Background:
Few treatments for back pain are supported by strong scientific evidence. Conventional treatments, although widely used, have had limited success. Dissatisfied patients have, therefore, turned to complementary and alternative medical therapies and providers for care for back pain.
Purpose:
To provide a rigorous and balanced summary of the best available evidence about the effectiveness, safety, and costs of the most popular complementary and alternative medical therapies used to treat back pain.
Data Sources:
MEDLINE, EMBASE, and the Cochrane Controlled Trials Register.
Study Selection:
Systematic reviews of randomized, controlled trials (RCTs) that were published since 1995 and that evaluated acupuncture, massage therapy, or spinal manipulation for nonspecific back pain and RCTs published since the reviews were conducted.
Data Extraction:
Two authors independently extracted data from the reviews (including number of RCTs, type of back pain, quality assessment, and conclusions) and original articles (including type of pain, comparison treatments, sample size, outcomes, follow-up intervals, loss to follow-up, and authors' conclusions).
Data Synthesis:
Because the quality of the 20 RCTs that evaluated acupuncture was generally poor, the effectiveness of acupuncture for treating acute or chronic back pain is unclear. The three RCTs that evaluated massage reported that this therapy is effective for subacute and chronic back pain. A meta-regression analysis of the results of 26 RCTs evaluating spinal manipulation for acute and chronic back pain reported that spinal manipulation was superior to sham therapies and therapies judged to have no evidence of a benefit but was not superior to effective conventional treatments.
Conclusions:
Initial studies have found massage to be effective for persistent back pain. Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. The effectiveness of acupuncture remains unclear. All of these treatments seem to be relatively safe. Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy.
References
- 1.
Deyo RA ,Cherkin D ,Conrad D ,Volinn E . Cost, controversy, crisis: low back pain and the health of the public. Annu Rev Public Health. 1991;12:141-56. [PMID:1828670 ] CrossrefMedlineGoogle Scholar - 2.
Sternbach RA . Survey of pain in the United States: the Nuprin pain report. Clin J Pain. 1986;2:49-53. CrossrefGoogle Scholar - 3.
Frymoyer JW ,Cats-Baril WL . An overview of the incidences and costs of low back pain. Orthop Clin North Am. 1991;22:263-71. [PMID:1826550 ] CrossrefMedlineGoogle Scholar - 4. Bigos S, Bowyer O, Braen G, Brown K, Deyo R, Haldeman S, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; December 1994. AHCPR publication no. 95-0642. Google Scholar
- 5.
van Tulder MW ,Koes BW ,Bouter LM . Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized, controlled trials of the most common interventions. Spine. 1997;22:2128-56. [PMID:9322325 ] CrossrefMedlineGoogle Scholar - 6. How is your doctor treating you? Consumer Reports. 1995; Feb:81-8. Google Scholar
- 7.
Eisenberg DM ,Davis RB ,Ettner SL ,Appel S ,Wilkey S ,Van Rompay M ,9820257 ] CrossrefMedlineGoogle Scholar - 8.
Cherkin DC ,Deyo RA ,Sherman KJ ,Hart LG ,Street JH ,Hrbek A ,12463292 ] MedlineGoogle Scholar - 9.
Shekelle PG ,Adams AH ,Chassin MR ,Hurwitz EL ,Brook RH . Spinal manipulation for low-back pain. Ann Intern Med. 1992;117:590-8. [PMID:1388006 ] LinkGoogle Scholar - 10. Sandefur R, Coulter ID. Licensure and Legal Scope of Practice. In: Cherkin DC, Mootz RD, eds. Chiropractic in the United States: Training Practice and Research. Rockville, MD: Agency for Healthcare Policy and Research; December 1997:33. AHCPR publication no. 98 N002. Google Scholar
- 11.
Jensen GA ,Roychoudhury C ,Cherkin DC . Employer-sponsored health insurance for chiropractic services. Med Care. 1998;36:544-53. [PMID:9544594 ] CrossrefMedlineGoogle Scholar - 12. American Massage Therapy Association. Accessed at www.amtamassage.org on 19 November 2002. Google Scholar
- 13.
van Tulder MW ,Assendelft WJ ,Koes BW ,Bouter LM . Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for Spinal Disorders [Editorial]. Spine. 1997;22:2323-30. [PMID:9355211 ] CrossrefMedlineGoogle Scholar - 14.
