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Complementary and Integrative Interventions for Arthritis and Back Pain 

Complementary and Integrative Interventions for Arthritis and Back Pain
Chapter:
Complementary and Integrative Interventions for Arthritis and Back Pain
Author(s):

Karen J. Sherman

and Michelle L. Dossett

DOI:
10.1093/med/9780199380862.003.0028
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Introduction

Chronic pain is common in older adults, affecting up to 50% of community-dwelling seniors and up to 80% of seniors living in residential housing (1). Arthritis, especially osteoarthritis, and back pain are the most common pain conditions in older adults. Complementary and integrative medicine (CIM) is often used for symptom relief in these conditions. In this chapter, we will briefly describe the epidemiology of these pain conditions in older adults and review the evidence for the efficacy and safety of CIM in patients with osteoarthritis and back pain, focusing whenever possible on studies of older adults.

Arthritis

Osteoarthritis is one of the most common musculoskeletal diseases and is characterized by progressive loss of articular cartilage in synovial joints, joint space narrowing, hypertrophy of surrounding bones, and thickening of the joint capsule (2). The resulting changes frequently result in pain, impaired mobility and activities of daily living, and reduced quality of life (2). The most commonly affected joints are the knees, hips, and hands. Risk factors include older age, obesity, female gender, history of heavy work or joint trauma, and genetics. The World Health Organization estimates that worldwide 10% of men and 18% of women over the age of 60 have symptomatic osteoarthritis, and that 80% of those with osteoarthritis have limitations in movement and 25% cannot perform everyday activities (3). In adults 75 years and older the prevalence of knee and hip osteoarthritis is 40% and 10%, respectively (3). The overall prevalence of osteoarthritis is expected to increase given the rise in obesity and the aging population.

Management approaches aim to reduce pain and to improve function, as no substantial disease- modifying interventions have been described. For severe pain, joint replacement surgery is usually recommended. Recently, a number of professional societies have updated their recommendations on the non-surgical management of osteoarthritis (4). They endorse weight loss, exercise, education, and self-management, as well as analgesics (e.g., acetaminophen and non-steroidal anti-inflammatory drugs [NSAIDs]) and assistive devices (e.g., canes) when necessary (4). Recommendations for the use of CIM therapies vary, though generally they are not recommended, or no specific recommendation is made. Notably, the effect sizes of available interventions (both conventional and complementary) are generally low to moderate (0.2–0.4) (4). Use of NSAIDs is limited by the risk of GI bleeding and is generally discouraged in the elderly. Recently, the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) published a stepwise algorithm (5) for the management of knee osteoarthritis, which includes a number of CIM therapies: acupuncture, manual therapy, tai chi, and prescription glucosamine sulfate and chondroitin sulfate.

Acupuncture

Acupuncture is one of the most studied interventions for osteoarthritis as well as other types of chronic pain. Manheimer and colleagues (6) published a review of trials of acupuncture for peripheral joint osteoarthritis that included 16 trials and 3498 participants. The mean age of the trial participants was in the early to mid-sixties for most trials. They found that for sham-controlled trials, acupuncture showed statistically significant, but clinically irrelevant, short-term benefits. Of note, however, the largest and best controlled trial included in this analysis was also the one most likely to have a partially active sham acupuncture arm, and the primary pain measurement occurred 7 weeks after treatment, thus potentially underestimating the effect of real acupuncture (6,7). Acupuncture provided both statistically and clinically relevant improvements in pain compared to wait-list controls and some other active treatments. The benefits of acupuncture were similar to that of exercise programs but appeared to have no benefit as an adjuvant to exercise. A subgroup analysis suggested that trials with an insufficient number of treatment sessions yielded fewer benefits than studies with an adequate number of treatment sessions (6).

Vickers and colleagues (8) obtained individual patient data to conduct a meta-analysis of acupuncture compared to sham acupuncture and to no treatment control (29 studies, n = 17,922) for chronic pain conditions. They chose only large, high-quality studies for their analysis. For studies of osteoarthritis, they found an effect size of 0.57 (95% CI: 0.50 to 0.64) for acupuncture compared to no treatment control (6 studies, n = 1968) and 0.26 (95% CI: 0.17 to 0.34) for acupuncture compared to sham acupuncture (5 studies, n = 1487). They found similar effect sizes for studies of acupuncture for other chronic pain conditions.

Corbett and colleagues (7) used a network meta-analysis approach to compare the efficacy of acupuncture to a variety of other conservative physical treatments that have not been directly compared in head-to-head trials. They did this by comparing relative improvements in short-term pain relief in the active arms to changes in usual care and placebo groups. In their primary analysis of 114 trials (9709 patients), eight treatments had a mean effect suggesting improved pain relief over usual care: interferential therapy, acupuncture, transcutaneous electrical nerve stimulation (TENS), pulsed electrical stimulation (PES), balneotherapy, aerobic exercise, sham acupuncture, and muscle-strengthening exercise. Using acupuncture as the comparator, acupuncture was significantly better at reducing pain than sham acupuncture, muscle-strengthening exercise, weight loss, pulsed electromagnetic fields (PEMF), placebo, insoles, neuromuscular electrical stimulation (NMES), and no intervention.

