Cochrane Database of Systematic Reviews (Reviews) || Herbal medicine for low back pain

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<ul><li><p>Herbal medicine for low back pain (Review)</p><p>Gagnier JJ, van Tulder MW, Berman BM, Bombardier C</p><p>This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2011, Issue 2</p><p>http://www.thecochranelibrary.com</p><p>Herbal medicine for low back pain (Review)</p><p>Copyright 2011 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd.</p></li><li><p>T A B L E O F C O N T E N T S</p><p>1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>3BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7</p><p>10DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>11AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>12ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>12REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>14CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>29DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>29ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>29WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>30HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>30CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>30DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>30SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>31INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .</p><p>iHerbal medicine for low back pain (Review)</p><p>Copyright 2011 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd.</p></li><li><p>[Intervention Review]</p><p>Herbal medicine for low back pain</p><p>Joel J Gagnier1, Maurits W van Tulder2, Brian M Berman3, Claire Bombardier4</p><p>1Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA. 2Department of Health</p><p>Sciences, Faculty of Earth and Life Sciences, VU University, Amsterdam, Netherlands. 3Center for Integrative Medicine, University of</p><p>Maryland School of Medicine, Baltimore, Maryland, USA. 4Institute for Work &amp; Health, Toronto, Canada</p><p>Contact address: Joel J Gagnier, Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington</p><p>Heights, Rm M5158, Ann Arbor, MI, 48109-2029, USA. jgagnier@umich.edu.</p><p>Editorial group: Cochrane Back Group.</p><p>Publication status and date: Edited (no change to conclusions), published in Issue 2, 2011.</p><p>Review content assessed as up-to-date: 14 December 2005.</p><p>Citation: Gagnier JJ, van TulderMW, Berman BM, Bombardier C. Herbal medicine for low back pain.Cochrane Database of SystematicReviews 2006, Issue 2. Art. No.: CD004504. DOI: 10.1002/14651858.CD004504.pub3.</p><p>Copyright 2011 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd.</p><p>A B S T R A C T</p><p>Background</p><p>Low-back pain is a common condition and a substantial economic burden in industrialized societies. A large proportion of patients</p><p>with chronic low-back pain use complementary and alternative medicine (CAM), visit CAM practitioners, or both. Several herbal</p><p>medicines have been purported for use in low-back pain.</p><p>Objectives</p><p>To determine the effectiveness of herbal medicine for non-specific low-back pain.</p><p>Search methods</p><p>We searched the following electronic databases: Cochrane Complementary Medicine Field Trials Register (Issue 3, 2005), MEDLINE</p><p>(1966 to July 2005), EMBASE (1980 to July 2005); checked reference lists in review articles, guidelines and retrieved trials; and</p><p>personally contacted individuals with expertise in this very specialized area.</p><p>Selection criteria</p><p>We included randomized controlled trials, examining adults (over 18 years of age) suffering from acute, sub-acute or chronic non-</p><p>specific low-back pain. The interventions were herbal medicines, defined as plants that are used for medicinal purposes in any form.</p><p>Primary outcome measures were pain and function.</p><p>Data collection and analysis</p><p>Two authors (JJG&amp;MVT) conducted the database searches. One author contacted content experts and acquired relevant citations. Full</p><p>references and abstracts of the identified studieswere downloaded. Ahard copywas retrieved for final inclusion decisions.Methodological</p><p>quality and clinical relevance were assessed separately by two individuals. Disagreements were resolved by consensus.</p><p>Main results</p><p>Ten trials were included in this review. Twohigh quality trials examining the effects ofHarpagophytumProcumbens (Devils Claw) found</p><p>strong evidence that daily doses standardized to 50 mg or 100 mg harpagoside were better than placebo for short-term improvements</p><p>in pain and rescue medication. Another high quality trial demonstrated relative equivalence to 12.5 mg per day of rofecoxib (Vioxx).</p><p>Two trials examining the effects of Salix Alba (WhiteWillow Bark) found moderate evidence that daily doses standardized to 120 mg or</p><p>1Herbal medicine for low back pain (Review)</p><p>Copyright 2011 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd.