Complementary Therapies - Conservative Measures: Back Pain

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Complementary therapies

When back pain strikes, people often turn to complementary therapies — such as chiropractic care, acupuncture, and transcutaneous electrical nerve stimulation (TENS). Massage is also a popular treatment choice (see box above). Studies have shown that some of these therapies can help speed recovery from acute back pain, especially when combined with an exercise program.

Chiropractic care

Spinal manipulation is a form of therapy for back pain. It is most often performed by chiropractors (practitioners who believe that normal function of the spine can be restored by manipulation of the bones and joints), although it may also be done by osteopaths (doctors with training analogous to that of an M.D., who use medicine and surgery in addition to manipulation therapy) and orthopedists.

Manipulation therapists apply pressure directly to the spinous processes of one or more vertebrae using a finger or the palm of the hand. Most manipulations also involve indirect force: The practitioner carefully twists the patient's head, shoulders, and hips, temporarily displacing parts of the spine.

Studies to assess the benefits of chiropractic manipulations in low back pain treatment have been uneven. However, the current consensus is that although manipulation therapy is no better than other standard treatments, it can be helpful in hastening relief of acute back pain when done within the first weeks after symptoms begin and combined with an individualized exercise program. For some people, chiropractic manipulation lessens the amount of medication needed for pain control. But not enough studies have been done to recommend chiropractic manipulation for relief from chronic back pain. And chiropractic techniques are not advisable if you are suffering from leg numbness, pain, or weakness, which suggest nerve-related back pain or other serious conditions.

Chiropractic manipulation carries a small degree of risk, especially for people with neck pain. Very rarely, chiropractic manipulations can exacerbate or even cause disk herniation and nerve-root irritation. And individuals with osteoporosis and rheumatoid arthritis should avoid chiropractic care because it is possible that spinal manipulation could worsen these conditions. The best candidates for chiropractic manipulation are people who have no sign of nerve impairment and no measurable evidence of joint problems.

Manipulation clearly provides relief for some people. One well-designed study appeared in 1998 in the New England Journal of Medicine. The study assessed whether people who learned back exercises from a physical therapist recovered from their low back pain any faster than those who went to a chiropractor for spinal manipulation. Researchers from the University of Washington assigned 321 participants to one of the following: up to nine visits with a chiropractor, a similar number of sessions with a physical therapist, or no special treatment except for being given an educational booklet on back pain.

Both the chiropractic and the physical therapy groups recovered at the same rate, which was slightly faster than the control group. The three groups did not differ significantly in terms of missed work, reduced activity, or recurrent episodes of low back pain during the subsequent year.

But one study is not enough to create a consensus. To further muddy the waters, two major reviews, analyzing multiple studies on the subject, reached completely different conclusions. A 2003 review analyzing 39 studies concluded that there was little evidence that spinal manipulation was better than the other standard treatments — analgesics and exercise (including physical therapy) — for acute or chronic back pain. But a 2004 review found evidence that spinal manipulation was beneficial. This review noted that few studies distinguished between acute and chronic back pain, and most of the follow-up had been short-term.

If you do try spinal manipulation, always receive treatment from an experienced practitioner who errs on the side of caution. And until there is more evidence, a short-term approach is probably best. If you don't experience considerable improvement after about six spinal manipulations, additional treatments aren't likely to be of much benefit.

Acupuncture

Perhaps the best known — and oldest — alternative treatment is acupuncture, an ancient Chinese physical science and art. Acupuncture can be used as either an anesthetic or a treatment for many types of physical pain and dysfunction. Extremely thin, sterilized needles, sometimes electrified by a low-voltage power source, are inserted for brief periods at precise points along a complex network of body pathways termed meridians, or lines of energy, that encircle the body like global lines of longitude and latitude.

Two reviews of earlier studies suggest that acupuncture therapy helps some people with chronic back pain. There is little information on acupuncture for short-term acute low back pain. Both the reviews noted that more careful investigations are needed. Why acupuncture might work is not clear. It may block pain signals from reaching the central nervous system. It may stimulate the production of endorphins. Or it may work in part because of the placebo effect.

If you want to try acupuncture, be sure to choose a licensed acupuncturist. Most states require a license to practice acupuncture. If you live in a state that does not require a license, choose a practitioner who is licensed in another state or is certified by the National Certification Commission for Acupuncture and Oriental Medicine (see "Resources"). It's also important to make sure that all needles used have been properly sterilized.

Transcutaneous electrical nerve stimulation (TENS)

This therapy resembles acupuncture, at least superficially. Small electrodes are placed strategically on your skin at or near the site(s) of pain or dysfunction. These electrodes transmit an electrical current of very low voltage to underlying tissues, which is thought to provide pain relief by stimulating the release of endorphins.

TENS has been around for years, but whether it offers any appreciable benefit for people with chronic low back pain remains unclear. A 2005 analysis found that two rigorous TENS studies reached conflicting conclusions. One study found that TENS provided pain relief, but the other showed that a group of people treated with TENS did no better than a group that wasn't. Less rigorous studies have found that improvement attributed to TENS occurred during the first month of treatment, but over the next two months, the condition of almost every person deteriorated to the level before treatment.

Without rigorous research to support its use, currently TENS is rarely recommended for reliable, sustained pain relief. There are better-substantiated options available for controlling chronic low back pain.

Last updated:	January 23, 2007