The authors also conducted a pre-specified sensitivity analysis of better quality studies that included 35 trials (11 of acupuncture and 9 of muscle-strengthening exercise) and 3499 patients. Compared to standard of care, the interventions that resulted in statistically significant better pain relief were acupuncture, balneotherapy, sham acupuncture, and muscle-strengthening exercise. In addition, acupuncture resulted in significantly better pain relief than sham acupuncture, muscle-strengthening exercise, weight loss, aerobic exercise, and no intervention. For studies compared to placebo-controls, inferential therapy (one study) also showed a strong effect. Of note, the studies included in this analysis were quite heterogeneous. Most were low-quality studies, and even some of the better quality studies were pragmatic studies where blinding was not possible.

Overall, these studies suggest that compared to sham acupuncture, verum acupuncture likely significantly improves osteoarthritis pain, in the short to medium term, although the overall effect size may be small. In addition, sham acupuncture significantly improves pain in many trials, and whether this is entirely placebo effect or a partially active intervention is unclear, as the types of sham controls used vary widely. Of note, few of the most common treatments for osteoarthritis, including NSAIDS, meet the cutoff for clinically meaningful effect sizes (6), and the effect size for acupuncture versus sham acupuncture is similar to that of NSAIDS versus placebo (SMD 0.32; 95% CI: 0.24 to 0.3 (7). Moreover, while the overall effectiveness of acupuncture may be limited, it is one of the more effective treatment options for short-term relief of osteoarthritis-related pain and has an excellent safety profile. The treatment frequency in these trials varied from one to three times a week and from 3 to 26 weeks. The optimal treatment frequency for pain relief has not been determined, nor has the average duration of treatment effect.

Two pragmatic studies (one from Germany and one from the UK) (9) examined the cost- effectiveness of acupuncture treatment for osteoarthritis and found that the cost per quality-adjusted life year (QUALY) (in 2013 US dollars) ranged from $6000 to $24,900, indicating good value.

Mind–Body Exercise

Three different meta-analyses have examined the effects of tai chi on pain in osteoarthritis (3,10,11). Two of these meta-analyses also examined physical function and stiffness (10,11). The trials included in these analyses are only partially overlapping and include wait-list as well as attention control groups. Two of these analyses included studies on hip (in addition to knee) osteoarthritis (3,11). All three analyses demonstrated short-term improvements in pain with tai chi relative to control groups, and improvements in physical function and stiffness were found as well (10,11). The authors encouraged the incorporation of tai chi into standard rehabilitation programs (11), yet cautioned that results may be limited by potential biases. There are insufficient data on the long-term benefits of tai chi practice for osteoarthritis. Nonetheless, this slow, meditative mind–body movement-based practice seems uniquely suited for the elderly and those whose health poses physical limitations.

Though exercise programs are commonly recommended for patients with osteoarthritis, there are relatively few published randomized controlled trials, and their structure and content are very heterogeneous. Escalante and colleagues concluded that overall, exercise programs based on tai chi had better results than mixed exercise programs, but without clear differences. There are little data at this time to support the use of yoga for relief of osteoarthritis pain; however, a few studies have been conducted (12).

Manual Therapies

One small systematic review (2) has examined the effects of manual therapy on hip (1 trial) or knee (3 trials) osteoarthritis. Recently, three additional studies assessing the effect of manual therapies on knee osteoarthritis (13), hip osteoarthritis (14), or either joint (15) have been published. Together, these studies have included a range of different manual techniques (physiotherapy, massage, chiropractic) and have suggested that these techniques may be more effective than usual care and possibly cost-effective as well (16). A dose finding study of massage therapy for knee osteoarthritis demonstrated maximum pain relief at 8 weeks with 60 minutes of treatment once weekly compared to usual care (13). However, this improvement was not sustained at 24 weeks.

Dietary Supplements and Herbs

Dietary Supplements

The most studied supplements for osteoarthritis are glucosamine and chondroitin. Glucosamine is an amino sugar and an important component of glucosaminoglycans, a component of cartilage (17). As a dietary supplement, it is available as both glucosamine hydrochloride and glucosamine sulfate. Data suggest that the sulfate form is more effective; however, there are likely differences in bioavailability across glucosamine sulfate preparations (17,18). Chondroitin is a type of glycosaminoglycan found in articular cartilage, and the bioavailability of chondroitin sulfate also varies across manufacturers. Both glucosamine sulfate and chondroitin sulfate are available by prescription in Europe. The proposed mechanism of action of these compounds includes decreasing inflammation, increasing synthesis of cartilage precursors, and altering chondrocyte activity (17).