</p></li><li><p>240 mg salicin were better than placebo for short-term improvements in pain and rescue medication. An additional trial demonstrated</p><p>relative equivalence to 12.5 mg per day of rofecoxib. Three low quality trials on Capsicum Frutescens (Cayenne), examining various</p><p>topical preparations, found moderate evidence that Capsicum Frutescens produced more favourable results than placebo and one trial</p><p>found equivalence to a homeopathic ointment.</p><p>Authors conclusions</p><p>Harpagophytum Procumbens, Salix Alba and Capsicum Frutescens seem to reduce pain more than placebo. Additional trials testing</p><p>these herbal medicines against standard treatments are needed. The quality of reporting in these trials was generally poor. Trialists</p><p>should refer to the CONSORT statement extension for reporting trials of herbal medicine interventions.</p><p>P L A I N L A N G U A G E S U M M A R Y</p><p>Herbal medicine for low-back pain</p><p>Significance of the review</p><p>Back pain is common, affecting as much as 35% of the population in a given month. Non-specific low-back pain is defined as pain</p><p>between the lowest rib and the bottom of the buttocks that is not caused by serious, underlying problems such as rheumatoid arthritis,</p><p>infection, fracture, cancer, or sciatica due to a herniated disc or other pressure on nerves. Oral and topical herbal medicines are being</p><p>used to treat many conditions; several are used for back pain and have been tested in clinical trials.</p><p>Description of the trials</p><p>Three oral herbal medications were tested in ten randomized controlled trials that included 1567 adults with non-specific acute or</p><p>chronic low-back pain. Two oral herbal medications, Harpagophytum Procumbens (Devils Claw) and Salix Alba (WhiteWillow Bark),</p><p>were compared with placebo (fake pills) and with rofecoxib (Vioxx). Topical Capsicum frutescens (Cayenne) was compared with placebo</p><p>and a homeopathic gel.</p><p>Findings</p><p>Devils Claw, in a standardized daily dose of 50 mg or 100 mg harpagoside, seemed to reduce pain more than placebo; a standardized</p><p>daily dose of 60 mg reduced pain about the same as a daily dose of 12.5 mg of Vioxx. While Willow Bark, in a standardized daily dose</p><p>of 120 mg and 240 mg of salicin reduced pain more than placebo; a standardized daily dose of 240 mg reduced pain about the same as</p><p>a daily dose of 12.5 mg of Vioxx. Cayenne was tested in plaster form and reduced pain more than placebo and about the same as the</p><p>homeopathic gel Spiroflor SLR. Adverse effects were reported, but appeared to be primarily confined to mild, transient gastrointestinal</p><p>complaints.</p><p>Limitations</p><p>Most of the trials were of moderate or high quality, but they only tested the effects of short term use (up to six weeks). The authors</p><p>of half of the studies were judged to have a potential conflict of interest and two others did not discuss conflict of interest. Vioxx has</p><p>been withdrawn from the market because of adverse effects, so all three substances should be compared with readily available pain</p><p>medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, to test for relative effectiveness and safety.</p><p>Conclusion</p><p>Although there are good results with three herbal medicines in short-term trials, with strong evidence for a particular form of one of</p><p>the herbal medicines, there is no evidence yet that any of these substances are safe and useful for long term use.</p><p>2Herbal medicine for low back pain (Review)</p><p>Copyright 2011 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd.</p></li><li><p>B A C K G R O U N D</p><p>Low-back pain and related disability are major public health prob-</p><p>lems across industrialized nations. As a result, the past 15 years</p><p>have seen an intensive research effort to identify effective treatment</p><p>and management strategies for low-back pain (Mounce 2002).</p><p>The one-month prevalence of low-back pain is reported to be be-</p><p>tween 35% and 37%, with a lifetime prevalence between 70%</p><p>and 85%, peaking between 45 and 59 years of age (Papageorgiou</p><p>1995; Andersson 1999). In the United States, back pain is the</p><p>most common cause of disability in those under 45 years of age</p><p>(Borkan 1995) and back sprains and strains represent about one</p><p>quarter of work-related injuries resulting in lost work-days (Dept</p><p>Labor 1995). Low-back pain is the second most frequent cause</p><p>of work absence in industrialized nations (Praemer 1992) and is a</p><p>frequent reason for visits to a physician (Coste 1994; Andersson</p><p>1999). It has been estimated that in the United States, back pain</p><p>has associated direct costs of US $20 billion and indirect costs of</p><p>between US $75 and 100 billion (Borkan 1995). In the United</p><p>Kingdom, costs associated with low-back pain are estimated to</p><p>be over 500 million (Little 1996). This amounts to substantial</p><p>societal loss of productivity and an economic burden for health-</p><p>care systems in many industrialized countries (Mounce 2002).