Low back pain is one of the most common health conditions today. According to some estimates, each year nearly 15% to 20% of the United States population experiences low back problems, and as many as 80% of all adults experience significant low back pain at some point during their lives.1,2Back pain is the second most common reason adults under age 45 miss days from work (after the common cold). The total cost of back pain has been estimated to reach $25 billion per year in the US.3

When back pain occurs suddenly (after lifting a heavy object, for example), it is called acute back pain or sprain. In most cases, acute back pain eventually improves by itself, but there may be weeks of discomfort, time lost from work, and impaired function at home.

When back pain persists over months or years, it is called chronic back pain. In the majority of cases, the cause of chronic back pain is unknown. Identifiable causes include osteoarthritis, fracture, or injury to the discs between the vertebrae.

Conventional treatment of acute back pain involves anti-inflammatory drugs, muscle relaxants, and the passage of time. Chronic back pain requires a medical workup to make sure there are no serious underlying causes, although evidence suggests that, in most cases, x-rays are not necessary.4 Treatment may also include physical therapy and a graded exerciseprogram. However, there is little reliable evidence that these treatments actually provide much benefit.64,65 Surgery may be recommended in certain cases, such as when there are severe disc problems, but most forms of back surgery also lack reliable supporting evidence.

Extract of the herb white willow appears to be helpful for acute and chronic back pain, presumably because of its similarity to aspirin. The little-known injection technique known as prolotherapy may be effective for back pain as well. Lesser evidence supports the use of chiropractic and acupuncture.

White Willow

Willow bark has been used as a treatment for pain and fever in China since 500 BC. It contains the substance salicin, which is chemically related to aspirin. Another ingredient of white willow, tremulacin, may also be important.

In a 4-week, double-blind, placebo-controlledstudy of 210 individuals with chronic back pain, two different doses of willow bark extract were compared against placebo.5 The higher-dose group received extract supplying 240 mg of salicin daily; in this group, 39% were pain-free for at least the last 5 days of the study. In the lower-dose group (120 mg of salicin daily), 21% became pain-free. In contrast, only 6% of those given placebo became pain-free. Stomach distress did not occur in this study. The only significant side effect seen was an allergic reaction in one participant given willow.

Note: White willow should not be combined with standard anti-inflammatory drugs, such as ibuprofen. For more information, including dosage and safety issues, see the full White Willow article.

Chiropractic

Chiropractic spinal manipulation is one of the most popular treatments for acute and chronic back pain in the US, and it may provide at least modest benefit; however, as yet, research evidence has failed to find chiropractic manipulation convincingly more effective than standard medical care.49,50,76

Chiropractic does seem to be more effective than placebo, if not by a great deal. For example, a single-blind, controlled study of 84 people suffering from low back pain compared manipulation to treatment with a diathermy machine (a physical therapy machine that uses microwaves to create heat beneath the skin) that was not actually functioning.16 The researchers asked the participants to assess their own pain levels within 15 minutes of the first treatment, then 3 and 7 days after treatment. The only statistically significant difference between the two groups was within 15 minutes of the manipulation. (Chiropractic had better results at that point.)

In another single-blind, placebo-controlled study, researchers assigned 209 participants to one of three groups: a high-velocity, low-amplitude (HVLA) spinal manipulation; a sham manipulation group; or a back education program.17Though this has been reported as a positive study,18 most of the differences seen between the groups were too small to be statistically significant.

Unimpressive results were also seen in a well-designed study of 321 people with back pain, comparing chiropractic manipulation, a special form of physical therapy (the Mackenzie method), and the provision of an educational booklet in treating low back pain.25 All groups improved to about the same extent.

Several studies evaluated the effectiveness of chiropractic manipulation combined with a different kind of treatment called mobilization, but they too found little to no benefit.43,45,46

On a positive note, one study of 100 people with back pain and sciatica symptoms (pain down the leg due to disc protrusion) found that chiropractic manipulation was significantly more effective at relieving symptoms than sham chiropractic manipulation.57

For low back pain, several studies have found that chiropractic is at least as helpful as other commonly used therapies, such as muscle relaxants, soft-tissue massage, and physical therapy.22-26,51,74Furthermore, in one well-designed study, 2 months of chiropractic spinal manipulation produced somewhat greater pain relief than exercise therapy, and this relative superiority endured to the 1-year follow-up point.41

For more information, see the full Chiropractic article.

Acupuncture

The ancient technique of acupuncturehas become increasingly popular as a treatment for pain and other conditions. However, thus far, research has not produced clear evidence of acupuncture’s effectiveness for back pain.52In a review of 23 randomized trials involving over 6,000 patients with chronic low back, researchers concluded that acupuncture is more effective than no treatment for short-term pain relief, but there was no significant difference between the effects of true and sham.79

A 6-month, double-blind trial of 1,162 people with back pain compared real acupuncture, fake acupuncture, and conventional therapy.72 Both real and fake acupuncture were twice as effective as conventional therapy according to the measures used. However, there was only a minimal difference between real and fake acupuncture. These results do not, in fact, indicate that acupuncture is effective per se; rather, it shows the significant power of acupuncture as a placebo.

Similarly, in a single-blind, sham-acupuncture, and no-treatment controlled study of 298 people with chronic back pain, use of real acupuncture failed to prove significantly more effective than sham-acupuncture.58Also, in a fairly large randomized trial involving 638 adults with chronic back pain, there was no difference in pain at one year in patients receiving real compared to fake acupuncture (with neither group improving significantly over standard care). Both real and simulated acupuncture were, however, associated with improved function at one year.80Other studies have failed to find benefit as well; in several controlled studies enrolling a total of over 300 people, real acupuncture again failed to prove more effective than sham-acupuncture or other placebo treatments.19,29,32,53

One study compared the effects of acupuncture, massage, and education (such as videotapes on back care) for 262 people with chronic back pain over a 10-week period.28 The exact type of acupuncture and massage was left to practitioners, but only 10 visits were permitted. At the 10-week point, evaluations showed benefit with massage but not with acupuncture. One year later, massage and education were nearly equivalent, and both were superior to acupuncture.

Low level laser therapy (LLLT) is a technique similar to electro-acupuncture that uses precision laser energy instead of electricity conducted through a needle. In a detailed review of 7 randomized trials, researchers were unable to draw any conclusions regarding the effectiveness of LLLT for nonspecific low back pain.73

A review of 32 randomized trials compared acupuncture to no or other therapies with mixed results in patients with nonspecific chronic low back pain. For pain reduction and function, acupuncture was better than sham acupuncture. Acupuncture was more effective for functional improvements when it was used in combination with usual care. Modest improvements in pain and function were seen with acupuncture treatment when compared to pain relievers and muscle relaxants, but the differences were not clinically significant. Biases included types of acupuncture used, duration of treatment, and number of treatment sessions in the patient population. Increased numbers of biases in trials affects the quality of the results.91

Many other studies have compared acupuncture to such treatments as transcutaneous electrical nerve stimulation (TENS), physical therapy, chiropractic care, and massage.14,33-37,59In many of these trials, acupuncture provided benefits comparable to the other options tested. However, because TENS, physical therapy, and so forth, have not been proven effective for back pain, studies of this type cannot be taken as evidence that acupuncture is effective. One study did find acupressure massage more effective than standard physical therapy; however, it was performed in a Chinese population that may have had more faith in this traditional approach than in physical therapy.60

For more information, see the full Acupuncture article.