There has been a recent surge in interest among policymakers and physicians in the nonpharmacologic treatment of pain in general, and low back pain in particular. This is the result of growing awareness that pharmacologic treatments have not only caused significant harm, they have also failed to achieve a reduction in the number of people in chronic pain.
It is now widely acknowledged that prescription opioids, even used as directed, can cause addiction, even after short-term use. Millions of patients have become addicted and over 190,000 have died. Opioids are also implicated in 21% of fatal auto accidents, cause an increase in all-cause mortality1, can cause falls in the elderly, and can lower immunity.2 There is also no evidence that opioids are an effective treatment for chronic pain, with some studies finding that patients who use opioids do worse in the long term than similar patients who were never prescribed opioids.3,4,5
There is also growing evidence that NSAIDs, both prescription and over-the-counter, cause a significant increase in the risk of heart disease and stroke, even after short-term use. This led the FDA in 2015 to require a black box warning on all NSAIDs except aspirin. The increased risk of GI complications and related deaths from NSAIDs has long been known.
At the same time, pharmacologic treatment of pain has failed to stem the tide of Americans who suffer from chronic pain, with 100 million Americans estimated to suffer.6 This is more than cancer, heart disease, and diabetes combined. Chronic pain costs our economy over $600 billion annually, with about half due to medical expense and the rest attributable to lost productivity. Low back pain is the leading cause of disability in the U.S. and worldwide.
These dismal developments caused the CDC in 2016 to issue voluntary prescribing guidelines for opioids that recommended limiting the use of opioids and replacing them with less risky treatments, including nonpharmacologic treatments. These guidelines were quickly followed by the National Pain Strategy, which also recommended moving away from pharmacologic treatment for pain and using more nonpharmacologic treatments. Earlier this year, the American College of Physicians issued revised guidelines for the treatment of low back pain which recommended that nonpharmacologic treatments replace pharmaceuticals as first-line treatments for both acute and chronic low back pain. Even the traditionally very conservative American Medical Association has recently started including articles about the efficacy of alternative medicine approaches to low back pain in the Journal of the American Medical Association (JAMA).
This shift in medical opinion is not only a reaction to concerns about drug efficacy and safety, it is a response to the growing body of evidence, including both randomized, controlled trials and patient surveys, demonstrating the efficacy and safety of many nonpharmacologic treatments for low back pain. What follows is a brief review of selected nonpharmacologic treatments.
Acupuncture is a treatment system that involves inserting thin needles into specific points on the body in order to positively affect a patient’s health. The needles affect the flow of energy, known as qi. Acupuncture is a therapy that has been developed and refined over thousands of years and is part of traditional Chinese medicine (TCM).7
Acupuncture has been the subject of significant research, including research into its underlying mechanisms and its effect on clinical conditions, including pain. Studies have shown that acupuncture affects the supply of neurochemicals, including levels of endorphins, cortisol, serotonin, and dopamine.8 Other studies have shown changes in levels of brain activity with needling of acupuncture points.9
A 2007 study of 1,162 patients compared acupuncture, sham acupuncture (superficial needling at non-acupuncture points), and conventional therapy (a combination of drugs, physical therapy, and exercise) for effectiveness against low-back pain. The study concluded that both acupuncture and sham acupuncture were almost twice as effective as the conventional treatment for chronic back pain. The improvements lasted at least six months.10
In a 2012 study that included individual patient data from 29 controlled studies with a total of 17,922 patients, researchers concluded that acupuncture is an effective treatment for chronic back and neck pain, osteoarthritis, and chronic headaches.11
The World Health Organization states that acupuncture is safe if it is properly performed by a well-trained practitioner. WHO reported that acupuncture is nontoxic and that adverse reactions are minimal. Effects on pain were found to be comparable to morphine without the side effects and risks.12
Biofeedback uses sensitive electronic instruments to measure a person’s bodily processes and then feeds back that information to the person so that control of the physiology can be learned. Several types of biofeedback—including muscle tension (EMG), temperature (blood flow), heart rate variability (HRV), and brain wave (neurofeedback)—have been shown to be helpful for reducing chronic pain. Biofeedback is often paired with coaching in relaxation techniques.