Numerous randomized controlled trials and meta-analyses have been conducted using these compounds, either alone or in combination with both positive and negative results. Trial heterogeneity (e.g., supplement formulation, dose, length of intervention, population, outcomes) and the poor quality of early studies in this field have been major limitations to understanding the true effect of these compounds (17). Overall, their safety profile is similar to that of placebo (17).

Many of the RCTs of glucosamine have been performed using a product by Rottapharm/Madaus, which appears to be more active than other products that have been tested and is purported to be in a more bioavailable form. In 12 trials of this product for osteoarthritis-related pain, the effect size was −1.05 (95% CI: −1.43 to −0.68) compared to an effect size of −0.11 (95% CI: −0.46 to 0.24) in 13 trials of other products (18). When the authors restricted their analysis only to studies with low risk of bias, the effect sizes were −0.27 (95% CI:−0.43 to −0.12, 3 trials) and 0.02 (95% CI:−0.08 to 0.12, 5 trials). The standard dose was 1500 mg of glucosamine sulfate once daily. There does not appear to be any benefit for hip-related osteoarthritis pain (17).

A meta-analysis of 20 trials (3846 patients, median age 61) examined chondroitin sulfate for treating osteoarthritis-related pain (19). Doses ranged from 800 to 2000 mg per day. The effect size was −0.75 (95% CI: −0.99 to −0.50). However, there was a high degree of trial heterogeneity that was largely explained by three study characteristics: concealment of allocation, intention-to-treat analysis, and sample size. Studies that reported analgesic co-interventions also showed smaller benefits of chondroitin. When the authors restricted their analysis to three large, higher quality trials that included 40% of the patients, the effect size was −0.03 (95% CI: −0.13 to 0.07). Notably, while more recent trials were generally of higher quality, they also tended to enroll patients with less severe disease (19).

In addition to assessing pain outcomes, some of the longer term trials have examined structural effects by assessing changes in joint space narrowing. A meta-analysis (20) assessing this outcome concluded that glucosamine sulfate had no effect on joint space narrowing over the first year of treatment, but had a small to moderate protective effect after 3 years of daily dosing (SMD 0.432; 95% CI: 0.235 to 0.628, p < 0.001). Similar results were observed for chondroitin sulfate, which had a small but significant protective effect after 2 years (SMD 0.261; 95% CI: 0.131 to 0.392, p < 0.001) (20). Thus, both of these compounds may delay radiologic progression of osteoarthritis after daily administration for 2–3 years.

A few studies have examined the use of other sulfur-containing compounds such as S-adenosylmethionine (SAMe) and methylsulfonylmethane (MSM) for the treatment of osteoarthritis- related pain. While initial studies appear promising, there are insufficient data to recommend the routine use of these products (21).

Herbal Supplements

A growing number of herbal preparations are being investigated for osteoarthritis treatment, many with promising results in initial studies. Recently two Cochrane reviews have examined the body of evidence for oral and topical herbal therapies for osteoarthritis (22,23).

Cameron and Chrubasik (22) examined 49 studies of oral preparations of 33 different plants, used individually or in combination, for the treatment of osteoarthritis. There were no serious adverse events for any of the herbal products tested, and some appeared to have safety profiles that were better than NSAIDs. Many of these studies had a high risk of bias, and there were only a sufficient number and quality of studies to form definitive conclusions about two agents. They concluded that there is high-quality evidence that Boswellia serrata slightly improves pain and function in individuals with osteoarthritis. Individuals taking 100 mg of enriched Boswellia serrata extract rated their pain 17 points lower (on a 100-point scale) than individuals taking placebo at 90 days. The number needed to treat for an additional beneficial outcome (NNTB) was 2. Quality of life and joint changes were not examined.

They also concluded that there was moderate evidence that the avocado-soybean unsaponifiables (ASU) product Piascledine probably improves pain and function slightly but does not decrease joint space narrowing (22). People taking Piascledine rated their joint pain 8 points lower at 3 to 12 months compared to those taking a placebo. NNTB was 8. While there was no increased incidence of adverse events compared to placebo in the studies examined, a pharmacovigilance analysis has noted 117 post-marketing reports of adverse events with this product.

In their analysis of studies of topical herbal preparations, Cameron and Chrubasik (23) examined seven studies of seven different interventions including 785 participants in total. From a single study each, they concluded that topical arnica extract gel probably improves pain and function as well as topical 5% ibuprofen, that comfrey extract gel probably improves pain more than placebo, and that topical capsicum extract gel will likely not improve pain or function better than placebo. Side-effect profiles were similar for arnica and comfrey compared to placebo but were significantly higher for capsicum extract. As these authors used a strict definition of herbal preparation, they did not include studies of pharmaceutical preparations of topical capsaicin. In a separate review (24), they concluded from five studies of capsaicin (n = 456) that there was moderate evidence that 4 times daily use of topical capsaicin (0.025% w/v) cream over 3–4 weeks significantly reduces osteoarthritis pain (mean difference from placebo −7.65 on a 100-point VAS scale, 95% CI: −12.69 to −2.61).

