Related Terms

• Acute, ankylosing spondylitis, atrophy, cerebrospinal fluid, cervical disc disease, cervical disc herniation, chronic, computerized tomography, contrast dye, CT, discitits, disectomy, electromyogram, EMG, fusion, herniated disc, herniation, IDET, intervertebral disc, intradiscal electrothermal therapy, joints, lamina, laminectomy, laminotomy, ligaments, magnetic resonance imaging, meninges, MRI, muscle, myelography, myofacial, nervous tissue, osteoarthritis, osteomyelitis, osteoporosis, peripheral, radioactive tracer, rheumatoid arthritis, sciatica, scoliosis, shoulder pain, slipped disc, spinal column, spinal stenosis, spinal tap, spine problems, spondylolisthesis, spine, sprains, tendons, tissues, vertebrae, vertebral, whiplash.

Background

• Back and neck pain are the most common chronic pain conditions. Back and neck pain can arise from soft tissues, bony parts of the back and neck, and joints holding the spine in alignment. It can arise directly or indirectly from the discs in the back or neck, and it can occur when nerves and nervous tissue, normally protected by the bones of the spine, are compressed by those bones.

• Back pain can range from a dull, constant ache to a sudden, sharp pain that leaves the individual suffering and/or incapacitated. Back pain can be acute (immediate) or chronic (long-term). Acute back pain usually gets better on its own without treatment. However, chronic back pain may require medication and/or surgery.

• The back is an intricate structure of bones, ligaments, muscles, nerves, and tendons. The spine, or backbone, is made up of 33 bony segments called vertebrae. The vertebrae are arranged in a long vertical column and held together by ligaments that are attached to muscles by tendons. Between each vertebra lies a gel-like cushion called an intervertebral disc, consisting of a semi-fluid matter that is surrounded by a capsule of elastic fibers.

• The spinal cord is an extension of the brain that runs through a long, hollow canal in the column of the vertebrae. The meninges (membranes that surround the brain and spinal cord), cerebrospinal fluid (fluid that circulates around the brain and spinal cord), fat, and a network of veins and arteries nourish and protect the spinal cord.

• Thirty-one pairs of nerve roots emerge from the spinal cord through spaces in each vertebra. The spinal cord and peripheral (outside the brain and spinal column) nerves perform essential sensory and motor activities of the body. The peripheral nervous system conveys sensory information from the body to the brain and conveys motor signals from the brain to the body.

• Back problems are the most frequent cause of activity limitations in working-age adults. The American Academy of Family Physicians estimates that about 85% of Americans experience back pain by age 50. More than 26 million Americans between the ages of 20-64 experience frequent back pain. Two-thirds of American adults will have back pain during their lifetime. Back pain is the leading cause of disability in Americans under 45 years old.

• Each year 13 million people go to the doctor for chronic back pain. It is estimated that the condition leaves 2.4 million Americans chronically disabled and another 2.4 million temporarily disabled. Back pain is the second most common reason why individuals in the United States seek medical care from their primary care physicians.

Risk Factors

• Age:The first attack of low back pain typically occurs between the ages of 30-40. Back pain becomes more common with age. Aging produces wear and tear on the spine that may result in conditions (such as disc degeneration or spinal stenosis) that produce neck and back pain. Having a previous back injury puts the individual at risk for another injury and increased pain.

• Diet:A diet high in calories and fat, especially trans-fats found in fried foods, combined with an inactive lifestyle, can lead to obesity. Obesity has been found to be a major risk factor in the development of back pain due to increased stress on the back.

• Heredity: Some causes of back pain, including disc disease, may be genetic or passed from one generation to the next through genes. More research is being performed in the area of back pain and heredity.

• Race: Race can be a factor in back problems. African American women, for example, are two to three times more likely than white women to develop spondylolisthesis, a condition in which a vertebra of the lower spine (lumbar spine) slips out of place.

• Occupation: Physically demanding occupations, such as construction work and healthcare, which require repetitive bending and lifting, have a high incidence of back injury. Jobs that require long hours of standing without a break (such as hairdressing and fast food service) or sitting in a chair that does not support the back well (computer keyboard operation or writing) also put a person at risk for neck and lower back injury.

• Lifestyle: Back pain is more common among people who are not physically fit. Weak back and abdominal muscles may not properly support the spine. Clinical studies report that low-impact aerobic exercise is good for the discs that cushion the vertebrae.