Biofeedback can enhance the effectiveness of relaxation training by giving the patient information on the effectiveness of his efforts. Biofeedback takes measurements on the surface of the body, and this information is used as part of an educational process. It is completely safe and without negative side effects.
In a 1993 study comparing EMG biofeedback, cognitive behavioral therapy, and conservative medical management for back pain and temporomandibular joint (jaw) pain, the biofeedback group had the most positive changes posttreatment. At 6- and 24-month follow-ups, only the biofeedback group had maintained significant improvements in pain severity, interference with daily activities, emotional distress, and reductions in the use of the healthcare system for pain treatment.13 In another study, 50 chronic pain patients were randomly assigned to a biofeedback-plus-relaxation training group or a pain education group. The biofeedback/relaxation group reported significantly less pain and anxiety compared to the pain education group.14
The chiropractic profession was founded in the United States in 1895. Chiropractors diagnose, treat, and prevent disorders of the musculoskeletal system. More than 90% of patients who seek care from chiropractors are seeking relief from pain, including back and neck pain and headaches.15
Chiropractic treatment has been shown to be much safer than any conventional pain treatments. The estimated risk for serious complications for cervical (neck) manipulation is 6.39 per 10 million manipulations; for lumbar (low-back) manipulation, the estimate is 1 serious complication for every 100 million manipulations, according to a 1998 study sponsored by nonpartisan nonprofit research institute, the RAND Corporation. Compare this to the 156,000 serious complications per 10 million cervical spine surgeries and 32,000 serious complications per 10 million patients using nonsteroidal anti-inflammatory drugs (NSAIDs). The same literature review found that spinal manipulation was more effective for both acute and subacute low-back pain without sciatica than comparison treatments, and that cervical manipulation was effective for neck pain and muscle tension-type headaches.16
In 1997, the Agency for Health Care Policy and Research reported that chiropractic spinal manipulation was one of the few evidence-based treatments recommended for the treatment of low-back pain.17
A systematic review and meta-analysis published last month in JAMA of 26 randomized clinical trials of spinal manipulation for acute low back pain found statistically significant moderate improvements in both pain and function.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is based on the idea that thoughts affect behavior and emotions and that changing maladaptive thoughts can improve mood and functioning. Many chronic pain patients fear the consequences of their pain and worry about their ability to cope with it. They may have unrealistic fears that their resumption of normal activities at home and at work will result in further injury. These thoughts and fears may prolong or prevent recovery. CBT uses cognitive restructuring (replacing unhelpful beliefs with more positive ones) and behavioral experiments, such as gradual exposure to feared situations and activities, to improve emotional and physical well-being.
A 2012 meta-analysis of 46 randomized controlled studies of CBT for chronic low-back pain found that when compared with wait-list controls, CBT had the following effects: Reduced pain, anxiety, avoidance, back-related worry, catastrophizing, depression, disability, and stress and increased coping, health-related quality of life (females only), pain control, pain self-efficacy, perceived ability to function, general quality of life, and social support. CBT also offers economic benefits in terms of reduced healthcare visits, reduction in work days lost, and a higher likelihood of return of work.18
Many studies have shown that CBT and exercise in combination were as effective as back surgery over both the short and long term, with lower costs and fewer risks.19,20,21,22,23,24
A 2016 study published in JAMA found that both cognitive behavioral therapy and mindfulness-based stress reduction treatment of adults with chronic low back pain found significantly greater improvement in back pain and functional limitations than with usual care.
1. Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA, 2016, Jun 14.315(22) 2415-22.
2. Vellejo, R., de Leon-Casasola, O., & Benyamin, R. (2004). Opioid therapy and immunosuppression. American Journal of Therapeutics, 11, 354-365.
3. Vogt, M. T., Kwoh C. K., Cope, D. K., Osial, T. A., Culyba, M., & Starz, T. W. (2005). Analgesic usage for low-back pain: Impact on health care costs and service use. Spine, 30, 1075-81.
4. Webster, B. S., Verma, S. K., & Gatchel, R. J. (2007). Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery, and late opioid use. Spine, 32, 2127-2132.
