Massage

One of the most common nonpharmacologic treatments for low back pain is massage. It is often the first treatment that patients seek out and is considered a passive treatment. Among those previously using CAM, massage was rated the most helpful for their current low back pain. There is a large spectrum on which specific techniques can be considered massage. The range of massage techniques can be grouped in various ways. One such grouping categorizes types of massage by the goal of treatment ( Table 1 ). Common massage styles and techniques include Swedish massage; cross-fiber and frictional massage; myofascial techniques, including myofascial release; and neuromuscular techniques. The list of neuromuscular techniques included trigger point therapy, muscle energy, positional release, proprioceptive neuromuscular facilitation, lymphatic, and craniosacral techniques. These techniques are employed by massage therapists but also frequently used by other manual practitioners, including osteopaths, chiropractors and physical therapists. When evaluating effectiveness of massage, it has been shown that, when compared with a relatively inexperienced masseuse, a licensed massage therapist or an experienced trained massage therapist had better outcomes. These studies, however, have not evaluated massage techniques employed by other practitioners of manual medicine.

Theories on the pathophysiology of massage are centered primarily on the effects at the central nervous system (CNS), the peripheral nervous system, or the local muscle and tissues. At the level of the CNS, the effects of massage might be explained by using Melzack and Wall gate control theory. It could be postulated that massage stimulates the large diameter afferent nerve fibers, which along with the small diameter pain transmitting nerve fibers, synapse at the dorsal horn of the spinal cord. If the afferent input from the large fibers is greater than the afferent pain input from the small fibers, then inhibition of T cells occurs and the gate closes so that pain transmission does not occur. It also has been postulated that massage might stimulate the parasympathetic nervous system while decreasing the response of the sympathetic nervous system. Craniosacral techniques in particular are thought to assert their influence on the autonomic system.

Peripheral influence of massage has been thought to occur at the tissue level or through vasculature. Massage can be used to treat trigger points in muscles, decrease muscle tension, or loosen fibrous adhesions in fascia. Massage is also thought to decrease vascular congestion in peripheral tissues and improve lymphatic drainage.

The current best synthesis of evidence of the effectiveness of massage comes from a Cochrane systematic review in 2009 of 13 randomized trials. Researchers concluded that massage is beneficial for patients with subacute and chronic nonspecific low back pain for improving symptoms and function. The benefits of massage were increased when combined with exercises and education. When different techniques were compared, it appeared that Thai and Swedish massage were equally effective, but acupressure massage was more effective than Swedish massage. The notable comparison studies involved a comparison with exercise and acupuncture. Comparing massage with exercise for pain reduction, short-term results were favored massage, but long-term results were similar. Massage was found to be superior to acupuncture for short-term function as well as long-term pain reduction and improved function.

There is no current recommendation on which types of patients would benefit most from massage compared with other treatments. It is also not clear which type of massage is most efficacious. Although acupressure massage seems to be better than Swedish massage, relaxation massage has yet to be well studied. Cherkin and colleagues are undertaking a trial to determine which patient characteristics would prompt a clinician to consider massage as a treatment for low back pain. They are also comparing Swedish massage with relaxation massage and usual medical care. What is clear is that massage is most efficacious when it is combined with an active exercise treatment.

Manual Spine Treatment

The origins of spinal manipulation trace back to the Chinese in 2500 bc . In the United States, the emergence of manual spine techniques occurred in late 19th century, when chiropractic medicine and osteopathic medicine were born. Founders Andrew Taylor Still and David Palmer, of osteopathy and chiropractic medicine, respectively, felt that they could influence the body’s mechanisms with manipulation of joints. Osteopathy is now practiced in 47 countries, and chiropractors currently perform most spine manipulation techniques in the United States. Practitioners of manual therapy use techniques that range from active techniques, like muscle energy, to passive techniques, like spinal manipulation. In fact, some of the techniques described in the massage section of this article, like craniosacral manipulation and myofascial release, are used frequently by osteopaths and chiropractors. When sorting through the literature, it becomes difficult to ascertain the effectiveness of the various manual techniques because of the diversity of study populations and of the practitioners.

