Conditions:
Back Pain
Principal Proposed Treatments
•
White Willow, Prolotherapy, Chiropractic, Acupuncture
Other Proposed Treatments
•
Devil's Claw, Osteopathic Manipulation, Proteolytic Enzymes, Boswellia, Butterbur, Chondroitin, Ginger, Glucosamine, Turmeric
Low back pain is one of the most common health conditions today. According to some estimates, each year nearly 15 to 20% of the United States population experiences low back problems, and as many as 80% of all adults experience significant low back pain at some point during their lives.1,2 Back pain is the second most common reason adults under age 45 miss days from work (after the common cold). The total cost of back pain has been estimated to reach $25 billion per year in the United States.3
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 arthritis, 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 workup to make sure there are no serious underlying causes, although evidence suggests that in most cases x rays are not necessary.4 Treatment includes weight loss, physical therapy, and a graded exercise program. Surgery may be necessary in certain cases, such as when there are severe disc problems.
Principal Proposed Treatments for Back Pain
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 may be effective for back pain as well. Lesser evidence supports the use of chiropractic and acupuncture.
White Willow
Willow bark has been used as a treatment for pain and fever in China since 500 B.C. It contains the substance salicin, which is chemically related to aspirin. Another ingredient of white willow, tremulacin, may also be important.
What Is the Scientific Evidence for White Willow?
In a 4-week double-blind placebo-controlled study of 210 individuals with chronic back pain, two different doses of willow bark extract were compared against placebo.5 The higher-dose group received extract supplying 240 mg of salicin daily; in this group, 39% were pain free for at least the last 5 days of the study. In the lower-dose group (120 mg of salicin daily), 21% became pain free. In contrast, only 6% 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.
For more information, including dosage and safety issues, see the full white willow article.
Prolotherapy
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 cause tissue to proliferate (grow), increasing the strength and thickness of ligaments. This tightens up the joint and presumably allows the associated muscles to stop having spasms. In the case of arthritic joints, increased ligament strength may allow the joint to function more efficiently, reducing pain.
Prolotherapy has not yet been widely accepted in conventional medicine. However, highly respected institutions have studied it, and standard textbooks of orthopedics and rehabilitation medicine mention the technique. It is used by prolotherapy practitioners to treat many conditions including fibromyalgia, osteoarthritis, plantar fasciitis, sciatica, sports injuries, temporomandibular joint (TMJ) disorder, tendinitis, and tension headaches. The best evidence at present is for its use in back pain and osteoarthritis.
Animal and human studies have found that prolotherapy injections increase strength and thickness of ligaments.9,10,11
In a double-blind study, 81 individuals with low back pain of many years' duration were given either prolotherapy injections or placebo treatment.12 Both groups also received intense spinal manipulation with local anesthetic on the first visit, although in the treatment group this was more extensive. The injections were given 6 times on a weekly basis. The prolotherapy group received a mixture of dextrose, glycerin, and phenol, thought to irritate tissues and cause ligament growth. The placebo group received saline (salt-water) injections.
The results were positive. Prolotherapy-treated participants showed significantly less pain and disability within a month, and the relative benefit continued for the full 6 months of the study.
A subsequent double-blind study of nearly identical design and size performed by many of the same researchers found similar benefits.13
For more information, see the full prolotherapy article.
Chiropractic
Chiropractic spinal manipulation is one of the most popular treatments for acute and chronic back pain in the United States. In 1994, the Agency for Health Care Policy and Research (AHCPR), a branch of the U.S. Department of Health and Human Services, surveyed all the treatments in common use for acute back pain. They concluded that spinal manipulation (chiropractic treatment) is a useful approach for reducing pain and improving overall daily functioning in people suffering from acute low back pain.14 However, as described below, the research record actually proves little, and what meaningful evidence that can be found is mostly negative.
A 1996 review of clinical trials of spinal manipulation for low back pain evaluated 11 trials comparing spinal manipulation to placebo.15 Overall, the results were not very positive. Furthermore, many of these studies involved manipulation techniques differing significantly from standard chiropractic.
