Treatments for Back Pain: Can We Get Past Trivial Effects?

The history of treatments for back and neck pain is generally one of small increments in benefit. For patients with acute pain, the natural history is favorable, and it is hard to prove that most treatments result in greater improvement than the nonspecific effects of natural history, placebo, and regression to the mean. The treatments that appear better than placebo, such as nonsteroidal anti-inflammatory drugs, muscle relaxants, and spinal manipulation, generally have modest effects (1-3). For chronic pain, the natural history is less favorable, but it is similarly difficult to prove that most treatments are better than nonspecific effects alone. The literature is replete with conflicting results, modest effects, and weak studies. The treatments that may be better than placebo, such as exercise programs, tricyclic antidepressants, and cognitive behavioral therapy, often require substantial patient commitment or lifestyle changes. In both clinical practice and clinical trials, many patients decline these treatments or find adherence difficult.

Furthermore, drug side effects and surgical risks attend many conventional treatments. Patients say that doctors spend too little time, don't understand their problems, or are dismissive. The combination of desperate patients, clinicians eager to offer relief, advocacy for favored approaches, lack of definitive end points (death or cure), and misleading nonspecific effects has promoted wide adoption of treatments that have ultimately been discredited. These include bed rest, lumbar traction, sacroiliac fusion, and others, all of dubious efficacy.

It should be no surprise, then, that patients turn increasingly to complementary and alternative treatments for symptoms like back and neck pain. Spinal manipulation, acupuncture, and massage therapy are the most commonly used alternative treatments for these conditions. Such …