In yester years spine specialists use to scoff at various alternate treatments for chronic back pain like Acupuncture, Taiichi ,Chiropractic treatment etc.These days, with wide variety of choices available and with more research coming out the so-called alternative treatments are becoming popular. The line between the allopathic approach to back pain and the alternative methods to treat back pain is becoming blurry. Now a days I would call these treatment methods as complimentary health approach rather than an alternative approach.
Let’s analyze these various treatments that are available today for treating chronic back pain.
Patients are often dissatisfied with conventional medical approaches or are averse to modern medications and surgical interventions and turn to complementary and alternative medicines to manage their symptoms.
Acupuncture
Acupuncture is a treatment derived from ancient Chinese medicine. Fine needles are inserted at certain sites in the body for therapeutic or preventative purposes.
Each acupuncture needle produces a tiny injury at the insertion site, and although it’s slight enough to cause little to no discomfort, it’s enough of a signal to let the body know it needs to respond,
It involves stimulating sensory nerves under the skin and in the muscles.
This results in the body producing natural substances, such as pain-relieving endorphins. It’s likely that these naturally released substances are responsible for the beneficial effects experienced with acupuncture.
A course of acupuncture usually creates longer lasting pain relief than when a single treatment is used.
The Chinese philosophy behind acupuncture is a bit more complicated, as the ancient practice isn’t traditionally based in science and medicine. They believed that the human body was filled with and animated by an invisible life-giving force which they called ‘qi’ (pronounced ‘chee’) and when the qi was flowing well and going to all the right places, then a person would experience good mental and physical health. When the qi was flowing incorrectly (blocked or deficient) that would result in illness
The concept of qi isn’t too out there — think of it as your body’s natural inner workings. Sometimes you’re more prone to illness when feeling stressed or anxious. When you’re relaxed and healthy, your body physically reflects that too. After all, your mood, mental health, and general well-being do affect your physical health. Thus, acupuncture aims to assist people in achieving balance, or qi, and, as a result, provide relief for many ailments.
There are a number of forms of acupuncture including needling, moxibustion, and cupping .
Needling involves inserting needles, typically 32–36 gauge, into specific acupuncture points on the body. Needles can be made of ceramic, bronze, iron, gold, silver, or stainless steel.
In electroacupuncture, a current is applied through the needle. Laser acupuncture uses non-thermal laser irradiation on standard acupuncture points.
Moxibustion utilizes burning moxa above the skin near pressure points. Finally, cupping is a technique in which bamboo, glass, or ceramic cups are used to create a vacuum over the acupuncture points.
What are the recommendations?
There are guidelines now for usage of acupuncture for chronic pain
Currently, NICE only recommends considering acupuncture as a treatment option for:
- chronic (long-term) pain
- chronic tension-type headaches
- migraines
Acupuncture is also often used to treat other musculoskeletal conditions (of the bones and muscles) and pain conditions, including:
- joint pain
- dental pain
- postoperative pain
However, the evidence on the effectiveness of acupuncture compared with other treatments is unclear
What’s the evidence?
Over the past quarter of a century, numerous systematic reviews have investigated the effectiveness of acupuncture in the management of LBP, but review conclusions are sometimes contradictory and often limited by the quantity and quality of the included studies.
In the past decade, three clinical practice guidelines have been published with inconsistent conclusions regarding the recommendations for acupuncture in the treatment of chronic LBP .
Overall the analysis suggests that,
(1) for acute LBP, there exists inconsistent evidence that acupuncture has a more favourable effect than sham acupuncture in relieving pain but consistent evidence that acupuncture does not significantly differ from sham acupuncture in improving function;
(2) for chronic LBP, consistent evidence found that acupuncture provides short-term clinically relevant benefits on pain relief and functional improvement when compared with no treatment or when acupuncture is added to another conventional intervention;
(3) for chronic LBP, it seems that genuine acupuncture produces a clinically significant reduction in pain when compared to sham acupuncture and sham therapy at short-term follow-up, but no impact on functional limitation.
According to these findings, it is encouraging to note that acupuncture, either used in isolation or as an adjunct to other interventions, has been demonstrated as an effective clinical option for patients with chronic LBP and may be advocated in routine clinical practice.
Considering the intractable nature of LBP, more effective, comprehensive treatment options, which might include acupuncture, are needed to optimize current management.
Ayurveda
Ayurveda, a natural system of medicine, originated in India more than 3,000 years ago. The term Ayurveda is derived from the Sanskrit words ayur (life) and veda (science or knowledge). Thus, Ayurveda translates to knowledge of life.
Based on the idea that disease is due to an imbalance or stress in a person’s consciousness, Ayurveda encourages certain lifestyle interventions and natural therapies to regain a balance between the body, mind, spirit, and the environment.
