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Am Fam Physician. 2004;69(3):695-696

Back pain is a common complaint for which few effective treatments are available. Patients with low back pain often seek complementary and alternative medicine therapies, some of which provide symptom relief. The most popular alternative therapy for back pain is spinal manipulation, usually performed by chiropractors, followed by massage therapy and acupuncture. Evaluation of these treatments has been difficult because of poor study designs and inconsistent conclusions. Cherkin and associates reviewed the literature on the use of acupuncture, massage therapy, and spinal manipulation in the management of low back pain and discussed what is known about each modality.

Examination of randomized studies comparing acupuncture and placebo in the treatment of back pain demonstrated some efficacy with acupuncture but not necessarily more than when sham acupuncture was used. Acupuncture appears to be safe, especially in the United States, where disposable needles are used.

Therapeutic massage has been tested recently in several randomized, controlled studies. Massage and soft tissue manipulation were more effective than placebo or, in one study, acupuncture in relieving back pain. Massage has only minor adverse effects, including pain and discomfort in some patients. Possible contraindications for massage therapy include deep venous thrombosis, burns, skin infections, eczema, open wounds, and advanced osteoporosis. Massage has been shown to have some longer term cost benefit when compared with acupuncture and self-care.

Spinal manipulation has been tested with varying results in a large number of studies. In these studies, spinal manipulation seems to be superior to sham or ineffective therapies, although it could not be compared with other conventional therapies. Serious complications of spinal manipulation are rare and caused mainly by cervical manipulation, a bleeding disorder, presence of a herniated disc, or improper technique. The authors found no documentation of increased cost efficiency with spinal manipulation.

The authors conclude that recent studies show that (1) the effectiveness of acupuncture is unclear, (2) acupuncture is less effective than massage therapy, (3) massage is helpful in treating acute and subacute back pain, and (4) spinal manipulation has real, but modest, benefits in patients with acute and chronic low back pain. All three treatments are relatively safe. Although massage therapy may be the most cost-effective treatment, conclusive data do not exist. Therapeutic trials are difficult because the success of these treatments depends on the needs of individual patients.

In a meta-analysis of randomized, controlled studies in the same journal, Assendelft and colleagues conclude that no evidence shows that spinal manipulation is superior to any other treatment in patients with acute or chronic low back pain.

editor's note: The management of low back pain often requires unconventional treatments. Physicians may allow patients to choose which type of therapy to pursue. Randomized controlled trials provide some information, and the Cochrane Database has reviewed several unconventional treatments. Cochrane reviews reached the following conclusions regarding the treatment of acute and chronic lower back pain: (1) acupuncture probably is not effective, (2) massage might be beneficial, (3) behavior treatments that include environmental modification and use of cognitive processes may work in certain patients, (4) bed rest is unlikely to be beneficial and may be harmful, (5) exercise probably is not helpful in the acute phase but may help patients with chronic back pain to return to work earlier, and (6) a multidisciplinary biopsychosocial approach might help. Clearly, more studies are needed, but physicians should discuss alternative therapies for low back pain with patients and try to direct them to one that may alleviate their discomfort.—R.S.

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