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January 16, 2006 -- Short-term treatments with certain herbal medicines (including Devil's claw and willow bark) are effective for relief of acute low back pain, according to the results of a Cochrane review reported in the January issue of Spine.
"Low back pain is a common condition and a substantial economic burden in industrialized societies," write Joel J. Gagnier, ND, MSc, PhD(cand.), from the University of Toronto in Ontario, Canada, and colleagues. "A large proportion of patients with chronic low back pain use complementary and alternative medicine (CAM) and/or visit CAM practitioners. Several herbal medicines have been purported for use in low back pain."
The authors searched Medline (1966 to April 2003), EMBASE (1980 to April 2003), Cochrane Controlled Trials Register (Issue 1, 2003), and Cochrane Complementary Medicine field Trials Register for appropriate trials, as well as reference lists in review articles, guidelines, an in the retrieved trials. Criteria for review were randomized controlled trials of herbal medicines, enrolling adults (> 18 years of age) with acute, subacute, or chronic nonspecific low back pain. Herbal medicines were defined as plants used for medicinal purposes in any form. The main endpoints were pain and function.
Two reviewers conducted electronic searches in all databases; 1 reviewer contacted content experts and obtained relevant citations; and 2 individuals evaluated methodologic quality and clinical relevance.
Ten trials meeting criteria were identified and reviewed. Two high-quality trials of Harpagophytum procumbens (Devil's claw) showed strong evidence for short-term improvements in pain and rescue medication for daily doses standardized to 50 or 100 mg harpagoside, and another high-quality trial showed relative equivalence to 12.5 mg per day of rofecoxib.
Two moderate-quality trials of Salix alba (white willow bark) showed moderate evidence for short-term improvements in pain and rescue medication for daily doses standardized to 120 or 240 mg salicin, and an additional trial showed relative equivalence to 12.5 mg per day of rofecoxib. Three low-quality trials of Capsicum frutescens (cayenne) used topically showed moderate evidence for favorable results compared with placebo, and 1 trial showed equivalence to a homeopathic ointment.
" Harpagophytum procumbens, Salix alba, and Capsicum frutescens seem to reduce pain more than placebo," the authors write. "Additional trials testing these herbal medicines against standard treatments will clarify their equivalence in terms of efficacy. The quality of reporting in these trials was generally poor; thus, trialists should refer to the CONSORT statement in reporting clinical trials of herbal medicines."
Study limitations include poor methodologic and reporting quality in some trials reviewed; insufficient evidence to make definitive conclusions about trials comparing herbal-medicine interventions with standard treatments; lack of reporting of sufficient raw data; lack of information on the size of the treatment effect; and heterogeneity of herbal-medicine products.
"The following herbal medicines have strong evidence for the short-term treatment of acute episodes of chronic NSLBP [nonspecific low back pain]: an aqueous extract of H. procumbens at a standardized daily dosage of 50 mg harpagoside, an extract of S. alba at a standardized dosage of 240 mg salicin per day," the authors conclude. "The following herbal medicines have moderate evidence for the short-term treatment of acute episodes of chronic NSLBP: an aqueous extract of H. procumbens at a standardized daily dosage of 100 mg harpagoside, an extract of S. alba at a standardized dosage of 120 mg salicin per day, and a plaster of C. frutescens. Additional high-quality trials must be done to determine if H. procumbens standardized to 100 mg harpagoside and S. alba standardized to 120 mg salicin are effective in the treatment of LBP [low back pain]."
The Cochrane Collaborative Back Review Group, the Canadian Institutes of Health Research, and the Natural Health Products Directorate supported this study. Federal funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article. One of the authors is coordinating editor of the Cochrane Back Review Group.
Spine. 2007;32:82-92.
Low back pain and related disability is a major cause of disability in industrialized nations, and the second-leading cause of work absenteeism, with a 1-month prevalence of 35% to 37% and a lifetime prevalence of 70% to 85%. Traditional treatment of low back pain consists of pain medication, tissue stimulation, rest, and orthotics, whereas acute exacerbations of low back pain can be managed by activity, reassurance, and short-term pain control. Many patients with low back pain visit alternative practitioners (37% vs 17% of the general population), and a variety of modalities of treatment have been reported as useful in low back pain in additional to traditional approaches. Several herbal medicines have been reported to be useful for treating varying levels of back pain, including Camphora molmol, C frutescens, S alba, Maleluca alternifolia, Angelica sinensis, Aloe vera, Thymus officinalis, Menthe peperita, Arnica montana, Curcuma longa, Tancaetum parthenium, H procumbens, and Zingiber officinicalis.
This is a systematic review of evidence supporting or refuting the efficacy of herbal medicines in overall pain, improvement, and function, including return to work, based on comprehensive searching of the Medline, EMBASE, Cochrane, and Clinical Evidence databases to 2005.