</p><p>The traditional treatment of low-back pain includes medication,</p><p>tissue stimulation (e.g. TENS, ultrasound), rest and orthotics (e.g.</p><p>braces; Cherkin 1993). Although systematic reviews suggest that</p><p>few of these have enough evidence to suggest benefit, it does appear</p><p>that acute low-back pain can usually be effectively managed by en-</p><p>couraging activity, reassurance and short-term symptom control</p><p>(analgesics or non-steroidal anti-inflammatory drugs (NSAIDs);</p><p>van Tulder 2002a). Treatments that demonstrate some effective-</p><p>ness for the management of chronic low-back pain include ex-</p><p>ercise therapy, behavioural treatment and multidisciplinary treat-</p><p>ment programs (van Tulder 2002b). To alter beliefs about back</p><p>pain that are correlated with impairment or disability is one of the</p><p>major challenges in low-back pain management (Borkan 1995).</p><p>Research in complementary and alternative medicine (CAM) has</p><p>blossomed in the past 10 years. Rigorous literature is growing</p><p>steadily and is subsequently clarifying the validity of these tech-</p><p>niques. Specifically, the number of randomised trials of comple-</p><p>mentary treatments has doubled approximately every five years</p><p>(Vickers 2000) and currently, the Cochrane Complementary</p><p>Medicine Field Trials Registry contains over 6500 randomized</p><p>and controlled clinical trials. In addition, CAM teaching insti-</p><p>tutions are now beginning to teach principles of evidence-based</p><p>medicine and clinical epidemiology (Mills 2002; Sierpina 2002).</p><p>These initiatives are well placed, given the large number of visits</p><p>to CAM practitioners (Millar 2001). A recent population survey</p><p>in Canada found that 2.2 million women and 1.6 million men</p><p>visited a CAM practitioner during 1998-1999 (Millar 2001). Of</p><p>these, more than 26% of individuals who reported chronic pain</p><p>visited an alternative practitioner during the previous year, com-</p><p>pared with only 15% of those who did not report chronic pain.</p><p>Those who reported back pain had a higher percentage of visits</p><p>to alternative practitioners than any other pain condition. More</p><p>specifically, 37% of the individuals who reported back pain visited</p><p>an alternative practitioner, compared with only 17% of the entire</p><p>population (Millar 2001). Similar percentages have been found in</p><p>surveys conducted in the United States (Astin 2000; Druss 1999;</p><p>Eisenberg 1998).</p><p>Several herbal medicines have been reported to be treatments</p><p>for various types of pain. These include: Camphora Molmol,</p><p>Capsicum Frutescens, Salix Alba, Maleluca Alternifolia, Angelica</p><p>Sinensis, Aloe Vera, Thymus Officinalis, Menthe Peperita, Arnica</p><p>Montana, Curcuma Longa, Tancaetum Parthenium, Harpago-</p><p>phytum Procumbens, and Zingiber Officinicalis (Blumenthal</p><p>1998). Many of these herbs have been the subject of extensive</p><p>biochemical research, resulting in the delineation of their pharma-</p><p>cological and physiological effects (Mills 2000). For example, the</p><p>mechanism of Capsicum Frutescens is partially related to its abil-</p><p>ity to deplete substance P (Keitel 2001). Salix Alba is a platelet in-</p><p>hibitor and analgesic, and Harpagophytum Procumbens has anal-</p><p>gesic and anti-inflammatory properties (Chrubasik 1996). In ad-</p><p>dition, some of these herbal species have been clinically tested for</p><p>the relief of symptoms of low-back pain (Mills 2000; Stam 2001;</p><p>Laudahn 2001a; Krivoy 2000).</p><p>Given the large public health and economic burden low-back pain</p><p>causes and the large number of such sufferers who regularly visit</p><p>CAM practitioners, a systematic review of these practices was war-</p><p>ranted.</p><p>O B J E C T I V E S</p><p>To determine the effectiveness of herbal medicine compared to</p><p>placebo, no intervention, or other interventions in the treatment</p><p>of non-specific low-back pain.</p><p>M E T H O D S</p><p>Criteria for considering studies for this review</p><p>Types of studies</p><p>Only randomized controlled trials (RCTs) were included.</p><p>Types of participants</p><p>Trials included adults (older than 18 years of age), suffering from</p><p>acute (lasting up to six weeks), sub-acute (lasting six to 12 weeks)</p><p>or chronic (lasting longer than 12 weeks) non-specific low-back</p><p>pain.</p><p>3Herbal medicine for low back pain (Review)</p><p>Copyright 2011 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd.</p></li><li><p>Low-back pain was defined as pain localized to the area between</p><p>the costal margin or the 12th rib to the inferior gluteal fold.</p><p>Non-specific low-back pain indicated that no specific cause was</p><p>detectable, such as infection, neoplasm, metastasis, osteoporosis,</p><p>rheumatoid...</p></li></ul>

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