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Low Back Pain: NACCAM Symposium
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If you have struggled with a painful back, you are not alone. Back pain is one of the most common medical problems in the United States, affecting 8 out of 10 people at some time in their lives. Low-back pain (LBP) costs the nation an estimated $50 billion each year and is also the most common cause of job-related disability. In the great majority of cases of LBP (85 percent, according to one estimate), the cause is unknown.
Back pain and other back problems are the number-one reason that Americans use CAM therapies, according to a large national survey. Do they work for this purpose? What goes on in the body when one of these therapies, spinal manipulation, is given? Two researchers spoke on these topics at the September 2007 meeting of the National Advisory Council for Complementary and Alternative Medicine (NACCAM). The symposium was also open to the public. Partap S. Khalsa, D.C., Ph.D., D.A.B.C.O., a program officer at NCCAM, served as moderator.
Toward a Better Understanding of Spinal Manipulation
Speakers Joel Pickar, D.C., Ph.D., and Daniel Cherkin, Ph.D.,
with Partap Khalsa, D.C., Ph.D., of NCCAM
Joel Pickar, D.C., Ph.D., is a professor at the Palmer Center for Chiropractic Research, Palmer Chiropractic University, Davenport, Iowa. A member of NACCAM, he is trained in both neuroscience (scientific study of the nervous system) and chiropractic.
Dr. Pickar is the lead investigator at NCCAM's Developmental Center for the Study of Mechanisms and Effects of Chiropractic Manipulation—a multiinstitution, multidisciplinary center that is administered at Palmer and builds on work by an earlier developmental center there. The center's research focus is
- The structures and tissues in and near the spine, especially the lower back
- Their properties related to function, the nervous system, and mechanical forces
- What happens in them when forces mimicking those of chiropractic spinal manipulation are applied.
Why study this therapy? "We know that 10 percent of Americans seek chiropractic care," Dr. Pickar says, "a figure that rises to 20 to 40 percent of Americans who have back pain. Spinal manipulation is a core practice in chiropractic care. There have been positive results from over 40 studies on spinal manipulation for low-back pain, but many have had consistency or quality issues. In short, there are reasons to recommend spinal manipulation for low-back pain, but there's also a lot we don't know about this therapy."
Inside a muscle spindle are specialized muscle fibers that
receive inputs from motor neurons
Versatile Muscle Spindles
Dr. Pickar first explained how the bony segments of the spine (vertebrae) must work with each other, under muscle control, and with the nervous system so that people can maintain an upright, stable posture and can move. The vertebrae couldn't do these things without muscle spindles—long, narrow structures in the muscles made up of smaller muscle fibers and sensory receptors. They monitor muscle length and send signals to the nervous system about the positioning of a person's joints.
Dr. Pickar and his colleagues have developed an animal model and, with the aid of sophisticated technology, they are studying how muscle spindles and other tissues and structures in the low back respond when manipulation-like forces are applied. They have designed these forces to be similar to the most common type in chiropractic— high-velocity, low-amplitude manipulation.
Which Therapies Seem To Help LBP? Do Expectations Play a Part?
Many CAM therapies are among those claimed to help LBP. Does the evidence from studies indicate that CAM is effective for this purpose? How does someone choose among treatment options? Daniel C. Cherkin, Ph.D., summed up one group of experts' efforts to answer these and some related questions. Dr. Cherkin is associate director for research and senior investigator at the Group Health Center for Health Studies, in Seattle, Washington. He has developed methods for the rigorous study of CAM and has studied a number of CAM therapies for LBP.
Dr. Cherkin first discussed a new guideline for clinicians on the diagnosis and treatment of low-back pain, sponsored by the American College of Physicians (ACP) and the American Pain Society (APS) and published in October 2007. Dr. Cherkin served on an expert panel for selecting therapies to be reviewed (including from CAM) for this guideline and evaluating the evidence. One part of this project was to determine whether nonpharmacological (nondrug) treatment options offered any benefit. The nondrug therapies the panel selected are in the box below.
As one of the guideline's seven recommendations, the authors conclude that for patients whose LBP does not improve with conventional medications, education, and self-care, clinicians should consider adding "nonpharmacologic therapies with proven benefits." They identify those therapies as the following (CAM therapies are in bold):
ACUTE LBP:
- spinal manipulation
CHRONIC LBP:
- intensive interdisciplinary rehabilitation
- exercise therapy
- acupuncture
- massage therapy
- spinal manipulation
- yoga
- cognitive-behavioral therapy
- progressive relaxation
Dr. Cherkin said that it is an "enormous change from the past for so many CAM treatments to be recommended by a major review of this nature." He described the quality of the available evidence as generally fair, and stronger for spinal manipulation. "The authors are not saying that any of these are 'fabulous' or first-line treatments for LBP," he said, "but that they are reasonable to try when usual care— such as medications, back care information, and self-care—has not resolved the problem. There is now fair-to-good evidence that [some] popular CAM therapies have a moderate effect on chronic low-back pain."