• Although smoking tobacco may not directly cause back pain, it increases the risk of developing low back pain and low back pain with sciatica. Sciatica is back pain that radiates to the hip and/or leg due to pressure on a nerve. Smoking has been reported to negatively affect bone mineral density, lumbar disk disease, the rate of hip fractures, and the rate and extent of bone and wound healing.

• Poor posture, such as slouching in a chair, driving hunched over, standing incorrectly, and using poor body mechanics when lifting and carrying heavy loads, are risk factors. Sleeping on a soft or sagging mattress also can lead to back pain.

• Sports that involve twisting the back, such as golf and basketball, can result in back injury and they also worsen existing lower back pain.

Causes

• Movement problems: A movement or mechanical problem is a problem with the way the spine moves or the way an individual feels when they move the spine in certain ways. Perhaps the most common mechanical cause of back pain is intervertebral disc degeneration. In this condition, the discs located between the vertebrae of the spine break down with age. As the vertebrae deteriorate, they lose their cushioning ability. This problem can lead to pain if the back is stressed. Other mechanical causes of back pain include spasms, muscle tension, and ruptured or herniated discs.

• Injuries: Spinal injuries, such as sprains and fractures, can cause either acute (short-lived) or chronic (long-term) pain. Sprains or tears in the ligaments that support the spine can occur from twisting or lifting improperly. Fractured vertebrae are often the result of osteoporosis, a condition that causes weak, porous bones. Less commonly, back pain may be caused by more severe injuries that result from accidents and falls.

• Whiplash is a non-medical term used to describe neck pain following an injury to the soft tissues of the neck, specifically ligaments, tendons, and muscles. Whiplash is caused by an accidental motion or force applied to the neck that results in movement beyond the neck's normal range of motion. Whiplash occurs in motor vehicle accidents, sporting activities, accidental falls, and assault.

• Conditions and diseases: Many diseases can cause or contribute to back pain. These include various forms of arthritis, such as herniated disk (occurs when disk material presses on a nerve), osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis, and cancers from elsewhere in the body that may spread to the spine. Scoliosis, which causes curvature of the spine, does not usually cause pain until mid-life. Spinal stenosis, or a narrowing of the spinal column that puts pressure on the spinal cord and nerves, also contributes to back pain. While osteoporosis itself is not painful, it can lead to painful fractures of the vertebrae. Other causes of back pain include pregnancy, kidney stones or infections, endometriosis (the buildup of uterine tissue in places outside the uterus), and fibromyalgia (which causes fatigue and widespread muscle pain).

• Infections and tumors: Although they are not common causes of back pain, infections can cause pain when they involve the vertebrae. Osteomyelitis is an infection (typically caused by bacteria) of bone and bone marrow in which the resulting inflammation can lead to a reduction of blood supply to the bone. Discitis is when the infection involves the discs that cushion the vertebrae. Tumors are relatively rare causes of back pain. Occasionally, tumors begin in the back, but more often they appear in the back as a result of cancer that has spread from elsewhere in the body.

• Emotional stress: Although the causes of back pain are usually physical, emotional stress may also play an important role in back pain and how severe and long it lasts. For example, stress may cause back muscles to become tense and painful.

Signs and Symptoms

• Pain: Pain can be constant or intermittent (off and on). Intensity can vary from a dull ache to searing agony. The onset may be sudden or acute (short-term), with or without apparent reason, or gradual and chronic (long-term).

• Most back pain resolves in a few days or weeks with or without treatment. However, some individuals have chronic pain that lasts months or years.

• Severe pain lasting more than a few days without improvement may require medical attention. Individuals having difficulty passing urine; numbness in the back or genital area; numbness, pins and needles, or weakness in the legs; shooting pain down the leg; or unsteadiness when standing should see a doctor immediately.

• Pain is often described as aching, tight, stiff, sore, burning, throbbing, or pulling. The pain may worsen while bending, sitting, walking, or standing too long in one position. It may also be more prevalent at different times of the day, such as when a person wakes up in the morning.

• Pinched nerves produce numbness or tingling, warm or cold sensations, and burning or stabbing pain that begin in the back and radiate down the leg or the arm. Activities such as coughing, sneezing, or walking may increase pressure on the pinched nerve and aggravate the pain.