Ayurveda treats low back pain with various forms of dietary modifications, yoga and massages with warm oil.
Although there is no real evidence how it works , it probably relieves chronic pain by mindfulness and releasing endorphins that relieves pain.
In India, Ayurveda is considered a form of medical care, equal to conventional Western medicine, traditional Chinese medicine, naturopathic medicine, and homeopathic medicine. Practitioners of Ayurveda in India undergo state-recognized, institutionalized training.
Modern medicine is based more on rationalism, reductionism with deeper understanding of molecules, cells, organs or diseases as parts. In the process, however, the sight of the whole person seems to have been somewhat neglected. In general, Ayurveda is experiential and holistic, whereas that of the modern medicine is based more on experimental, analytical and reductive reasoning.
Ayurveda as an ancient science of life has a long history, and its basic principles may be valid even today. However, essence of any science is a continuous quest for new knowledge through research, development and newer applications. The mode of manifestation of disease, the geo-climatic environment, plants, animals and microbes have evolved.
Definitely, human behaviour, lifestyle and genetics have changed. Clearly, continuous research on safety, quality and efficacy of Ayurvedic drugs and procedures is needed and the patients have the right to that information these days.
However, the new philosophy of health care is moving from illness to wellness, from treatment to prevention and early diagnostics and from generalized approach to personalized medicine and in that category ayurveda will have a definite and significant role to play along with contemporary medicine.
Chiropractic treatment
Chiropractic adjustment is a procedure in which trained specialists (chiropractors) use their hands or a small instrument to apply a controlled, sudden force to a spinal joint.
Chiropractors approach patient care in a manner similar to that used in conventional medicine. They interview the patient, obtain a detailed health history, perform an examination, do tests, and develop a working diagnosis. They then develop a management plan, start treatment, and monitor the patient’s progress. Chiropractors often treat problems related to the musculoskeletal system.
The manual treatment methods used by chiropractors range from stretching and sustained pressure to specific joint manipulations, which are usually delivered by hand and involve a quick and gentle thrust. The purpose of the manipulations is to improve joint motion and function. Manipulations are most commonly done on the spine, but other parts of the body may also be treated in this way.
Common treatments include:
- Manual, ‘hands-on’ therapy
- Soft tissue therapy
- Electronic modalities, such as therapeutic ultrasound and cold laser therapy
- Customized, therapeutic exercise programs
- Self-management tools and techniques (like positions for relief or coping strategies for pain)
- Advice and education
Spinal manipulation and manual manipulation.
This type of manual manipulation refers to a high-velocity, short lever arm thrust that is applied to abnormal vertebra with the goal of improving functionality, reducing nerve irritability and restoring range of motion in the back. It is also commonly known as chiropractic adjustment.
Mobilization.
Refers to low velocity manipulation, movement and stretching of the muscles and joints, with the goal of increasing the range of motion within those areas.
What’s the evidence?
The overall evidence suggests:
Mobilisation can be delivered as a standalone therapy, although it is typically offered within the constructs of a broader treatment package, together with exercise therapy or combined with usual care.
This is important because chiropractic treatement is by nature a passive treatment. Therefore, to prevent inappropriate behaviour and to empower patients to take control of their condition it is vital that practitioners impart the proper message to their patients.
The incidence and causal relations with serious adverse events are difficult to establish, in part due to inherent methodological limitations of the included studies.
Importantly, predictors of these events are unclear. Given this, clinicians should ensure that patients are fully informed of potential risks before treatment.
Biofeedback therapy
Biofeedback is a type of therapy that uses sensitive electronic instruments to measure a person’s bodily processes, such as heart rate, and then feeds back that information to the patient.
With this information, an individual can learn how to control their own physiology and, in many cases, reduce symptoms or improve function.
There are two main types of biofeedback:
peripheral biofeedback and neurofeedback. Both have been shown to be helpful in reducing a wide range of chronic pain conditions.
Peripheral biofeedback involves measuring a person’s muscle tension using electromyography (EMG), hand temperature (blood flow), heart rate, respiration rate, skin moisture (clinically known as galvanic skin response or GSR) – all of which relate to levels of stress. A person can gain voluntary control over these measures by combining relaxation techniques with the information provided.
Neurofeedback, also known as neurotherapy, involves electroencephalogram (EEG) biofeedback or brainwave biofeedback, which measures the electrical activity of the brain. This process is more complex because it involves unconscious learning, which can be achieved by rewarding the brain with audio and visual feedback for making desired changes in its electrical activity.
