Low back pain is one of the most common health conditions today. According to some estimates, each year nearly 15% to 20% of the United States population experiences low back problems, and as many as 80% of all adults experience significant low back pain at some point during their lives.1,2 Back pain is the second most common reason adults under age 45 miss days from work (after the common cold). The total cost of back pain has been estimated to reach $25 billion per year in the US.3

When back pain occurs suddenly (after lifting a heavy object, for example), it is called acute back pain or sprain. In most cases, acute back pain eventually improves by itself, but there may be weeks of discomfort, time lost from work, and impaired function at home.

When back pain persists over months or years, it is called chronic back pain. In the majority of cases, the cause of chronic back pain is unknown. Identifiable causes include osteoarthritis, fracture, or injury to the discs between the vertebrae.

Conventional treatment of acute back pain involves anti-inflammatory drugs, muscle relaxants, and the passage of time. Chronic back pain requires a medical workup to make sure there are no serious underlying causes, although evidence suggests that, in most cases, x-rays are not necessary.4 Treatment may also include physical therapy and a graded exercise program, which includes walking. However, there is little reliable evidence that these treatments actually provide much benefit.64,65,94-97 Surgery may be recommended in certain cases, such as when there are severe disc problems, but most forms of back surgery also lack reliable supporting evidence.

Principal Proposed Natural Treatments

Extract of the herb white willow appears to be helpful for acute and chronic back pain, presumably because of its similarity to aspirin. The little-known injection technique known as prolotherapy may be effective for back pain as well. Lesser evidence supports the use of chiropractic and acupuncture.

Willow bark has been used as a treatment for pain and fever in China since 500 BC. It contains the substance salicin, which is chemically related to aspirin. Another ingredient of white willow, tremulacin, may also be important.

In a 4-week, double-blind, placebo-controlled study of 210 individuals with chronic back pain, two different doses of willow bark extract were compared against placebo.5 The higher-dose group received extract supplying 240 mg of salicin daily; in this group, 39% were pain-free for at least the last 5 days of the study. In the lower-dose group (120 mg of salicin daily), 21% became pain-free. In contrast, only 6% of those given placebo became pain-free. Stomach distress did not occur in this study. The only significant side effect seen was an allergic reaction in one participant given willow.

Note: White willow should not be combined with standard anti-inflammatory drugs, such as ibuprofen. For more information, including dosage and safety issues, see the full White Willow article.

Chiropractic spinal manipulation is one of the most popular treatments for acute and chronic back pain in the US, and it may provide at least modest benefit; however, as yet, research evidence has failed to find chiropractic manipulation convincingly more effective than standard medical care.49,50,76

Chiropractic does seem to be more effective than placebo, if not by a great deal. For example, a single-blind, controlled study of 84 people suffering from low back pain compared manipulation to treatment with a diathermy machine (a physical therapy machine that uses microwaves to create heat beneath the skin) that was not actually functioning.16 The researchers asked the participants to assess their own pain levels within 15 minutes of the first treatment, then 3 and 7 days after treatment. The only statistically significant difference between the two groups was within 15 minutes of the manipulation. (Chiropractic had better results at that point.)

In another single-blind, placebo-controlled study, researchers assigned 209 participants to one of three groups: a high-velocity, low-amplitude (HVLA) spinal manipulation; a sham manipulation group; or a back education program.17 Though this has been reported as a positive study,18 most of the differences seen between the groups were too small to be statistically significant.

Unimpressive results were also seen in a well-designed study of 321 people with back pain, comparing chiropractic manipulation, a special form of physical therapy (the Mackenzie method), and the provision of an educational booklet in treating low back pain.25 All groups improved to about the same extent.

Several studies evaluated the effectiveness of chiropractic manipulation combined with a different kind of treatment called mobilization, but they too found little to no benefit.43,45,46

On a positive note, one study of 100 people with back pain and sciatica symptoms (pain down the leg due to disc protrusion) found that chiropractic manipulation was significantly more effective at relieving symptoms than sham chiropractic manipulation.57

For low back pain, several studies have found that chiropractic is at least as helpful as other commonly used therapies, such as muscle relaxants, soft-tissue massage, and physical therapy.22-26,51,74 Furthermore, in one well-designed study, 2 months of chiropractic spinal manipulation produced somewhat greater pain relief than exercise therapy, and this relative superiority endured to the 1-year follow-up point.41

For more information, see the full Chiropractic article.

The ancient technique of acupuncture has become increasingly popular as a treatment for pain and other conditions. However, thus far, research has not produced clear evidence of acupuncture’s effectiveness for back pain.52 In a review of 23 randomized trials involving over 6,000 patients with chronic low back, researchers concluded that acupuncture is more effective than no treatment for short-term pain relief, but there was no significant difference between the effects of true and sham.79

A 6-month, double-blind trial of 1,162 people with back pain compared real acupuncture, fake acupuncture, and conventional therapy.72 Both real and fake acupuncture were twice as effective as conventional therapy according to the measures used. However, there was only a minimal difference between real and fake acupuncture. These results do not, in fact, indicate that acupuncture is effective per se; rather, it shows the significant power of acupuncture as a placebo.