• Compressed nerves may cause numbness and weakness in the muscle associated with the nerve. The muscle may atrophy (waste away) if the compression is not relieved.

Diagnosis

• Examination: Diagnosing the underlying cause of neck and back pain can be difficult. A medical history that includes age, weight, current and past medical problems, medications, and height is taken. Also, a complete physical examination, which may include a neurological exam, is performed.

• X-ray: X-rays show the alignment of the spine and may reveal degenerative joint diseases, fractures, or tumors.

• Magnetic resonance imaging: Magnetic resonance imaging (MRI) scans provide clear images of disc deterioration, pathologies of the spinal cord, spinal stenosis, herniated discs, spinal tumors, and abnormalities in nerves and ligaments. MRIs are conducted in a small, confined areas and some individuals may find this uncomfortable. Some individuals may have to be sedated using a mild sedative such as alprazolam (Xanax®) or lorazepam (Ativan®). If the individual is sedated, transportation should be organized with a family member or friend to take and return home the individual, due to drowsiness and decreased coordination.

• Computerized tomography: Computerized tomography (CT) scan is an X-ray that uses computer technology and can be enhanced with the injection of a contrast dye. CT scans are used to show abnormalities in bones and soft tissue. CT scans can be used for individuals who are unable to tolerate MRIs.

• Myelography: Myelography is used to examine the spinal canal and cord. Contrast dye is injected into the cerebrospinal fluid in the spine. This allows the doctor to outline the spinal cord and nerve roots, and abnormal disc conditions or bone spurs can then be visualized using an X-ray or CT scan.

• Electromyogram: Electromyogram, or EMG, is the use of tiny electrodes inserted into muscle tissue to test for abnormal electrical signals. Abnormal electrical signals may indicate that a nerve root is pinched or irritated at the spine. An anesthetic, such as lidocaine or Xylocaine®, is used to reduce the pain of electrode insertion into the skin.

• Spinal tap: Spinal tap involves drawing a sample of cerebrospinal fluid and analyzing it for elevated pressure, infection, bleeding, or tumor. Spinal tap may be painful and may require sedation.

• Radioactive bone scan: Radioactive bone scans locate problems (such as a fracture or osteoporosis) in the vertebrae. A chemical called a radioactive tracer is injected into the patient and after several hours, a gamma camera picture will reveal bone undergoing rapid changes where large amounts of tracer accumulate.

Complications

• Complications of back pain include: limited mobility, such as trouble walking up stairs, standing, or sitting; pain; lost work time; surgery; and disability.

Treatment

• In many cases, it is not necessary to see a doctor for back pain because pain usually goes away without treatment. However, an individual should see a doctor if they experience numbness or tingling, severe pain, or pain that does not improve with medication and rest. Also, individuals should see a doctor if they have pain after a fall or an injury. It is also important to see a doctor if pain occurs along with any of the following problems: trouble urinating; weakness, pain, or numbness in the legs; fever; or unintentional weight loss. Such symptoms could signal a serious medical condition that requires treatment.

• Applying ice as soon as possible during the 48 hours after straining a muscle can reduce pain. Ice slows inflammation and swelling, numbs soft tissue, and slows nerve impulses in the injured area. After spasms and acute pain subside, heat can be applied to loosen tight muscles. Over-the-counter (OTC) pain-relieving medications, such as acetaminophen (Tylenol®), ibuprofen (Advil®), or naproxen (Aleve®), may be used for short-term (less than two weeks). Two or three days of bed rest followed by a gradual return to normal activity is sometimes recommended.

• Physical therapy and exercise: A physical therapist may apply a variety of treatments (such as heat, ice, ultrasound, electrical stimulation, and muscle release techniques) to the back muscles and soft tissues to reduce pain. As pain improves, the physical therapist can teach the individual specific exercises to increase flexibility, strengthen the back and abdominal muscles, and improve posture. Regular use of these techniques may help prevent pain from coming back. Exercise can correct current back problems, help prevent new ones, and relieve back pain, particularly after an injury. Exercise also strengthens bones and reduces the risk of falls and injuries.

