Integrative Approaches to Spine
Pain
Carolyn E. Keeler, DO, FAAPMR
Physical Medicine & Rehabilitation
Assistant Professor
Division of Neurosurgery
Duke University Medical Center
“Complementary” vs. “Alternative”
• Complementary
medicine is used
alongside conventional
medicine.
• Alternative medicine is
used in place of
conventional medicine.
Integrative medicine combines
conventional and CAM treatments for
which there is evidence of safety and
effectiveness.
National Institute of Health Center for Complementary and Alternative Medicine
Integrative Medicine
• Philosophy: neither rejects conventional
medicine nor accepts alternative medicine
uncritically
• Recognition that good medicine should be
inquiry driven, based in good science and
open to new paradigms
Complementary and Alternative
Treatment Use
2007 National Health
Interview Survey
• Information collected:
23,000+ adults aged 18
years or older
• 9,000+ children aged 17
years and under.
CAM Therapies Included in the
2007 NHIS
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Acupuncture
Ayurveda
Biofeedback
Chelation therapy
Manipulation/ Manual
medicine
• Energy
healing therapy/Reiki
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Movement therapies
Naturopathy
Traditional healers
Hypnosis
Massage
CAM Therapies Included in the
2007 NHIS
• Deep
breathing exercises
• Progressive relaxation
• Qi gong
• Tai chi
• Diet-based therapies
• Meditation
• Yoga
• Guided imagery
• Homeopathic treatment
• Natural products
Reasons patients don’t tell us about
CAM use
• "It wasn't important for the doctor to know"
(61%)
• "The doctor never asked" (60%)
• "It was none of the doctor's business" (31%)
• "The doctor would not understand" (20%)
• “The doctor would disapprove” (14%)
Respondents felt CAM therapies to be more helpful for the
treatment of headache and neck and back conditions, but
considered conventional care to be more helpful for treatment
of hypertension.
Eisenberg DM. Ann Int Med 2001;135(5):344-51
Treatment of Back and Neck Pain:
Range of Evidence
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Diet/Nutrition
Supplements
Botanicals
Acupuncture
Spinal manipulation
Yoga
Mind-body interventions
American College of Physicians/American Pain
Society 2007 clinical guidelines: Low back pain
Promising, beneficial
• Acupuncture
• Massage
• Spinal manipulation
• CBT
• Exercise
• Progressive relaxation
• Intensive interdisciplinary
rehabilitation
• Yoga
Ann Intern Med. 2 October 2007;147(7):I45
Limited, mixed, or none
• Herbal therapies
• Prolotherapy
“Doctors and patients should
consider the following nondrug
treatments for patients who do
not respond to self-care:
rehabilitation, spinal
manipulation, exercise
therapy, massage,
acupuncture, yoga,
progressive relaxation, or
cognitive-behavioral therapy.”
American College of Physicians/American Pain
Society 2007 clinical guidelines: Neck pain
Mixed evidence
• Manual therapy
(manipulation and
mobilization)
• Acupuncture
• Chronic tension-type or
cervicogenic headaches:
possible benefit.
• No overall consensus,
need for additional
research
Problems with research
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Difficulty blinding practitioner
Difficulty blinding participants
Issues with sham treatments
Individualized treatments
Standardization of botanicals
Placebo
Spine pain subgroups
DIET
"No illness which can be treated by the diet should
be treated by any other means."