Summary

Osteoarthritis is a major source of pain and disability in elders, and its prevalence is expected to increase in the next decade. The majority of studies in this field are focused on treatments for knee osteoarthritis (see Table 28.1 for a summary). The mean age of participants in most studies is in the early to mid-sixties; however, tai chi studies tended to enroll older adults with a mean age closer to 70. The effect sizes for both conventional and complementary non-surgical management approaches are low to moderate. Within complementary approaches, acupuncture, tai chi, massage, glucosamine sulfate, and condroitin sulfate (both pharmaceutical grade), Boswellia serrata extract, and possibly topical arnica and comfrey extract may play a role in pain reduction. It is important to note that placebo effects can be large in many trials of CIM for osteoarthritis, may be long lasting, and that this effect represents real relief of symptoms (4). Importantly, the safety profile of these approaches is generally better than that of NSAIDs, an important consideration in the elderly population. Preliminary data suggest that acupuncture treatment may be cost-effective. Further studies assessing the cost-effectiveness of other approaches are necessary. At present, none of these complementary approaches are covered by Medicare (social insurance program for the elderly in the US), thus keeping these treatments out of reach for most senior citizens in the United States.

Table 28.1. Summary of Data on CIM Therapies for Osteoarthritis (OA)–Related Pain

Therapy

Effect Size (95% CI)

Cautions and Contraindications

Dosing/Notes

Acupuncture

  • 0.42 (0.15 to 0.70) (reference 7)

  • 0.16 (0.07 to 0.25) compared to sham (6)

Caution in individuals at high risk for bleeding and those prone to vasovagal episodes.

Studies included knee and hip OA with treatments ranging 1–3 times per week and 3–26 weeks; 6 treatments or less may be suboptimal.

Tai chi

0.45 (0.70 to 0.20) (11)

Individuals with severe pain in weight-bearing joints may have difficulty.

Studies included knee and hip OA with treatments ranging 1–3 times per week and 8–24 weeks.

Yoga

Insufficient data

May require modification or be contraindicated in individuals with cardiovascular disease or osteoporosis.

Insufficient data

Manual therapy

Between 0.48 (0.08 to 0.87) and 0.94 (0.44 to 1.44) (2)

Caution in individuals with cancer. Avoid if local open wound or infection.

60 minutes once a week for 8 weeks for massage for knee OA (13); 25 minutes twice a week for 5-6 weeks for combined manual therapy for hip OA (2,14).

Glucosamine sulphate

  • Between 1.05 (1.43 to 0.68) and 0.27 (95% CI: 0.43 to 0.12)

  • (18)

Avoid in individuals with shellfish allergy.

1500 mg/day. May reduce joint space narrowing when taken over years. Non-pharmaceutical grade products may not be active. Benefit only demonstrated for knee OA.

Chondroitin sulfate

Between 0.75 (0.99 to 0.50) and 0.03 (0.13 to −0.07) (19)

Avoid in individuals with shellfish allergy and with prostate cancer (theoretical increased risk of spread).

800–2000 mg/day. May reduce joint space narrowing when taken over years. Unclear if reduces pain. Non-pharmaceutical grade products may not be active. Studied in hip and knee OA.

SAMe, MSM*

Insufficient data

Avoid use of SAMe in individuals with bipolar disorder due to risk of hypomania.

Insufficient data

Boswellia serrata

  • 16.57 (24.67 to 8.47)

  • (22)

  • Improvement on VAS pain scale at 90 days

Caution, inhibits some CYP enzymes.

100 mg daily. NNT = 2. Only studied in knee OA.

Avocado-soybean unsaponifiables (ASU) product Piascledine

  • 8.47 (15.90 to 1.04)

  • (22)

  • Improvement on VAS pain scale

Adverse events in post-marketing studies.

300 mg daily. NNT = 8. Hip or knee OA.

Arnica

  • 3.80 (10.10 to 2.50)

  • (23)

  • Improvement on VAS pain scale compared to topical ibuprofen

Side-effect profile similar to topical ibuprofen gel.

Tincture applied topically 3 times daily. Single study (n = 204) of an herbal extract for hand OA.

Comfrey

  • 41.50 (48.39 to 34.61)

  • (23)

  • Improvement on VAS pain scale compared to placebo

No

2 g applied topically 3 times daily. Single study (n = 200) of an herbal extract for knee OA.

Capsicum

  • 1.00 (6.76 to −4.76) (23)

  • Improvement in VAS pain scale compared to placebo

Causes skin irritation and burning.

2 inches of gel applied topically 3 times daily. Single study (n = 100) of an herbal extract for knee OA.

