Selected Complementary Therapies for Low Back Pain
Selected Complementary Therapies for Low Back Pain
By Dónal P. O'Mathúna, PhD, Dr. O'Mathúna is a lecturer in Health Care Ethics, School of Nursing, Dublin City University, Ireland; he reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.
Low back pain is responsible for much personal suffering, loss of work productivity, and societal costs.1 It is estimated that 50-70% of all people experience low back pain at least once during their lives.2 Primary health care settings provide most of the initial treatment.3 However, clinical management of low back pain varies considerably between health care providers. A wide variety of interventions (one estimate listing 50 potential therapies) has been recommended, including both conventional and complementary therapies.4
Low back pain arises from many different causes. The most common diagnostic classification scheme divides patients into three groups: those with serious spinal pathology, those with neurological involvement, and nonspecific low back pain.1 It is crucial to ensure that adequately trained professionals assess patients to confirm their condition does not place them into either of the first two categories. The majority of patients will have nonspecific low back pain. Those falling into this third category vary considerably in their responses to different treatments, and they are usually not candidates for more invasive treatments and surgery. The important good news is that prognosis is good for many people in this latter category. Most pain and disability associated with lower back pain resolves within a couple of weeks.2 However, recurrence is frequent and symptoms can fluctuate. Such factors make the evaluation of effectiveness of back pain treatments difficult. Nonetheless, more than 1,000 randomized controlled trials have been conducted to assess the various interventions now available.2 Many countries and professional organizations have developed evidence-based recommendations for low back pain. European guidelines were published in March 2006 in a special issue of the European Spine Journal.5 These guidelines took five years to develop and analyzed more that 70 clinical guidelines and 800 systematic reviews.
This review will focus on the evidence available for some of the more popular non-invasive complementary therapies used for nonspecific low back pain. Acupuncture and yoga will not be included here as sufficient data on them exists to warrant their own review in a later issue. Pharmaceutical drugs and herbal remedies also will not be discussed.
Advice to Stay Active
The most basic form of therapy involves advice about daily activities. A 2004 Cochrane review examined the effectiveness of bed rest for acute low back pain and sciatica.6 Sciatica is caused by pinching or irritation of the sciatic nerve and leads to pain radiating from the back and down the leg. Sciatica is distinct from low back pain. Eleven randomized controlled trials (RCTs) were included in this Cochrane review, but only those involving low back pain will be discussed here. Three trials compared advice to rest in bed with advice to stay active for acute simple low back pain. The overall results showed that bed rest was ineffective. Two trials compared bed rest of 2-3 days with seven days of bed rest. No significant differences in pain intensity or functional status were found between the different durations examined. Two other trials reported no significant differences between bed rest and exercises for acute low back pain. The reviewers concluded that advice to rest in bed is not effective in the treatment of acute low back pain.
A 2006 systematic review found four studies comparing bed rest with advice to stay active.3 One of these trials was rated as high-quality and found clear evidence of benefit from advice to stay active. In this trial, the group advised to stay active had significantly improved function, reduced sick leave, and reduced pain intensity after three weeks compared with the group advised to stay in bed for two days. The three low-quality studies had conflicting results.
Exercise
Exercise is now commonly recommended for the treatment of low back pain. However, the specific form of exercise employed varies widely, ranging from stretching or strengthening exercises to general physical activity to aerobic exercise. A meta-analysis pooled the results of four trials comparing exercise to no treatment for acute low back pain and found no differences in effectiveness.7 This review also included 11 trials comparing exercise to other treatments for acute low back pain. The pooled analysis found no significant differences for pain relief or functional outcomes. For chronic low back pain, 25 trials were located comparing various exercise approaches to other non-invasive treatments or no treatment.3 Eleven found improved outcomes for the exercise therapies while 14 found no differences. Only two positive trials and two negative trials were rated of high quality. Pooled results revealed statistically significant improvements for exercise vs. no treatment or other non-invasive treatments.
A variety of strengthening, flexibility, stretching, flexion, and extension exercises have been developed specifically for low back pain. Strong evidence now exists that these back exercises are not effective.2 In a number of trials groups using these exercises fared no better than those getting no treatment or those exposed to placebo protocols.
Manipulation
Spinal manipulation is a general approach to musculoskeletal pain frequently associated with chiropractors, but also practiced by osteopaths and some physical therapists. In practice, spinal manipulation is carried out in at least two distinctly different ways: Spinal manipulation itself involves high-velocity thrusts to a joint that takes it beyond its restricted range of movement, while spinal mobilization involves low-velocity, passive movements within or at the limit of joint motion.5 However, most studies and systematic reviews do not distinguish between the two approaches and they will be considered together here also.
