Low Back Pain
The low back supports most of the body’s weight, and as a result, is susceptible to pain caused by injury or other problems. Over 80% of adults experience low back pain (LBP) sometime during their life.1 More than half will have a repeat episode.
It is often difficult to pinpoint the root of low back pain, though poor muscle tone, joint problems, and torn muscles or ligaments are common causes. A herniated or slipped disc may also cause low back pain as well as sciatica, a condition where pain travels down one or both buttocks and/or legs.
Standing or sitting for extended periods, wearing high heels, and being sedentary increase the risk of developing low back pain, as do obesity and back strain due to improper lifting. Up to half of pregnant women experience some low back pain.2 Long hours spent driving a car may contribute to a herniated disc.3 This is possibly due to the vibration caused by the car.4
Many people with low back pain recover without seeing a doctor or receiving treatment. Up to 90% recuperate within three to four weeks,5 though recurrences are common,6 7 8 and chronic low back pain develops in many people.9 Low back pain is considered acute, or short-term, when it lasts for a few days up to many weeks. Chronic low back pain refers to any episode that lasts longer than three months.
While low back pain is rarely life threatening, it is still important to have chronic or recurring back pain assessed by a healthcare professional. Potentially serious causes include spinal tumor, infection, fracture, nerve damage, osteoporosis, arthritis, or pain caused by conditions found in internal organs such as the kidneys.
What are the symptoms of low back pain?
Low back pain may be a steady ache or a sharp, acute pain that is worse with movement.
Lifestyle changes that may be helpful for low back pain
Preliminary data indicate that smoking may contribute to low back pain.10 One survey of over 29,000 people reported a significant association between smoking and low back pain.11 Smaller people (children, women, those who weigh less) are most affected. A study involving people with herniated discs found that both current and ex-smokers are at much higher risk of developing disc disease than nonsmokers.12 Other research reveals 18% greater disc degeneration in the lower spines of smokers compared with nonsmokers.13 Smoking is thought to cause malnutrition of spinal discs, which in turn makes them more vulnerable to mechanical stress.14
One survey reported that people who drank wine healed more quickly after disc surgery in the lower back than those who abstained.15 However, alcohol consumption may cause cirrhosis of the liver, cancer, high blood pressure, and alcoholism. As a result, many doctors never recommend alcohol even though moderate consumption has been linked to some health benefits. For those deciding whether light drinking might help with recovery from disc surgery, it is best to consult a doctor.
Regular exercise and proper lifting techniques help prevent low back problems from developing. Proper lifting involves keeping an object close to the body and avoiding bending forwarding, reaching, and twisting while lifting. Low back pain and disc degeneration are both more likely to develop among sedentary people than those who are physically active.16 However, long-term participation in some competitive sports may contribute to spinal disc degeneration.17
Therapeutic exercise helps people recover from low back pain18 and low back surgery.19 Less clear are details about how this should be done for greatest benefit. In other words, the best type of exercise, frequency, duration, and timing of a program still need to be determined. One study reported therapeutic exercise significantly improved chronic low back pain compared to exercise performed at home without professional guidance.20 Another trial discovered that women with chronic low back pain who began supervised back strengthening exercises at a fitness center were more consistent exercisers than those who started and continued therapeutic exercises at home.21 Both groups experienced significant improvement in pain. However, the supervised group experienced better long-term improvement.
While heavy lifting and other strenuous labor may contribute to low back pain, one trial found that people with sedentary jobs gained more benefit from an exercise program than those who have physically hard or moderate occupations.22 Motivational programs may also improve exercise consistency, which in turn decreases pain and disability.23 People with low back pain who wish to embark on an exercise program should first consult with a physical therapist or other practitioner skilled in this area.
Supervised bed rest, for two to four days, coupled with appropriate physical therapy and therapeutic exercise, is often recommended by medical doctors for acute low back pain.24 However, reviews of bed rest recommendations have concluded that bed rest is, at best, ineffective and may even delay recovery.25 26 It is better to try to stay active and maintain a normal daily schedule as much as possible.
General recommendations for people recuperating from low back pain include wearing low-heeled comfortable shoes, sitting in chairs with good lower back support, using work surfaces that are a comfortable height, resting one foot on a low stool if standing for long periods, and supporting the low back during long periods of driving.27
Nutritional supplements that may be helpful for low back pain
Three double-blind trials have investigated the effects of supplementing a combination of the enzymes trypsin and chymotrypsin for seven to ten days on severe low back pain with or without accompanying leg pain. Eight tablets per day were given initially in all trials, but in two trials the number of pills was reduced to four per day after two to three days. One of these trials reported small, though statistically significant improvements, for some measures in people with degenerative arthritis of the lower spine.28 People with sciatica-type leg pain had significant improvement in several measures in one trial,29 while another found the enzymes were not much more effective than a placebo.30 These trials included chronic low back conditions, so their relevance to acute LBP alone may be limited.