The techniques that are the staple of manual practitioners of low back pain are spinal manipulation and mobilization. Spinal manipulation in the literature is also called adjustment and is often synonymous with a high-velocity, low-amplitude technique (HVLA). This technique involves applying a thrusting force to distract the zygapophyseal joints slightly beyond their passive range of motion. Mobilization, however, involves the application of force to the joints within the physiologic range. This is usually achieved by applying cyclical force. These techniques have been studied in patients with acute, subacute, and chronic low back pain. Furthermore, there is literature applying these techniques to patients with various etiologies of low back pain.

Most of the evidence for the effectiveness of spinal manipulation comes from chiropractic literature. Both practitioners of spinal manipulation and referring physicians should be aware of are the red and yellow flags that accompany this form of manual therapy. Commonly cited red flags, as described by the Agency for Healthcare Research and Quality (AHCPR) guidelines, include fever, unrelenting night pain or pain at rest, pain with below-knee numbness or weakness, leg weakness, loss of bowel or bladder control, progressive neurologic deficit, direct trauma, unexplained weight loss, and a history of cancer. Severe spinal stenosis and vertebral artery disease generally are considered contraindications to HVLA-type manipulation. In a review by Bronfort and colleagues, the authors stated that manipulation might not be the best choice for patients who cannot increase activity/workplace duties, are physically deconditioned, and have psychosocial barriers to recovery, or yellow flags. In a recent prospective multicenter study, however, psychological factors were not found to be relevant in predicting treatment outcome.

Which patients will benefit most from spinal manipulation or mobilization? To date, most of the studies on manual treatments for low back pain use mixed populations or nonspecific low back pain patients. Furthermore, few studies standardize treatment protocols. Therefore, with the current available data, one can make very few conclusions on the ideal patient who would benefit most from manual treatments. What is known is that there are certain patients who would benefit least from certain manual treatments like mobilization. Patients with acute or chronic radicular pain seem to not fare as well as those without radiating leg pain. Furthermore, patients with electromyographic evidence of a lumbosacral radiculopathy do not fare as well as patients with negative electromyographic lumbosacral radiculitis when manipulation is performed under general anesthesia.

There have been several reviews of manual treatments for low back pain. The most recent review of chronic low back pain was performed by Bronfort and colleagues in 2008. They examined the evidence for spinal manipulation and mobilization in chronic low back pain. They defined chronic as longer than 3 months. They recommended spinal manipulation or mobilization for nonspecific low back pain. They also noted that there is fair-to-moderate evidence that spinal mobilization with stabilizing exercises is just as effective as nonsteroidal anti-inflammatory medications in the short term and long term. Further, a study by Aure and colleagues showed greater improvement in pain intensity, functional disability, general health, and return to work in a group receiving manual therapy versus general exercise.

A Cochrane review noted that spinal manipulation was superior to sham manipulation for short-term gain. Furthermore, a chiropractic consensus article stated that for acute low back pain there is fair evidence that spinal manipulation has better short-term efficacy than mobilization and limited evidence of better short-term efficacy than exercise, ergonomic modifications, or diathermy.

The best evidence of the effectiveness of osteopathic manipulative treatment (OMT) comes from a review by Licciardone and colleagues. Osteopathic techniques include spinal manipulation, muscle energy technique, counterstrain, myofascial release, and osteopathy in the cranial field. As previously mentioned, techniques were very heterogeneous. The authors concluded that OMT reduces low back pain and that its level of pain reduction is greater than what could be expected from placebo. Furthermore, the effect of OMT lasted at least 3 months. When examining the individual studies, it seems that most of them were conducted in patients with subacute to chronic low back pain.

How safe are spinal manipulation techniques? An observational study noted that the common adverse effects of spinal manipulation included local discomfort (53%), headache (12%), tiredness (11%), radiating pain (10%), and dizziness (5%). The sample included patients who had received manipulative therapy of the cervical, thoracic, or lumbar spine. In addition, most symptoms occurred within 4 hours of manipulation and disappeared the same day. However, there have been cases of cerebrovascular accidents and spinal cord injury associated with cervical manipulation.

