Julia Belluz

Yoga, Pilates, and tai chi seem to help — but it’s not clear that they’re any better than other exercise. There’s lots of research on back pain and yoga. Not all of it is high-quality, but taken together, the evidence pretty uniformly suggests yoga can both decrease pain and improve back-related function. The most recent Cochrane systematic review on yoga and chronic low back pain, published in 2017, sums up the results of the best available studies, which mostly focused on the Iyengar, Hatha, or Viniyoga forms of yoga. There is low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at three and six months. Yoga may also be slightly more effective for pain at three and six months, however the effect size did not meet predefined levels of minimum clinical importance.

So again, this isn’t an end-all treatment — but the evidence we have points in the direction of a benefit. Importantly, the review authors also noted that it’s not clear whether yoga is better than other exercises, since there were few head-to-head comparisons tracking yoga against other kinds of workouts. As for tai chi and Pilates, the Agency for Healthcare Research and Quality (AHRQ), a federal agency that crunches the best available data on the effectiveness of health care interventions, recently published a comprehensive 800-page systematic review of research on noninvasive treatments for low back pain, including these two kinds of exercises. It found „tai chi seemed to reduce chronic back pain and help people return to their daily activities when compared with no exercise, and that it was more effective in alleviating pain than backward walking or jogging but not necessarily better than swimming. For Pilates, the evidence was a little more mixed: It was associated with small or no effects on pain and no effects on function compared with other types of exercise. Again, though, pretty much every back expert I spoke to said any exercise is better than no exercise, so if Pilates is something you enjoy, do it.  Try to find a “back whisperer,” or try these three exercises from one. The “back whisperers” come from many different backgrounds: doctors of physical therapy with an orthopedic clinical specialist certification, personal trainers with a degree in exercise science, physical therapists. “The specialists are able to observe how you walk and sit and stand, and grasp what your posture and gait say about your muscles, tendons, and ligaments,” she writes in Crooked. “Generally, they focus on functional training, prescribing exercise regimens that are ‘non-pain-contingent’ (you don’t stop when it hurts, sorry), ‘quantitative’ (you will not be allowed to quit until you hit your ‘number’), and ‘high-dose’ (you will do this routine on a schedule rather than when the spirit moves you).”

One renowned “back whisperer” is spine biomechanic Stuart McGill, of the University of Waterloo in Canada, who has treated everyone from Olympic athletes to professional football players. He spends several hours watching his patients move, and identifies the specific motions, postures, and loads that trigger their back pain. He then tailors exercise programs that build a foundation for pain-free activity, so that those triggers no longer result in pain. It can be difficult to find someone with the expertise of a back whisperer like McGill, and their time can also be costly. There’s also no study that brings together research on these folks, but if you can find a good one who works for you, your back pain could be improved. We’re learning how much back pain is mental, and that mind-body approaches can help.

Nowadays, though, there are also several different kinds of physical therapies that also integrate psychotherapy or cognitive behavioral therapy, often called multidisciplinary rehabilitation. Multidisciplinary rehab takes the “biopsychosocial” view of back pain — again, that the pain arises from the interplay of physical, psychological, and social factors. It can of course be tricky to disentangle whether mood disorders like anxiety or depression contribute to people’s pain, or whether they arise out of the pain, but either way, the biopsychosocial model views the physical as only one part of the equation. So these practitioners deal with what’s going on inside the head as part of their back pain therapy — helping patients get treatment for their depression or anxiety, or guiding them through cognitive behavioral therapy to improve their coping skills. Perhaps not surprisingly, multidisciplinary therapy appears to work slightly better than physical therapy alone for chronic back pain in both the short and long term. Patients who get these more holistic treatments are also more likely to return to work.

Spinal manipulation by chiropractors works about as well as exercise or over-the-counter drugs — with some big caveats. Passive therapies can also play a role in helping people manage back pain, though there’s no silver bullet among them, and their effects also tend to be modest and short-lived. The research base for these alternative therapies is also generally weak: There’s a lot of variability among the practice styles and programs on offer, even within one category of treatment like massage. You also can’t blind the patients to the treatment they are receiving, and the people who seek out particular therapies — acupuncture, massage — are probably more amenable to them, which may bias the results. With that said, here’s what we know.

Spinal manipulation, the cranking and tweaking on offer when you visit a traditional chiropractor, is among the most popular approaches to back pain. Practitioners lay their hands on the patient and move their joints to or beyond their range of motion — a technique that’s often accompanied by a pop or crack. There is some evidence the approach can help people with chronic back pain — but not any more than over-the-counter painkillers or exercise, and you need to take precautions when seeking out a chiropractor.