Similarly, in a single-blind, sham-acupuncture, and no-treatment controlled study of 298 people with chronic back pain, use of real acupuncture failed to prove significantly more effective than sham-acupuncture.58 Also, in a fairly large randomized trial involving 638 adults with chronic back pain, there was no difference in pain at one year in patients receiving real compared to fake acupuncture (with neither group improving significantly over standard care). Both real and simulated acupuncture were, however, associated with improved function at one year.80 Other studies have failed to find benefit as well; in several controlled studies enrolling a total of over 300 people, real acupuncture again failed to prove more effective than sham-acupuncture or other placebo treatments.19,29,32,53

One study compared the effects of acupuncture, massage, and education (such as videotapes on back care) for 262 people with chronic back pain over a 10-week period.28 The exact type of acupuncture and massage was left to practitioners, but only 10 visits were permitted. At the 10-week point, evaluations showed benefit with massage but not with acupuncture. One year later, massage and education were nearly equivalent, and both were superior to acupuncture.

Low level laser therapy (LLLT) is a technique similar to electro-acupuncture that uses precision laser energy instead of electricity conducted through a needle. In a detailed review of 7 randomized trials, researchers were unable to draw any conclusions regarding the effectiveness of LLLT for nonspecific low back pain.73 A randomized trial of 144 adults with chronic nonspecific low back pain found no differences in pain or disability when comparing low- and high-dose laser acupuncture to sham treatments over 8 weeks.92

A review of 32 randomized trials compared acupuncture to no or other therapies with mixed results in patients with nonspecific chronic low back pain. For pain reduction and function, acupuncture was better than sham acupuncture. Acupuncture was more effective for functional improvements when it was used in combination with usual care. Modest improvements in pain and function were seen with acupuncture treatment when compared to pain relievers and muscle relaxants, but the differences were not clinically significant. Biases included types of acupuncture used, duration of treatment, and number of treatment sessions in the patient population. Increased numbers of biases in trials affects the quality of the results.91

Many other studies have compared acupuncture to such treatments as transcutaneous electrical nerve stimulation (TENS), physical therapy, chiropractic care, and massage.14,33-37,59 In many of these trials, acupuncture provided benefits comparable to the other options tested. However, because TENS, physical therapy, and so forth, have not been proven effective for back pain, studies of this type cannot be taken as evidence that acupuncture is effective. One study did find acupressure massage more effective than standard physical therapy; however, it was performed in a Chinese population that may have had more faith in this traditional approach than in physical therapy.60

For more information, see the full Acupuncture article.

Other Proposed Natural Treatments

In a double-blind, placebo-controlled study enrolling 215 people with back pain, use of a topical cream made from the herb comfrey produced statistically significant benefits as compared to placebo.61 A second randomized trial of 379 people with acute back pain also found a topical combination of comfrey and methyl nicotinate cream reduced back pain (at rest and with movement), decreased functional impairment, and reduced use of rescue medication compared to methyl nicotinate cream alone or placebo.90 Topical comfrey was associated with reduced back pain (upper and lower) compared to placebo in a randomized trial with 120 adults.93

The herb devil's claw is used for the treatment of osteoarthritis, and has been tried for back pain as well. However, the results have been less than impressive. A double-blind, placebo-controlled study of 197 individuals with chronic back pain found devil's claw only marginally effective at best.38 Similarly poor results were seen in an earlier 4-week, double-blind, placebo-controlled study of 118 individuals with acute back pain.39 However, a 4-week, double-blind, placebo-controlled study of 63 people with mild to moderate chronic muscular tension in the neck, back, and shoulders did find some benefit.27

The herb cayenne contains capsaicin, a substance that produces an immediate burning sensation but later reduces pain. One double-blind study found a topical cayenne treatment more effective than placebo in 320 people with low back pain.54 However, on the face of it, one finds it difficult to believe that this study was truly double-blind. When cayenne is applied to the skin, it causes such an intense sensation that participants could hardly fail to notice it. When people in a study know whether they are getting real treatment or placebo treatment, the validity of the study's results is greatly decreased. In another randomized trial of 40 people with low back pain, a topical cayenne-based cream was associated with reduced acute low back pain compared to placebo.43

A randomized trial with 200 patients found collagen hydrolysate significantly reduced joint pain when compared to placebo. Patients, who were followed for 6 months, were over 50 years old with hip, knee, elbow, shoulder or lumbar spine pain.87

Other herbs and supplements sometimes recommended for back pain, but with no real supporting evidence, include: boswellia, butterbur, chondroitin, ginger, glucosamine, and turmeric.

