MEDLINE, Cochrane Central, Cochrane Database of Systematic Reviews, CINAHL, and EMBASE were searched up to 2010; unpublished literature and reference lists of relevant articles were also searched. study selection: All records were screened by two independent reviewers. Primary reports of comparative efficacy, effectiveness, harms, and/or economic evaluations from randomized controlled trials (RCTs) of the CAM
therapies in adults (age ≥ 18 years) with back, neck, or thoracic
pain were eligible. Non-randomized controlled trials and observational studies (case-control, cohort, cross-sectional) comparing harms were also included. Reviews, case reports, editorials, commentaries or letters were excluded.
DATA EXTRACTION: Two independent reviewers using a predefined form extracted data on study, participants, treatments, and outcome characteristics.
RESULTS: 265 RCTs and 5 non-RCTs were included. Acupuncture for chronic nonspecific
low back pain was associated with significantly lower
pain intensity than placebo but only immediately post-treatment (VAS: -0.59, 95 percent CI: -0.93, -0.25). However, acupuncture was not different from placebo in post-treatment disability,
pain medication intake, or global improvement in chronic nonspecific
low back pain. Acupuncture did not differ from
sham-acupuncture in reducing chronic non-specific
neck pain immediately
after treatment (VAS: 0.24, 95 percent CI: -1.20, 0.73). Acupuncture was superior to no treatment in improving
pain intensity (VAS: -1.19, 95 percent CI: 95 percent CI: -2.17, -0.21), disability (PDI), functioning (HFAQ), well-being (SF-36), and range of mobility (extension, flexion), immediately after the treatment. In general, trials that applied
sham-acupuncture tended to produce negative results (i.e., statistically non-significant) compared to trials that applied other types of placebo (e.g.,
TENS, medication,
laser). Results regarding comparisons with other active treatments (
pain medication, mobilization,
laser therapy) were less consistent Acupuncture was more cost-effective compared to usual care or no treatment for patients with chronic
back pain. For both low back and
neck pain, manipulation was significantly better than placebo or no treatment in reducing
pain immediately or short-term after the end of treatment. Manipulation was also better than acupuncture in improving
pain and function in chronic nonspecific
low back pain. Results from studies comparing manipulation to
massage, medication, or physiotherapy were inconsistent, either in favor of manipulation or indicating no significant difference between the two treatments. Findings of studies regarding costs of manipulation relative to other
therapies were inconsistent. Mobilization was superior to no treatment but not different from placebo in reducing
low back pain or spinal flexibility after the treatment. Mobilization was better than physiotherapy in reducing
low back pain (VAS: -0.50, 95 percent CI: -0.70, -0.30) and disability (Oswestry: -4.93, 95 percent CI: -5.91, -3.96). In subjects with acute or subacute
neck pain, mobilization compared to placebo significantly reduced
neck pain. Mobilization and placebo did not differ in subjects with chronic
neck pain.
Massage was superior to placebo or no treatment in reducing
pain and disability only amongst subjects with acute/sub-acute
low back pain.
Massage was also significantly better than
physical therapy in improving
back pain (VAS: -2.11, 95 percent CI: -3.15, -1.07) or disability. For subjects with
neck pain,
massage was better than no treatment, placebo, or exercise in improving
pain or disability, but not neck flexibility. Some evidence indicated higher costs for
massage use compared to general practitioner care for
low back pain. Reporting of harms in RCTs was poor and inconsistent. Subjects receiving CAM
therapies reported soreness or
bleeding on the site of application after acupuncture and worsening of
pain after manipulation or
massage. In two case-control studies
cervical manipulation was shown to be significantly associated with
vertebral artery dissection or vertebrobasilar vascular accident.
CONCLUSIONS: Evidence was of poor to moderate grade and most of it pertained to chronic nonspecific
pain, making it difficult to draw more definitive conclusions regarding benefits and harms of CAM
therapies in subjects with acute/subacute, mixed, or unknown duration of
pain. The benefit of CAM treatments was mostly evident immediately or shortly after the end of the treatment and then faded with time. Very few studies reported long-term outcomes. There was insufficient data to explore subgroup effects. The trial results were inconsistent due probably to methodological and clinical diversity, thereby limiting the extent of quantitative synthesis and complicating interpretation of trial results. Strong efforts are warranted to improve the conduct methodology and reporting quality of primary studies of CAM
therapies. Future well powered head to head comparisons of CAM treatments and trials comparing CAM to widely used active treatments that report on all clinically relevant outcomes are needed to draw better conclusions.