5. Mahmud M. A., Webster, B. S., Courtney, T. K., Matz, S., Tacci, J. A., & Christiani D. C. (2000). Clinical management and the duration of disability for work-related low back pain. JOccup Environ Med, 42, 1178-1187
6. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education. (2011) Relieving Pain in America, a Blueprint for Transforming Prevention, Care, Education and Research. Washington, D.C.: The National Academies Press.
7. Wang, D. & Audette, J. (2008). Acupuncture in Pain Management in Contemporary Pain Medicine: Integrative Pain Medicine: The Science and Practice of Complementary and Alternative Medicine in Pain Management, Audette JF and Bailey A, eds. Totowa, NJ: Humana Press, 379.
8. Wang & Audette. (2008). Acupuncture in Pain Management, 385-388
9. Wang & Audette. (2008). Acupuncture in Pain Management, 389-391.
10. Haake, M., Muller, H., Schade-Brittinger, C., Basler, H., Schafer H, Maier C, Endres H, Trampisch H, Molsberger A. (2007). German acupuncture trials (GERAC) for chronic low-back pain. Archives of Internal Medicine, 167(17), 1892-1898.
11. Vickers, A., Cronin, A., Maschino, A., Lewith, G., MacPherson, H., Victor, N., Foster, N., Sherman, K., Witt, C., & Linde, K. (2012). Acupuncture for chronic pain: individual patient data meta-analysis. Archives of Internal Medicine, 172(9), 1444-1453.
12. World Health Organization. (2002). Acupuncture review and analysis of reports on controlled clinical trials, 5.
13. Flor, H. & Birbaumer, N. (1993). Comparison of the efficacy of electromyographic biofeedback, cognitive-behavioral therapy and conservative medical interventions in the treatment of chronic musculoskeletal pain. Journal of Consulting and Clinical Psychology, 61(4), 653-658.
14. Corrado, P., Gottlieb, H., & Abdelhamid, M. H. (2003). The effect of biofeedback and relaxation training on anxiety and somatic complaints in chronic pain patients. American Journal of Pain Management, 13(4), 133-139.
15. Plamondon, R. (1995). Summary of 1994 ACA annual statistical study. Journal of the American Chiropractic Association, 32(1), 57-63.
16. Coulter, I., (1998). Efficacy and risks of chiropractic manipulation: What does the evidence suggest? Integrative Medicine, 1(2), 61-66.
17. Cherkin, D. C.., Mootz, R. D., (eds.) (1997). Chiropractic in the United States: training, practice and research. Rockville, Maryland: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services. AHCPR Publication No. 98-N002.
18. Sveinsdotir, V., Eriksen, H.R., & Reme, S.E. (2012) Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain. Journal of Pain Research, 5, 371-80.
19. Brox, J. I., Sorensen, R., Friis, A. et Al. (2003). Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low-back pain and disc degeneration. Spine, 28(17), 1913–1921.
20. Brox J. I., Reikeras, O., Nygaard, O., et al. (2006). Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain, 122(1–2), 145–155.
21. Brox, J. I., Nygaard, O. P., Holm, I., Keller, A., Ingebrigtsen, T., & Reikeras, O. (2010). Four-year follow-up of surgical versus non-surgical therapy for chronic low-back pain. Ann Rheum Dis, 69(9), 1643–1648.
22. Keller, A., Brox, J. I., Gunderson, R., Holm, I., Friis, A., & Reikeras, O. (2004). Trunk muscle strength, cross-sectional area, and density in patients with chronic low-back pain randomized to lumbar fusion or cognitive intervention and exercises. Spine, 29(1):3–8.
23. Froholdt, A., Holm, I., Keller, A., Gunderson, R. B., Reikeraas, O., & Brox, J. I. (2011), No difference in long-term trunk muscle strength, cross-sectional area, and density in patients with chronic low-back pain 7 to 11 years after lumbar fusion versus cognitive intervention and exercises. The Spine Journal, 11(8), 718–725.
24. Fairbank, J., Frost, H., Wilson-MacDonald, J., Yu, L. M., Barker, K., & Collins, R. (2005). Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low-back pain: the MRC spine stabilisation trial. BMJ, 330(7502), 1233.