The determination on which patient will respond best to manual treatment of low back pain is still not entirely clear from the current literature. One approach could be to rule out potential nonresponders first. Those with red flags would be excluded first, and those with yellow flags would warrant further deliberation. Based on the literature, it would be reasonable to be cautious when referring patients with radicular symptoms to practitioners who just perform spinal manipulation. Now, to assist in determining which patients would benefit from manual treatments of the spine, a clinical prediction rule has been formulated and is currently being studied. It has been postulated that patients with acute, nonradicular, low back pain would have a more favorable response to manual treatment. In addition, patients with low fear avoidance beliefs would be better responders. This prediction rule has been validated and generalized for thrust techniques. As more outcomes research is done using this prediction rule and others like it, one might get a better sense of how manual treatments fit into low back pain treatment.

Acupuncture

Acupuncture is a widely used complementary alternative treatment for low back pain. The National Institutes for Health issued a consensus statement in 1998 endorsing acupuncture as an adjunctive or alternative treatment for low back pain. In a National Health Interview Survey conducted in 2007 by the Centers for Disease Control and Prevention, 3 million American adults responded that they had used acupuncture in the prior year for back pain. A prior survey in 2002 found that 8.2 million American adults had used it during their lifetime.

Acupuncture’s proposed mechanism of effect is based in both Eastern and Western theory. The use of acupuncture was documented as early as the first century bc , at which time it was already an established treatment in Chinese medicine. According to traditional Eastern philosophy, the human body is comprised of channels called meridians. The energy that flows through those channels is known as Qi (pronounced ch-ee). Disease states and pain occur when the flow of Qi is unbalanced. By placing needles at specific points along the meridians, balance is restored, thus addressing the disease state and achieving pain reduction or other desired therapeutic effects.

Researchers have attempted to establish a neurobiological model for its mechanism of action to provide a sounder scientific basis and gain better acceptance in the mainstream Western medical community. In fact, many skeptics consider acupuncture to be nothing more than a placebo. Although high-quality clinical studies that definitively support its use remain scarce, the body of basic science research is abundant. Manual needling and electroacupuncture have been found to produce stimulation of A-delta afferent nerve fibers, resulting in release of endorphins and other neuropeptides in the brain and other sites. In a widely cited study by Han, acupuncture induced analgesia induced in a donor rabbit was transferred to a recipient rabbit by cerebrospinal fluid transfusion. Additionally, there are several studies that demonstrate reversal of acupuncture-induced analgesia when naloxone is administered. More recently, functional magnetic resonance imaging (fMRI) and other advanced imaging modalities have helped to demonstrate the importance of the limbic system in the analgesic effects of acupuncture. Functional imaging also has helped to differentiate nonspecific placebo effects from the proposed physiologic effects of acupuncture.

There have been several systematic reviews and multiple randomized controlled trials (RCTs) evaluating efficacy. According to a 2005 Cochrane review, acupuncture is effective for chronic low back pain compared with sham or no treatment, based on 35 RCTs. No advantage was found compared with other conventional or alternative treatments, and acupuncture was endorsed as useful when combined with other conventional treatments. Two systematic reviews were published in 2008 with similar conclusions, aside from disagreement on whether acupuncture is proven to be superior to sham. In each systematic review, high-quality RCTs were scarce.

The German Acupuncture Trials (GERAC) randomized 1162 patients to acupuncture, sham acupuncture, or conventional therapy, defined as treatment according to German guidelines. Both acupuncture and the sham treatment were superior to conventional therapy; however, there was no difference between acupuncture and the sham treatment. In a more recently published study by Cherkin, acupuncture was compared with simulated acupuncture, described as needling along nonmeridian points, and with usual care. Six hundred thirty-eight subjects were followed for up to 1 year. No difference was found between acupuncture and simulated acupuncture, although both were better than usual care. In both studies, acupuncture appeared to be efficacious, whether or not traditional points were used. However, because usual or conventional care was poorly defined and highly variable, another reasonable conclusion from this study is that needling of any kind is better than nonspecific or no care and may simply represent a placebo effect. In the same group of subjects as the Cherkin study, Sherman was unable to find consistent patient characteristics to predict a positive response to acupuncture, although patients with higher baseline dysfunction did have a better short-term response. Pre-existing notions of acupuncture had no relationship with outcome in this study, although a prior study did demonstrate that positive expectations predict a good response to acupuncture compared with negative expectations.