~ Moses Maimonides (1135-1204)
Dietary Basics
• Spinal structures require proper nutrition to
function property
• Lean meats, fish, legumes
• Vitamin B12
• Calcium, vitamin D, and magnesium
Anti-inflammatory Diet
http://www.drweil.com/drw/u/ART02995/Dr-Weil-Anti-InflammatoryFood-Pyramid.html
Mediterranean Diet
http://oldwayspt.org/resources/heritage-pyramids
Dietary Supplement Fact Sheet:
Calcium
Recommended Dietary Allowances (RDAs) for Calcium
Age
Male
Female
Pregnant
Lactating
0–6 months*
200 mg
200 mg
7–12 months*
260 mg
260 mg
1–3 years
700 mg
700 mg
4–8 years
1,000 mg
1,000 mg
9–13 years
1,300 mg
1,300 mg
14–18 years
1,300 mg
1,300 mg
1,300 mg
1,300 mg
19–50 years
1,000 mg
1,000 mg
1,000 mg
1,000 mg
51–70 years
1,000 mg
1,200 mg
71+ years
1,200 mg
1,200 mg
ods.od.nih.gov/factsheets/Calcium-HealthProfessional/
*adequate intake
Calcium
Deficiency risk factors
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Women
Vegan
Lactose-intolerance
Amenorrhea
Medication affecting
absorption/excretion
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Corticosteroids
Aromatase inhibitors,
Anticonvulsants
Thiazide-type diuretics
Tetracycline
Aluminum or magnesiumcontaining antacids
Calcium and Vitamin D
FDA authorized health
claim for food and
supplements related to
osteoporosis:
• 1993: Calcium and
balanced diet
• 2010: Calcium +
vitamin D
• Calcium absorption can
be enhanced by
increased vitamin D
intake from food or
through sunlight
exposure
Wimalawansa SJ. Annals of the New York
Academy of Sciences, 2011
Dietary Resources
http://www.choosemyplate.gov
/index.html
http://health.gov/dietaryguidelines/
http://www.mayoclinic.com/hea
lth/nutrition-facts/
DIETARY SUPPLEMENTS
Regulation
• Dietary Supplement Health Education Act in
1994
• FDA Current Good Manufacturing Practices in
2007
Supplement Labels
DSHEA and previous food labeling laws: three
types of claims permitted by the FDA
1. Nutrient content claims
2. Health claims (that a substance has impact
on a disease)
3. Structure/function claims
Quality and Safety
• United States
Pharmacopeia (USP)
• National Sanitation
Foundation (NSF
International)
• Consumer Labs
Botanicals
History:
• Ancient Egypt, Greece,
Rome, India, China and
the Middle East
• Rich oral traditions of
Africa and the Americas
Current US (2007)
• Rising popularity
• $15 billion USD
Botanicals Adverse Effects
Systematic review of complementary and
alternative therapies
• Most reported adverse effects were associated
with herbal medicines when compared to
other CAM therapies
Ernst E. Serious adverse effects of unconventional therapies for children and
adolescents: a systematic review of recent evidence. European journal of pediatrics
2003
Safety of Botanicals
• Adulterated or
contaminated
ingredients
• Inappropriate use
• Pregnancy, nursing,
children or elderly
• More concentrated
products
• Safety <-> Quality
• Herb-drug
interactions
http://reference.medscape.com/druginteractionchecker
Efficacy: Research challenges
• Systematic Reviews & Meta-Analyses of
Botanicals
• Biological & Pharmaceutical Equivalence
• Single Herb vs. Formulation
• Individualization
• Dose
• Mechanism of Action
Common Supplements used for Pain
and/or Arthritis
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Fish oil (Omega-3 FA)
Vitamin D
ASUs
SAM-e
Glucosamine &
Chondroitin
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Devil’s Claw
Bromelain
Turmeric
Willow
Ginger
Rhodiola
Topicals Arnica, Capsaicin, Comfrey
Omega-3 Fatty Acids
• EPA and DHA
• Enhance the conversion of
COX to prostaglandin E2
competitive inhibition of AA
• Inhibition of inflammatory
cytokines
• Inhibit conversion of AA to
inflammatory leukotrienes
Omega-3 Fatty Acids
• 250 patients with cervical and lumbar disc
disease taking NSAIDs
• 59% were able to discontinue NSAIDs
• 60% reported improvement in pain
• Dosage 1200-2400mg of EPA and DHA per day
Maroon JC, Bost JW. Omega-3 fatty acids (fish oil) as an antiinflammatory: An
alternative to nonsteroidal anti-inflammatory drugs for discogenic pain. Surg Neurol.
2006.
Avocado Soybean Unsaponafiables
• Inhibit IL-1 synthesis
• Anti-inflammatory
effect
• Articular chondrocytes
• ASU 300 mg vs. placebo
in hip and knee OA
• Decreased pain
• Reduced NSAID use
Ernst, E. Avocado-soybean unsaponifiables (ASU) for osteoarthritis - a
systematic review. Clin Rheumatol. 2003
SAM-e
S-adenosyl-L-methionine
• From essential AA
methionine
• Methyl donor in various
biochemical pathways
• Synthesis linked to
vitamin B12, folate
• Initially studied in
depression found
improvement in arthritis
pain
SAM-e
• Meta-analysis conducted by the AHRQ
• Several randomized clinical trials
• More effective than placebo and comparable
to NSAIDs in reducing osteoarthritis pain
S-Adenosyl-L-Methionine (SAMe) for Depression, Osteoarthritis, and Liver Disease.
