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Herbal Medicine for Low Back Pain: A Cochrane Review

Gagnier, Joel J. ND, MSc, PhD(cand.)*†; van Tulder, Maurits W. PhD; Berman, Brian MD§; Bombardier, Claire MD

doi: 10.1097/01.brs.0000249525.70011.fe
Cochrane Collaboration

Study Design. A systematic review of randomized controlled trials.

Objectives. To determine the effectiveness of herbal medicine compared with placebo, no intervention, or “standard/accepted/conventional treatments” for nonspecific low back pain.

Summary of Background Data. Low back pain is a common condition and a substantial economic burden in industrialized societies. 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.

Methods. The following databases were searched: Medline (1966 to April 2003), Embase (1980 to April 2003), Cochrane Controlled Trials Register (Issue 1, 2003), and Cochrane Complementary Medicine (CM) field Trials Register. Additionally, reference lists in review articles, guidelines, and in the retrieved trials were checked. Randomized controlled trials (RCTs), using adults (>18 years of age) suffering from acute, subacute, or chronic nonspecific low back pain. Types of interventions included herbal medicines defined as a plant that is used for medicinal purposes in any form. Primary outcome measures were pain and function. Two reviewers (J.J.G. and M.W.T.) conducted electronic searches in all databases. One reviewer (J.J.G.) contacted content experts and acquired relevant citations. Authors, title, subject headings, publication type, and abstract of the isolated studies were downloaded or a hard copy was retrieved. Methodologic quality and clinical relevance were assessed separately by two individuals (J.J.G. and M.W.T.). Disagreements were resolved by consensus.

Results. Ten trials were included in this review. Two high-quality trials utilizing Harpagophytum procumbens (Devil’s claw) found strong evidence for short-term improvements in pain and rescue medication for daily doses standardized to 50 mg or 100 mg harpagoside with another high-quality trial demonstrating relative equivalence to 12.5 mg per day of rofecoxib. Two moderate-quality trials utilizing Salix alba (White willow bark) found moderate evidence for short-term improvements in pain and rescue medication for daily doses standardized to 120 mg or 240 mg salicin with an additional trial demonstrating relative equivalence to 12.5 mg per day of rofecoxib. Three low-quality trials using Capsicum frutescens (Cayenne) using various topical preparations found moderate evidence for favorable results against placebo and one trial found equivalence to a homeopathic ointment.

Conclusions. Harpagophytum procumbens, Salix alba, and Capsicum frutescens seem to reduce pain more than placebo. 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.

The authors set out to determine the effectiveness of herbal medicine for nonspecific low back pain (NSLBP). The authors searched Medline, Embase, and the Cochrane library for randomized controlled trials, using adults suffering from nonspecific low back pain. Interventions included herbal medicines. Ten trials suggested that Harpagophytum procumbens, Salix alba, and Capsicum frutescens are effective for NSLBP. Supplemental Digital Content is Available in the Text.

From the *Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; †Ottawa St. Medical Centre, Windsor, Ontario, Canada; ‡Institute for Research in Extramural Medicine, EMGO, VU University Medical Center, Amsterdam, The Netherlands; §Complementary Medicine Program, University of Maryland, College Park, MD; and ¶Institute for Work and Health, Toronto, Ontario, Canada.

Supported by the Cochrane Collaborative Back Review Group, the Canadian Institutes of Health Research, and the Natural Health Products Directorate, the latter two public funding bodies within Health Canada (to J.J.G. with a postgraduate fellowship).

Adapted from Gagnier JJ, van Tulder M, Berman B, et al. Herbal medicine for low back pain. Cochrane Database of Systematic Reviews 2006;2:CD004504.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

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 manuscript.

One of the authors (C.B.) is coordinating editor of the Cochrane Back Review Group. Editors are required to conduct at least one Cochrane review. Dr. Bombardier is not the first author of the review. Any editor who is a reviewer is excluded from editorial decisions on the review in which they are contributors. Therefore, this involvement does not seem to be a source of conflict of interest in the Back Review Group.

Address correspondence to Joel J. Gagnier, ND, MSc, Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; E-mail: j.gagnier@utoronto.ca

© 2007 Lippincott Williams & Wilkins, Inc.