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National Institutes of Health • National Center for Complementary and Alternative Medicine

NCCAM Clinical Digest

Chronic Low-Back Pain and Complementary Health Approaches :
What the Science Says

March 2014

Spinal Manipulation

The term spinal manipulation includes a class of interventions in which practitioners (e.g., chiropractors or osteopathic physicians, or physical therapists) use their hands or a device to apply a controlled force to the spine. In general current evidence does not permit direct comparisons of various specific techniques.

Strength of the Evidence Base

  • The evidence base from many studies on the effects of spinal manipulation on low-back pain is of sufficient size and quality to permit independent systematic reviews and meta-analyses, and inclusion of recommendations into independent clinical practice guidelines.

Efficacy

  • The systematic review supporting the 2007 clinical practice guidelines from the ACP/APS found good evidence that spinal manipulation (as well as cognitive-behavioral therapy, exercise, and interdisciplinary rehabilitation) are all moderately effective for chronic or subacute (>4 weeks' duration) low back pain.
  • A 2010 Agency for Healthcare Research and Quality (AHRQ) systematic review concluded that spinal manipulation was more effective than placebo and as effective as medication in reducing low-back pain intensity. The researchers did not find consistent differences when they compared spinal manipulation with massage or physical therapy.
  • A 2011 Cochrane review of 26 clinical trials looked at the effectiveness of different treatments, including spinal manipulation, for chronic low-back pain. The authors concluded that spinal manipulation is as effective as other interventions for reducing pain and improving function.
  • A 2009 meta-analysis looked at the evidence from 76 trials that studied the effects of several conventional and complementary health practices for low-back pain. The researchers found that the pain-relieving effects of many treatments, including spinal manipulation, were small and were similar in people with acute or chronic pain.

Safety

  • Many reviews have concluded that spinal manipulation for low-back pain is relatively safe when performed by a trained and licensed practitioner. The most common minor side effects include feeling tired and temporary soreness.
  • There have been a few reports of cauda equina syndrome (CES), a significant narrowing of the lower part of the spinal canal in which nerves become pinched and may cause pain, weakness, loss of feeling in one or both legs, and bowel or bladder problems, following spinal manipulation. However, the vast majority of cases of CES are not associated with previous spinal manipulation, and in the few cases which are it is unclear whether this is a complication of manipulation or an underlying disease condition which is causing back pain.
  • In people whose pain is caused by a herniated disc, manipulation of the low back appears to have a very low chance of worsening the herniation.
  • For risks associated with spinal manipulation affecting the upper (cervical) spine, see the NCCAM fact sheet Chiropractic: An Introduction.

Acupuncture

Acupuncture is being actively studied for its efficacy in alleviating many kinds of pain. Evidence of benefit has been found in many conditions, including chronic low back pain. Whether the beneficial clinical effects of acupuncture treatment are specific or non-specific is unsettled, and under active investigation.

Strength of Evidence

  • The strongest evidence concerning the efficacy of acupuncture in chronic low back pain consists of the systematic review which supports the ACP/APS clinical practice guidelines, and a more recent individual patient data meta-analysis published in 2012.

Research Results

  • The systematic review supporting the 2007 ACP/APS clinical practice guidelines found fair evidence that acupuncture (as well as massage, yoga, and functional restoration) is effective for chronic low back pain. The 2007 clinical practice guidelines included them as options physicians should consider when patients with chronic low-back pain do not respond to conventional treatment.
  • A rigorous 2012 patient data meta-analysis found clear evidence that acupuncture is useful in treating chronic back and neck pain, and the investigators concluded that it is therefore a reasonable referral option. While they found evidence of acupuncture-specific effects attributable to needling, suggesting that acupuncture is more than an elaborate placebo, they noted that these effects are relatively modest and that other non-acupuncture-specific factors are major contributors to the clinical benefit. Ongoing research is actively investigating the mechanism(s) of acupuncture’s effects on pain.

Safety

  • Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles.
  • Reports of serious adverse events related to acupuncture are rare, but include infections and punctured organs.

Massage

Massage therapy has been or is being studied in for its effects in alleviating pain and other symptoms associated with a number of conditions. While largely preliminary and sometimes conflicting, much of the evidence points toward beneficial effects. In general these effects are short term.