Rockville, MD: Agency for Healthcare Research and Quality August 2002
SAM-e
• SAMe 1,200 mg/d vs. celecoxib 200 mg per
day
• Celecoxib more effective than SAM-e in
reducing pain during the first month of
treatment
• After two months of use, no difference in pain
relief was noted between the two agents
Najm WI, Reinsch S, Hoehler F, Tobis JS, Harvey PW. S-adenosyl methionine (SAMe)
versus celecoxib for the treatment of osteoarthritis symptoms: a double-blind crossover trial. BMC musculoskeletal disorders 56 Feb, 2004
Vitamin D
Osteoporosis
• Long-term effect of deficiency
• Older adults
• Non-ambulatory individuals who have
difficulty exercising
• Postmenopausal women
• Chronic steroid therapy
http://ods.od.nih.gov/factsheets/VitaminD-QuickFacts/
Vitamin D
• 360 people, low back pain >6 months, age 15 to 52
• 83% had an abnormally low level of vitamin D before
treatment with vitamin D supplements.
• After treatment, clinical improvement in symptoms
was seen in all the groups with low level of vitamin D.
Vitamin D deficiency is a contributor to chronic low back
pain in areas where vitamin D deficiency is endemic.
Al Faraj S, Al Mutairi K. Vitamin D deficiency and chronic low back pain in Saudi
Arabia.
Spine. 2003 Jan 15; 28(2):177-9.
Devil’s Claw
Harpagophytum procumbens
• Native to Southern
Africa
• Back pain specific
studies, also OA
• Side effects: GI upset
• Avoid in PUD
Devil’s Claw:
Systematic Review
12 trials, 4 studied low back pain
Moderate evidence of effectiveness
• Aqueous extract 100 mg harpagoside/day in the
treatment of acute exacerbations of chronic non-specific
LBP
• 60 mg was equivocal to 12.5 mg rofecoxib per day for
chronic non-specific low-back pain (short term)
Strong evidence: 50 mg / day for acute
exacerbations of chronic low back pain.
Harpagophytum procumbens for osteoarthritis and low back pain: a
systematic review. Gagnier JJ, Chrubasik S, Manheimer E. BMC Complement
Altern Med. 2004
Willow Bark
Salix alba
• Among many salicincontaining plants
• Salicin levels vary widely
across species
• Not everyone can convert
to salicylic acid
• Studies provide mixed
results
• Poor methodology
• Likely safe: less inhibition
of platelet aggregation
than 100mg ASA
Willow Bark
Salix alba
• Two moderate-quality trials utilizing Salix alba
(White willow bark)
• Moderate evidence for short-term
improvement in pain and rescue medication
use
• 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
Herbal medicine for low back pain: a Cochrane review. Spine (Phila Pa
1976). 2007 Jan 1 ;32(1):82-92.
Turmeric
Curcuma longa
• Flowering plant- Ginger
family
• Common spice
• Ayurveda, TCM
• Anti-inflammatory,
antioxidant effects
• Ongoing clinical trials,
emerging data
Turmeric
SAFETY
• Safe for most adults
• Indigestion,
nausea, diarrhea
• Liver disease (animal
studies)
• Gallbladder disease
Use:
• Standardized turmeric
powder 400–600 three
times/day
Caution:
• Anticoagulants or high
doses of NSAIDS
• May be used in combination
with lower doses of NSAIDs
Turmeric
Curcuma longa
• Standardized turmeric powder 400–600 three
times/day
• Side effects: GI upset, gastric ulcers (high
doses).
• Caution: anticoagulants or high doses of
NSAIDS.
• May be used in combination with lower doses
of NSAIDs
Specific Safety Concerns:
Interventional Procedures & Surgery
ANTICOAGULATION
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Devil’s claw
Ginger
Turmeric
Ginseng
Garlic
Ginkgo
Omega-3 fatty acids
Chamomile
Feverfew
Others
STEROIDS
• Ginseng (potentiates)
• Echinacea (decreased
effect)
Acupuncture
• Yellow emperor’s classic
of internal medicine
• >2300 years ago
• Qi
• Meridians
• Sir William Osler 19th
century
• France 1950s
Acupuncture
• 1971- US
• Appendectomy under
acupuncture anesthesia
in China
• 1997 NIH consensus
Mechanisms
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Augmentation of Immunity Theory
Endorphin Theory
Neurotransmitter Theory
Circulatory Theory
Gate Control Theory
Complications
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Pneumothorax
Organ injury
Vascular injury
Infection
Bleeding/bruising
Contraindications
• Electro acupuncture -> pacemakers/
implantable defibrillators.