Considerable debate surrounds the effectiveness of spinal manipulation for any condition. A growing number of RCTs have been conducted, although the quality of some has been poor. One study located 16 systematic reviews of spinal manipulation for various conditions published between 2000 and 2005.8 It concluded that spinal manipulation should not be recommended for any condition, although it noted that back pain was the one condition where some supportive evidence exists. The methods and conclusions of this article have been challenged by others.9
The most extensive systematic review of spinal manipulation for low back pain is a 2004 Cochrane review that included 39 trials.10 For acute low back pain the authors concluded that spinal manipulation was superior to sham treatment or other treatments known to be ineffective for pain relief or short-term improvement in function. Spinal manipulation was found to have no statistical or clinical advantage over conventional primary medical care, analgesics, physical therapy, exercise therapy, or back school. Two subsequent trials have found that spinal manipulation in addition to primary medical care is more effective than primary medical care alone for pain relief and improved function for those with chronic low back pain.5
Massage
A 2002 Cochrane review found eight RCTs comparing massage with other complementary therapies for nonspecific low back pain.4 A large number of trials were excluded because massage was given along with other therapies making it impossible to isolate the impact of massage itself. The type of massage varied from one trial to another, with two trials using a mechanical device to massage, not just the hands. One trial compared massage to a sham laser treatment and found massage was superior, especially if combined with exercises and education.
Three trials compared massage with spinal manipulation. Immediately after the first session, manipulation showed more pain relief and improved activity. Over the course of treatment, there was moderate evidence that manipulation remained more beneficial based on measurements of function. Ultimately, however, the two interventions proved equally beneficial for pain, range of motion, and fatigue.
Three trials compared massage with different types of electrical stimulation. Massage was found to be less effective in relieving pain and improving range of motion compared to transcutaneous electrical nerve stimulation (TENS), but equally effective to transcutaneous muscular stimulation or stimulation using faradic current. One trial found massage more beneficial than exercise for short-term functional improvement, but equally beneficial for pain intensity and pain quality on both short-term and long-term follow-up. One trial found massage as beneficial as relaxation therapy.
Another trial found massage more beneficial than acupuncture for improved function after 10 weeks and equally effective for pain relief. After 52 weeks, however, massage was more effective on all outcomes. This same trial found that those receiving massage had better outcomes than a group receiving self-care education after 10 weeks, but after 52 weeks the education group did significantly better.
Overall, massage appears to be beneficial for those with nonspecific low back pain, especially when combined with exercise and education.
Ice and Heat
Heat and ice are commonly applied to alleviate low back pain. Traditionally, ice has been recommended for acute injuries and heat for more long-term injuries. A 2006 Cochrane review of heat and ice for lower back pain included nine studies.11 Six examined heat compared to no heat or other interventions, one compared ice to another intervention, and two compared heat to ice. Only studies involving superficial or surface heat were included, such as that from heating pads and other hot items, hot baths, and infra-red heat lamps. Deep heating is achieved through microwaves or ultrasound and was not the focus of this Cochrane review.
Four higher-quality trials examined heated wraps compared to an oral placebo or nonheated wrap for acute and sub-acute low back pain (up to three months). Three of these trials showed significant improvement in pain relief after five days of wearing a heated wrap for eight hours each day. Two of these trials reported significant improvement in disability after four days of heated wraps. Another trial found that heated wraps gave significantly better pain relief and function compared to oral ibuprofen after one and four days of treatment. One trial compared heated wraps plus exercise to heat alone, exercise alone, and an educational booklet. The heat plus exercise provided significantly more pain relief and improved function after seven days, but not after two and four days. No trials reported on the long-term effectiveness of heat or its use with chronic low back pain.
Evidence involving ice is even more sparse. Two low-quality studies compared heat and ice and came to conflicting conclusions. One low-quality study compared ice to TENS for chronic low back pain and found the interventions equally effective in reducing pain. No studies compared ice with placebo for low back pain. A recent RCT found ice massage no more beneficial than placebo for exercise-induced muscle damage.12
The authors concluded that the evidence for using heat with low back pain is not strong. Some short-term benefit can be expected for acute and sub-acute low back pain, and addition of exercise further reduces pain and disability. In spite of its popular use, no evidence-based conclusions can be drawn for the use of ice for low back pain.
