by Dan Lukaczer, N.D.
Chronic low-back pain is the most common reason people see a health care practitioner. About one-fourth of U.S. adults report LBP in any three-month period,1 and 80 percent of people have it some time in their lives. The cost of back pain treatment in the U.S. is conservatively estimated to be upwards of $90 billion—not including people's out-of-pocket expenses, costs of compensation benefits or lost time at work.
Low-back pain is generally attributed to a single, acute traumatic event, but it may also be caused by cumulative trauma. The severity of events causing LBP varies widely, from twisting or bending to a car accident. The back is an amazingly complex anatomical structure composed of bones, ligaments, tendons, discs and muscles. Any of these may have a role in pain. A common thread among most instances of back pain is the release of inflammatory chemicals such as substance P, leukotrienes, cyclooxygenases and histamine, all of which can produce pain.
Standard medical treatment usually involves drug therapy to decrease the inflammation. Surgical interventions are often reserved for cases involving disc degeneration or herniation. Drug treatment centers on nonsteroidal anti-inflammatory drugs, although muscle relaxants, antidepressants, steroids and narcotics are also used. Many of these drugs have serious side effects. NSAIDs can cause gastric ulceration and hemorrhage and increase the risk of cardiovascular mortality. They also inhibit cartilage repair and maintenance,2-6 actually worsening back pain in the long run, even as pain symptoms improve in the short term. Furthermore, it is estimated that more than 17,000 Americans per year die from NSAID use.2 These factors provide many good reasons to look at other therapies to address LPB.
Alternative treatments include exercise, chiropractic manipulation, yoga, meditation, acupuncture, electrical stimulation and other physical modalities. In various studies, all of these alternative treatments have shown some positive effect. Numerous nutritional and botanical strategies also show promise.
Omega-3 fats. The average American diet is notoriously imbalanced with regard to fat intake, with an excess of saturated fats, trans fats and omega-6 fats, but few omega-3 fatty acids. Saturated and trans fats can trigger inflammation, which can lead to pain, but so can an overabundance of omega-6s.7-10
Unlike other fats, omega-3s (found in flaxseeds, walnuts and fatty fish, among other foods) have a pronounced anti-inflammatory effect. Several researchers have hypothesized that changing the ratio of non-inflammatory to inflammatory fats may affect pain in general,11 and a few researchers have studied omega-3s' effect on back pain in particular. In an uncontrolled 2006 study, 125 LBP patients took 1,200 mg per day of omega-3 fats (EPA and DHA). At follow-up, 60 percent reported that their overall pain was improved, and 59 percent of those with improved pain had discontinued their prescription NSAID medications.12 While controlled trials using omega-3 fats for LBP are needed, an abundance of literature suggests they help alleviate pain.13, 14
Minerals. Mineral deficiency may also play a role in back pain. Researchers used a low-potency, alkalinizing mineral supplement (such as Basica) in 82 patients complaining of chronic LBP. Basica contains magnesium, calcium, sodium, potassium, iron, zinc, copper, molybdenum, chromium and selenium. Using the Arhus rating scale for LBP, 76 of the 82 participants noted a 49 percent reduction in pain after four weeks of taking the alkalized 10-mineral combination.15 The researchers found magnesium levels increased in epithelial tissue after supplementation. Again, more work should be done in this area, but magnesium is used extensively as an analgesic for many conditions, such as migraines and muscle spasms, and has an anesthetic, analgesic and muscle relaxation effect.16
Vitamin D. People with chronic LBP may suffer from a vitamin D deficiency. This deficiency causes a failure of mineralization of the periosteum and endosteum, membranes covering the outer and inner surfaces of bones, respectively. These areas are susceptible to hydration, swelling and subsequent compression of highly sensitive nerve fibers, which, without proper nutrition, could result in LBP.17 A 2003 study of 360 patients with LBP reported that 83 percent of the participants had abnormally low levels of vitamin D. After vitamin D supplementation, improvement in symptoms was seen in 100 percent of individuals who had low levels of vitamin D to start, and in 95 percent of all the patients supplemented.18 In a more recent study, 60 female patients complaining of LBP lasting more than three months were compared with healthy controls. Patients with LBP had significantly lower vitamin D levels than the controls, again suggesting a correlation.19
When supplementing with vitamin D, the preferred form is D3 (colecalciferol); vitamin D2 (ergocalciferol) is not as effective.20 Generally, dietary sources are insufficient for obtaining vitamin D3,21 so supplementation or full-body sun exposure (20 to 60 minutes per day) are recommended for overcoming deficiencies. A simple blood test can assess vitamin D levels and determine whether supplementation is needed.
