Low-Back Pain and CAM
Four out of five American adults will experience
low-back pain (LBP) at some time in their
lives. If you are a health care provider, you have almost certainly cared for such patients. No doubt, some of
them have asked you about using complementary and alternative medicine (CAM) to relieve their pain. This article provides an
overview of the use of CAM therapies for LBP and lists evidence-based sources for additional
A Challenging Condition
LBP is a major public health burden in the
United States. It is the leading cause of
work-related disability and missed days of work, and the fifth-most-common reason for physician visits. A
2006 report estimated that annual costs of LBP in this country exceed $100 billion. Two-thirds of that is for
indirect costs, such as lost wages and reduced productivity.
Definitions of nonspecific LBP and its subtypes in the literature
vary; a representative definition is in the box below. LBP is often classified either as acute (pain that lasts up
to 4 weeks); subacute (pain lasting from 4 to 12 weeks); or chronic (pain lasting for 3 months or longer). Only a small percentage of
acute cases of LBP—2 to 7 percent, according to one guideline—become chronic. However, this condition can cause
substantial disability and accounts for the majority of LBP-associated costs.
What Is Nonspecific Low-Back Pain?
Nonspecific low-back pain is pain occurring primarily in the back
with no signs of a serious underlying condition, spinal stenosis or radiculopathy, or another specific spinal
cause. Degenerative changes on lumbar imaging correlate poorly with symptoms and are usually considered
Condensed from Chou R, Qaseem A, Snow V, et al.,
Seeking Options in CAM
"Low-back pain is one of our society's most common, burdensome
health problems," says Josephine P. Briggs, M.D., Director of NCCAM. "The currently available treatments have
limitations. Many patients turn to CAM with the hope of decreasing pain, improving function and quality-of-life, preventing
recurrence and chronicity, or avoiding side effects of other treatments."
According to the 2007 National Health Interview Survey, back pain
is the most common condition for which American adults use CAM. Data suggest that the CAM therapies most frequently used for LBP are
chiropractic/manipulation, massage, and acupuncture. Other CAM approaches include yoga, herbal and other dietary
supplements, devices, and lifestyle products.
Beth Tedesco, D.C., performs spinal manipulation (known in
chiropractic as adjustment)
© Matthew Lester
Evaluating Treatment Options
Identifying optimal treatment approaches for LBP can be difficult
for both patients and clinicians. A thorough patient assessment is the first step for a clinician who may be
considering recommending CAM therapies. Clinical practice guidelines stress the importance of ruling out serious
underlying conditions and evaluating a patient's psychosocial factors and emotional distress when doing an
assessment of LBP.
Among recent recommendations on LBP are joint clinical guidelines
from the American College of Physicians and the American Pain Society
(ACP/APS). Released in 2007, the statement's seven major recommendations to clinicians include:
- Conducting a focused history and physical
examination to help place patients into one of three categories: nonspecific LBP, back pain potentially
associated with radiculopathy or spinal stenosis, or back pain potentially from another specific spinal
- Providing patients with evidence-based
information on the expected course and on effective self-care options, and advising them to remain
- Considering use of medications with proven
benefits (first-line options are acetaminophen or NSAIDs)
- Considering nonpharmacologic therapy that
has proven benefits for patients whose LBP does not improve with self-care alone.
The ACP/APS guidelines' levels of evidence and net benefit for
nonpharmacologic treatments are in:
Findings on CAM from Systematic Reviews
Systematic reviews on CAM for LBP may be divided into two
Reviews. The Cochrane Collaboration is an international
nonprofit organization of health care professionals. Its authors use a systematic process to analyze the
results of clinical trials and other sources to explore the evidence for and against the effectiveness and
appropriateness of health care treatments. Topics pertaining to CAM for LBP include:
- Herbal medicine
- Spinal manipulative
- Behavioral treatments (including some
Other Systematic Reviews. The CAM on
PubMed database, a service of NCCAM and the National Library of Medicine, provides abstracts of systematic reviews
published in peer-reviewed medical and scientific journals. Examples of relevant review topics
- Spinal manipulation and
- Osteopathic manipulative
- Herbal and other dietary
- Willow bark
- Devil's claw
- Spa therapy and balneotherapy (treatment
based on bathing in water).
Two of the themes that are consistent throughout the body of
systematic reviews on CAM for LBP
are that the evidence evaluated is limited—for example, in its quantity or quality—and that more high-quality
research is needed.
Specific areas for future research in CAM for LBP include the cost-effectiveness of
CAM therapies; head-to-head comparisons of
therapies and studies of the effectiveness of CAM therapies versus usual care; and the optimal form, duration, and frequency for
"There is much more to learn about the
effectiveness and safety of CAM therapies for chronic LBP and other pain conditions." — Josephine P. Briggs,
Additional Clinical Considerations:
CAM for LBP
When a health care provider considers treatment options for a
patient with LBP, other factors play a part as well, such as clinical experience and the patient's condition,
preferences, and expectations. Consider the following additional tips on CAM:
- Ask your patients about
CAM. Research has found that most
patients do not disclose CAM use to their health care providers. Let them know they can discuss any therapy
with you that they are interested in or are using.
- Evidence-based information for you and your
patient is available from NCCAM as well as other resources listed below. Visit the NCCAM Web site for additional links.
- When making referrals to other
practitioners, find out about their training, and their licensing or certification, if applicable. Ask
specifically about the nature and length of their experience in treating LBP.
- Health care providers of all types may be
involved in the care of patients with LBP. Open and clear communication between providers helps ensure
coordinated and safe care.
"There is much more to learn about the effectiveness and safety
of CAM therapies for chronic LBP and
other chronic pain conditions," says Dr. Briggs. "Building a better and clearer evidence base in these areas, and
sharing reliable information, are priorities for NCCAM."
Literature Searches In PubMed
Selected Citations on Low-Back Pain
- Search Limits: Publication within the past 5
years; randomized controlled trials, reviews, meta-analyses, or practice guidelines
NCCAM-Funded Research Results on Low-Back Pain
- Search Limit: Articles mentioning NCCAM
- Balagué F, Mannion AF, Pellisé F, et al.
Clinical update: low back pain. The
- Barnes PM, Bloom B, Nahin R.
Complementary and alternative medicine use among adults and
children: United States, 2007. CDC National Health Statistics Report
- Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical
practice guideline from the American College of Physicians and the American Pain
Annals of Internal Medicine. 2007;147(7):478–491.
- Cohen SP, Argoff CE, Carragee EJ. Management of low back pain. BMJ.
- Katz JN. Lumbar disc disorders and low-back pain: socioeconomic
factors and consequences. Journal of Bone and Joint
Surgery. American volume. 2006;88(suppl
- NationalCenter for Complementary and Alternative Medicine. Spinal Manipulation for Low-Back Pain.
Bethesda, MD: NationalCenter for Complementary and Alternative Medicine. NCCAM publication no.
- Shen FH, Samartzis D, Andersson GB. Nonsurgical management of acute and chronic low back
Journal of the AmericanAcademy of Orthopedic
- Wilson JF. In the clinic: low back pain. Annals of Internal Medicine.