Nyiendo J ,Haas M ,Goldberg B ,Sexton G . Patient characteristics and physicians' practice activities for patients with chronic low back pain: a practice-based study of primary care and chiropractic physicians. J Manipulative Physiol Ther. 2001;24:92-100. [PMID:11208221 ] CrossrefMedlineGoogle Scholar - 15. Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R, Shekelle PG. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine. 2002; 27:291-6; discussion 297-8. [PMID: 11805694] Google Scholar
- 16. NIH Consensus Conference. Acupuncture. JAMA. 1998;280:1518-24. [PMID:
9809733 ] MedlineGoogle Scholar - 17.
Ernst E ,White AR . Acupuncture for back pain: a meta-analysis of randomized, controlled trials. Arch Intern Med. 1998;158:2235-41. [PMID:9818803 ] CrossrefMedlineGoogle Scholar - 18.
Jadad AR ,Moore RA ,Carroll D ,Jenkinson C ,Reynolds DJ ,Gavaghan DJ ,8721797 ] CrossrefMedlineGoogle Scholar - 19.
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;24:1113-23. [PMID:10361661 ] CrossrefMedlineGoogle Scholar - 20.
Smith LA ,Oldman AD ,McQuay HJ ,Moore RA . Teasing apart quality and validity in systematic reviews: an example from acupuncture trials in chronic neck and back pain. Pain. 2000;86:119-32. [PMID:10779669 ] CrossrefMedlineGoogle Scholar - 21.
Ernst E . Massage therapy for low back pain: a systematic review. J Pain Symptom Manage. 1999;17:65-9. [PMID:9919867 ] CrossrefMedlineGoogle Scholar - 22. Furlan AD, Brosseau L, Welch V, Wong J. Massage for low back pain. Cochrane Database Syst Rev. 2000:CD001929. [PMID: 11034734] Google Scholar
- 23. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM. Spinal manipulation for low back pain. An updated systematic review of randomized clinical trials. Spine. 1996; 21:2860-71; discussion 2872-3. [PMID: 9112710] Google Scholar
- 24.
Koes BW ,Assendelft WJ ,van der Heijden GJ ,Bouter LM ,Knipschild PG . Spinal manipulation and mobilisation for back and neck pain: a blinded review. BMJ. 1991;303:1298-303. [PMID:1836153 ] CrossrefMedlineGoogle Scholar - 25.
Bronfort G . Spinal manipulation: current state of research and its indications. Neurol Clin. 1999;17:91-111. [PMID:9855673 ] CrossrefMedlineGoogle Scholar - 26.
Assendelft WJ ,Morton SC ,Yu EI ,Suttorp MJ ,Shekelle PG . Spinal manipulative therapy for low back pain. Meta-analysis of effectiveness relative to other therapies. Ann Intern Med. 2003;138:871-81. LinkGoogle Scholar - 27.
Giles LG ,Mller R . Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. J Manipulative Physiol Ther. 1999;22:376-81. [PMID:10478769 ] CrossrefMedlineGoogle Scholar - 28.
Grant DJ ,Bishop-Miller J ,Winchester DM ,Anderson M ,Faulkner S . A randomized comparative trial of acupuncture versus transcutaneous electrical nerve stimulation for chronic back pain in the elderly. Pain. 1999;82:9-13. [PMID:10422654 ] CrossrefMedlineGoogle Scholar - 29.
Carlsson CP ,Sjlund BH . Acupuncture for chronic low back pain: a randomized placebo-controlled study with long-term follow-up. Clin J Pain. 2001;17:296-305. [PMID:11783809 ] CrossrefMedlineGoogle Scholar - 30.
Cherkin DC ,Eisenberg D ,Sherman KJ ,Barlow W ,Kaptchuk TJ ,Street J ,11322842 ] CrossrefMedlineGoogle Scholar - 31.
Kittang G ,Melvaer T ,Baerheim A . [Acupuncture contra antiphlogistics in acute lumbago]. Tidsskr Nor Laegeforen. 2001;121:1207-10. [PMID:11402745 ] MedlineGoogle Scholar - 32.
Leibing E ,Leonhardt U ,Koster G ,Goerlitz A ,Rosenfeldt JA ,Hilgers R ,11932074 ] CrossrefMedlineGoogle Scholar - 33.
Preyde M . Effectiveness of massage therapy for subacute low-back pain: a randomized, controlled trial. CMAJ. 2000;162:1815-20. [PMID:10906914 ] MedlineGoogle Scholar - 34.