Other Recent Work by Dr. Cherkin
Dr. Cherkin also discussed several NCCAM-supported studies by his group. A clinical trial published in 2005 found that 12 sessions of a type of yoga called viniyoga reduced back pain more than an exercise program or a self-care book. Another, nearing completion, compares the effects, on outcomes and costs, of:
- Acupuncture added to usual care, versus usual care alone
- True acupuncture versus sham acupuncture (delivered via a toothpick in a tube that stimulates the skin but does not penetrate it)
- Individualized acupuncture versus standardized acupuncture. In the individualized approach, a diagnostician selects points on each person for LBP treatment; in the standardized approach, a practitioner treats the points identified as most effective for LBP from the literature and practitioner surveys.
This randomized study was conducted with 640 participants who had had chronic LBP for at least 3 months and had never had acupuncture. Dr. Cherkin gave a preview of some findings:
- Acupuncture added to usual care was superior to usual care.
- Individualized acupuncture was not more effective than standardized acupuncture.
- Real acupuncture was not more effective than sham acupuncture.
He commented that it appears acupuncture is effective for LBP, but not from the insertion of needles, and that it is possible that acupuncture's observed benefits arise from the stimulation alone of points and/or from nonspecific effects such as beliefs and expectations.
Currently, Dr. Cherkin's team is recruiting for a study that will compare, as treatments for chronic low-back pain, relaxation massage (also called Swedish massage) and focused structural massage, both with each other and with usual care. Another study will examine yoga compared with usual care and exercise therapy.
"We hope that these studies will clarify the value of these CAM therapeutic approaches for treating LBP, one of the most common, challenging, and expensive health problems that plague developed countries," he told CAM at the NIH. "As in our other studies, we also hope that the findings will help physicians to make informed and confident referrals, consumers and insurers to make safe and cost-effective choices, and schools that train practitioners to make responsible curriculum decisions."
Nondrug Therapies Included in the ACP/APS Guideline
Acupuncture—Defined in NCCAM's publication Acupuncture
Back schools—Group programs that offer education, skills, and exercise therapy and are led by a professional
Exercise therapy—A supervised exercise program or home fitness regimen
Functional restoration—For injured workers, testing intended to improve job performance and job fitness and performed in a supervised environment
Interdisciplinary therapy—Therapy with physical, vocational, and behavioral components, provided by multiple professionals from different disciplines
Massage—See NCCAM's publication Massage Therapy as CAM
Physical therapies—Interferential therapy, low-level laser therapy, lumbar supports, short-wave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography
Psychological therapies—A category including biofeedback, progressive relaxation, cognitive-behavioral therapy, and operant therapy
Yoga—The use of specific body positions and breathing techniques, with an emphasis on mental focus
Definitions, where provided, are condensed from the full ACP/APS articles.
Selected References
Effect of massage on chronic low-back pain. ClinicalTrials.gov Web site. Accessed at http://www.clinicaltrials.gov/ct/show/NCT00371384?order=1 on November 6, 2007.
Cherkin DC, Sherman KJ, Deyo RA, et al. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Annals of Internal Medicine. 2003;138(11):898-906.
Chou R, Huffman LH, American Pain Society, American College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine. 2007;147(7):492-504.
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 Society. Annals of Internal Medicine. 2007;147(7):478-491. Summary for patients: I45.
Deyo RA, Weinstein JN. Low back pain. New England Journal of Medicine. 2001;344(5):363-370.
National Institute of Arthritis and Musculoskeletal and Skin Diseases. Handout on health: back pain. Accessed at http://www.niams.nih.gov/health_info/back_pain/default.asp on October 19, 2007.
Pickar JG, Kang YM. Paraspinal muscle spindle responses to the duration of a spinal manipulation under force control. Journal of Manipulative and Physiological Therapeutics. 2006;1:22-31.
Sherman KJ, Cherkin DC, Erro J, et al. Comparing yoga, exercise, and a selfcare book for chronic low back pain: a randomized, controlled trial. Annals of Internal Medicine. 2005;143(12):849-856.
Sung PS, Kang YM, Pickar JG. Effect of spinal manipulation duration on low threshold mechanoreceptors in lumbar paraspinal muscles: a preliminary report. Spine. 2005;30(1):115-122.