Cognitive Behavioral Therapy
A variety of cognitive behavioral therapies are popular, especially for chronic low back pain. The underlying premise of these approaches is that back pain involves more than organic components. This broad range of therapies addresses people's thoughts and/or feelings about their pain or disability. Different approaches address beliefs about pain, involve behavior-modification strategies, or relieve muscle tension through progressive muscle relaxation or biofeedback. A 2005 Cochrane review of cognitive behavioral treatments included 21 trials.13 Strong evidence found cognitive behavioral therapies in general more effective than waiting list controls. Too few trials of individual therapies were found to allow specific conclusions on the best methods. Within each trial, the therapy involved various components used in different combinations. Two small trials found progressive muscle relaxation more effective than placebo. The review concluded that there is limited evidence that cognitive behavioral therapies are similar in effectiveness to other effective treatments like exercise therapy.
Back School
The original Swedish back school was introduced in 1969 and contained four 45 minute sessions discussing back anatomy, posture, ergonomics, and back exercises.14 Since that time, the content and duration of back schools have diversified, but they are characterized by educational material and training in proper use of the back. A 2004 Cochrane review included 19 RCTs, though only six were of high quality.14 One trial compared back school to placebo for acute low back pain. Back school was more effective for short-term recovery and return to work, but no different to placebo for pain relief and recurrence rate. Eight trials examined chronic low back pain and found conflicting results. Seven trials compared back school to other non-invasive treatments (advice, exercises, or spinal manipulation). Most trials found back school more effective for pain relief and functional status in the short term (less than six weeks follow-up) but no more effective than other treatments in the long term (more than 12 months follow-up). Back schools conducted in occupational settings tended to have more beneficial results. Because of the diversity in back school format and study design, data could not be pooled for the review.
Conclusion
A large number of randomized controlled trials have been published on the many interventions used to treat low back pain. However, many of the trials themselves are small and of low methodological quality. For some treatments the results are conflicting. At the very least, however, a growing body of evidence is giving clear indications about some therapies. Definite recommendations cannot, as yet, be given for many of the interventions. Given the diverse nature of the causes of back injury and pain, it is likely that different interventions will be more or less effective for specific patients. One important point of reassurance is that adverse effects were not noted with the treatments reviewed here.
Recommendation
There is clear evidence that bed rest should be avoided with low back pain. Patients should be encouraged to stay active and engage in appropriate general exercise. Specific back exercises do not appear to be warranted. Some evidence supports the use of spinal manipulation, massage, cognitive behavioral therapies, or back schools with particular groups of patients. However, little evidence is available to help determine which, if any, of these is generally more effective than another. For many patients, then, finding the best treatment for their low back pain may be a matter of trial and error until a suitable method is found.
References
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2. Koes BW, et al. Diagnosis and treatment of low back pain. BMJ 2006;332:1430-1434.
3. van Tulder MW, et al. Outcome of non-invasive treatment modalities on back pain: An evidence-based review. Eur Spine J 2006;15(Suppl 1):S64-S81. Epub 2005 Dec 1.
4. Furlan AD, et al. Massage for low-back pain. Cochrane Database Syst Rev 2002;(2):CD001929.
5. COST B13. European guidelines for the management of low back pain. Eur Spine J 2006;15(Suppl 2):S125-S300.
6. Hagen KB, et al. Bed rest for acute low-back pain and sciatica. Cochrane Database Syst Rev 2004;(4):CD001254.
7. Hayden JA, et al. Metaanalysis: Exercise therapy for nonspecific low back pain. Ann Intern Med 2005;142:765-775. Summary for patients: Ann Intern Med 2005;142:171.
8. Ernst E, Canter PH. A systematic review of systematic reviews of spinal manipulation. J R Soc Med 2006;99:192-196.
9. Bronfort G, et al. Review conclusions by Ernst and Canter regarding spinal manipulation refuted. Chiropr Osteopat 2006;14:14 [Epub ahead of print].
10. Assendelft WJ, et al. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev 2004;(1):CD000447.
11. French SD, et al. Superficial heat or cold for low back pain. Cochrane Database Syst Rev 2006;(1):CD004750.
12. Howatson G, et al. The efficacy of ice massage in the treatment of exercise-induced muscle damage. Scand J Med Sci Sports 2005;15:416-422.
13. Ostelo RW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev 2005;(1):CD0002014.
14. Heymans MW, et al. Back schools for non-specific low-back pain. Cochrane Database Syst Rev 2004;(4):CD000261.
O'Mathúna D. Selected complementary therapies for low back pain. Altern Med Alert 2006;9(10):116-119.Subscribe Now for Access
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