Several animal studies and some research involving humans suggest that a synthetic version of the natural amino acid phenylalanine called D-phenylalaline (DPA), reduces pain by decreasing the enzyme that breaks down endorphins.31 It is less clear whether DPA may help people with LBP, though there are a small number of reports to that effect,32 including one uncontrolled report of 27 of 37 people with LBP experiencing “good to excellent relief.”33 In a double-blind trial, University of Texas researchers found that 250 mg of DPA four times per day for four weeks was no more effective than placebo for 30 people with various types of chronic pain; 13 of these people had low back pain.34 In a Japanese clinical trial, 4 grams of DPA per day was given to people with chronic low back pain half an hour before they received acupuncture.35 Although not statistically significant, the results were good or excellent for 18 of the 30. The most common supplemental form of phenylalanine is D,L-phenylalanine (DLPA). Doctors typically recommend 1,500–2,500 mg per day of DLPA.
A combination of vitamin B1, vitamin B6, and vitamin B12 has proved useful for preventing a relapse of a common type of back pain linked to vertebral syndromes,36 as well as reducing the amount of anti-inflammatory medications needed to control back pain, according to double-blind trials.37 Typical amounts used have been 50–100 mg each of vitamins B1 and B6, and 250–500 mcg of vitamin B12, all taken three times per day.38 39 Such high amounts of vitamin B6 require supervision by a doctor.
Proteolytic enzymes, including bromelain, papain, trypsin, and chymotrypsin, may be helpful in healing minor injuries because they have anti-inflammatory activity and are capable of being absorbed from the gastrointestinal tract.40 41 42 Several preliminary trials have reported reduced pain and swelling, and/or faster healing in people with a variety of conditions who use either bromelain43 44 45 or papain.46 47 48
A preliminary report in 1964 suggested that 500–1,000 mg per day of vitamin C helped many people avoid surgery for their disc-related low back pain.49 No controlled research has been done to examine this claim further.
Are there any side effects or interactions with low back pain?
Refer to the individual supplement for information about any side effects or interactions.
Herbs that may be helpful for low back pain
Colchicine, a substance derived from autumn crocus, may be helpful for chronic back pain caused by a herniated disc. A review shows that colchicine has provided relief from pain, muscle spasm, and weakness associated with disc disease50 51 including several double-blind trials.52 The author of these reports has suggested that 0.6 to 1.2 mg of colchicine per day leads to dramatic improvement in four out of ten cases of disc disease. In most clinical trials, colchicine is given intravenously.53 However, the oral administration of this herb-based remedy also has had moderate effectiveness. People with low back pain should consult a physician skilled in herbal medicines before taking colchicine due to potentially severe side effects.
Willow bark is traditionally used for pain and conditions of inflammation. According to one controlled clinical trial, use of high amounts of willow bark extract may help people with low back pain. One trial found 240 mg of salicin from a willow extract to be more effective than 120 mg of salicin or a placebo for treating exacerbations of low back pain.54
Topical cayenne pepper has been used for centuries to reduce pain, and more recently, to diminish localized pain for a number of conditions,55 including chronic pain,56 although low back pain has not been specifically investigated. Cayenne creams typically contain 0.025–0.075% capsaicin.57 While cayenne cream causes a burning sensation the first few times used, this decreases with each application. Pain relief is also enhanced with use as substance P, the compound that induces pain, is depleted.58 To avoid contamination of the mouth, nose, or eyes, hands should be thoroughly washed after use or gloves should be worn. Do not apply cayenne cream to broken skin.
One double-blind trial found that devil’s claw capsules (containing 800 mg of a concentrated extract taken three times per day) were helpful in reducing acute low back pain in some people.59 Another double-blind trial (using 200 mg or 400 mg of devil’s claw extract three times daily) achieved similar results in some people with exacerbations of chronic low back pain.60
Herbalists often use ginger to decrease inflammation and the pain associated with it, including for those with low back pain. They typically suggest 1.5 to 3 ml of ginger tincture three times per day, or 2 to 4 grams of the dried root powder two to three times per day. Some products contain a combination of curcumin and ginger. However, no research has investigated the effects of these herbs on low back pain.
A combination of eucalyptus and peppermint oil applied directly to a painful area may help. Preliminary research indicates that the counter-irritant quality of these essential oils may decrease pain and increase blood flow to afflicted regions.61 Peppermint and eucalyptus, diluted in an oil base, are usually applied several times per day, or as needed, to control pain. Plant oils that may have similar properties are rosemary, juniper, and wintergreen.
