Research Database -
International Updates

Back Pain

Issue 92

CHERKIN and colleagues, Group Health Cooperative and University of Washington, Seattle, Washington 98101, USA, have reviewed (48 references) the efficacy, safety, and cost of acupuncture, massage, and spinal manipulation for back pain.
Background: Conventional treatments for back pain, although widely used, have limited success. Therefore sufferers often turn to complementary therapies. This study was aimed at providing a balanced summary of the best available evidence for the efficacy, safety and cost of the most popular complementary treatments for back pain.
Methods: Medline, Embase, and the Cochrane Controlled Trials Register were searched. Randomized controlled trials published since 1995 and studying acupuncture, massage, or spinal manipulation were extracted and reviewed.
Results: Because the quality of the 20 trials of acupuncture included in the review is generally poor, the effectiveness of acupuncture for back pain is at present unclear. 3 studies of massage reported that massage is effective for subacute and chronic back pain. 26 trials of spinal manipulation suggest that spinal manipulation is better than placebo therapy but no better than conventional treatment.
Conclusions: Initial studies find that massage is beneficial for chronic back pain. Spinal manipulation offers small benefits comparable to those found with conventional treatment. All of the treatments investigated seem to be relatively safe. Preliminary evidence suggests that massage but not acupuncture or spinal manipulation may reduce healthcare costs.
Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. 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 138 (11): 898-906, Jun 2003.

HARVEY and colleagues, Department of Health Sciences, Alcuin College, University of York, York, UK, e.l.harvey@leeds.ac.uk, introduce a treatment package of spinal manipulation for back pain agreed on by the UK
chiropractic, osteopathy and physiotherapy professional associations.
Abstract: In this review (29 references), a spinal manipulation package agreed by the UK professional associations representing chiropractors, osteopaths and physiotherapists is described. It was devised for use in a large national trial of exercise and spinal manipulation for back pain designed to answer important questions about the benefits of spinal manipulation for back pain. In the design of this trial it was acknowledged that the spinal manipulation treatments provided by practitioners from the three professions shared more similarities than differences, and it became possible to devise a homogeneous package representative of, and acceptable to, all three. The resulting package is pragmatic in that it represents what happens to most people undergoing manipulation, and it excludes discipline-specific variations and other ancillary treatments.
Harvey E, Burton AK, Moffett JK, Breen A. Spinal manipulation for low-back pain: a treatment package agreed to by the UK chiropractic, osteopathy and physiotherapy professional associations. Manual Therapy 8 (1): 46-51, Feb 2003.

Issue 89

MOLSBERGER and co-workers, Orthopedic Surgery and Research, Kasernenstr. 1b, 40213 Duesseldorf, Germany, molsberger@t-online.de, have conducted a randomized controlled trial of acupuncture in the orthopaedic management of chronic low back pain.
Background: The aim of the study was to answer the question if a
combination of acupuncture and conservative orthopaedic treatment is an improvement over conservative orthopaedic treatment alone in chronic low back pain (LBP).
Methods: In this prospective, randomized controlled trial with three parallel groups, patient and observer blindness for real and sham acupuncture. and a follow-up of 3 months, 186 in-patients at a LBP rehabilitation centre with a history of at least 6 weeks low back pain and a pain intensity of at least 50 on a scale from 0 to 100 were selected and randomly divided into three groups. Each group received 4 weeks of treatment: real acupuncture plus conservative orthopaedic treatment (real + COT), sham acupuncture (unspecific needling) plus COT (sham + COT), and conservative orthopaedic treatment only (nil + COT). The primary outcome measure was a reduction in the Pain VAS at 3 months follow-up, with pain reduction immediately after treatment as a secondary outcome measure.
Results: 174 patients completed the treatment course, and 124 reported at 3 months follow-up. Immediately after treatment the Pain VAS was reduced by 65% in the real + COT group as compared to 34% in the sham + COT group and 43% in the nil + COT group (p = 0.02 for real vs. sham). At 3 months follow-up, the results were even more striking: 77% reduction in Pain VAS in the real + Cot group, 29% in the sham + COT group, and 14% in the nil + COT group (p = 0.0001 for real vs. both sham and nil). No difference was found in the mobility of patients or in the intake of analgesic medication.
Conclusions: Acupuncture can be an important supplement of conservative orthopaedic treatment in the management of chronic low back pain.
Molsberger AF, Mau J, Pawelec DB, Winkler J. Does acupuncture improve the orthopaedic management of chronic low back pain – a randomized, blinded, controlled trial with 3 months follow up. Pain 99 (3): 579-587, Oct 2002.

Issue 19

ELKAYAM and colleagues, Department of Rheumatology, Tel Aviv Sourasky Medical Center, Ichilov Hospital, Tel Aviv University, Sackler Faculty of Medicine, Israel evaluated a multidisciplinary approach to patients with chronic back pain. METHODS: 67 patients with back pain for more than 3 months participated in a comprehensive 4-week programme including back schooling, psychological intervention, acupuncture treatment, chiropractic, Alexander technique and a pain specialist. At admission to the study, patients completed a questionnaire about their socio-demographic background and disease history and also underwent a psychological evaluation based upon a questionnaire and an interview. Based upon this evaluation, patients were graded on three criteria: i) predominance of psychological factors; ii) secondary gain; iii) personality features. At treatment end, patients were divided into three groups according to their degree of improvement. Evaluation of patients occurred at the end of the 4-week programme and after 6 months. RESULTS: There was significant improvement to pain rating, pain frequency and pain-relief drug consumption in the treatment group, which was maintained for 6 months. Satisfactory outcome was correlated to a moderate predominance of psychological factors, good functioning, high degree of motivation and family support. Poor outcome was associated with divorced marital status and unemployment, diffuse complaints, post surgery status, a high predominance of psychological factors and presence of secondary gain and personality disorders. CONCLUSIONS: Patients with chronic back pain appear to benefit from the multidisciplinary approach followed in this study. Improvement was maintained for 7 months and the outcome was clearly related to psychosocial factors.
Elkayam O et al. Multidisciplinary approach to chronic back pain: prognostic elements of the outcome. Clin Exp Rheumatol 14(3): 281-8. May-Jun 1996.

COMMENTS: Considering the huge amount of misery caused by back pain, suffered by a majority of people at some time in their lives, the success of such a holistic, multi-disciplinary approach which includes psychological and social evaluation as well as physical treatment, makes one wonder why this approach is not the norm. Just as it is well known that bereavement and poor family and social support are poor prognostic factors for cancer and heart disease, it is not surprising that back pain may be refractory to improvement in people who are recovering from surgery, unemployed, without strong family support or stressed or depressed. It is hoped that increased publication of multi-disciplinary research such as the above may hasten the adoption and spread of such treatment approaches internationally.