• Prescription medications: A doctor may prescribe non-steroidal anti-inflammatory drugs (such as flurbiprofen or Ansaid® and celexocib or Celebrex®), muscle relaxants (such as cyclobenzaprine or Flexeril®), and narcotic pain relievers (such as hydrocodone or Lortab®). A skin patch containing an opioid called transdermal fentanyl (Duragesic®) may relieve chronic back pain more effectively than oral opioid drugs. Muscle relaxants, opiate agonists, and narcotic pain relievers may cause drowsiness. Narcotic pain relievers may also cause physical dependence and should be used with caution. Corticosteroid injections (steroids, such as dexamethasone or Decadron®) may be used if pain-relieving and anti-inflammatory medications do not offer relief. The long-term use of steroid medications can cause complications such as weakened immune systems and swelling.

• Tricyclic antidepressants, such as amitriptyline (Elavil®) and nortriptyline (Pamelor®), may be used for numbness, burning, aching, throbbing, or stabbing pains that shoot down the limbs. Side effects of these drugs include drowsiness, dry mouth, blurred vision, and constipation.

• Surgery: Few individuals need surgery for back pain. Surgery is usually reserved for pain caused by a herniated disk. If the individual is experiencing unrelenting pain that is unable to be relieved by medications or progressive muscle weakness caused by nerve compression, surgery may be beneficial.

• Disc removal: There are three common types of surgeries that involve the removal of damaged or herniated discs in the spine, including laminotomy, laminectomy, and disectomy. A laminotomy is the surgical removal of part of the lamina (bony arch) above and below an affected nerve. A laminectomy consists of the surgical removal of most of the lamina of a vertebra. A laminectomy is most often performed when back pain fails to improve with more conservative medical treatments such as pain medications and physical therapy. A discectomy is the surgical removal or partial removal of a spinal disk.

• Fusion surgery: Fusion surgery involves joining two vertebrae to eliminate painful movement. Recovery following fusion surgery generally takes longer compared to other types of spinal surgery. Patients typically stay in the hospital for three or four days, but a longer stay after more extensive surgery is not uncommon. A short stay in a rehabilitation unit after release from the hospital is often recommended for patients who have had extensive surgery, or for elderly or debilitated patients. Pain from surgery varies.

• Intradiscal electrothermal therapy (IDET): In intradiscal electrothermal therapy (IDET), doctors insert a needle through a catheter into the damaged spinal disk. The needle is heated to a high temperature for up to 20 minutes. The heat thickens and seals the disk wall, reducing disk bulge and the related spinal nerve irritation. It is unclear whether this treatment is effective for back pain.

• Implanted pumps: Pumps may be implanted into the spinal area to deliver a constant flow of pain-relieving medications (such as opiates like morphine). Surgically implanted spinal cord stimulators modulate the pain response so that the individual with a back condition experiences less pain. The implantation may put the individual at an increased risk for infection.

Integrative Therapies

• Good scientific evidence:

• Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. The broad term "spinal manipulative therapy" incorporates all types of manual techniques, including chiropractic. There are more than 150 published human trials and case reports that detail the use of chiropractic manipulation in patients with low back pain (subacute or chronic). Results are variable, with some studies reporting benefits, and others suggesting no significant effects. Most trials are not well designed or reported, with inconsistent use of definitions of disease, techniques, and measured outcomes. Despite these problems with existing research, the available scientific evidence overall suggests some improvement in pain symptoms. Better research is necessary before a definitive conclusion can be reached.

• Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders or migraines. Use cautiously with the risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.

• Devil's claw: Devil's claw (Harpagophytum procumbens) has traditionally been used as an anti-inflammatory and pain reliever for joint diseases, back pain, and headache. There are several human studies that support the use of devil's claw for the treatment of low back pain. However, most studies have been small with flaws in their designs, and many have been done by the same authors. Therefore, although these results can be considered promising early evidence, additional well-designed trials are necessary before a firm conclusion can be reached. It is not clear how devil's claw compares to other therapies for back pain.

• Avoid if allergic to devil's claw and to plants in the Harpagophytum procumbens family. Use caution with stomach ulcers or with a history of bleeding disorders, diabetes, gallstones, gout, heart disease, stroke, ulcers or with prescription drugs used for these conditions. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

• Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. Several small controlled clinical trials report that regular use of hot whirlpool baths with massaging jets decreases the duration and severity of low back pain when added to standard therapy, compared to standard therapy alone. It is not clear if there is a reduced need for pain control drugs, or if benefits are long-standing. Because these studies are small with flaws in design and reporting, better quality research is necessary before a strong conclusion can be drawn.

• Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.