Osteopathic manipulation (OM) is a form of treatment related to chiropractic manipulation, but it tends to use gentle, extended movements (low velocity, high amplitude) rather than the quick, short, cracking movements of chiropractic. OM has shown some promise for the treatment of back pain,15,20,40 including a randomized trial of 455 patients. The trial assessed the effects of 6 OM sessions over 8 weeks compared to sham treatments. At 12 weeks, OM was associated with moderate or substantial pain reduction compared to sham OM. OM also reduced the use of prescription pain medications.89

However, one of the best-designed trials failed to find it a superior alternative to conventional medical care. In this 12-week study of 178 individuals, osteopathic manipulation proved no more effective than standard treatment for back pain.40 Another study failed to find OM more effective than sham manipulation.55

In a review of 13 randomized trials, researchers concluded that massage may be effective for nonspecific low back pain, and the beneficial effects can last for up to 1 year in patients suffering from chronic pain.77 They also noted that exercise and education appear to enhance the effectiveness of massage. A subsequent large study involving 401 adults (aged 20-65 years old) with nonspecific back pain also supports the use of massage.84 The patients were randomized to one of three groups: structural massage, relaxation massage, or usual care. At 10 weeks, those in the massage groups had improved function and fewer symptoms compared to the usual care group. But unlike the previous review, there were no differences, though, at weeks 26 and 52. See the article on Massage for more details.

The Alexander Technique is a special method of postural training popular among dancers and other performers. A review of the literature found no more than weak preliminary evidence that Alexander may help with back pain, but concluded that further research is warranted.56 A subsequent controlled trial involving 579 patients with chronic or recurrent low back pain found that Alexander technique lessons, particularly when combined with exercise, was more effective than normal care or massage after one year.78

Tai Chi is a traditional form of martial art that involves gentle, dance-like movements. In one trial, 160 people with low back pain were randomized to do Tai Chi (18 sessions lasting 40 minutes each over a period of 10 weeks) or usual care.85 Those who participated in Tai Chi experienced a greater improvement in their symptoms, including less pain and less disability. However, the lack of an attention control group diminishes the reliability of these results.

The use of prolotherapy to treat back pain has had mixed results in clinical studies.

Invented in the 1950s by George Hackett, prolotherapy is based on the theory that chronic pain is often caused by laxness of the ligaments that are responsible for keeping a joint stable. When ligaments and associated tendons are loose, the body is said to compensate by using muscles to hold the joint stable. The net result, according to prolotherapy theory, is muscle spasms and pain.

Prolotherapy treatment involves injections of chemical irritant solutions into the area around such ligaments. These solutions are believed to cause tissue to proliferate (grow), increasing the strength and thickness of ligaments.9,10,11 This presumably serves to tighten up the joint and allow the associated muscles to stop having spasms. In the case of arthritic joints, increased ligament strength would allow the joint to function more efficiently, reducing pain.

Although two studies have suggested prolotherapy may be effective,12,13 two more recent studies found prolotherapy to be ineffective.47,48

In a review of five studies, three found prolotherapy to be no more effective than control treatments for treating low back pain. The other two studies suggested that prolotherapy was more effective than control treatments when used with therapies such as spinal manipulation and exercise.81 Another review suggested prolotherapy may be effective when used with other therapies, but not when used alone.82

What can one make of this contradictory evidence? When used alone prolotherapy is probably no more effective than a placebo injection for the treatment of chronic low back pain. However, there is some evidence that the technique may be beneficial when combined with other therapies.

For more information, see the full Prolotherapy article.

Biofeedback,21balneotherapy,66-67hatha yoga,62, 63,75magnet therapy,70,71 and relaxation therapies69,83,99 have also shown at least a hint of promise for treating back pain. Though for some of these, there have been as many negative as positive studies, and for many of them only short-term benefits were shown.

In one interesting study, 444 people with acute low back pain were randomly assigned to receive either usual care or usual care plus a choice of alternative therapies (chiropractic, acupuncture, or massage).68 The results showed that while the use of alternative therapies improved patient satisfaction, it did not significantly improve symptoms.

Yoga had positive effect on chronic low back pain in a randomized trial of 80 patients. Patients randomized to treatment with a yoga program showed improvement in pain, depression, and anxiety symptoms compared to patients in physical therapy. The program was carried out in a residential setting over seven days and included technique, counseling, and educational lectures.86 Yoga had a minimal, but positive effect on chronic low back pain in a review of 12 radomized trials with 1,080 patients. Yoga was compared to no-exercise alternatives and participants were not blinded, meaning they knew which treatment they were getting. There was no clinical improvement with pain and function. It wasn't clear if yoga was better than no exercise or if adding yoga to exercise was better.98

Pilates showed symptom improvement in a small randomized trial involving 31 sedentary women with nonstructural scoliosis. Twenty-four 60-minute sessions of Pilates twice weekly was associated with decreased degree of scoliosis, improved trunk flexion range of motion, and decreased pain compared to no therapy.88

Preliminary evidence suggests that proteolytic enzymes might be helpful for back pain.44

Herbs and Supplements to Use Only With Caution

Various herbs and supplements may interact adversely with drugs used to treat back pain. For more information on this potential risk, see the individual drug article in the Drug Interactions section of this database.