• Bleeding disorders?
• Infection
• Recent total joint arthoplasty
Research challenges
• Many clinical trials for spinal pain
• Double-blind and sham controlled trials
difficult to design and to perform
• Meta-analyses show conflicting results
• ? Expectations
Acupuncture and neck pain
Moderate evidence:
• More effective for pain relief than sham controls,
(measured immediately post-treatment)
• More effective than sham treatments measured
immediately post-treatment and at short-term
follow-up
• Chronic neck disorders with radicular symptoms:
acupuncture was more effective than a wait-list
control at short-term follow-up
Trinh K, Graham N, Gross A, Goldsmith C, Wang E, Cameron I, Kay T. Acupuncture for
neck disorders. Spine 2007 Jan 15 ;32(2):236-43.
Acupuncture and back pain
Moderate evidence - more effective than no
treatment
Strong evidence
• No significant difference between acupuncture
and sham acupuncture (short-term)
• Useful supplement to other forms of
conventional therapy for nonspecific LBP
Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S. Effectiveness of
acupuncture for low back pain: a systematic review. Spine 2008 Nov 1; 33(23):E887900.
Acupuncture and back pain
• Chronic low back pain: pain relief and functional
improvement for acupuncture compared to no
treatment or sham (post-treatment, short-term
follow-up)
• Acupuncture + conventional therapies: pain relief
and functional improvement superior to
conventional therapies alone (small effect)
• Dry-needling - useful adjunct to other therapies
for chronic low back pain.
Acupuncture and dry-needling for low back pain: an updated systematic review within
the framework of the Cochrane collaboration. Furlan AD, van Tulder M, Cherkin D,
Tsukayama H, Lao L, Koes B, Berman B. Spine (Phila Pa 1976). 2005 Apr 15; 30(8):94463.
Agency for Healthcare Research and
Quality (US)
Systematic review: acupuncture, spinal manipulation,
mobilization, and massage  spinal pain.
265 RCTs and 5 non-RCTs
Acupuncture: lower pain intensity than placebo
but only immediately post-treatment
• Sham acupuncture studies: negative results
• Compared with placebo or other treatment
Furlan AD, Yazdi F, Tsertsvadze A, et al. Complementary and Alternative Therapies for
Back Pain II. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010
Oct.
Barriers
Insurance coverage?
Out of pocket cost
Nonresponders
Possible factors
•Chronicity
•Opioid use
•Other…
SPINAL MANIPULATION
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Osteopathy
Chiropractic
Physical Therapy
Massage Therapy
Ultimate goal -> correct imbalances in the musculoskeletal system
to improve health and function
Spinal Manipulation: Credentialing
Osteopathic
• Certificate of Special
Proficiency in Osteopathic
Manipulative Medicine
• Board Certification in
Neuromusculoskeletal
Medicine
• American Academy of
Osteopathy
Chiropractic
• Licensure by state
• Variation from state to state
• Scope of practice:
generally limited to
neuromusculoskeletal
system diagnosis, treatment
Massage Therapy
• 500 hours
• State licensure
• AMTA
Contraindications: Manipulation
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Fracture
DVT
Systemic anticoagulation treatment
Vertebrobasilar disease or insufficiency
Ligamentous joint instability or laxity
Aseptic necrosis
Local aneurysm
Osteoporosis, osteomalacia
Malignancy
Acute disk herniation
Complications
• Reporting inconsistent
• Soreness or bleeding on the site of application
after acupuncture
• Worsening of pain after manipulation or
massage
• Cervical manipulation (HVLA): significantly
associated with vertebral artery dissection or
vertebrobasilar stroke
Research
Unique challenges
• Double-blinded placebo-controlled trials
• Random selection and random assignment
• Patient preference trial
• Clinical effectiveness vs. mechanism
• Heterogeneity
• Natural history
Efficacy of Manipulation
Low back pain
• Mix of acute and chronic LBP  similar or
superior pain outcomes in the short and long
term when compared with placebo and with
other conventional treatments
Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and
mobilization for low back pain and neck pain: a systematic review and best evidence
synthesis. Spine J. 2004 May-Jun ;4(3):335-56.
Efficacy of Manipulation
Chronic low back pain
Moderate evidence:
• Similar efficacy to NSAIDs
• Effective in the short term when compared
with placebo and general practitioner care,
and in the long term compared to physical
therapy.
Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and
mobilization for low back pain and neck pain: a systematic review and best evidence
synthesis. Spine J. 2004 May-Jun ;4(3):335-56.
Efficacy of Manipulation and Mobilization
Neck pain
Acute: Few studies, inconclusive evidence
Chronic:
• Moderate evidence that
manipulation/mobilization is superior to
general practitioner management for shortterm pain reduction
• Manipulation offers at most similar pain relief
to rehabilitation exercises (short and long
term)
Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and
mobilization for low back pain and neck pain: a systematic review and best evidence
synthesis. Spine J. 2004 May-Jun ;4(3):335-56.
Manipulation
• Low back and neck: superior to placebo or no
treatment in reducing pain immediately or
short-term
• Chronic nonspecific low back pain:
Manipulation appeared effective in improving
pain and function
Furlan AD, Yazdi F, Tsertsvadze A, et al. Complementary and Alternative Therapies for
Back Pain II. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010
Oct.
Issues
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Evidence was of poor to moderate grade
Most studies: chronic nonspecific pain
Subgroup effects: insufficient data
The benefit of CAM treatments was mostly
evident immediately or shortly after the end
of the treatment and then faded with time.
• Long-term outcomes?
• Methodological and clinical diversity
Furlan AD, Yazdi F, Tsertsvadze A, et al. Complementary and Alternative Therapies
for Back Pain II. Rockville (MD): Agency for Healthcare Research and Quality (US);
2010 Oct.
YOGA
Yoga Styles
Hatha yoga
• Iyengar
• Vinyasa
• Ashtanga
• Power yoga
• Bikram yoga
• Viniyoga
Yoga
• Clinically significant improvement in functional
outcomes in mild-moderate LBP and fibromyalgia
• Trend to improvement in kyphosis
• Improved pain in OA, RA and mild-severe LBP
• Psychosocial outcomes were significantly
improved in mild-to-moderate LBP and OA
• Meta-analysis: moderate treatment effect for
yoga
Yoga for Functional Ability, Pain and Psychosocial Outcomes in Musculoskeletal
Conditions: A Systematic Review and Meta-Analysis.
Musculoskeletal Care. 2013 Jan 9.
Yoga
• Systematic review, chronic LBP
• 10 trials, 967 patients
• Outcomes: pain, back-specific and general
disability, QOL
• Strong evidence for long-term effect on pain
• Moderate evidence for long-term effect on
back-specific disability
Cramer H, Lauche R, Haller H, Dobos G. A Systematic Review and Metaanalysis of Yoga for Low Back Pain. Clin J Pain. 2012 Dec 14.
MIND-BODY
Mindfulness-Based Stress Reduction
Chronic low back pain
3 RCTs, 117 chronic low back pain patients
• FBSS: significant and clinically important shortterm improvements in pain intensity and
disability for MBSR compared to no treatment
• Older adults with chronic specific or non-specific
SBP: no improvements in pain or disability for
MBSR compared to no treatment or health
education
• Larger short-term improvements of pain
acceptance for MBSR compared to no treatment.
Cramer H, Haller H, Lauche R, Dobos G. Mindfulness-based stress
reduction for low back pain. A systematic review. BMC Complement
Altern Med. 2012; 12: 162.
Cognitive-Behavioral Therapy
• Systematic review, 46 studies included
• CBT -> beneficial treatment for chronic back
pain, especially when compared to wait-list
controls/treatment as usual.
Sveinsdottir et al. Assessing the role of cognitive behavioral therapy in
the management of chronic nonspecific back pain. J Pain Res. 2012
Current NCCAM Funded Research
• Chronic low-back pain: acupuncture,
massage, spinal manipulation, yoga
• Osteoarthritis pain: prolotherapy, tai chi,
and yoga
• Chronic neck pain: massage
• Chronic headaches: acupuncture, spinal
manipulation
• Fibromyalgia pain: acupuncture, tai chi
Future research
• Valid experimental design
• Pretesting and post-testing
• Appropriate sample sizes and statistical
analysis methods
• Reliable and valid measurement
• Standardization of duration and frequency of
treatment
• Attempt to control placebo
RESOURCES
• NIH National Center for Complementary and Alternative Medicine
http://nccam.nih.gov/
• Agency for Healthcare Research and Quality
http://www.ahrq.gov/clinic/epcindex.htm
• Consumer Lab www.consumerlab.com
• Natural Medicines Comprehensive Database
www.naturaldatabase.com
• The Natural Standard www.naturalstandard.com
• NIH Office of Dietary Supplements http://ods.od.nih.gov/
• Memorial Sloan Kettering Cancer Center: Herbs and supplements
www.mskcc.org/cancer-care/integrative-medicine
• My Plate http://www.choosemyplate.gov/index.html
• American Academy of Medical Acupuncture
www.medicalacupuncture.org
References
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Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complementary
and Alternative Medicine Use Among Adults and Children: United States, 2007. December
10, 2008
Eisenberg et. al. Perceptions about complementary therapies relative to conventional
therapies among adults who use both: results from a national survey. Ann Intern Med.
