LAS VEGAS—Complementary and alternative medicine (CAM) for chronic low back pain: “what works, how much, and for how long?”The answer: it depends on the strength of the evidence, the expertise of the clinician, the patient’s values—and finding the overlap.
In his presentation, Michael S. Saenger, MD, Atlanta, Georgia, reviewed evidence-based CAM in the management of chronic low back pain that included identifying nonscientific evidence that commonly leads to CAM misuse.
He guided attendees through the nuances of how they can determine whether clinical studies of CAM are powered to detect differences, including the definition of randomized controlled trials, numbers needed to treat, intent to treat, confidence intervals, and the Jadad score, which independently assesses a study’s methodological qualities.
The goal: to guide patients to “take advantage of therapies that have the best evidence,” versus “snake oil.”
Categories of CAM include whole medical systems; mind-body medicine; natural, biologically based products; manipulation and body-based practices; and energy medicine.
Whole medical systems embrace traditional Chinese medicine, Ayurvedic medicine, traditional healers, homeopathy, and naturopathy, while mind-body medicine comprises progressive relaxation, deep breathing exercises, meditation and mindfulness, prayer, music therapy, and yoga.
Dr. Saenger reviewed mindfulness, yoga/Tai Chi, dietary supplements (eg, “Devil’s claw,” or Harpagophytum, a plant native to southern Africa), acupuncture, spinal manipulation therapy, massage, the Alexander technique, and Reiki in depth for the treatment of chronic low pack pain, reviewing relevant clinical trials, efficacy, safety, and cost for each.
After reviewing the state of evidence-based practice for CAM for chronic low back pain, he concluded that the quality of evidence is low to moderate, with short term, modest benefits possible from Devil’s claw, massage, spinal manipulation, and acupuncture. Long-term modest benefits are possible using the Alexander technique, yoga, Tai Chi and, possibly, mindfulness.
Duration of therapy depends both on cost and treatment benefit and on whether the patients themselves can practice the therapy, such as yoga, in contrast, for example, to spinal manipulation, massage, and acupuncture.
When asking, “can I apply this CAM for my patient,” Dr. Saenger said that if the treatment is reasonably valid and moderately effective, considerations should then include the preferences and expectations of the patient, the cost of therapies, the local availability of therapies, and possible side effects.
Ultimately, CAM may be useful in transitioning patients with chronic low back pain away from therapies that are dangerous, ineffective, or passive—high-dose opioids, benzodiazepines, chronic muscle relaxants and chronic sleep medications—towards therapies that are safe, moderately effective, and self-efficacious, which he defined as deep breathing, stretching, use of the Alexander technique, yoga/Tai Chi, and progressive relaxation, or mindfulness. Therapies that can bridge this transition include massage, spinal manipulation, and acupuncture.
He left attendees with this thought: although what is known about CAM—“not much”—long-term opioid therapy for chronic noncancer pain is also based on low-quality evidence.