• Physical therapy: There is emerging evidence that physical therapy may be beneficial for reducing the time to heal following whiplash injury. Studies have found benefit of physical therapy and active exercises over standard of care. According to limited available study, manipulative treatment may shorten recovery time faster than physiotherapy treatment. Higher-quality trials with control groups would help make a stronger recommendation.

• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

• Willow bark: White willow (Salix alba) bark has been compared to conventional treatments for low back pain, such as cyclooxygenase-2 inhibitors (COX-2). Many of the studies found willow bark to be as effective or superior to other methods. Cost effectiveness studies have also been performed between white willow bark and conventional treatment; they found that willow bark was more cost effective. Additional study in humans is needed.

• Avoid if allergic/hypersensitive to aspirin, willow bark (Salix spp.), or any of its constituents, including salicylates. Use cautiously with gastrointestinal problems, such as ulcers, hepatic disorders, diabetes, gout, hypertension, hyperlipidemia, history of allergy or asthma, and leukemia. Use cautiously if taking protein-bound medications, antihyperlipidemia agents, alcohol, leukemia medications, beta-blockers, diuretics, Phenytoin (Dilantin®), probenecid, spironolactone, sulfonylureas, valproic acid, or methotrexate. Use cautiously if pre-disposed to headaches. Use cautiously in patients taking other tannin-containing herbs or supplements. Avoid operating heavy machinery. Avoid in children with chickenpox and any other viral infections. Avoid with blood disorders and renal disorders. Avoid if taking other NSAIDs, acetazolamide or other carbonic anhydrase inhibitors. Avoid with elevated serum cadmium levels. Avoid if pregnant or breastfeeding.

• Unclear or conflicting scientific evidence:

• Acupressure, Shiatsu: The practice of applying finger pressure to specific acupoints (energy points) throughout the body has been used in China since 2000 B.C. Shiatsu technique can incorporate palm pressure, stretching, massaging, and other manual techniques. Shiatsu practitioners commonly treat musculoskeletal and psychological conditions, including neck/shoulder and lower back problems, arthritis, depression, and anxiety. Limited clinical study reported that acupressure was effective in reducing low back pain in terms of disability, pain scores, and functional status. The benefit was sustained for six months. More research is needed.

• With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. No serious long-term complications have been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

• Acupuncture: Evidence is inconsistent regarding the effects of acupuncture in back pain. Research on acupuncture for neck pain and cervical myofascial pain also shows mixed results. Early study does not show that laser acupuncture is any more effective than sham laser acupuncture when used in combination with drugs and other mobilization therapies. Further human research is needed.

• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

• Alexander technique: The Alexander technique is an educational program that teaches movement patterns and postures with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being. There is limited evidence on the use of Alexander technique for back pain, and no firm conclusion can be drawn at this time.

• No serious side effects have been reported. It has been suggested that the Alexander technique may be less effective with learning disabilities or mental illnesses. This technique has been used safely in pregnant women.

• Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. The broad term "spinal manipulative therapy" incorporates all types of manual techniques, including chiropractic. Multiple studies have examined the effects of spinal manipulation in patients with lumbar disc herniation, acute or chronic neck pain, whiplash injuries, and cervical disc herniation. Results are variable, with some studies reporting benefits, and others finding no effects. Various techniques, measurement systems, and study designs have been used, and overall the quality of studies has been poor. Better quality research is necessary before a firm conclusion can be drawn.

• Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders or migraines. Use cautiously with a risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.

• Feldenkrais Method®: The Feldenkrais technique involves stretching, reaching, and changing posture in specific patterns. Limited research suggests that Feldenkrais sessions may be helpful when added to other therapies for low back pain and may have mild benefits when used alone. Limited evidence suggests that Feldenkrais may reduce neck and shoulder pain, although additional research is necessary before a firm conclusion can be drawn. There is currently a lack of available scientific studies or reports of safety of the Feldenkrais Method®.

• Healing touch: One poor quality, clinical study using 20 participants with chronic low back pain suggested that healing touch may significantly decrease pain, improve range of motion, and improve orthopedic measurements. More research needs to be performed before a conclusion can be drawn. Healing touch (HT) should not be regarded as a substitute for established medical treatments. Use cautiously if pregnant or breastfeeding.