2001 Sep 4 ;135(5):344-51.
Chou R, Huffman LH: Nonpharmacologic therapies for acute and chronic low back pain: a
review of the evidence for an American Pain Society/American College of Physicians clinical
practice guideline. Ann Intern Med 2007:147(7):492-505
Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK Diagnosis and
treatment of low back pain: a joint clinical practice guideline from the American College of
Physicians and the American Pain Society. Ann Intern Med 2007 147(7)478-91
Ernst E. Serious adverse effects of unconventional therapies for children and adolescents:
a systematic review of recent evidence. European journal of pediatrics 2003
Wimalawansa SJ. Vitamin D: an essential component for skeletal health. Annals of the
New York Academy of Sciences 1240E1-12 Dec, 2011
Cramer et. al.,. S-Adenosyl-L-Methionine (SAMe) for Depression, Osteoarthritis, and Liver
Disease. Rockville, MD: Agency for Healthcare Research and Quality August 2002
Ernst, E. Avocado-soybean unsaponifiables (ASU) for osteoarthritis - a systematic review.
Clin Rheumatol. 2003 Oct ;22(4-5):285-8.
Najm WI, Reinsch S, Hoehler F, Tobis JS, Harvey PW. S-adenosyl methionine (SAMe) versus
celecoxib for the treatment of osteoarthritis symptoms: a double-blind cross-over trial.
BMC Musculoskelet Disord. 2004 Feb 26 ;5:6.
Al Faraj S, Al Mutairi K. Vitamin D deficiency and chronic low back pain in Saudi Arabia.
Spine. 2003 Jan 15; 28(2):177-9.
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Gagnier JJ, Chrubasik S, Manheimer E. Harpagophytum procumbens for osteoarthritis and
low back pain: a systematic review. BMC Complement Altern Med. 2004 Sep 15; 4:13. Epub
2004 Sep 15.
Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of
the cervical spine: a systematic review of the literature. Spine 1996;21:1746-1760
Curtis CL, Rees SG, Little CB, Flannery CR, Hughes CE, Wilson C, et al. Pathologic indicators
of degradation and inflammation in human osteoarthritic cartilage are abrogated by
exposure to n-3 fatty acids. Arthritis Rheum. 2002;46:1544–53.
Maroon JC, Bost JW. Omega-3 fatty acids (fish oil) as an anti-inflammatory: an alternative
to nonsteroidal anti-inflammatory drugs for discogenic pain. Surg Neurol. 2006 Apr;
65(4):326-31.
Furlan AD, Yazdi F, Tsertsvadze A, et al. Complementary and Alternative Therapies for Back
Pain II. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010 Oct.
Trinh K, Graham N, Gross A, Goldsmith C, Wang E, Cameron I, Kay T. Acupuncture for neck
disorders. Spine 2007 Jan 15 ;32(2):236-43.
Yoga for Functional Ability, Pain and Psychosocial Outcomes in Musculoskeletal Conditions:
A Systematic Review and Meta-Analysis. Musculoskeletal Care. 2013 Jan 9.
Cramer H, Lauche R, Haller H, Dobos G. A Systematic Review and Meta-analysis of Yoga for
Low Back Pain. Clin J Pain. 2012 Dec 14.
Mindfulness-based stress reduction for low back pain. A systematic review. BMC
Complement Altern Med. 2012 Sep 25 ;12:162. doi: 10.1186/1472-6882-12-162.
Cramer H, Haller H, Lauche R, Dobos G. Mindfulness-based stress reduction for low back
pain. A systematic review. BMC Complement Altern Med. 2012; 12: 162.
Sveinsdottir et al. Assessing the role of cognitive behavioral therapy in the management of
chronic nonspecific back pain. J Pain Res. 2012
Thank you!
carolyn.keeler@duke.edu