Turmeric is another herb known traditionally for its anti-inflammatory effects, a possible advantage for people suffering from low back pain. Several preliminary studies confirm that curcumin, one active ingredient in turmeric, may decrease inflammation in both humans62 and animals.63 64 In one double-blind trial, a formula containing turmeric, other herbs, and zinc significantly diminished pain for people with osteoarthritis.65 Standardized extracts containing 400 to 600 mg of curcumin per tablet or capsule are typically taken three times per day. For tinctures of turmeric, 0.5 to 1.5 ml three times per day are the usual amount.
Are there any side effects or interactions with low back pain?
Refer to the individual herb for information about any side effects or interactions.
Holistic approaches that may be helpful for low back pain
Acupuncture may be helpful in the treatment of low back pain in some people. Case reports66 67 and numerous preliminary trials68 69 70 71 72 73 74 have described significant improvement in both acute and chronic back pain following acupuncture (or acupuncture with electrical stimulation) treatment. In a single controlled study of acute back pain, both electroacupuncture and drug therapy (acetaminophen) led to statistically significant pain reduction and improved mobility.75
Several controlled clinical trials have evaluated acupuncture for chronic low back pain. A controlled trial found acupuncture was significantly superior to placebo (fake electrical stimulation through the skin) in four of five measures of pain and physical signs.76 Controlled trials using electroacupuncture have reported either benefit77 or no benefit78 for chronic back pain. A double-blind trial compared acupuncture to injections of anesthetic just below the skin at non-acupuncture points, and found no difference in effect between the two treatments.79 Controlled trials have compared acupuncture to transcutaneous nerve stimulation (TENS). Some,80 81 though not all,82 demonstrated greater pain relief with acupuncture when compared to TENS, and one found improved spinal mobility only with acupuncture.83
In one preliminary trial, acupuncture relieved pain and diminished disability in the low back during pregnancy better than physiotherapy.84
A recent analysis and review of studies reported acupuncture was effective for low back pain,85 though another recent review concluded acupuncture could not be recommended due to the poor quality of the research.86 A third review concluded that acupuncture was beneficial for people with slipped discs and sciatica and could be recommended at the very least as a supplementary therapy.87 Since the vast majority of controlled acupuncture research addresses chronic low back pain, it remains unknown whether people with acute low back pain benefit significantly from acupuncture.88
The federally funded Agency for Health Care Policy and Research has deemed spinal manipulation effective for acute low back pain during the first month following injury.89 This recommendation is supported by other research, though some has not been well controlled.90 91 People whose initial pain or disability is severe to moderate appear to benefit the most, though those with longer lasting or chronic pain may also be helped by spinal manipulation.92 93 One 12-month controlled study found no difference in benefit between manipulation and standard physical therapy.94 Another controlled study found a series of eight treatments with spinal manipulation was as effective as conventional medical therapy, but the manipulation group needed less pain medication and physical therapy.95 Practitioners who perform spinal manipulation include chiropractors, some osteopaths, and some physical therapists.
Some researchers suggest that spinal manipulation should not be performed on people with a herniated (slipped) disc, because it may lead to spinal cord injuries.96 However, other preliminary trials report that spinal manipulation helps those with herniated discs,97 98 99 100 as did one controlled study comparing manipulation to standard physical therapy.101 In one investigation of 59 people with slipped discs who received chiropractic treatment, including manipulation, 90% reported improvement.102 Those with a history of low back surgery had poor outcomes. People with LBP due to herniated discs who wish to try this method should first consult with a chiropractor or other physician skilled in spinal manipulation. A recent controlled study compared manipulation, acupuncture, and medication for chronic spinal pain. Only manipulation significantly improved pain and disability scores.103
There is inconclusive evidence that massage alone helps people with low back pain, though preliminary research indicates it has potential.104 Many practitioners use massage in combination with other physical therapies, such as spinal manipulation or therapeutic exercise. People with low back pain who want to try massage should consult with a qualified massage therapist.
Some controlled trials indicate that biofeedback benefits people with chronic low back pain,105 106 but other trials do not.107 108 One study found that biofeedback was more effective than behavioral therapy or conservative medical treatment for people with chronic back pain. The study also found biofeedback to be the only method where people experienced significant reduction in pain for up to the two years of follow-up.109 People wishing to try biofeedback should discuss this method with a qualified practitioner.
Emotional distress has been associated with aggravating low back pain,110 including that caused by a herniated disc.111 The effects on back pain of counseling aimed at reducing emotional stress remain unknown, though it is used in some clinics employing multidisciplinary approaches to treating chronic lower back pain.