Hernandez-Reif M ,Field T ,Krasnegor J ,Theakston H . Lower back pain is reduced and range of motion increased after massage therapy. Int J Neurosci. 2001;106:131-45. [PMID:11264915 ] CrossrefMedlineGoogle Scholar - 35. Milne S, Welch V, Brosseau L, Saginur M, Shea B, Tugwell P, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain. Cochrane Database Syst Rev. 2001:CD003008. [PMID: 11406059] Google Scholar
- 36. Lytle CD. An overview of acupuncture. Center for Devices and Radiological Health. Washington, DC: Food and Drug Administration; May 1993. Google Scholar
- 37.
MacPherson H ,Thomas K ,Walters S ,Fitter M . The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ. 2001;323:486-7. [PMID:11532841 ] CrossrefMedlineGoogle Scholar - 38.
White A ,Hayhoe S ,Hart A ,Ernst E . Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ. 2001;323:485-6. [PMID:11532840 ] CrossrefMedlineGoogle Scholar - 39.
Ernst E ,White AR . Prospective studies of the safety of acupuncture: a systematic review. Am J Med. 2001;110:481-5. [PMID:11331060 ] CrossrefMedlineGoogle Scholar - 40.
Odsberg A ,Schill U ,Haker E . Acupuncture treatment: side effects and complications reported by Swedish physiotherapists. Complement Ther Med. 2001;9:17-20. [PMID:11264965 ] CrossrefMedlineGoogle Scholar - 41.
Ernst E ,eds . The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach. Edinburgh: Mosby; 2001:60-1. Google Scholar - 42. Senstad O, Leboeuf-Yde C, Borchgrevink C. Frequency and characteristics of side effects of spinal manipulative therapy. Spine. 1997; 22:435-40; discussion 440-1. [PMID: 9055373] Google Scholar
- 43.
Assendelft WJ ,Bouter LM ,Knipschild PG . Complications of spinal manipulation: a comprehensive review of the literature. J Fam Pract. 1996;42:475-80. [PMID:8642364 ] MedlineGoogle Scholar - 44.
Cherkin DC ,Deyo RA ,Battie M ,Street J ,Barlow W . A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998;339:1021-9. [PMID:9761803 ] CrossrefMedlineGoogle Scholar - 45. Skargren EI, Carlsson PG, Oberg BE. One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain. Subgroup analysis, recurrence, and additional health care utilization. Spine. 1998; 23:1875-83; discussion 1884. [PMID: 9762745] Google Scholar
- 46.
Crow R ,Gage H ,Hampson S ,Hart J ,Kimber A ,Thomas H . The role of expectancies in the placebo effect and their use in the delivery of health care: a systematic review. Health Technol Assess. 1999;3:1-96. [PMID:10448203 ] CrossrefMedlineGoogle Scholar - 47.
Kalauokalani D ,Cherkin DC ,Sherman KJ ,Koepsell TD ,Deyo RA . Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine. 2001;26:1418-24. [PMID:11458142 ] CrossrefMedlineGoogle Scholar - 48.
Mondloch MV ,Cole DC ,Frank JW . Does how you do depend on how you think you'll do? A systematic review of the evidence for a relation between patients' recovery expectations and health outcomes. CMAJ. 2001;165:174-9. [PMID:11501456 ] MedlineGoogle Scholar
Author, Article, and Disclosure Information
From Group Health Cooperative and University of Washington, Seattle, Washington; Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California; and RAND, Santa Monica, California.
Grant Support: By grant RO1 HS 09989 from the Agency for Healthcare Research and Quality and the National Center for Complementary and Alternative Medicine, National Institutes of Health, and by grants AT00622 and AT00606 from the National Center for Complementary and Alternative Medicine, National Institutes of Health.
Disclosures:Employment: K.J. Sherman (former Research Director of the Northwest Institute of Acupuncture and Oriental Medicine); Grants pending: D.C. Cherkin (National Institutes of Health), K.J. Sherman (National Institutes of Health).
Corresponding Author: Daniel C. Cherkin, PhD, Center for Health Studies, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101.
Current Author Addresses: Drs. Cherkin and Sherman: Center for Health Studies, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101.
Dr. Deyo: Departments of Medicine and Health Services, University of Washington, 146 North Canal Street, Suite 300, Seattle, WA 98103-8652.
Dr. Shekelle: RAND, 1700 Main Street, PO Box 2138, Santa Monica, CA 90407.
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