Capsaicin

  • 7.65 (12.69 to 2.61)

  • (24)

  • Mean difference in VAS pain scores compared to placebo

Causes skin irritation and burning.

0.025% ointment (4 studies, 1 study 0.075%) applied topically 4 times daily. 5 studies of a pharmaceutical preparation for multiple joint sites.

* SAMe = S-adenosylmethionine, MSM = methylsulfonylmethane.

Back Pain

Back pain, typically affecting the lower back, is common among adults, with up to 80% of individuals reporting it at some point in their lives. A national survey found that about 30% of community-dwelling adults over the age of 65 reported back pain in the prior 3 months (25), with 6%–12% of all adults reporting disabling back pain (26). In adults of all ages, about 85% of back pain cannot be given a pathophysiological diagnosis, but in older adults, specific causes, including disc degeneration, disc herniation, soft tissue disorders (e.g., myofascial pain, sacroiliac joint dysfunction), spinal stenosis, and vertebral fractures, are more common (27).

Among older adults with chronic low back pain, Rundell et al. (28) found that both pain and back-related dysfunction were more severe as age increased. Only about 40% of patients reported a clinically important improvement in their back pain at 3 or 12 months, and about 35% had clinically significant improvement in their back-related dysfunction at these time points. Roughly 25% reported that their back pain had resolved by 12 months.

Risk factors for new onset back pain include previous back pain, depression, and poor self-rated health (29). Being female, presence of concomitant leg pain, worse baseline levels of pain and dysfunction, longer duration of symptoms, presence of pain in other sites, and a diagnosis of lumbar spinal stenosis are associated with persistent pain and disability (28).

Typical care for back pain is designed to reduce pain and improve functional status and should address other symptoms associated with pain, including psychological distress, impaired sleep, reduced appetite, and inappropriate increases in healthcare utilization. Rates of lumbar spinal fusion have skyrocketed more than increases in the prevalence of low back pain, even though they are not indicated for the majority of older adults with chronic low back pain (26). Non-surgical management of low back pain includes medications plus a number of evidence-based non-pharmacological therapies, including exercise and physical therapy (1,30). Some medications typically used for back pain, such as non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, are potentially problematic in older adults. However, the 2007 guidelines released by the American Pain Society/American College of Physicians recommended eight evidence-based non-pharmacological therapies for back pain. Four of these therapies were CIM therapies (i.e., acupuncture, massage therapy, spinal manipulation, and yoga). Effect sizes are typically moderate, with no clear evidence of superiority of one therapy over another.

A large number of alternative treatments, primarily non-pharmacological, are being used by individuals with back pain. Herein we review those that are most popular and contain the largest evidence base (i.e., acupuncture, massage therapy, spinal manipulation as well as chiropractic and osteopathic care, and yoga), as well as some promising therapies with emerging evidence (Alexander Technique, herbal medicine, meditation and tai chi).

Acupuncture

Reviews of acupuncture papers have been compiled for acute low back pain, sciatica, spinal stenosis, and non-specific chronic low back pain, as well as back pain in general. Overall, while these studies include needle acupuncture, they vary in the specific location and number of acupoints needled, the use of adjunctive treatments such as heat, the number of treatments per week, and the number of weeks of treatment. This variation, coupled with differences in the comparators used and the schedule of outcome assessments, which typically include pain intensity or pain bothersomeness as well as back-related dysfunction, makes summary of the results challenging.

In 2013, Lee and colleagues (31) reviewed 11 trials with 1139 participants who had acute low back pain. Eight of the trials were from China, one from Japan, and two from Europe. The dose varied from one treatment to up to 12 over a period of 4 to 6 weeks. While there were substantial methodological limitations, there were statistically significant benefits of acupuncture for pain (mean difference = −9.38; 95% CI: −17.00 to −1.76) but not function compared to sham acupuncture, and modest but significant benefits compared to NSAIDS (RR 1.11; 95% CI: 1.06 to 1.16). In a network meta-analysis of patients with sciatica, Lewis (32) found that acupuncture and four other treatments (among 21 treatments from 90 trials and quasi-trials that were included in the analysis) were statistically superior to usual care or an inactive control. In a systematic review that included six trials from China (and 582 patients), Kim et al. (33) found positive results for “treatment success” for acupuncture for adults with lumbar spinal stenosis on pain, symptoms, and function, but given the poor quality and heterogeneity of the trials were unwilling to draw firm conclusions.

