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- Good Scientific Evidence:
[Chiropractic]: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. The broad term "spinal manipulative therapy" incorporates all types of manual techniques, including chiropractic. Multiple clinical studies have examined the effects of spinal manipulation in patients with acute or chronic neck pain. Overall, the quality of studies has been poor, and reviews of this topic have been unable to form clear or convincing conclusions. Better quality clinical research for the use of chiropractic for neck pain is necessary before a firm conclusion can be drawn. Although chiropractic helps many people with back pain (including lower back pain), there is not enough reliable scientific evidence to conclude whether chiropractic techniques are beneficial in the management of back pain when compared to conventional approaches, such as medication and surgery. Chiropractic has also been studied in lumbar disc herniation and whiplash injuries, with mixed results.
[Devil's claw]: Devil's claw (Harpagophytum procumbens) has traditionally been used as an anti-inflammatory and pain reliever for joint diseases, back pain, and headache. There are several human studies that support the use of devil's claw for the treatment of low back pain. However, most studies have been small with flaws in their designs, and many have been done by the same authors. Therefore, although these results can be considered promising early evidence, additional well-designed trials are necessary before a firm conclusion can be reached. It is not clear how devil's claw compares to other therapies for back pain. Devil's claw may lower blood sugar levels. A qualified healthcare provider should monitor patients taking drugs for diabetes by mouth or insulin closely. Medication adjustments may be necessary. Devil's claw may increase stomach acidity and therefore may interact with drugs used to decrease the amount of acid in the stomach, such as antacids, sucralfate, ranitidine (Zantac ®), and esomeprazole (Nexium ®).
[Hydrotherapy]: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. Several small controlled clinical trials report that regular use of hot whirlpool baths with massaging jets decreases the duration and severity of back pain when added to standard therapy, compared to standard therapy alone. It is not clear if there is a reduced need for pain control drugs, or if benefits are long-standing. Because these studies are small with flaws in design and reporting, better quality research is necessary before a strong conclusion can be drawn.
[White willow]: White willow (Salix alba) bark has been compared to cyclooxygenase-2 inhibitors (COX-2, commonly used for back pain and arthritis), and many of the studies found willow bark to be as effective or superior to other methods. Cost effectiveness studies have also been performed between white willow bark and conventional treatment; they found that willow bark was more cost effective. Additional study in humans is needed.
- Unclear or Conflicting Scientific Evidence:
[Acupressure, Shiatsu]: The practice of applying finger pressure to specific acupoints (energy points) throughout the body has been used in China since 2000 B.C. Shiatsu technique can incorporate palm pressure, stretching, massaging, and other manual techniques. Shiatsu practitioners commonly treat musculoskeletal and psychological conditions, including neck/shoulder and lower back problems, arthritis, depression, and anxiety. One clinical study reported that acupressure was effective in reducing low back pain in terms of disability, pain scores, and functional status. The benefit was sustained for six months. More research is needed.
[Acupuncture]: Evidence is inconsistent regarding the effects of acupuncture in back pain. The research on acupuncture for neck pain and cervical myofascial pain also shows mixed results. Additionally, early study does not show that laser acupuncture is any more effective than sham laser acupuncture when used in combination with drugs and other mobilization therapies. Further human research is needed.
[Alexander technique]: The Alexander technique is an educational program that teaches movement patterns and postures with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being. There is limited evidence in this area, and no firm conclusion can be drawn based on scientific research.
[Healing touch]: One poor quality, clinical study using 20 participants with chronic low-back pain suggested that healing touch may significantly decrease pain, improve range of motion, and improve orthopedic measurements. However, more research using healing touch for back pain needs to be performed before a conclusion can be drawn.
[Magnet therapy]: The use of permanent or harnessed bipolar magnets in the treatment of chronic back pain is controversial. Early evidence with stronger magnets (up to 2,000 gauss strength) reported benefits, while more recent study with lower strength (450 gauss strength) noted no effects. Additional research is necessary in this area before a firm conclusion can be drawn.
[Massage]: Several human trials report temporary improvements in low back pain with various massage methods. A clinical study reported slightly more efficacy for traditional therapy such as pain medications and surgery. However, the additional benefits of massage may contribute to its value for holistic nursing practice. Further research is necessary.
[Meditation]: Various forms of meditation have been practiced for thousands of years throughout the world, with many techniques originating in Eastern religious practices. Based on preliminary research, patients suffering from chronic low back pain may improve with breath therapy. Further clinical research is needed to confirm these results.
[TENS]: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. The effects of TENS or acupuncture-like TENS on low back pain remain controversial, and multiple controlled trials have been published in this area. Studies have not been consistent in the type of TENS techniques used (location, intensity, frequency, duration) or in definitions of back pain, and most trials have not been well designed or reported. Published meta-analyses have grouped some of these studies together to try to determine whether this technique is effective, but have also yielded inconsistent results, with some authors reporting overall benefits, and others finding no clear advantage over placebo. Better-designed research is needed before a firm conclusion can be reached.
[Trigger point therapy]: Trigger points are discrete, focal, hyperirritable spots located in skeletal muscle. The spots may be painful on compression and associated with pain and tenderness, motor dysfunction, and autonomic nervous system phenomena. The goal of trigger point therapy for back pain is to eliminate the trigger points, and thus lessen the pain. There have been few studies that addressed the therapeutic potential of this therapy. Overall, the evidence is positive and demonstrates that this therapy might be effective for the treatment of back pain. However, because back pain may be insidious and brought on by unrecognized causes, future studies should address trigger point therapy in various causes of back pain.
[Yoga]: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian (Hindu) philosophy. Preliminary research reports that yoga may improve chronic low back pain in humans. However, larger, better-designed studies are needed before a firm conclusion can be drawn.
- Fair or negative scientific evidence:
[Reflexology]: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. Reflexology is often used with the intention to relieve stress or prevent/treat physical disorders. Pressure may also be applied to the hands or ears. A large trial comparing reflexology to relaxation or no therapy reports that reflexology is not effective for managing chronic lower back pain.
- Historical or Theoretical Uses Lacking Sufficient Evidence:
- Integrative therapies used in back pain or related conditions that have historical or theoretical uses but lack sufficient clinical evidence include: homeopathic aconite (Aconitum napellus), alizarin (1,2- dihydroxyathraquinones), homeopathic arnica (Arnica montana), aromatherapy, bacopa (Bacopa monnieri), black cohosh (Actaea racemosa), bromelain, chamomile (Matricaria recutita, Chamaemelum nobile), detoxification therapy (cleansing), dong quai (Angelica sinensis), glucosamine, homeopathic nux vomica (Strychnos nux-vomica), and spiritual healing.
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