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 US. 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 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 workup to make sure there are no serious underlying causes, although evidence suggests that, in most cases, x-rays are not necessary. 4 Treatment may also include physical therapy and a graded exercise program. However, there is little reliable evidence that these treatments actually provide much benefit. 64,65 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.
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 BC. It contains the substance salicin, which is chemically related to aspirin. Another ingredient of white willow, tremulacin, may also be important.
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.
Note: White willow should not be combined with standard anti-inflammatory drugs, such as ibuprofen. 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 the joint's stability. 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 (along with local anesthetic), thought to irritate tissues and cause ligament growth. The placebo group received saline (saltwater) 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 using the same prolotherapy mixture (but without manipulation) also found benefits. 13
However, a third study of similar size and using the same mixture failed to find benefit. 47 Furthermore, a study of 110 people using a different prolotherapy mixture (20% glucose plus local anesthetic) also failed to find prolotherapy more effective than placebo. 48
What can one make of this contradictory evidence? The most likely conclusion is that prolotherapy, if it is effective at all, offers no more than modest benefits for back pain.
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 US, and it may provide at least modest benefit; however, as yet, research evidence has failed to find chiropractic manipulation convincingly more effective than standard medical care. 49,50,76
Chiropractic does seem to be more effective than placebo, if not by a great deal. For example, a single-blind, controlled study of 84 people suffering from 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. 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. (Chiropractic had better results at that point.)
In another single-blind, placebo-controlled study, researchers assigned 209 participants to one of three groups: a high-velocity, low-amplitude (HVLA) spinal manipulation; a sham manipulation group; or a back education program. 17 Though this has been reported as a positive study, 18 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 in treating low back pain. 25 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 they too found little to no benefit. 43,45,46
On a positive note, one study of 100 people with back pain and sciatica symptoms (pain down the leg due to disc protrusion) found that chiropractic manipulation was significantly more effective at relieving symptoms than sham chiropractic manipulation. 57
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. 22-26,51,74 Furthermore, in one well-designed study, 2 months of chiropractic spinal manipulation produced somewhat greater pain relief than exercise therapy, and this relative superiority endured to the 1-year follow-up point. 41
For more information, see the full Chiropractic article.
Acupuncture
The ancient technique of acupuncture has become increasingly popular as a treatment for pain and other conditions. However, thus far, research has not produced clear evidence of acupuncture’s effectiveness for back pain. 52 In a review of 23 randomized trials involving over 6,000 patients with chronic low back, 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 true and sham. 79
A 6-month, double-blind trial of 1,162 people with back pain compared real acupuncture, fake acupuncture, and conventional therapy. 72 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. These results do not, in fact, 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, use of real acupuncture failed to prove significantly more effective than sham-acupuncture. 58 Other studies have failed to find benefit as well; in several controlled studies enrolling a total of over 300 people, real acupuncture again failed to prove more effective than sham-acupuncture or other placebo treatments. 19,29,32,53
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 10-week period. 28 The exact type of acupuncture and massage was 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.
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 7 randomized trials, researchers were unable to draw any conclusions regarding the effectiveness of LLLT for nonspecific low back pain. 73
Many other studies have compared acupuncture to such treatments as transcutaneous electrical nerve stimulation (TENS), physical therapy, chiropractic care, and massage. 14,33-37,59 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. 60
For more information, see the full Acupuncture article.
In a double-blind, placebo-controlled study enrolling 215 people with back pain, use of a topical cream made from the herb comfrey produced statistically significant benefits as compared to placebo. 61
The herb devil's claw is used for the treatment of osteoarthritis , and has been tried for back pain as well. However, the results have been less than impressive. A double-blind, placebo-controlled 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 4-week, double-blind, placebo-controlled study of 118 individuals with acute back pain. 39 However, a 4-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. 27
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. 54 However, on the face of it, 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 could 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.
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, 15,20,40 one of the best-designed trials failed to find it a superior alternative to conventional medical care. In this 12-week study of 178 individuals, osteopathic manipulation proved no more effective than standard treatment for back pain. 40 Another study failed to find OM more effective than sham manipulation. 55
In a review of 13 randomized trials, researchers concluded that massage may be effective for nonspecific low back pain, and the beneficial effects can last for up to 1 year in patients suffering from chronic pain. 77 They also noted that exercise and education appear to enhance the effectiveness of massage. See the article on Massage for more details.
The Alexander Technique 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 Alexander may help with back pain, but concluded that further research is warranted. 56 A subsequent controlled trial involving 579 patients with chronic or recurrent low back pain found that Alexander technique lessons, particularly when combined with exercise, was more effective than normal care or massage after one year. 78
Biofeedback , 21balneotherapy , 66-67hatha yoga , 62, 63,75magnet therapy , 70,71 and relaxation therapies69 have also shown at least a hint of 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 interesting 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). 68 The results showed that while the use of alternative therapies improved patient satisfaction, it did not significantly improve symptoms.
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 .
Various herbs and supplements may interact adversely with drugs used to treat back pain. For more information on this potential risk, see the individual drug article in the Drug Interactions section of this database.
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