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A Systematic Review and Meta-analysis of Efficacy, Cost-effectiveness, and Safety of Selected Complementary and Alternative Medicine for Neck and Low-back Pain

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A Systematic Review and Meta-analysis of Efficacy, Cost-effectiveness, and Safety of Selected Complementary and Alternative Medicine for Neck and Low-back Pain

The Chiro.Org Blog

SOURCE:   Evid Based Complement Alternat Med [Epub 2011 Nov 24]

Andrea D. Furlan, Fatemeh Yazdi, Alexander Tsertsvadze, * Anita Gross, Maurits Van Tulder, Lina Santaguida, Joel Gagnier, Carlo Ammendolia, Trish Dryden, Steve Doucette, Becky Skidmore, Raymond Daniel, Thomas Ostermann, and Sophia Tsouros

Clinical Epidemiology Methods Centre,
Ottawa Hospital Research Institute,
University of Ottawa Evidence-Based Practice Center,
Box 208, Ottawa, ON, Canada K1H 8L6

Background: Back pain is a common problem and a major cause of disability and health care utilization.

Purpose: To evaluate the efficacy, harms, and costs of the most common CAM treatments (acupuncture, massage, spinal manipulation, and mobilization) for neck/low-back pain.

Data Sources: Records without language restriction from various databases up to February 2010.

Data Extraction: The efficacy outcomes of interest were pain intensity and disability.

Data Synthesis: Reports of 147 randomized trials and 5 non-randomized studies were included. CAM treatments were more effective in reducing pain and disability compared to no treatment, physical therapy (exercise and/or electrotherapy) or usual care immediately or at short-term follow-up. Trials that applied sham-acupuncture tended towards statistically non-significant results. In several studies, acupuncture caused bleeding on the site of application, and manipulation and massage caused pain episodes of mild and transient nature.

Conclusions: CAM treatments were significantly more efficacious than no treatment, placebo, physical therapy, or usual care in reducing pain immediately or at short-term after treatment. CAM therapies did not significantly reduce disability compared to sham. None of the CAM treatments was shown systematically as superior to one another. More efforts are needed to improve the conduct and reporting of studies of CAM treatments.


Back pain is a general term that includes neck, thoracic, and lower-back spinal pain. In the majority of cases, the aetiology of back pain is unknown and therefore is considered as “nonspecific back pain”. Back pain is considered “specific” if its aetiology is known (e.g., radiculopathy, discogenic disease). Although back pain is usually self-limited and resolves within a few weeks, approximately 10% of the subjects develop chronic pain, which imposes large burden to the health-care system, absence from work, and lost productivity [1]. In a recent study, the direct costs of back pain related to physician services, medical devices, medications, hospital services, and diagnostic tests were estimated to be US$ 91 billion or US$ 46 per capita [2]. Indirect costs related to employment and household activities were estimated to be between US$ 7 billion and US$ 20 billion, or between US$25 and US$ 71 per capita, respectively [3–5]. One study published in 2007 showed that the 3-month prevalence of back and/or neck pain in USA was 31% (low-back pain: 34 million, neck pain: nine million, both back and neck pain: 19 million) [6].

The prevalence of back pain and the number of patients seeking care with complementary and alternative medicine (CAM) therapies in the US has increased over the last two decades [7]. The most prevalent CAM therapies for back and neck pain in the US are spinal manipulation, acupuncture, and massage [7]. The exact mechanisms of action of CAM therapies remain unclear. Recently, many randomized controlled trials (RCTs) have been conducted to study the effects of CAM therapies for back pain. The results of many systematic reviews [8–12], meta-analyses [13], and clinical practice guidelines [14–17] regarding the effectiveness of CAM therapies for back pain relative to no treatment, placebo, or other active treatment(s) in reducing pain and disability have been inconsistent.

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About the Author:

I was introduced to Chiro.Org in early 1996, where my friend Joe Garolis helped me learn HTML, the "mark-up language" for websites. We have been fortunate that journals like JMPT have given us permission to reproduce some early important articles in Full-Text format. Maintaining the Org website has been and remains my favorite hobby.


  1. Chriatopher Lauria January 3, 2012 at 9:18 am

    One positive thing I see in this study is that some treatment is better than none. So many people hear that bed rest is what to do. Finding out the cause of the problem and treating it is the right way.

  2. karl January 4, 2012 at 4:59 pm

    Just asking………..if a physical therapist performs osseous/spinal manipulation is that treatment/therapy considered “alternative” and/or “complimentary”. I haven’t decided if being alternative is a good thing vs. being an option…….period. I try not to sweat the small stuff but I’m just asking.

    • Frank M. Painter, D.C. January 4, 2012 at 5:49 pm

      Hi Karl

      I don’t know what percentage of PTs provide spinal manipulation. Several States have legislated against PTs providing osseous manipulation.

      When you look at the “usual” medical treatment…pain meds, muscle relaxers…manipulation is an alternative to that approach.

      Is it complementary? Complementary to what? I believe that term was designed strictly to make any alternative treatment appear as if it was an appendage of medicine. Nothing could be further from the truth.

      I feel that it is dishonest to pretend that chiropractic care is a complement to usual medical care. In reality, it’s frequently the only alternative to failed medical treatment. And, as we all know, chiropractic thrived in spite of decades of viscous attacks by organized medicine.

      OTOH, PT is definitely an appendage of medicine. PT is also complementary to medicine…it is certainly not an alternative. If PT and drugs fail, they should look for an alternative that has a track record…like chiropractic care.

  3. karl January 4, 2012 at 10:40 pm

    Maybe this is a agree to disagree type thing. I believe chiropractic care is becoming an option. Of course this could be linguistics/semantics. Manipulation is a growing trend in physical therapy and osteopathes are taking notic also. I recently read an opinion in the osteopath journal by a military osteopath bringing up the need for more osteopaths to perform manipulation. I guess what I’m saying in the health care world of integration I believe it’s going to called an option. I think its better linguistics than alternative especially for certain demographics. If a patient goes to a M.D. for NMS condition I want that person to be told their options of one being chiropractic care. Now many medical settings have chiropractors in house this is an example of a integrative option. Just sayin.

    • Frank M. Painter, D.C. January 5, 2012 at 1:07 pm

      Hi Karl

      I agree that SMT is a more popular “option” than ever before.

      I only mention this distinction (alternative vs. conventional) so that we don’t forget that chiropractic is a true alternative when medical approaches fail…and even before that.

      The term “separate and equal” comes to mind. No shame in that, and no controversy either.

      The truth is…medical doctors should love us, because we can help their patients recover. If they refer, and the patient gets better, the MD is a hero to the patient. What’s not to love about that?

  4. […] article shows that, “CAM treatments were significantly more efficacious than no treatment, placebo, […]

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