Biofeedback is an active rather than passive treatment. This means that the patient takes an active role in the therapy. The therapist will guide you through talking about or imagining specific scenarios. They’ll ask you to pay attention to how your body reacts when you’re stressed, and in contrast, when you’re relaxed, by looking at the feedback displayed on the monitor. For example if you’re focusing on heart rate, when you’re stressed your heart rate will rise. This will cause the monitor to beep or flash, and you’ll be able to see how high your heart rate is.
The therapist will then teach you how to recognise those states of stress and relaxation within your body. Together you will work on how to actively calm yourself. You’ll be able to see your progress on the monitor. The goal is to give you an awareness of what is happening within your body and equip you with the tools to actively relax yourself without the use of the monitor. You’ll then be able to use these techniques in your day to day life to help you tackle your health issues.
What’s the evidence?
There is more evidence on biofeedback therapy on chronic back pain
International Journal of Behavioral Medicine evaluated the efficacy of peripheral biofeedback for treating chronic back pain. Twenty-one studies were reviewed that included a total of 1,062 patients. The reviewers found a significant small-to-medium effect on pain intensity reduction. Improvements were maintained or increased over an average of 8 months of follow-up, with a significant small-to-large effect size. Biofeedback also significantly reduced Depression and muscle tension and improved cognitive coping, both at the end of treatment and at follow-up. The reviewers found that longer biofeedback treatments were more effective at reducing disability in general.
Yoga, Pilates, Tai chi
By adopting very basic and sometimes very complex body postures and breathing techniques, the goal of these methods is to provide the practitioner a number of physical and mental benefits.
Physical Benefits
Strengthening from holding positions.
These methods helps increase strength in very specific muscles and muscle groups. Holding positions is not intended to be uncomfortable. However, it does require concentration and specific use of muscles throughout the body. Muscle strength improves by remaining in these positions and incorporating various movements.
Many of the postures in yoga gently strengthen the muscles in the back, as well as the abdominal muscles. Back and abdominal muscles are essential components of the muscular network of the spine, helping the body maintain proper upright posture and movement. When these muscles are well conditioned, back pain can be greatly reduced or avoided.
Posture, balance, and body alignment
Poses for these methods are meant to train the body to be healthy and supple. Consistent practice and application will result in improved posture, and an increased sense of balance, with head, shoulders and pelvis in proper alignment.
Many believe that suffering from back pain increases because of perception. Negative psychological and emotional factors may not necessarily change the physiology of the back, but may tend to magnify a problem that already exists.
Thus, reducing the perception of the pain (such as through meditation) yoga helps people concentrate their energy on breathing and maintaining posture.
Mindfulness and cognitive behavioural therapy
Mindfulness is a type of meditation in which you focus on being intensely aware of what you’re sensing and feeling in the moment, without interpretation or judgment. Practicing mindfulness involves breathing methods, guided imagery, and other practices to relax the body and mind and help reduce stress.
Cognitive behavioural therapy (CBT) is a type of psychotherapeutic treatment that helps people learn how to identify and change the destructive or disturbing thought patterns that have a negative influence on their behaviour and emotions.
Mindfulness-based interventions, including mindfulness meditation (referred to just as “meditation”), help train the mind in non-judgmental attention to the present moment experiences. They have great potential as therapies for Chronic low back pain(CLBP). These approaches are already widely used to improve health, well-being, and pain, and they show sustained effects over time. Mindfulness-based interventions can positively impact many chronic health problems, including depression and anxiety, which are common in patients with CLBP.
Mindfulness-based interventions can exert biological effects and have been associated with beneficial changes in brain areas involved in adaptive pain, stress, cognitive, and affect regulation. Meditation-learned skills can complement those acquired through “traditional” behavioural therapies, such as Cognitive Behavioural Therapy (CBT), which is a part of evidence-based, standard-of-care treatments for CLBP.
Meditation helps with opioid use and mood effects in people with CLBP as well. Preliminary evidence also suggests that mindfulness-based treatments can assist patients with chronic pain with reducing aberrant opioid-use-related behaviours, desire for opioids, and daily opioid use.
Mindfulness-based interventions, including mindfulness meditation practice, facilitate Pain coping skills. They play a major role in how patients cope with and experience pain. Acceptance-based pain coping has been linked to improved outcomes in chronic pain.
Although a considerable variety of conservative therapy alternatives are available for the treatment of LBP, no single modality appears to be superior.
These treatment modalities act as complimentary methods of treatment rather than as an alternative.
The pillars for treatment for chronic back pain like physiotherapy and core strengthening exercises, adopting good posture techniques, watching out for redflag symptoms, regular follow up with a spine specialist, still remain important.
Each of these treatment modalities has to be customised and tailored to each patient depending on the geo-climactic environment, cultural acceptance and more importantly over evidence available so that the patient can make an informed choice.