Complementary Therapies for Low Back Pain Are Crucial Recommendations for Pharmacists to Relay
Complementary and integrative medicine have become an important treatment choice for many Americans, especially those with low back pain. If you need proof, stop to consider that a whopping $8.5 billion in out-of-pocket payments go to complementary therapies for back pain.
Many in Western medical practices express concern about evidence-based proof of efficacy and safety. While patients’ individual health needs and response to treatment must always be considered, several new studies have evaluated the scientific evidence to date and recommend complementary approaches to back pain management.
Design of Study Evaluating Complementary Treatments
In September 2016, a group of experts from the National Center for Complementary and Integrative Health presented a report to the Mayo Clinic Symposium on Pain.1 They offered their review of complementary approaches to pain management, which was carefully designed to be as relevant as possible to primary care physicians in the United States. For this reason, they limited the review to randomized controlled trials (RCTs) that were either performed in the U.S. or included participants from the U.S. They chose these criteria for several reasons:
- To develop results based on the standards used in this country, noting that whether a method performs well or poorly in another country may not indicate how it would fare in U.S. trials.
- To acknowledge that regulations vary significantly across countries.
- To recognize cross-cultural differences—in other countries, some therapies aren’t labeled as complementary because they’re already integrated into routine care.
This approach comes with significant pros and cons. On one hand, a U.S.-centric approach reassures physicians and pharmacists that they can genuinely recommend certain complementary practices. On the other hand, it may leave out therapies being used by patients, which could put you in a tough position if a patient who gets pain relief from a complementary treatment that’s not verified by RCTs stops by to ask what the pharmacist thinks.
Such a strict review offers one especially vital benefit—evidence-based proof is a step towards getting insurance coverage for complementary therapies. Considering how recalcitrant low back pain becomes to treatment—and the fact that health care professionals must reduce reliance on opioids—any adjunctive treatment that’s effective is a vital treatment tool.
Complementary Therapies to Relieve Back Pain
When your patients continue to suffer with low back pain regardless of prescription medications, it’s time to talk with them about adding complementary treatments to their regimen. Of course, they should consult their physician to be sure they don’t have an underlying physical condition that may prevent them from choosing an adjunctive treatment. They’ll also benefit from consulting a physical therapist if they prefer more traditional exercise and stretching. But at least you can talk with them about these options reported in the September 2016 symposium:
- Acupuncture – Four RCTs with a total of 1,092 participants found a moderate to significant reduction in pain intensity and an improvement in functional status compared with usual care or no treatment. Additionally, no adverse events were reported.
- Massage therapy – Eight RCTs with 829 participants reported on various types of massage, including Swedish/relaxation, structural and muscle energy. Massage sessions lasted from 15 to 90 minutes. Two of the largest studies found modest improvement in pain and function after 10 weeks of massage compared to usual care, while two others reported the same results compared to no treatment. Studies that compared massage to outpatient rehabilitation or relaxation didn’t find a significant difference between groups.
- Yoga – Six RCTs studied hatha, viniyoga and iyengari forms of yoga in 12 to 24 sessions lasting from 60 to 90 minutes. Yoga provided improved pain and function compared to usual care, but came up with mixed results when compared with exercise.
- Spinal manipulation – A total of 24 RCTs indicated that spinal manipulation may be effective, but it depends on the number of sessions. With six or more sessions, patients achieved modest improvement in back pain, but it was not significantly different compared to other therapies like massage, physical therapy and usual care.
- Osteopathic manipulative therapy – Six RCTs reported mixed results for pain intensity and no functional improvement, except in pregnant women with lower back pain, who found modest improvement. However, a review published in Practical Pain Management in October 2016 came up with more promising results.2 They reported that three months of osteopathic manipulative treatment is effective for chronic low back pain, with the results sometimes lasting as long as one year.
Conflicting information about osteopathic manipulative therapy highlights the conundrum of choosing studies to use as you counsel patients. If you have patients interested in this therapy, you can also fall back on American Osteopathic Association guidelines, which say that osteopathic manipulative therapy significantly relieves lower back pain and improves functional status—and it has not demonstrated any harm in clinical trials.3
Finally, capsaicin has gone mainstream, but many still think of it as an alternative herbal remedy. Several RCTs using topical capsaicin produced statistically significant reductions in chronic low back pain compared with a placebo. In fact, two studies reported a 60 percent reduction in pain, although it caused mild local reactions in about one-third of the participants.4 Patients also have the option of the high-concentration capsaicin 8 percent patch, which offers longer-lasting pain relief.
Pharmacists are Reliable Resources for Back Pain Patients
Whether your patients with chronic low back pain purchase OTC products or prescription medications, one thing is certain—they’re frequent customers in your pharmacy. This gives you a unique opportunity to reach out and talk about complementary treatments. Remember that they’re safe—none of the studies reported adverse events—and each individual experiences different levels of pain relief, so treatments with limited efficacy in clinical studies may provide significant relief to some patients. In the end, it comes down to this advice from Pharmacy Times—pharmacists should discuss complementary treatment regimens.5
Pharaceutica North America provides a diverse selection of prescription drug products, bulk and unit-dose active pharmaceutical ingredients, and OTC supplements that will help relieve low back pain. Contact us today to talk about how we can support your pharmaceutical needs.
- “Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States,” September 2016, http://www.mayoclinicproceedings.org/article/S0025-6196(16)30317-2/pdf ↩
- “Low Back Pain and Osteopathic Manipulative Medicine: A Trend in Pain Management,” October 2016, http://www.practicalpainmanagement.com/treatments/low-back-pain-osteopathic-manipulative-medicine-trend-pain-management ↩
- “American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain,” August 2016, http://jaoa.org/article.aspx?articleid=2538814 ↩
- “Treatment of Low Back Pain: The Potential Clinical and Public Health Benefits of Topical Herbal Remedies,” April 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3995208/ ↩
- “Starting Conversations About Complementary and Integrative Medicine,” July 2016, http://www.pharmacytimes.com/contributor/swana-thomas-pharmd-mph-candidate-2018/2016/07/starting-conversations-about-complementary-and-integrative-medicine ↩