Strength of Evidence

  • The strongest evidence concerning efficacy of massage in chronic low back pain consists of a systematic review which supports ACP/APS clinical practice guidelines (published in 2007), another Cochrane systematic review published in 2008, and a subsequent large randomized clinical trial.

Research Results

  • A systematic review supporting the 2007 ACP/APS clinical practice guidelines found fair evidence that massage (as well as acupuncture, yoga, and functional restoration) are effective for chronic low back pain. The 2007 clinical practice guidelines included them as options physicians should consider when patients with chronic low-back pain do not respond to conventional treatment.
  • A 2008 systematic review of 13 clinical trials found evidence that massage might be useful for chronic low-back pain.
  • Results of a subsequent large randomized clinical trial published in 2011 showed that massage therapy may have short‑term benefits for people with chronic low-back pain. Massage therapy helped reduce pain and improve function more rapidly than usual medical care at 10 weeks; however, at 1 year the benefits of massage over usual care were not significant.

Safety

  • Massage therapy appears to have few risks when performed by a trained practitioner. However, massage therapists should take some precautions with certain health conditions.
  • In some cases, pregnant women should avoid massage therapy. Talk with your health care provider before getting a massage if you are pregnant.
  • Forceful and deep tissue massage should be avoided by people with conditions such as bleeding disorders or low blood platelet counts, and by people taking anticoagulant medications such as warfarin (also known as blood thinners).
  • Massage should not be done in any potentially weak area of the skin, such as wounds.
  • Deep or intense pressure should not be used over an area where the patient has a tumor or cancer, unless approved by the patient’s health care provider.

Yoga

Yoga, a mind and body practice that combines physical activity or postures, breathing exercises, and meditation, has been studied for several pain conditions such as chronic low-back pain and arthritis. NCCAM is also supporting research specifically associated with safety of this widely-used self-care practice

Strength of Evidence

  • The current evidence base on efficacy of yoga in chronic low back pain consists the systematic review which supports the ACP/APS clinical practice guidelines (published in 2007), and several subsequently published randomized clinical trials.
  • Several studies have examined the effects of yoga for chronic low-back pain.

Research Results

  • A systematic review supporting the 2007 ACP/APS clinical practice guidelines found fair evidence that viniyoga (as well as acupuncture, massage, and functional restoration) are effective for chronic low back pain. The 2007 clinical practice guidelines included them as options physicians should consider when patients with chronic low-back pain do not respond to conventional treatment.
  • A subsequent NCCAM-funded study published in 2009 of 90 people with chronic low-back pain found that participants who practiced Iyengar yoga had significantly less disability, pain, and depression after 6 months than patients who received standard medical care.
  • In a 2011 study, also funded by NCCAM, researchers compared yoga (a protocol developed using the principles of viniyoga) with conventional stretching exercises or a self-care book in 228 adults with chronic low-back pain. The investigators concluded that yoga classes were more effective than a self-care book, but not more effective than stretching classes, in improving function and reducing symptoms due to chronic low back pain, with benefits lasting at least several months.
  • Conclusions from another 2011 study of 313 adults with chronic or recurring low-back pain suggested that 12 weekly yoga classes resulted in better function than usual medical care.

Safety

  • Overall, clinical trial data suggest yoga as taught and practiced in these research studies under the guidance of skilled teacher has a low rate of minor side effects.
  • However, injuries from yoga, some of them serious, have been reported in the popular press.
  • People with health conditions should work with an experienced teacher who can help modify or avoid some yoga poses to prevent side effects.

NCCAM Clinical Digest is a service of the National Center for Complementary and Alternative Medicine, NIH, DHHS. NCCAM Clinical Digest, a monthly e-newsletter, offers evidence-based information on CAM, including scientific literature searches, summaries of NCCAM-funded research, fact sheets for patients, and more.

The National Center for Complementary and Alternative Medicine is dedicated to exploring complementary and alternative healing practices in the context of rigorous science, training CAM researchers, and disseminating authoritative information to the public and professionals. For additional information, call NCCAM's Clearinghouse toll-free at 1-888-644-6226, or visit the NCCAM Web site at nccam.nih.gov. NCCAM is 1 of 27 institutes and centers at the National Institutes of Health, the Federal focal point for medical research in the United States.

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