Lam et al. (34) included 32 studies in their systematic review of chronic non-specific low back pain, which found acupuncture effective for pain reduction compared to no treatment, medications, or sham acupuncture, but noted methodological weaknesses in many studies. Improvement in back-related dysfunction was evident among acupuncture patients compared with no treatment and medications (34). Compared to patients receiving usual care alone, those who were randomized to acupuncture plus usual care reported less pain and improved back-related dysfunction (34). Finally, Lam (34) found that patients receiving electro-acupuncture had less pain and improved back-related dysfunction. In an individual patient–level meta-analysis of high-quality randomized trials of chronic non-specific low back pain, Vickers et al. (2012) (8) found that acupuncture was superior to both sham acupuncture (effect size = 0.20; 95% CI: 0.09 to 0.31; 5 trials, n = 1068) and a no-acupuncture control (effect size = 0.46; 95% CI: 0.4 to 0.51; 5 trials, n = 3864). The vast majority of patients in most trials were under 65 years of age, though the trials that included older adults were also positive. Overall, acupuncture trials have been associated with a favorable safety profile.

The cost-effectiveness of acupuncture treatment for low back pain has been studied in two pragmatic studies (one from Germany and one from the UK) (9). The cost per QUALY (in 2013 US dollars) ranged from $7370 to $13,800, indicating good value by US standards.

Chiropractic, Osteopathy, and Spinal Manipulation

In a review of spinal manipulation for chronic low back pain that included 26 randomized controlled trials (6070 patients), Rubinstein et al. (35) found high-quality evidence that spinal manipulation had statistically significant, but clinically irrelevant, benefits on pain relief (mean difference = −4.16; 95% CI: −6.97 to −1.36) and on back-related dysfunction (standardized mean difference = −0.22; 95% CI: −0.36 to −0.07) compared to other interventions. When added to another intervention, spinal manipulation showed statistically significant improvement in pain and back-related disability in the short term. Very low-quality evidence found spinal manipulation not superior to sham manipulation or inert interventions for short-term pain relief or back-related dysfunction. No serious adverse events were associated with spinal manipulation.

In a review of spinal manipulation for acute low back pain that included 20 trials (2674 patients) (36), spinal manipulation was not superior to inert therapies or other recommended therapies. They noted that the number of trials for each specific comparison was small, however.

One trial reviewed by Rubinstein (35) focused on adults at least 55 years old and found that the typical technique of spinal manipulation used by chiropractors (HVLA, high velocity, low amplitude) had similar effects to a more gentle technique (LVLA, low velocity, low amplitude); both were moderately sized at the end of treatment. Three other trials of spinal manipulation in older adults are ongoing, but lack results.

Chiropractors can use a variety of manipulative and non-manipulative techniques that would be suitable for older adults who have special needs, such as frailty, severe osteoporosis and other bone diseases, or use of anticoagulant therapy. There has been considerable concern about the possibility that spinal manipulation is dangerous for older adults. Using Medicare administrative data on office visits, Whedon and colleagues (37) found that beneficiaries with neuromusculoskeletal complaints who made a chiropractic visit for their complaint were 76% less likely to have an injury to their head, neck, or body (trunk) in the following week compared to those who made a primary care visit for the same complaint.

In a systematic review of cost-effectiveness for guideline-endorsed back pain treatments, Lin (38) found that spinal manipulation was cost-effective for subacute and chronic low back pain. The cost-effectiveness of spinal manipulation for acute low back pain is presently unclear.

Massage Therapy

Kumar (39) identified nine systematic reviews of various types of massage for low back pain. Among those, Furlan (40) found two poor-quality trials (n = 158 patients) focused on massage for acute or sub-acute low back pain that found short-term benefits compared to inactive controls. For chronic low back pain (overall more than 1000 patients across the various studies), Kumar concluded that massage therapy may be effective in improving short-term pain and function compared to sham or placebo interventions, but is not consistently better than other active interventions. In a large trial of 401 patients, Cherkin (41) found that both relaxation and focused structural massage were superior to usual care in improving both pain and back-related function, with functional benefits persisting to one year, especially for relaxation massage. Older adults were not prominently featured in any of these trials, which had few adverse events, none of which was serious. A clinical trial of 140 Thai adults at least 60 years of age with chronic back pain randomized to receive 5 weeks of twice weekly 30-minute treatments of either Swedish massage with aromatic ginger oil or traditional Thai massage found that both groups improved their pain intensity and back-related dysfunction by the end of the treatment series (42). However, those randomized to Swedish massage had more significant reductions in pain and dysfunction, which persisted for 9 additional weeks.

Mind–Body Therapies

Meditation

Cramer et al. (43) identified three trials of mindfulness-based stress reduction (MBSR; total of 117 patients) for chronic low back pain. Compared to no treatment, MBSR was associated with clinically important short-term improvements in pain intensity, pain acceptance, and back-related dysfunction in patients with failed back surgery. Two trials of older adults with chronic back pain found that MBSR did not improve pain or back-related dysfunction compared to either health education or wait-list control. However, one of those trials found improved pain acceptance with MBSR. Two large trials of MBSR for individuals with chronic back pain are currently ongoing (44,45) and should offer more definitive conclusions about the value of MBSR for patients with chronic back pain. One trial (44) is recruiting 300 adults 65 years and older and randomizing them to a mindfulness intervention or an education control, while the other (45) has completed recruitment of 341 participants with chronic low back pain up to age 70 years who were randomized to MBSR, cognitive behavioral therapy, or usual care.

