Has your back been bothering you for months -- or years -- and still you and your doctor haven't been able to figure out why? You're not alone. Back pain is the most common cause of job-related disability in America, according to the National Institutes of Health, and costs about $50 billion a year in treatments. Some 80% of Americans will experience back pain at some time in their lives. But most cases of back pain can't be traced to a specific, definable cause.
"It's a huge problem that we have for both conventional and alternative techniques for treating back pain," says Daniel C. Cherkin, PhD, a senior investigator at the Group Health Cooperative's Center for Health Studies (CHS) in Seattle. "With this huge category of people who have what's referred to as non-specific back pain, you can't trace it to a particular cause."
This conundrum leads many back pain sufferers to seek out "alternative" treatments -- everything from massage and acupuncture to mind-body therapies and exercise programs like yoga and tai chi. For example, studies show that back pain accounts for 20% of visits to massage therapists and 14% of visits to acupuncturists, Cherkin notes. But do any of these options work?
In many cases, the scientific jury is still out. A recent review of dozens of studies looking at massage, acupuncture, and spinal manipulation (chiropractic) as treatments for low back pain, led by Cherkin, showed some evidence pointing toward the effectiveness of massage and spinal manipulation, but less is known about acupuncture.
"The studies we reviewed found massage to be effective for relieving symptoms and increasing function among people with persistent back pain," Cherkin explains. "Spinal manipulation shows small clinical benefits for back pain -- about the same as conventional medical treatments such as over-the-counter pain relievers and various types of physical therapy."
Based on existing studies, the effectiveness of acupuncture remains unclear, but a new, large study recently launched at the Group Health Cooperative aims to answer some of those questions. To be conducted over four years, the study is recruiting nearly 700 back pain sufferers and will compare acupuncture to conventional care.
Building a Stronger Back
"The most predictable way of resolving back problems, based on the scientific literature, is by increasing strength," says Vert Mooney, MD, director of U.S. Spine and Sport in San Diego. "There's good evidence that with chronic back pain, the muscles around the spine become inhibited, and the most rational treatment is a progressive strengthening program."
Ideally, says Mooney, such a program is best done with calibrated equipment that allows the person with low back pain to gradually increase the amount of strengthening involved so that performance and progress can be measured. "With calisthenic-type exercises, it's very difficult to increase the amount of exercise that you do, so you do enough to stimulate repair but not enough to increase pain," he says.
Florida chiropractor Thomas Hyde, DC, stresses the importance of "core stability" in any exercise program designed to strengthen the back and relieve chronic pain.
"I like to use the Swiss ball, for example," he says. "In the very early stages, the person may do nothing more than sit on the ball, learning the basics of what's called 'proprioception,'" a sense of balance and joint positioning. "Then they can move on to leg lifts and other various positions on the ball, to the use of weights or tubing to do strength training exercises while on the ball. Over the course of time, the patient should see an improvement in balance and in their complaints about back disorders, and it's a relatively inexpensive approach."
Other types of exercise, such as yoga, Pilates, and tai chi, are just beginning to be studied as treatments for back pain, says the GHC's Cherkin. The preliminary results of a study of yoga for back pain done at the GHC "looks promising," he reports.
Mind and Body
Chronic back pain may not be all in the mind, but for some people, the answer to conquering it may lie there. "A number of mind-body approaches to treating low back pain have demonstrated success," says Andrew Block, PhD, clinical assistant professor of psychiatry at the University of Texas Southwest Medical Center in Dallas and director of the Well-Being Group, a spine center in Plano, Texas. "The major approaches are what we call 'self-regulation strategies': hypnosis, biofeedback, and relaxation exercises. They're designed to promote muscle relaxation and pain control, reducing the amount of energy used for keeping muscles tight and giving the patient a sense of control over their situation -- something you feel like you've lost with chronic pain."
Often, says Block, the image he uses to help a patient control pain is one of electricity. "I saw a patient today and we talked about the pain signals coming up their spine like electrical wires. When they feel pain, they'll see the wires glowing," he explains. "As they get into a relaxed, hypnotic state, they'll see the glow decrease, visualize it not flowing as intensely or rapidly, and that enables them to mute the pain."
Sometimes, it's not about getting rid of the pain but managing it through other psychological approaches. "These fall into the category of 'cognitive behavioral intervention.' You take the thoughts that go along with back pain and help the patient change the way they view their situation so that they can cope with it better," Block says. "The main thing I advise people to do is to move from seeing the pain as a condition that can be cured to a condition of living that requires them to adapt and function as best they can. It's important to use your own strength to overcome what this does to your life."
Ultimately, says the GHC's Cherkin, the choice of alternative back pain treatment is a very individual thing. "I don't think any of these approaches have been shown to be dangerous for low back pain," he says. "So it really comes down to what works for an individual patient and what's worth trying. It's clear that there's no single treatment that's effective for everybody."
Published Aug. 16, 2004.