In summary, the strength of evidence supports acupuncture as an adjunctive treatment in the management of low back pain. More studies need to be done to evaluate cost-effectiveness and to definitively establish that acupuncture’s benefit is more than placebo.

Tai Chi, Meditation, Yoga

In recent years, there appears to have been a surge in the number of participants of the Eastern practices of yoga, tai chi and meditation. These practices are usually led by nonhealth care practitioners in studios and health clubs. Although there are many participants who attend regular classes for lifestyle changes, there are those who are seeking out an alternative way of managing their low back pain. The practices of tai chi, meditation, and yoga can be considered active treatments where daily practice is emphasized.

Tai chi is a form of low impact exercise that has roots in China and is an integral part of traditional Chinese medicine (TCM). It has gained in popularity, particularly in older patients due to known improvement in pain and decrease in falls. However, in patients with low back pain, it is not a commonly sought-out alternative treatment. The practice of tai chi consists of slow sequential controlled movements combined with deep diaphragmatic breathing. It also has been described as a martial art. Despite its popularity, it has not been well studied overall or specifically in patients with low back pain. There is currently a randomized controlled study underway studying the effects of a tai chi program versus a wait-list control in patients with chronic low back pain.

The common forms of meditation in North America are mindfulness meditation and transcendental meditation (TM). As Morone and Greco describe, mindfulness meditation involves bringing nonjudgmental moment-to-moment awareness of one’s thoughts, sensations, or emotions as they arise. The various practice techniques include sitting, walking, and loving-kindness. TM generally uses a sitting practice. Although patients are more knowledgeable about meditation, they are just as equally unlikely to seek out meditation as a helpful treatment for low back pain. The only study of meditation in low back pain is a preliminary controlled study using an 8-week mindfulness meditation program in patients with chronic low back pain. They noted improved pain acceptance and physical function after 3 months compared with the wait-list controls.

The practice of yoga in India dates back as early as 3000 bc . The practice of yoga consists of physical postures (asanas), meditation, relaxation, and breathing techniques. Hatha yoga and Raja yoga are the two most popular yoga forms in the Western world. The styles that make up Hatha yoga are Viniyoga, Iyengar yoga, Bikram yoga, and Ashtanga yoga. There are approximately 15 million Hatha yoga participants in the United States. Furthermore, yoga use by adults in the United States increased to more than 6% in 2007. Yoga offers another active approach of treating one’s back pain. It is usually directed by nonhealth care practitioners, and classes usually last 60 to 90 minutes. Although popular, there have been few randomized controlled studies that have evaluated yoga in low back pain. Just like other already mentioned treatments, there are several forms of yoga, each with their own poses and nuances that make study protocols quite difficult. However, the studies that have been published have been very favorable. All of the current prospective randomized studies have studied the effects of yoga in patients with chronic low back pain.

Iyengar is currently the most common style of yoga in the United States. The practice of Iyengar yoga focuses on strict adherence to the poses. Moreover, props, such as blocks and straps, are used to maintain these yoga positions. Williams and colleagues recently studied the effectiveness and efficacy of Iyengar yoga in patients with nonspecific chronic lower back pain. Study subjects underwent 24 weeks of biweekly yoga classes. Of note, back bending poses were excluded. Outcome assessments, including Oswestry Disability Questionnaire, Visual Analog Scale, and Beck Depression inventory were assessed at 12, 24, and 48 weeks. Most participants, (82%) completed the study, and adherence to the yoga classes and home practice was 88% and 87% respectively. They found that yoga made significant improvements in functional disability, pain intensity, and depression in adults with low back pain.