Yoga

Cramer and colleagues (46) conducted a systematic review and meta-analysis on the effectiveness of yoga for low back pain. They included 10 trials with 967 patients who had chronic low back pain, all under the age of 65. They reported strong evidence of yoga’s short- and long-term benefits on pain reduction (standard mean difference = −0.48; 95% CI: −0.65 to −0.31; and SMD= -0.33; 95% CI: −0.59 to −0.07, respectively). For back-specific function, they found strong evidence for short-term improvement (SMD = −0.59; 95% CI: −0.87 to −0.30) and moderate evidence for long-term improvement (SMD = −0.35; 95% CI: −0.55 to −0.15). They found no effects on health-related quality of life, nor did they report serious adverse effects. One large trial included an economic analysis suggesting that yoga is cost-effective because it is well below the US thresholds of $50,000 to 100,000 per QUALY.

Since the publication of the Cramer review, several other trials have been published. In a study of 80 patients with chronic low back pain randomized to a comprehensive week-long residential retreat focused on either yoga or physical exercise, Tekur et al. (47) found those randomized to comprehensive yoga had significantly greater improvements in pain, anxiety, depression, and spinal mobility. In a trial of 95 patients with chronic low back pain, Saper (48) found equivalent benefits for yoga classes given once or twice weekly for 12 weeks. None of these trials has included adults over the age of 65 years.

Tai Chi

Compared to a wait-list control, Hall et al. (49) found that community volunteers with persistent back pain (up to age 70) had improvement in back pain intensity, bothersomeness, and back-related dysfunction after a 10-week course of tai chi (n = 160). Longer term follow-up was not available.

Alexander Technique

Little et al. (50) published a study that included 579 patients under age 66 randomized to either 6 or 24 lessons in the Alexander Technique, massage, or usual care, with half of the patients in each intervention receiving an exercise prescription as well. Patients randomized to both doses of Alexander Technique or to exercise (or Alexander Technique plus exercise) showed clinically important improvement at both 3 months and 1 year. The strongest effects were found in the group receiving 24 Alexander Technique lessons, regardless of exercise prescription. No adverse events were reported for the Alexander Technique.

Dietary Supplements and Herbs

Dietary Supplements

Stuber et al. (51) conducted a systematic review to examine the evidence for the use of glucosamine, chondroitin sulfate, and methylsulfonylmethane (MSM) for patients with spinal degenerative joint disease and degenerative disc disease. One high-quality study with 34 patients (23 of whom had spinal degenerative joint disease) found no difference between the group receiving a combination of glucosamine, chondroitin, and manganese ascorbate and placebo. The second study, which included 80 patients with knee or low back pain, randomized patients to a combination of glucosamine, procine skin collagen, compos mucopolysaccharide, and vitamin C or a non-supplemented control group found decreases in pain intensity and increases in lumbar bone mineral density. They concluded that this contradictory evidence was insufficient to support the use of these supplements for spine degenerative joint disease.

Herbal Supplements

Oltean et al. (52) recently updated a Cochrane review of herbal supplements for low back pain. They included 14 randomized controlled trials (with 2050 adults with acute or chronic low back pain) for six different herbs. Eleven of these studies had a low risk of bias, but even they had serious methodological flaws (e.g., lack of control for co-interventions, unknown allocation concealment). All studies were 6 weeks or less, thus providing only short-term data. Very few adverse events were reported, largely transient gastrointestinal complaints and irritations of the skin.

Devil’s claw (Harpagophytum procumbens) was studied in three trials (n = 403 participants) as an oral herbal medication for chronic low back pain. Two trials with 315 patients found that doses standardized to 50 mg or 100 mg harpagoside were superior to placebo for pain relief and the need for rescue medication. A third trial of devil’s claw with 88 patients found it equivalent to 12.5 mg of rofecoxib.

Three trials of willow bark (Salix alba) included 489 patients. Among those, two found that daily doses standardized to 120 mg or 240 mg of salicin were superior to placebo for pain relief and the need for rescue medication. A third trial that included 228 patients found that willow bark was equivalent to 12.5 mg of rofecoxib. One severe allergic reaction was seen, but other adverse events were relatively mild.

Five trials tested cayenne (Capsicum frutescens) in several forms, including plaster or creams (three trials with 755 participants who had chronic low back pain and one trial with 40 participants who had acute low back pain) and a gel form (one trial with 161 participants having either acute back pain or acute flare-ups of chronic back pain where the control group was a homeopathic gel). The four placebo-controlled trials found cayenne superior to placebo for pain relief with only minor adverse effects. The gel trial found pain relief from the cayenne gel preparations similar to the homeopathic gel preparation.

