integrative approaches to spine pain carolyn e. keeler, do, faapmr physical medicine &...
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Integrative Approaches to Spine Pain
Carolyn E. Keeler, DO, FAAPMRPhysical Medicine & Rehabilitation
Assistant ProfessorDivision 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
• Acupuncture• Ayurveda• Biofeedback• Chelation therapy• Manipulation/ Manual
medicine• Energy
healing therapy/Reiki
• 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
• 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
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.”
Ann Intern Med. 2 October 2007;147(7):I-45
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
• Difficulty blinding practitioner• Difficulty blinding participants• Issues with sham treatments• Individualized treatments• Standardization of botanicals• Placebo• Spine pain subgroups
"No illness which can be treated by the diet should be treated by any other means."~ Moses Maimonides (1135-1204)
DIET
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-Inflammatory-Food-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 *adequate intake
ods.od.nih.gov/factsheets/Calcium-HealthProfessional/
Calcium
Deficiency risk factors
• Women• Vegan • Lactose-intolerance • Amenorrhea
Medication affecting absorption/excretion
• Corticosteroids• Aromatase inhibitors,• Anticonvulsants• Thiazide-type diuretics• Tetracycline• Aluminum or magnesium-
containing 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://www.mayoclinic.com/health/nutrition-facts/
http://health.gov/dietaryguidelines/
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/drug-interactionchecker
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
• Fish oil (Omega-3 FA)• Vitamin D• ASUs• SAM-e• Glucosamine &
Chondroitin
• 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-eS-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 cross-over 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 ClawHarpagophytum procumbens
• Native to Southern Africa
• Back pain specific studies, also OA
• Side effects: GI upset• Avoid in PUD
Devil’s Claw: Systematic Review
Harpagophytum procumbens for osteoarthritis and low back pain: a systematic review. Gagnier JJ, Chrubasik S, Manheimer E. BMC Complement Altern Med. 2004
12 trials, 4 studied low back painModerate 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.
Willow BarkSalix alba
• Among many salicin-containing 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 BarkSalix 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 rofecoxibHerbal 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• 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
• Augmentation of Immunity Theory• Endorphin Theory• Neurotransmitter Theory• Circulatory Theory• Gate Control Theory
Complications
• 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 painModerate 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 LBPYuan 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):E887-900.
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):944-63.
Agency for Healthcare Research and Quality (US)
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.
Systematic review: acupuncture, spinal manipulation, mobilization, and massage spinal pain.265 RCTs and 5 non-RCTs
Barriers
Insurance coverage?Out of pocket cost
Nonresponders
Possible factors
•Chronicity
•Opioid use
•Other…
SPINAL MANIPULATION
• 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
• 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 MobilizationNeck pain
Acute: Few studies, inconclusive evidenceChronic: • Moderate evidence that
manipulation/mobilization is superior to general practitioner management for short-term 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
• 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
yogaYoga 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 Meta-analysis 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 short-term
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• 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.
• 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
