies such as spinal manipulation and exercise. Another review suggested prolotherapy may be effective when used with other therapies, but not when used alone.
What can one make of this contradictory evidence? When used alone, prolotherapy is probably no more effective than a placebo injection for the treatment of chronic low back pain. However, there is some evidence that the technique may be beneficial when combined with other therapies.
Other therapies. Biofeedback, balneotherapy, hatha yoga, magnet
therapy, and relaxation therapies have also shown
some promise for treating back pain. Though for some of these, there have been as
many negative as positive studies, and for many of them only short-term benefits
were shown.
In one study, 444 people with acute low back pain were randomly assigned to receive either usual care or usual care plus a choice of alternative therapies (chiropractic, acupuncture, or massage). The results showed that while the use of alternative therapies improved patient satisfaction, it did not significantly improve symptoms. Finally, preliminary evidence suggests that proteolytic enzymes might be helpful for back pain.
Herbs and Supplements to Use Only with Caution
Various herbs and supplements may interact adversely with drugs used to treat back pain, so persons should be cautious when considering the use of herbs and supplements.
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