Three additional trials of lavender essential oil, Brazilian arnica, and topical comfrey (one for each herbal preparation) had high risk of bias, and their results are not described further.

Summary

Back pain, especially chronic pain, is the most common musculoskeletal complaint in older adults. In addition to pain intensity and bothersomeness, older adults with back pain may suffer from impaired physical function and back-related disability, as well as difficulties with sleep, mood, appetite, social interactions, and reduced quality of life. While there have been a substantial number of studies of CIM therapies for chronic low back pain and a good number of studies of CIM therapies for acute low back pain, most studies have typically focused on adults under the age of 65 (see Table 28.2). The effect sizes for both conventional and CIM non-pharmacological therapies are comparable, typically of moderate size and all with favorable safety profiles. Currently, the most extensive and compelling evidence of benefits exists for acupuncture, spinal manipulation, massage, and yoga in the short term. However, yoga classes as typically offered in community settings and yoga studios would need extensive modification for many seniors, especially those with a variety of health conditions besides back pain. Most yoga instructors would not be qualified to do this, although there are some instructors who have extensive experience working with older adults and others who have a healthcare background. While limited evidence exists for benefits from herbal and dietary supplements, the short-term effect sizes appear comparable to those for medications, with likely better safety profiles than for NSAIDs or opioids. Economic analyses of acupuncture, spinal manipulation, and yoga suggest that they are cost-effective. At present, only spinal manipulation is a Medicare benefit, thus making most of these treatments inaccessible for most older adults in the United States.

Table 28.2. Summary of Data on CIM Therapies for Low Back-Related Pain (LBP)*

Therapy

Effect Size (95% CI)

Cautions and Contraindications

Dosing/Notes

Acupuncture

  • 0.20 ( 0.09 to 0.31) compared to sham (8);

  • 0.46 (0.4 to 0.51) compared to no treatments (8)

Caution in individuals at high risk for bleeding and those prone to vasovagal episodes.

Typically 10 to 12 treatments (1 or 2x/week); range was 1 to 20 treatments.

Chiropractic, osteopathy, and spinal manipulation

  • −0.22 ( −0.36 to −0.07) for chronic LBP

  • (35)

Caution in individuals with severe osteoporosis; chiropractor may modify treatment.

Multiple doses/week more effective at the beginning of treatment for both chronic and acute back pain.

Massage therapy

  • Number needed to treat = 4.1

  • (41)

Caution in individuals with cancer. Avoid if local open wound or infection.

8 to 10 treatments may be needed. Inclusion of self-care most effective treatment.

Meditation

Inadequate data

May want to omit yoga exercises for older adults.

Typically use mindfulness-based stress reduction with 8 classes.

Yoga

  • −0.59 ( −0.87 to −0.30)

  • (46)

May require modification or be contraindicated in individuals with cardiovascular disease or osteoporosis.

Typically once or twice weekly classes for 8 to 12 weeks, sometimes supplemented with home practice.

Devil’s claw

Inadequate data

High doses may cause mild stomach problems, long-term safety unknown; may lower blood sugar.

50 mg or 100 mg harpagoside

Willow bark

Inadequate data

Do not use if allergic or sensitive to salicylates (e.g., aspirin).

120 mg or 240 mg of salicin

Capsicum

Number needed to treat of 5 for plaster (52)

Cream may occasionally cause itching or burning on the skin.

* Only CIM therapies with at least 3 studies are included here.

Suggestions for Future Research

Further research on CIM therapies for both osteoarthritis and back pain are warranted. For both conditions, studies in older adults are needed that focus on evaluating (1) additional CIM therapies, (2) the appropriate dose for all CIM therapies, (3) the full range of outcomes that CIM therapies might impact, (4) safety and adverse events associated with CIM therapies, and (5) the effects of CIM therapies over the longer term. Additional information on cost-effectiveness and cost savings, if any, would be useful. For osteoarthritis, further studies targeting older adults with hip osteoarthritis and hand osteoarthritis would be desirable. For back pain, further studies targeting older adults with specific causes of back pain, including disc disease and spinal stenosis, would be valuable. Studies that focus on special populations of older adults, such as frail elderly, individuals who are depressed, or those who have mild cognitive impairment, are needed. A focus on pragmatic trials with a broad range of the elderly is appropriate in all these settings. With the large increase in the proportion of adults over the age of 65 in the Western world, the need for additional research on these topics is even more compelling.

Disclosure Statement

Karen J. Sherman, PhD, MPH: Research grants: from the National Center for Complementary and Integrative Health and the Patient Centered Outcomes Research Institute. Consultant: on several NIH grants.

Michelle L. Dossett, MD, PhD, MPH, has no relevant financial conflicts of interest related to this chapter. She has served as a consultant for TJL Enterprises and has received grant funding from the National Center for Complementary and Integrative Health.

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