What’s the Bottom Line?

What do we know about the effectiveness of complementary health approaches for low-back pain?

• Research of low- to moderate-quality suggests that several mind and body practices—including acupuncture, electromyography (EMG) biofeedback, low-level laser therapy, mindfulness-based stress reduction, progressive muscle relaxation, spinal manipulation, tai chi, and yoga—may provide benefit for people with chronic low-back pain.

• For acute low-back pain, low-quality evidence indicates that acupuncture, massage therapy, and spinal manipulation may offer some relief.

• Topical preparations made from cayenne pepper appear to help reduce low-back pain in some individuals.

What do we know about the safety of complementary health approaches for low-back pain?

• The mind and body approaches listed above generally have favorable safety records when performed properly. However, no therapy is completely risk-free. Individual factors—such as overall health or pregnancy—can influence whether a treatment is appropriate.

• Natural products, whether taken by mouth or applied to the skin, are not automatically safe. Some may cause side effects or interact with medications.

Some Basics About Low-Back Pain

Low-back pain is extremely common in the United States and worldwide. Approximately 8 out of 10 adults experience it at some point. It is a leading cause of work-related disability and contributes significantly to missed workdays and medical visits.

Most cases are short-lived and are referred to as acute low-back pain, typically lasting up to 4 weeks. In many instances, acute pain improves on its own without lasting effects.

Pain lasting between 4 and 12 weeks is described as subacute.

When low-back pain continues for 12 weeks or longer, it is considered chronic. Some people respond well to treatment, while others continue to have persistent symptoms.

Clinical Practice Guidelines for Treating Low-Back Pain

Clinical practice guidelines are created by expert panels to support informed decisions about patient care. They are based on systematic reviews of research and careful evaluation of potential benefits and harms. These recommendations are revised as new evidence emerges.

In 2017, the American College of Physicians issued guidelines recommending nondrug therapies as the first option for chronic low-back pain. For acute pain, nondrug approaches are also recommended, either alone or in combination with medication. Several complementary health methods are included among the suggested treatment options.

What the Science Says About Complementary Health Approaches for Low-Back Pain

Mind and Body Approaches:

Acupuncture

• Acupuncture involves stimulating specific points on the body, most often with very thin needles inserted through the skin.

• A large 2017 review of 49 studies including more than 7,900 participants found that acupuncture offers modest improvement for acute low-back pain and moderate improvement for chronic pain.

• A 2018 review reported slightly better pain and function outcomes for chronic low-back pain at 1 to 6 months compared to sham acupuncture or usual care, with one study showing benefits lasting beyond a year.

• Clinical guidelines list acupuncture as a treatment option for both acute/subacute and chronic low-back pain.

• Serious side effects are uncommon when acupuncture is performed properly.

Biofeedback

• Biofeedback teaches individuals to control certain body functions. EMG biofeedback measures muscle tension and has been studied for back pain.

• A review of three small studies found low-quality evidence that EMG biofeedback may provide short-term relief for chronic low-back pain.

• Guidelines include EMG biofeedback as a possible initial therapy for chronic pain.

• No significant harmful effects have been reported.

Cupping

• Cupping uses suction applied to the skin with specially designed cups.

• Some studies suggest better outcomes compared to usual care or medication, but inconsistent methods and study quality limit firm conclusions.

• Possible side effects include skin discoloration, burns, scarring, infection, and risk of bloodborne disease transmission if equipment is not properly sterilized.

Dry Needling

• Dry needling places thin needles into tender muscle areas known as trigger points.

• A review of 16 studies suggests potential benefit, though overall study quality limits certainty.

• Serious complications are rare but have been reported.

Low-Level Laser Therapy

• This therapy uses low-intensity light to relieve pain. The exact mechanisms are not fully understood.

• Research indicates possible benefits, particularly with higher doses and shorter pain duration.

• One study showed moderate improvement in pain and slight functional gains lasting up to 6 months.

• It is included as a possible option for chronic low-back pain.

• Studies have not identified significant safety concerns.

Massage Therapy

• Massage involves manual manipulation of soft tissues to promote relief and relaxation.

• Reviews suggest short-term pain relief, though evidence quality is low.

• Benefits for chronic pain appear modest and may not extend beyond 6 months.

• Recommended as an option for acute or subacute low-back pain.

• The risk of serious side effects is low.