• Lavender: Early research suggests that the impression of pain intensity and unpleasantness may be reduced after treatment with lavender therapy. Other research has shown that lavender aromatherapy may be effective when used with acupressure for short-term relief of low back pain. Early human studies indicate a potential role for lavender aromatherapy in combination with massage in the short-term treatment of neck pain. More studies are needed. Avoid if allergic or hypersensitive to lavender. Avoid with history of seizures, bleeding disorders, eating disorders (anorexia, bulimia) or anemia (low levels of iron). Avoid if pregnant or breastfeeding.

• Magnet therapy: Pulsed electromagnetic therapy and magnetic "necklaces" have been used and studied in people with chronic neck pain. Research is limited and not well designed. Better studies are necessary before a firm conclusion can be drawn. Avoid with implantable medical devices like heart pacemakers, defibrillators, insulin pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole treatment for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss magnet therapy with a qualified healthcare provider before starting treatment.

• Massage: Several human trials report temporary improvements in low back pain with various massage methods. A clinical study reported slightly more efficacy for traditional therapy such as pain medications and surgery. However, the additional benefits of massage may contribute to its value for holistic nursing practice. Further research is necessary. Massage limited to local areas of the body rather than full body massage may be beneficial in neck or shoulder pain. It remains unclear whether massage itself is effective, and if so, if it is more effective than acupuncture.

• Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.

• Meditation: Various forms of meditation have been practiced for thousands of years throughout the world, with many techniques originating in Eastern religious practices. Based on preliminary research, patients suffering from chronic low back pain may improve with breath therapy. Further clinical research is needed to confirm these results. Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.

• Physical therapy: Despite the large amount of research conducted on physical therapy cost-effectiveness and treatments for back pain (including chronic and acute low back pain, pregnancy-related back pain, work-related back pain), neck and shoulder pain, and spine problems, there is a lack of conclusive evidence that physical therapy is more effective than other treatments or placebo. There is also not enough available evidence about physical therapy's benefits for sciatica. Additional study is needed to make a conclusion.

• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

• Reflexology: A large trial comparing reflexology to relaxation or no therapy reports that reflexology is not effective for managing chronic lower back pain. Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.

• Rolfing® Structural Integration: Rolfing® Structural Integration involves deep tissue massage aimed at relieving stress and improving mobility, posture, balance, muscle function and efficiency, energy, and overall well being. Rolfing® may improve pelvic tilt in healthy patients, suggesting that patients with other low back disorders may benefit from Rolfing®. More studies are needed to show that Rolfing® Structural Integration can effectively treat chronic lower back pain and other back disorders.

• Rolfing® Structural Integration should not be used as the sole therapeutic approach to disease, and it should not delay the time it takes to speak with a healthcare provider about a potentially severe condition. Rolfing® Structural Integration is generally believed to be safe in most people. Avoid in patients taking blood thinners and in patients with broken bones, severe osteoporosis, disease of the spine or vertebral disks, skin damage or wounds, bleeding disorders, blood clots, tooth abscesses, acute disc problems, aneurysm, fever, recent scar tissue, connective tissue disease, cancer, and in patients who have just received cortisone shots or who are on chronic cortisone therapy. Use cautiously in patients with varicose veins or phlebitis, joint diseases, psychosis or bipolar disorder, severe kidney, liver, or intestinal disease, diabetes, menstruation, infectious conditions, colostomies, high blood pressure, and stenoses or strictures.

• Spiritual healing: Spiritual healing may improve flexibility and pain in patients with neck stiffness and other spine problems. Spiritual healing should not be used as the only treatment approach for medical or psychiatric conditions, and should not delay the time it takes to consider more proven therapies.

• TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. The effects of TENS or acupuncture-like TENS on low back pain remain controversial, and multiple controlled trials have been published in this area. There is also not enough reliable evidence to draw a firm conclusion in the area of neck and shoulder pain. Studies have not been consistent in the type of TENS techniques used (location, intensity, frequency, duration) or in definitions of back pain, and most trials have not been well designed or reported. Published meta-analyses have grouped some of these studies together to try to determine whether this technique is effective, but have also yielded inconsistent results, with some authors reporting overall benefits, and others finding no clear advantage over placebo. Better-designed research is needed before a firm conclusion can be reached.

• Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.