First, a quick look at the evidence. There are two recent Cochrane reviews on spinal manipulation for low back pain: one focused on people with acute (again, episodic/short duration) pain and the other on chronic pain. The 2011 review on chronic low back pain found that spinal manipulation had small, short-term effects on reducing pain and improving the patient’s functional status — but this effect was about the same as other common therapies for chronic low back pain, such as exercise. That review was published in 2011; Up-To-Date reviewed the randomized trials that have come out since — and also found that spinal manipulation delivered modest, short-term benefits for chronic back pain sufferers.

The Cochrane review on acute pain found that spinal manipulation worked no better than placebo. So people with a short episode of back pain should probably not bother seeing a chiropractor. “Based on the evidence,” University of Amsterdam assistant professor Sidney Rubinstein, who is the lead author on the Cochrane reviews, told me, “it would appear [spinal manipulation] works as well as other accepted conservative therapies for chronic low back pain, such as non-prescription medication or exercise, but less well for patients with acute low back pain.” As a chiropractor himself, he had some advice for patients: They should avoid chiropractors who routinely make X-rays or do advanced diagnostics for low back pain because this adds nothing to the clinical picture, particularly in the case of nonspecific low back pain. Patients should also beware chiropractors who put them on extended programs of care. “Patients who respond to chiropractic care traditionally respond rather quickly,” he said. “My advice is those patients who have not responded to a short course of chiropractic care or manipulation should consider another type of therapy.”

While the risks of serious side effects from spinal manipulation for back pain are rare — about one in 10 million — the risks associated with chiropractic therapy for neck pain tend to be slightly higher: 1.46 strokes for every million neck adjustments.

The issue is the vertebral artery, which travels from the neck down through the vertebrae. Manipulating the neck can put patients at a higher risk of arterial problems, including stroke or vertebral artery dissection, or the tearing of the vertebral artery (though Rubinstein noted that people in the initial stages of stroke or dissection may also seek out care for their symptoms, such as neck pain, which makes it difficult to untangle how many of health emergencies are brought on by the adjustments). In general, massage therapists work by manipulating the muscle and soft tissue of the back and body.

There are many, many different styles of massage: Swedish, deep tissue, sport, myofascial release, Thai, the list goes on. Massages also vary in how long they last, how much pressure is used, and how frequent sessions are, which makes the evidence for massage pretty difficult to interpret. But there’s good news here: Massage is pretty harmless, and the researchers who study back pain say the approach makes sense from a pain relief perspective. So it may be worth trying.

According to AHRQ, for subacute (lasting between seven and 12 weeks) and chronic low back pain, massage seems to improve symptoms and function in the short term (i.e., one week) — but there’s no evidence that it leads to any long-term change. At best, you’ll get a bit of immediate relief, but nothing lasting. The Cochrane systematic review on massage for low back pain looked at 25 trials on massage and, like AHRQ, found short-term improvements in pain and function for both subacute and chronic low back pain but a very mixed evidence base.

Acupuncture seems to help too, though it’s more controversial. One of the oldest approaches to back pain is acupuncture, a core part of traditional Chinese medicine. The philosophical underpinning of acupuncture is that disease or pain in the body is the result of imbalances between the body’s “yin and yang forces.” “Vital energy circulates throughout the body along the so-called meridians, which have either Yin or Yang characteristics,” the Cochrane authors explain. Using needles to stimulate the parts of the body that are located on these meridians can modulate pain or reverse disease, practitioners claim.

A 2005 Cochrane review looked at the evidence for acupuncture and low back pain and came to a few useful conclusions: There was “insufficient evidence” to make any recommendations about acupuncture for acute low back pain — so it may or may not help people. For chronic pain, acupuncture seemed to offer more pain relief when compared with no treatment or sham acupuncture (when practitioners use needles that don’t actually penetrate the skin).

The needling also improved function in the short-term when compared with no treatment for chronic pain sufferers. But acupuncture was not more effective than other treatments. UpToDate looked at more recent research and noted that the studies on acute pain were still limited, and that evidence for acupuncture’s effects on chronic pain is somewhat conflicting. The review also noted it was unclear whether acupuncture’s benefit lies in the needling, or in the placebo effect.

The author of the Cochrane review, Andrea Furlan, pointed to a more recent randomized trial, which came out in 2009 after her review was published: It also found that acupuncture seemed to reduce chronic low back pain — but it didn’t seem to matter where the needles were placed, raising questions about the meridian philosophy guiding the practice.

This is what makes acupuncture controversial. Science suggests it might work — but the squishiness of the findings, combined with the lack of scientific underpinning in acupuncture’s philosophy, leaves room for interpretation. And evidence-based medicine thinkers and skeptics view the results of studies as suggestive of nothing more than acupuncture’s potent placebo effect.

Researchers have found that the more dramatic the medical intervention, the stronger the placebo effect. And getting poked all over the body by needles is a pretty dramatic intervention. That’s not to mention you can never run a double-blind placebo — the gold standard in health research — on acupuncture, since that would involve both practitioners and patients not knowing (or being blinded to) what treatment they are giving and receiving. (Concluded)