This is the third article in a series of posts about complementary therapies for chronic pain conditions, based on a review published in the British Medical Journal.
You can read the first two posts here:
Which therapies for chronic pain?
Which therapy – chronic pain and rheumatoid arthritis
This third article is about the efficacy of some complementary therapies for chronic low back pain according to the BMJ review findings. Low back pain, also known as lumbago, is the most common painful musculoskeletal condition. It has many causes but few therapies with much evidence of effectiveness. When I’m talking about evidence here, I mean evidence from scientific studies rather than anecdotal or historical evidence.
Chronic low back pain can be potentially disabling and is often treated with non-prescription medication. It can be the result of a sprain or a strain, but in most cases low back pain is not due to any serious cause. Yet, chronic low back pain is still responsible for many lost work days. Though it often gets better by itself, it can last for weeks or even months without treatment. With the added problems of lost sleep and tiredness causing higher pain sensitivity and therefore a vicious cycle.
The BMJ review looked at studies of several possible complementary therapies for chronic low back pain. Including acupuncture, cupping, herbal medicine, and mind-body practices such as yoga and meditation.
Acupuncture and low back pain
The World Health Organisation supports the use of acupuncture for low back pain, describing it as a cost effective treatment with low risk of adverse effects. In fact, according to the review, acupuncture is one of the most popular therapies for this type of chronic pain. With researchers finding several studies that support the use of this complementary therapy for the relief of chronic low back pain.
In one of these studies, acupuncture plus active physical therapy was better than physical therapy alone. Reducing pain intensity, pain related disability and psychological distress. This study also compared acupuncture treatment with a sham acupuncture and found a significant reduction in psychological distress with the acupuncture treatment. Whilst in another study, in comparison to sham acupuncture, acupuncture treatment significantly reduced pain intensity.
As an aside, it is very difficult to provide an authentic sham (or fake) acupuncture treatment. Acupuncture involves the insertion of very fine needles at specific acupuncture points in the skin. So, a sham acupuncture treatment either does not involve needling or the needles are not inserted at the specific points. However, other studies have shown that even inserting acupuncture needles in non-acupuncture points still has an effect on the patient. Yet, if needles are not used the patient does not experience the sensation of deqi. The sensation in the body caused by acupuncture, that the researchers admit is necessary for treatment efficacy.
In another trial, people with back pain receiving acupuncture reported a significant improvement in pain and function. Plus they were able to increase their number of work days compared with a control group.
The review also mentions several other types of acupuncture that are used for treatment of chronic low back pain. Such as scalp acupuncture, laser acupuncture, auricular acupuncture and electroacupuncture. Researchers describe the findings of a randomised controlled trial comparing manual and electroacupuncture treatments against a control. Participants had one treatment per week, for eight weeks and both types of acupuncture gave a significant reduction in pain compared to a control group.
Research suggests that several factors might have an influence on the efficacy and outcome of acupuncture treatment, and include:
- the method of needling
- the acupuncture points selected and needled
- the duration of the acupuncture treatment
In a study included in the BMJ review, different treatment times were compared. Both 30 minute and 45 minute acupuncture treatments were more effective than 15 minute treatments. Though there was no advantage in increasing the treatment time from 30 minutes to 45 minutes. Suggesting that acupuncture treatments are probably more effective at 30 minutes or longer.
Cupping therapy is often an adjunct treatment to acupuncture or massage therapy. It is an ancient technique in which suction is applied to areas of the skin using special cups. This suction boosts circulation the tissues which can help to reduce joint and muscle pain. The BMJ review discusses cupping as a separate therapy and found three trials of wet cupping for chronic low back pain. The three trials overall gave inconclusive results for cupping. One found cupping reduced pain significantly compared to medication. A second trial found significant pain reduction compared to patient’s usual care. Whilst the their trial provided no significant difference in pain compared to usual care.
Mind-body medicine and chronic low back pain
The review suggests inconclusive evidence exists for the effectiveness of mindfulness meditation for reduction of low back pain. However, one study of 342 patients with back pain, compared a mindfulness program with cognitive behaviour therapy, or the patient’s usual care. Whilst only 50% of the patients attended at least six of the eight treatment sessions, both treatment groups showed significantly greater improvement in back pain and function at six and twelve months, compared to usual care.
Yoga is a popular approach for management of back pain and several studies were included in the review. The studies mostly lasted twelve weeks and overall provided strong evidence that regular yoga practice reduces pain and improves function. In a comparison of yoga with exercise there was no difference in function at three to twelve months, but there was reduced low back pain with yoga. Researchers concluded that yoga may indeed have a role in reducing low back pain.
This is supported by a 2017 Cochrane review on yoga for chronic non-specific low back pain. This research showed there was at least some evidence that yoga provides small to moderate improvements in back-related function and pain, compared to doing no exercise.
Tai Chi and Qigong are other forms of exercise that could be included under the mind-body medicine category. They are often confused but have some differences. However, both can include some form of meditative motion. Studies show that Tai Chi provides a large improvement in the pain of fibromyalgia. However, researchers suggest there is less evidence for either Tai Chi or Qigong in the treatment of chronic low back pain. Having said that, a trial involving 18 sessions of Tai Chi over ten weeks, improved function and slightly reduced back pain. Whilst a second trial of patients with chronic low back pain, doing twelve sessions of Qigong over a three month period had comparable pain relief to those doing other exercise.
In a more recent trial of adults with an average age of 73, both qigong and yoga have similar benefit for chronic low back pain.
The Alexander technique teaches people how to change poor habits of posture or movement. Although seemingly a physical therapy the technique actually involves the unity of body and mind. The review discusses a large randomised and controlled study comparing the Alexander technique to massage, or to patient’s usual care. Patients allocated to the Alexander technique group were subdivided to receive with 6 or 24 Alexander technique lessons. Plus half of each of these groups were also given an exercise prescription. The study found that people receiving 24 sessions of Alexander technique that also exercised had the most benefit on function and pain relief. Whilst 6 lessons of Alexander technique followed by exercise was nearly as effective as 24 lessons. Researchers conclude that the combined approach was the most beneficial.
Diet and back pain
There is a well accepted association between obesity and low back pain. Having higher BMI is linked to higher intensity of pain pain and more disability. The review includes a discussion of a small preliminary study of obese patients with a mean BMI of 45 (extremely obese) eating a calorie restricted diet, over six months. This weight loss program led to significant weight loss, less back pain and more function, that remained at twelve months.
Herbal medicine and chronic back pain
The BMJ review mentions the herbs Capsicum and Devil’s Claw in relation to chronic back pain. In all the studies of capsicum, either as capsicum cream or plaster, the herbal remedy was more beneficial for relieving back pain than a placebo. Whilst three poor methodology trials using Devil’s Claw, also reduced back pain more than placebo. Leading researchers to suggest that only weak evidence for these herbal medicines and low back pain exists.
However, in a 2016 Cochrane review several other studies were discussed, that included additional herbal remedies for low back pain. Again, authors concluded that Capsicum had a greater benefit than placebo. Whilst Devil’s Claw, White Willow bark, comfrey ointment, Brazilian arnica and lavender essential oil also seemed to reduce pain more than placebo. Though researchers also mention the poor quality of the studies and emphasise that the effect of the remedies may only be in the short term.
In conclusion, from the BMJ review it appears that several complementary therapies have at least some evidence of efficacy for reducing low back pain, with a low risk of adverse effects.
If you have enjoyed this article you might want to read the next post in the series, which will discuss complementary therapies for neck and shoulder pain. Sign up for my newsletter to ensure you receive updates to your inbox.