For example, a single-blind controlled study of 84 people with acute or chronic low back pain compared chiropractic manipulation to "treatment" with a diathermy machine that was not actually functioning.16 The researchers asked the participants to assess their own pain levels within 15 minutes of the first treatment, then 3 and 7 days after treatment. The only statistically significant difference between the two groups was within 15 minutes of the manipulation! Both acute and chronic back pain participants responded similarly.
In another single-blind placebo-controlled study, researchers assigned 209 participants with chronic back pain to one of three groups: chiropractic-style spinal manipulation, sham manipulation, or a back education program.17 Though sometimes incorrectly reported as a positive study,18 the findings were actually inconclusive. The researchers assessed the individuals' pain levels at enrollment, after 2 weeks of treatment, and then 2 weeks later. No statistically significant differences between the groups were seen.
One of the studies reviewed as returning positive results actually used a combination of spinal manipulation with prolotherapy (see above).19 Another study reported as positive actually used physical therapy techniques that were unrelated to chiropractic.20
One well-designed double-blind trial did find some benefit with chiropractic manipulation for acute low back pain, but it was very small (18 participants).21
Putting this all together, there is inadequate evidence from placebo-controlled trials to scientifically conclude that chiropractic spinal manipulation is either effective or ineffective for any form of back pain.
Besides placebo-controlled studies, several trials have compared chiropractic to other commonly used (although unproven) therapies for back pain, such as soft-tissue massage, electrical stimulation, and physical therapy.22–26 In general, chiropractic spinal manipulation proved equally effective to these therapies, and in some studies appeared to produce faster pain relief.
For example, in one double-blind controlled study, researchers assigned 95 individuals (who had no previous chiropractic care) to either a chiropractic manipulation group or a soft-tissue massage group.27 Immediately after the initial treatment, the participants receiving spinal manipulation showed a significantly greater improvement in their mobility.
However, comparative studies such as these cannot prove chiropractic effective, since therapies to which it was compared have not been proven effective either.
For more information on chiropractic, including cost and safety information, see the full chiropractic article.
Acupuncture
The ancient technique of acupuncture has become increasingly popular as a treatment for pain and other conditions. Thus far, research has not found evidence that acupuncture is effective for chronic back pain; however, one study suggests it might be effective in acute back pain.
A comparative trial compared the effects of acupuncture, massage, and education (videotapes on back care, etc.) in 262 individuals with chronicback pain over a 10-week period.28 The details of acupuncture and massage were left to practitioners, but only 10 visits were permitted. At the 10-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.
A double-blind placebo-controlled crossover trial of 77 individuals with chronic low back pain found no significant difference between the real acupuncture and placebo groups.29 Two single-blind placebo-controlled trials with 30 and 60 participants respectively also failed to find evidence of benefit.30,31
However, a double-blind placebo-controlled study that enrolled 30 individuals with acutelow back pain did find some evidence of benefit with acupuncture.32
Several studies have compared acupuncture to other treatments for back pain, such as TENS, physical therapy, and chiropractic.33–37 The results suggest that acupuncture is a reasonable alternative to these other (equally unproven) approaches.
For more information on acupuncture, see the full acupuncture article.
Other Proposed Treatments for Back Pain
The herb devil's claw is used for the treatment of arthritis, and has been tried for back pain as well. However, the results have been less than impressive. A double-blind study of 197 individuals with chronic back pain found devil's claw only marginally effective at best.38 Similarly poor results were seen in an earlier double-blind study of 118 individuals with back pain.39
Another treatment, osteopathic manipulation, is 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 osteopathic manipulation is not well studied for back pain, a 12-week double-blind trial involving 155 individuals with back pain (of 3-week to 6-month duration) found it at least as effective as standard medical care.40 Individuals receiving osteopathic manipulation used less medication. However, two other studies enrolling a total of over 200 people have found osteopathy equivalent to placebo for chronic back pain41 and acute back pain.42 Another large trial combined osteopathic and chiropractic-style manipulation, and therefore can't be used to evaluate the effectiveness of osteopathy itself.43
Preliminary evidence suggests that proteolytic enzymes might be helpful for back pain.44
Other herbs and supplements sometimes recommended for back pain, but with no real supporting evidence, include boswellia, butterbur, chondroitin, ginger, glucosamine, and turmeric.
View References
Last reviewed March 2002 by Medical Review Board
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