Mindfulness-Based Stress Reduction (MBSR)

• MBSR teaches meditation and awareness practices that focus attention on the present moment.

• Studies show short-term improvements in pain and physical function, though the degree of benefit may be modest.

• Some longer-term pain reduction has been observed, but effects on function are less clear.

• Recommended as an option for chronic low-back pain.

• Generally considered safe, though research on potential harms is limited.

Progressive Relaxation

• This technique alternates muscle tension and relaxation to reduce physical and mental stress.

• Limited evidence suggests it may reduce pain intensity.

• Included as a possible treatment for chronic pain.

• Side effects are rare; individuals with heart disease should consult a provider before use.

Prolotherapy

• Prolotherapy involves injecting irritant solutions into ligaments to strengthen tissue.

• Research findings are inconsistent regarding its effectiveness.

• Temporary increases in pain and stiffness after treatment are common.

Spinal Manipulation

• Practitioners apply controlled force to spinal joints to improve mobility.

• Evidence shows modest short-term improvements in pain and function for acute low-back pain.

• For chronic pain, manipulation and mobilization may reduce pain and improve function, with manipulation showing somewhat stronger effects.

• Recommended as a treatment option for both acute and chronic low-back pain.

• Mild temporary discomfort is common; serious complications are rare.

Tai Chi

• Tai chi combines slow movements, posture, breathing, and mental focus.

• Studies indicate it may reduce chronic low-back pain and improve function.

• Listed as a treatment option for chronic pain.

• Generally safe, with minor aches being the most common complaint.

Transcutaneous Electrical Nerve Stimulation (TENS)

• TENS delivers mild electrical impulses through electrodes placed on the skin.

• Current evidence is insufficient to determine whether TENS effectively reduces low-back pain.

• Possible side effects include skin irritation. It should not be used by pregnant women, people with epilepsy, or those with implanted medical devices without medical advice.

Yoga

• Yoga typically incorporates postures, breathing exercises, and meditation.

• Research shows small to moderate improvements in function and modest pain relief for chronic low-back pain.

• Benefits may last up to 12 months compared to minimal or no intervention.

• Recommended as a treatment option for chronic low-back pain.

• Generally safe when taught by a qualified instructor, though injuries can occur.

Natural Products

Herbal Products

• Some herbal preparations have been studied for low-back pain. Topical cayenne has the strongest evidence for pain relief. Other products with limited supportive evidence include devil’s claw, white willow bark, comfrey, Brazilian arnica, and lavender oil.

• Herbal remedies may cause side effects or interact with medications. Consultation with a health care provider is recommended.

Vitamin D

• Low vitamin D levels are more common in people with low-back pain, particularly women under 60. However, supplementation has not consistently been shown to improve symptoms.

• Excessive vitamin D intake can be harmful. The upper recommended daily limit for adults is 4,000 IU.

NCCIH-Funded Research

The National Center for Complementary and Integrative Health supports large research projects examining nondrug approaches to pain management, including studies in military and veteran populations.

Research initiatives also focus on improving treatment strategies for low-back pain and reducing reliance on opioids. Ongoing projects are evaluating acupuncture, tai chi, mindfulness-based movement therapies, and psychosocial interventions for chronic low-back pain.

For More Information

NCCIH Clearinghouse

The NCCIH Clearinghouse provides information about complementary and integrative health approaches and related research. It does not offer medical advice or referrals.

Toll-free in the U.S.: 1-888-644-6226

Telecommunications relay service (TRS): 7-1-1

Email: [email protected]

Know the Science

Educational resources are available to help consumers understand scientific research, clinical studies, and how to interpret health information for informed decision-making.

MedlinePlus

MedlinePlus provides reliable health information from federal agencies and trusted organizations, including resources on back pain.

PubMed®

PubMed is a database of scientific and medical research articles, offering citations and summaries of published studies.

Key References

• Systematic reviews and clinical guidelines evaluating nonpharmacologic therapies for low-back pain.

• Meta-analyses examining acupuncture, spinal manipulation, yoga, tai chi, massage, dry needling, herbal medicine, TENS, vitamin D, and other approaches.

Other References

• Additional systematic reviews and case reports addressing safety, adverse events, and mechanisms of complementary therapies for low-back pain.

Acknowledgments

This publication was prepared with expert review and is in the public domain. It is intended for informational purposes only and should not replace professional medical advice. Consult your health care provider regarding diagnosis or treatment decisions.