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2010 ; ä (194
): 1-764
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Complementary and alternative therapies for back pain II
#MMPMID23126534
Furlan AD
; Yazdi F
; Tsertsvadze A
; Gross A
; Van Tulder M
; Santaguida L
; Cherkin D
; Gagnier J
; Ammendolia C
; Ansari MT
; Ostermann T
; Dryden T
; Doucette S
; Skidmore B
; Daniel R
; Tsouros S
; Weeks L
; Galipeau J
Evid Rep Technol Assess (Full Rep)
2010[Oct]; ä (194
): 1-764
PMID23126534
show ga
BACKGROUND: Back and neck pain are important health problems with serious
societal and economic implications. Conventional treatments have been shown to
have limited benefit in improving patient outcomes. Complementary and Alternative
Medicine (CAM) therapies offer additional options in the management of low back
and neck pain. Many trials evaluating CAM therapies have poor quality and
inconsistent results. OBJECTIVES: To systematically review the efficacy,
effectiveness, cost-effectiveness, and harms of acupuncture, spinal manipulation,
mobilization, and massage techniques in management of back, neck, and/or thoracic
pain. DATA SOURCES: MEDLINE, Cochrane Central, Cochrane Database of Systematic
Reviews, CINAHL, and EMBASE were searched up to 2010; unpublished literature and
reference lists of relevant articles were also searched. study selection: All
records were screened by two independent reviewers. Primary reports of
comparative efficacy, effectiveness, harms, and/or economic evaluations from
randomized controlled trials (RCTs) of the CAM therapies in adults (age ? 18
years) with back, neck, or thoracic pain were eligible. Non-randomized controlled
trials and observational studies (case-control, cohort, cross-sectional)
comparing harms were also included. Reviews, case reports, editorials,
commentaries or letters were excluded. DATA EXTRACTION: Two independent reviewers
using a predefined form extracted data on study, participants, treatments, and
outcome characteristics. RESULTS: 265 RCTs and 5 non-RCTs were included.
Acupuncture for chronic nonspecific low back pain was associated with
significantly lower pain intensity than placebo but only immediately
post-treatment (VAS: -0.59, 95 percent CI: -0.93, -0.25). However, acupuncture
was not different from placebo in post-treatment disability, pain medication
intake, or global improvement in chronic nonspecific low back pain. Acupuncture
did not differ from sham-acupuncture in reducing chronic non-specific neck pain
immediately after treatment (VAS: 0.24, 95 percent CI: -1.20, 0.73). Acupuncture
was superior to no treatment in improving pain intensity (VAS: -1.19, 95 percent
CI: 95 percent CI: -2.17, -0.21), disability (PDI), functioning (HFAQ),
well-being (SF-36), and range of mobility (extension, flexion), immediately after
the treatment. In general, trials that applied sham-acupuncture tended to produce
negative results (i.e., statistically non-significant) compared to trials that
applied other types of placebo (e.g., TENS, medication, laser). Results regarding
comparisons with other active treatments (pain medication, mobilization, laser
therapy) were less consistent Acupuncture was more cost-effective compared to
usual care or no treatment for patients with chronic back pain. For both low back
and neck pain, manipulation was significantly better than placebo or no treatment
in reducing pain immediately or short-term after the end of treatment.
Manipulation was also better than acupuncture in improving pain and function in
chronic nonspecific low back pain. Results from studies comparing manipulation to
massage, medication, or physiotherapy were inconsistent, either in favor of
manipulation or indicating no significant difference between the two treatments.
Findings of studies regarding costs of manipulation relative to other therapies
were inconsistent. Mobilization was superior to no treatment but not different
from placebo in reducing low back pain or spinal flexibility after the treatment.
Mobilization was better than physiotherapy in reducing low back pain (VAS: -0.50,
95 percent CI: -0.70, -0.30) and disability (Oswestry: -4.93, 95 percent CI:
-5.91, -3.96). In subjects with acute or subacute neck pain, mobilization
compared to placebo significantly reduced neck pain. Mobilization and placebo did
not differ in subjects with chronic neck pain. Massage was superior to placebo or
no treatment in reducing pain and disability only amongst subjects with
acute/sub-acute low back pain. Massage was also significantly better than
physical therapy in improving back pain (VAS: -2.11, 95 percent CI: -3.15, -1.07)
or disability. For subjects with neck pain, massage was better than no treatment,
placebo, or exercise in improving pain or disability, but not neck flexibility.
Some evidence indicated higher costs for massage use compared to general
practitioner care for low back pain. Reporting of harms in RCTs was poor and
inconsistent. Subjects receiving CAM therapies reported soreness or bleeding on
the site of application after acupuncture and worsening of pain after
manipulation or massage. In two case-control studies cervical manipulation was
shown to be significantly associated with vertebral artery dissection or
vertebrobasilar vascular accident. CONCLUSIONS: Evidence was of poor to moderate
grade and most of it pertained to chronic nonspecific pain, making it difficult
to draw more definitive conclusions regarding benefits and harms of CAM therapies
in subjects with acute/subacute, mixed, or unknown duration of pain. The benefit
of CAM treatments was mostly evident immediately or shortly after the end of the
treatment and then faded with time. Very few studies reported long-term outcomes.
There was insufficient data to explore subgroup effects. The trial results were
inconsistent due probably to methodological and clinical diversity, thereby
limiting the extent of quantitative synthesis and complicating interpretation of
trial results. Strong efforts are warranted to improve the conduct methodology
and reporting quality of primary studies of CAM therapies. Future well powered
head to head comparisons of CAM treatments and trials comparing CAM to widely
used active treatments that report on all clinically relevant outcomes are needed
to draw better conclusions.
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