Another important study of yoga in patients with nonspecific chronic low back pain was performed by Sherman and colleagues in 2005. The study population was middle age, middle class, working women in the Pacific Northwest. They compared the effects of Viniyoga classes to conventional therapeutic exercises and a self-care book. They described Viniyoga as a therapeutically oriented style of yoga that emphasizes safety and is easy to learn. Study subjects underwent 12 weeks of 75-minute weekly classes and were encouraged to practice at home on a daily basis. The primary outcome measures, modified Roland Disability Scale and bothersomeness of pain scale, were assessed at 6, 12, and 26 weeks. They noted that yoga was more effective than a self-care book in reducing pain and improving functional status. They also noted a nonstatistically significant decrease in pain and improved functional status as compared with the exercise group.

The mechanism by which yoga improves low back pain has yet to be fully elucidated. As stated earlier, yoga consists of physical postures (asanas), meditation, relaxation, and breathing techniques. Maintaining prolonged positions likely improves endurance of lumbar stabilizers and improves posture. Furthermore, improving flexibility in hips could also contribute to improved lumbar biomechanics. However, breathing techniques and meditation could have a significant effect on reduced pain and improved function in low back patients. It has been shown that patients with chronic low back pain exhibit altered breathing patterns during movements in which trunk stability muscles are challenged and that the changes in breathing pattern during motor control tests are not related to pain severity. It also has been shown that patients with sacroiliac joint pain have impaired kinematics of the diaphragm and pelvic floor with similar motor control tests. Furthermore, through motor learning strategies, diaphragm kinematics improved and were accompanied with reductions in pain and disability scores. In a study with healthy subjects, phrenic nerve stimulation of the diaphragm increased intra-abdominal pressure and enhanced spinal stiffness, without much activity of abdominal and lumbar musculature.

There is currently insufficient evidence to recommend tai chi and meditation as a treatment for low back pain. There appears to be evidence to support the practice of yoga in nonspecific chronic low back pain. However, caution should be taken to avoid poses that significantly exacerbate low back pain. Similar to other treatments, there are likely predictors of response that have yet to be elucidated. Although there is likely a core stabilizing effect of yoga, altered breathing patterns probably play a role in its efficacy.

Exercise

The use of exercise in low back pain treatment is central to the management of low back pain in the physiatric approach. Currently, there is no consensus on which form of exercise is most effective when treating this complex disorder. Furthermore, a Cochrane review stated that there was little evidence that exercise is an effective treatment for acute nonspecific low back pain. The authors also stated that it may be helpful for subacute and chronic low back pain to return to normal activities and work. However, the review looked primarily at studies in patients with nonspecific back pain and with nonspecific therapeutic exercise approaches. Currently, the two most common approaches to practitioner-directed spine rehabilitation involve core stabilization and the mechanical diagnosis and treatment approach (McKenzie method).

As McGill has pointed out, the spine must first be stable to minimize the risk of tissue overload and damage that result from either inappropriate muscle activation or spine joint position. He also states that the risk of spine tissue damage is a function of load magnitude, directional mode of the applied load, motion repetition, spine posture, hydration level and time of day, motor control and instantaneous stability, and age and gender. Changes to muscle activation and motor control, spine position, and stability are the principle ways by which a spinal stabilization program works. The goals are to re-establish motor patterns so that the spine is able to maintain stability during anticipated activities, as well as during those that are sudden. As Hodges and Jull point out, this is achieved via CNS control, which receives afferent signals from tissue mechanoreceptors and then modulates spinal stability via muscle activation. They also delineate the strategies for spinal control as feed-forward or feedback strategies. Feed-forward strategies involve responding to an anticipated perturbation by activating certain muscles. Feedback strategies involve activation of muscles in response to a sudden perturbation in the system.

Stabilizing muscles in the lumbar spine have been grouped into local and global muscles. Bergmark describes global muscles as larger, superficial muscles that attach from the pelvis to the thorax. These include rectus abdominis, internal and external obliques, and the erector spinae. They move the spine with a large moment arm. Local muscles cross one or a few segments, attach directly to the vertebrae, and are responsible for control of intervertebral motion. Muscles include lumbar multifidus, transverse abdominis, intertransversarii, interspinales, and posterior fibers of psoas.

