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Complementary and Alternative Medicine: Fair and Balanced

My aching back: A national concern
Acupuncture and chiropractic manipulation are among the more effective treatments for low back pain.

By John Russo Jr./Vicus.com

VICUS.COM (15 Aug. 2000) -- Low back pain afflicts 60% to 80% of Americans at some time during their lives, statistics indicate.

Here are some statistics about back pain that may make your head hurt:

  • Up to half of all Americans suffer from low back pain each year.  
  • Low-back symptoms are the second-most common reason to visit a doctor (after the common cold).  
  • The estimated cost of medical care for those disabled by severe back pain range from $30 billion to $70 billion annually, according to a September 1999 statement released by the National Institutes of Health. 

The good news is that despite the common occurrence of acute low back pain, the incidence of serious disease is very low -- approximately 1% of the population. The most common causes include compression fracture (4%), spondylolisthesis (3%), malignancy (0.7%), ankylosing spondylitis (0.3%) and vertebral osteomyelitis (0.1%). But in most cases (~80%), the exact cause is never discovered.

What works, and what doesn't

Patients with low back pain who present with so-called "red flag" (click on "red flag" for chart) may be at risk of serious disease and require further medical evaluation and treatment.

Patients who do not have any "red flag" symptoms during the history and physical examination may be treated conservatively. For those with acute low back pain, most will improve within six weeks. 

  • There is no evidence that corsets, bed rest, transcutaneous electrical nerve stimulation (TENS), or traction have a significant impact on the course of acute low back pain, although some people believe these therapies help relieve their pain. Treatment usually consists of muscle relaxants (which act more like tranquilizers and probably don't relax the specific tense or spastic muscles), anti-inflammatory drugs and physical therapy.  
  • Conventional medicine also appears to have little to offer in the treatment of chronic low back pain besides muscle relaxants, anti-inflammatory medicine, physical therapy and surgery. None of these are particularly effective.  
  • Osteopathic manual therapy can be effective in the hands of an experienced practitioner. A recent publication found that this therapy had, as its primary benefit, a reduction in the use of analgesics, anti-inflammatory agents and muscle relaxants (Andersson, et al., 1999). Surgery is effective in selected cases but it can carry the risk of causing more pain than it relieves. 
 

Alternative treatments for low back pain  

Acupuncture and chiropractic manipulation are among the more effective treatments for low back pain. In addition, the results of a recent study of massage to treat chronic low back pain appear encouraging.

  • Most studies with acupuncture are difficult to evaluate because of problems with study design. However, a recently published randomized controlled trial of 20 patients with low back pain lasting at least one month concluded that after 10 sessions of individualized acupuncture from a traditional acupuncturist, significant improvement was reported (MacPherson, et al., 1999). Patients reported reduced pain intensity, and improved daily living, physical functioning and mental health. Other studies have demonstrated growing evidence for the effectiveness of acupuncture in low back pain (van Tulderetal, 1999). 
  • In a comparison of spinal manipulation, acupuncture and medication (the non-steroidal anti-inflammatory drug, tenoxicam with ranitidine (Zantac) for chronic (greater than 13 weeks in duration) spinal pain syndromes, spinal manipulation was the only intervention that achieved statistically significant improvement in pain and disability (Giles and Muller, 1999).  
  • Massage outperformed acupuncture and state-of-the-art self-care education in a randomized trial of 262 patients. After 10 weeks, massage was superior in terms of patient function. In two other outcomes (satisfaction with care and reduced symptoms), both massage and acupuncture got higher marks than self-care. However, after a year, the acupuncture group didn't fare as well, having significantly worse symptoms and lower function scores than the massage or self-help group, according to the study results (Jancin, 1999). 

 

Conclusion  

Medical treatment for acute low back pain is not very effective. However, one good reason to seek medical attention is to make sure that what appears to be a bothersome but transient condition is not, in reality, a more serious condition.

Chiropractic is useful for acute back pain and can help in the management of chronic back pain as well. It is usually clear whether chiropractic will work within six sessions. If there is improvement, up to three more months of treatments may be helpful.

Acupuncture may be used alone or combined with chiropractic. Since they work by different mechanisms, there is logic in combining therapies. As with chiropractic therapy, it should be clear after six sessions if acupuncture is helping. If so, additional treatments may be required.

Massage seldom produces dramatic relief of back pain. However, positive results presented recently during a conference on complementary and alternative medicine at Stanford University are encouraging. Other considerations for the treatment of low back pain include movement therapy such as Feldenkrais movement therapy and Rolfing. Both techniques address abnormalities in movements that may contribute to back pain. 

John Russo, Jr., PharmD , is senior vice president of medical communications at Vicus.com. He is a pharmacist and medical writer with more than 20 years of experience in medical education.

This article was updated on 15 Aug. 2000.

References:

Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med. 1999; 341(19):1426-31.

Bratman S. The Alternative Medicine Ratings Guide: An Expert Panel Ranks the Best Treatments for Over 80 Conditions. Prima Health, Rocklin (CA): 1998.

Cypress BK. Characteristics of physician visits for back symptoms: a national perspective. Am J Public Health. 1983; 73(4):389-95.

Frymoyer JW. Back pain and sciatica. N Engl J Med. 1988; 318(5):291-300.

Giles LG, Muller R. Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. J Manipulative Physiol Ther. 1999; 22(6):376-81. 

MacPherson H, Gould AJ, Fitter M. Acupuncture for low back pain: Results of a pilot study for a randomized controlled trial. Complement Ther Med 1999; 7(2):83-90.

Massage vs. acupuncture in treatment of low back pain. Family Practice News, 1999 Nov. 15.

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

Troyanovich SJ, Harrison DD, Harrison DE. Low back pain and the lumbar intervertebral disk: Clinical considerations for the doctor of chiropractic. J Manipulative Physiol Ther. 1999: 22(2):96-104. 

van Tulder MW, Cherkin DC, Berman B, Lao L, Koes BW. The effectiveness of acupuncture in the management of acute and chronic low back pain. A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 1999; 24(11):1113-23.