Vitamin B12. This vitamin, involved in cell metabolism, may also alleviate LBP. In a double-blind, randomized, placebo-controlled trial involving 60 patients, researchers showed that intramuscular injection of vitamin B12 was safe and effective in the treatment of LBP among patients with no signs of nutritional deficiency. Compared with a placebo, vitamin B12 produced statistically significant, sustained reductions in pain, disability and acetaminophen use.22 It is unclear whether oral supplements of B12 would have the same effect. Vitamin B12 has a wide margin of safety when administered orally or injected.
Willow bark. Numerous studies validate the analgesic and anti-inflammatory benefits of willow bark (Salix alba). It contains many active agents, but the one that seems to be associated with pain relief is salicin. Salicin is metabolized to salicylic acid, which is the active ingredient in aspirin (acetylsalicylic acid). Salicylates are also found in smaller amounts in fruits, vegetables, teas and spices. While many people think of white willow bark as "herbal aspirin," there are some important differences. Salicin in willow bark is largely inactive until it travels past the stomach, suggesting that while it is metabolized to salicyclic acid, it happens in a different way than aspirin. It may be that compounds other than salicylate contribute to willow bark's analgesic activity, and studies support this hypothesis.23
A double-blind, placebo-controlled study of 210 patients, who rated their LBP severity as 5 or more on a 10-point scale, found a dose-response relationship when taking willow bark containing 120 mg or 240 mg of salicin; patients in the high-dose group benefited in the first week, and 39 percent were pain-free by the fourth week. This compared favorably with only 21 percent in the low-dose group who benefited and only 6 percent in the placebo group.24
Another study found a daily dose of 240 mg of salicin to be comparable in effectiveness to 12.5 mg per day of rofecoxib (marketed under the brand name Vioxx, which has since been pulled from the market because of increased cardiovascular risk).25 Because willow bark contains salicylates, this herb may present a safety risk to people who have an aspirin allergy or sensitivity, or who use other anticoagulants, and to children because of the potential to develop aspirin-related Reye's syndrome.26
Devil's claw. Harpagophytum procumbens has a long history of use for musculoskeletal pain, particularly osteoarthritis and chronic LBP. Studies show it modulates certain inflammatory molecules and activates genes that modulate the inflammatory response.27,28 The active ingredients, harpagosides, are found in the root of this African plant.29-34
Two trials using devil's claw found strong evidence for short-term improvements in pain with daily doses standardized to 50 mg or 100 mg of harpagosides.33,34 Another trial showed devil's claw to be equivalent to 12.5 mg per day of rofecoxib. In this study, 44 patients received a daily dose for six weeks of devil's claw extract containing 60 mg of harpagosides, while 44 people received 12.5 mg per day of rofecoxib. Eighteen devil's claw and 12 rofecoxib patients had more than a 50 percent reduction in the week's average of their pain scores between the first and sixth weeks. Pain was measured using the Arhus Index.31
Capsaicin. The spicy component of Capsicum annuum and Capsicum frutescens, capsaicin is more commonly known as cayenne pepper or chili pepper. Controlled clinical trials demonstrate topical capsaicin's ability to deplete sensory fibers of substance P, thus reducing pain in a variety of conditions. Two controlled trials have used a capsicum plaster (a topical treatment) in LBP patients. In the first, a double-blind, randomized study, a capsicum plaster was compared with a placebo plaster for three weeks in 154 patients with nonspecific back pain. Of those using the capsicum plaster, 60.8 percent experienced a reduction in their pain; in the placebo group, 42.1 percent experienced pain reduction.35 In a larger double-blind, placebo-controlled, multicenter study, 320 patients with LBP were randomly assigned to treatment or placebo groups (160 subjects each). After three weeks of treatment with capsicum, 82 percent of patients reported they were "improved" or "symptom-free" compared with 50 percent in the placebo group.36 Side effects in both trials were minimal.
Conclusions Many nutritional and botanical approaches can safely and effectively treat low back pain. LBP can be triggered by lifestyle and nutritional deficiencies, such as lack of vitamin D, omega-3 fatty acids and magnesium. The incorporation of these nutrients and botanical agents such as willow bark and devil's claw can help alleviate this common problem.
Dan Lukaczer is a naturopathic physician in Fife, Wash., and associate director of medical education at the Institute for Functional Medicine in Gig Harbor, Wash.