• Traditional Chinese medicine: Traditional Chinese medicine (TCM) herbs may augment conventional Western medicine for better outcomes in lower back pain and injury. Additional study is needed before a recommendation can be made. Chinese herbs can be potent and may interact with other herbs, foods or drugs. Consult a qualified healthcare professional before taking. There have been reports of manufactured or processed Chinese herbal products being tainted with toxins or heavy metal or not containing the listed ingredients. Herbal products should be purchased from reliable sources. Avoid ma huang, which is the active ingredient in ephedra. Avoid ginseng if pregnant or breastfeeding.

• Trigger point therapy: Trigger points are discrete, focal, hyperirritable spots located in skeletal muscle. The spots may be painful on compression and associated with pain and tenderness, motor dysfunction, and autonomic nervous system phenomena. The goal of trigger point therapy for back pain, including low back pain, is to eliminate the trigger points, and thus lessen the pain. There have been few studies that addressed the therapeutic potential of this therapy. Overall, the evidence is positive and demonstrates that this therapy might be effective for the treatment of back pain. However, because back pain may be insidious and brought on by unrecognized causes, future studies should address trigger point therapy in various causes of back pain.

• Use cautiously with local or systemic infection, anticoagulation or bleeding disorders, or acute muscle trauma. Avoid aspirin ingestion within three days of injection. Avoid with extreme fear of needles, large bruises, phlebitis, varicose veins, undiagnosed lumps, or open wounds. Avoid if allergic to anesthetic agents (mainly caused by aminoester agents). Use cautiously during pregnancy.

• Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian (Hindu) philosophy. Preliminary research reports that yoga may improve chronic low back pain in humans. However, larger, better-designed studies are needed before a firm conclusion can be drawn.

• Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

• Fair negative scientific evidence:

• Acupuncture: Early study does not show that laser acupuncture is any more effective than sham laser acupuncture when used as an adjunct with drugs and other mobilization therapies for whiplash. More study is needed in this area.

• Magnet therapy: The use of permanent or harnessed bipolar magnets in the treatment of chronic low back pain is controversial. Early evidence with stronger magnets (up to 2000 gauss strength) reported benefits, while more recent study with lower strength magnets (450 gauss strength) noted no effects. Additional research is necessary in this area before a firm conclusion can be drawn.

• Phenylalanine: D-phenylalanine has not been shown to enhance acupuncture's effect on low back pain. For D-phenylalanine as an adjunct to acupuncture for low back pain, the therapeutic rationale was the hypothetical possibility that D-phenylalanine may enhance, or prolong the duration of, the action of endorphins. Future clinical studies should include samples of an adequate size in order to reach a conclusion in this area.

Prevention

• Proper body mechanics: Many options exist for individuals wishing to prevent back and neck pain. Learning proper body mechanics, such as bending, lifting, and twisting, is particularly important if the individual's occupation involves repetitive bending, lifting, and twisting, as is the case with athletes and construction workers.

• Exercise: Regular exercise helps to keep back muscles strong and flexible. Regular low-impact aerobic activities do not strain or jolt the back and neck. Low-impact aerobic exercises may also increase strength and endurance in the back and allow the muscles to function better. Walking and swimming are also recommended by health professional. Abdominal and back muscle exercises, also called core-strengthening exercises, help condition back muscles so that they function more efficiently and help protect the back from injury. Flexibility in the hips and upper legs aligns the pelvic bones to improve back comfort. A healthcare professional can help the individual choose the best exercise program.

• Posture: Maintaining good posture, such as sitting straight in a chair and not slumping, can prevent and decrease back pain. Individuals with jobs that require long standing or sitting should take frequent breaks from standing or sitting positions to help prevent back pain.

• Weight control: Maintaining weight within an ideal range for the individual's body size is very important. Excess weight has been directly linked with the development and worsening of back pain.

• Diet: Eating a healthy diet is important to prevent back pain. A healthy diet, including fresh fruits and vegetables, provides the body with essential nutrients for health.

• Quitting smoking: Smokers have diminished oxygen levels in their spinal tissues that can hinder the healing process. Clinical studies have found mixed results on whether cigarette smoking leads to back conditions, but there is evidence that smoking may increase the risk of developing sciatica or back pain that radiates to the hip and/or leg due to pressure on a nerve.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

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2. American Association of Neurological Surgeons. www.aans.org.

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8. The Movement Disorder Society. www.movementdisorders.org.

9. National Institute of Neurological Disorders and Stroke. www.ninds.nih.gov.

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11. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.

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