It has been shown that the transverses abdominis and the lumbar multifidi contract before distal limb movement and that, in patients with low back pain, this anticipatory contraction is delayed. It also has been shown that patients with low back pain exhibit lumbar multifidi atrophy. Lumbar segmental stabilizing programs have been shown to lead to faster and more complete recovery of the multifidi. It also has been suggested that excessive activity in the superficial (global) muscles might be in response to poor intersegmental control. One of the goals of a stabilization program is to activate the deep local muscles and decrease the activity of the global muscles. The pattern of re-educating the transversus abdominus and the lumbar multifidi has been described by Richardson and colleagues.

The decision to use a stabilization program in a patient with low back pain can be made using the current evidence of chronicity of the low back pain and by using clinical prediction rules. In acute low back pain, segmental stabilizing exercises have been shown to be as effective in reducing pain and disability as general practitioner care after 4 weeks of treatment. However, there is moderate evidence that segmental stabilizing exercises are more effective in reducing long-term recurrence of low back pain, at 1- and 3-year follow-up, than treatment by general practioner. There are currently no randomized controlled trials for lumbar stabilization exercises in subacute low back pain. There is moderate evidence that a lumbar stabilization program can be effective in reducing pain and disability in patients with chronic low back pain from spondylolysis or spondylolisthesis for both short and long term. A clinical prediction rule was devised by Hicks and colleagues. Prognostic factors associated with clinical success with a stabilization exercise program included positive prone instability test, age less than 40 years, aberrant movements, straight leg raise greater than 91°, and presence of lumbar hypermobility. It further decreased lumbar multifidus activation, but no transversus abdominis activation was associated with factors predictive of clinical success with a stabilization exercise program.

The mechanical diagnosis and therapy method (MDT) is another well studied treatment for low back pain. It uses a diagnostic algorithm to categorize patients into one of three subgroups for a more specific treatment approach. The assessment process looks at mechanical and symptomatic responses to movement and positioning. The three subgroups (clinical patterns) include the postural syndrome, dysfunction syndrome, and derangement syndrome. In brief, the postural syndrome is one in which the patient has a full and pain-free range of motion. However, he or she has symptoms with sustained end-range loading. The dysfunction syndrome is when there is a loss in the range of motion caused by shortened structures (ie, scarring, fibrosis, nerve root adherence). There is also a limited and symptomatic end range of motion. The derangement syndrome is when there is a mechanically impeded end range that is perceived by the patient to be an obstruction, which may or may not be painful. In this case, a direction of rigidity often is contrasted by a direction of instability. The subtle difference in the previously mentioned syndromes prompts different treatment paradigms. Practitioners of the MDT method receive specialized training through the McKenzie Institute.

A key component of the MDT approach involves establishing a directional preference. A directional preference in the lumbar spine occurs when repeated movements in a single direction reduces or abolishes axial lumbar pain or causes peripheral or leg pain to retreat proximally (centralization). Both centralization and directional preference assessments have been studied in patients with low back pain. Long and colleagues noted that a subgroup that exhibited a directional preference had better outcomes (decreased pain, less medication use, decreased disability) when prescribed exercises that match each individual’s directional preference than with the opposite or a nondirectional treatment. The ability to centralize symptoms also has been used to predict success in treatment and create a clinical prediction tool. It has been shown that a subgroup of patients who centralized symptoms experienced greater improvements in disability than subjects who received a stabilization program. Centralization also has been shown to be of a predictor of outcome and to predict chronic pain and disability at 1 year.

Although the effectiveness of exercise for low back pain treatment has been shown to be equivocal, Delitto points out that it is because of the failure of researchers to adequately account for the importance of subgrouping. Core stabilization and MDT treatments have been shown to be effective in certain populations with low back pain. However, further research is needed to improve on choosing the appropriate patients for these active treatments.