LBP and its related disabilities are major public health problems worldwide. The conventional treatment of LBP consists of medication, tissue stimulation (e.g., electrical stimulation, ultrasound), rest and orthotics.[31
] Failure of the non-surgical treatment leads to alternative options, such as a variety of surgical approaches to achieve spinal fusion with various results.[32
Given the inadequate results of traditional treatment and their side effects, there has been increasing usage of complementary and alternative medicine (CAM) by LBP sufferers to relieve their symptoms.[33
There are more than 50 potential therapies promising to alleviate the pain, and provide a cure for this problem.[34
] So, several groups of health care providers, such as physicians, physiotherapists, chiropractors, and a host of more “alternative” caregivers are involved in management of LBP. Some experts take this over-abundance of therapeutic options as a sign that “nothing works very well” singly for LBP[35
] and recommend multi-disciplinary treatment programs.[36
The results of the current study showed that our integrative treatment package comprised of herbal medicines, acupuncture, bee venom acupuncture, and a Korean massage (Chuna) significantly decreased VAS and ODI and improved the HRQOL of patients.
Several traditional Chinese and Korean herbal medicine including Cibotium barometz, Atractylodes japonica, Ostericumkoreanum, Eucommia ulmoides, Acanthopanax Sessiliflorus, Achyranthesbidentata, Psoraleacorylifolia, Peucedanum japonicum, Lycium chinense, Boschniakia rossica
, and Cuscuta chinensis
have been used as treatments for LBP in this study. The above herbal medicines in powder and decoction forms are part of the historically developed treatment practiced at Jaseng Hospital for low back pain.[21
] It has been shown that the compounds of Cibotium barometz and Atractylodes japonica showed inhibition of osteoclast, and protection of the osteoblasts respectively. Furthermore, it has been reported that Eucommia ulmoides, Dioscorea spongiosa and Cuscuta chinensis have anti-osteoporotic effects through osteoblast-like cell proliferation, osteoclast inhibition effects[37
] and recover bone mineral density.[38
Psoralea corylifolia and Lycium chinense[40
] have known anti-inflammatory effects[41
] while Peucedanum japonicum and Boschniakia rossica are good anti-oxidant.[42
Acupuncture is based on ancient Chinese philosophical theories about the flow of vital energy through the body along the discrete pathways termed meridians. In acupuncture, specific points alongside of the meridians are utilized to balance the energy flows within the body. Many different styles of acupuncture and adjunctive techniques have been developed and disseminated into other cultures.[44
There are several systematic reviews on efficacy of acupuncture in LBP patients comparing acupuncture with sham acupuncture, other sham treatments, no additional treatment, or another active treatment. Acupuncture effectively relieves chronic LBP. No evidence suggests that acupuncture is more effective than other active therapies.[45
Traditional Korean doctors have used apitoxin, or honey bee venom, as a type of pharmacopuncture. Bee venom is extracted from a honey bee by using electrical stimulation. It has been shown that Bee venom administration is effective in pain relief of rheumatoid and degenerative arthritis, which require long-term treatment, as well as resolution of inflammation.[46
Several mechanisms have been suggested to clarify the bee venom induced antinociceptive and anti-inflammatory effects, including the activation of spinal alpha 2-adrenoceptors of descending noradrenergic, adrenergic, and serotonergic pathways and activation of capsaicin-sensitive primary afferent (CSPA) fibers.[47
The analgesic effects induced by BV acupuncture also may be attributable to bioactive BV compounds, including peptides (melittin, adolapin, apamin, and the mast-cell degranulating peptide), enzymes (phospholipase A2), and amines (histamine and epinephrine)[50
Massage is a simple way of pain relief, which stimulates large diameter nerve fibers that finally inhibits nociceptive fibers. It may also provide its benefits through shifting the autonomic nervous system from a state of sympathetic response to a state of para-sympathetic response, and increasing the pain threshold through the release of endorphins[34
The results of a systematic review showed that massage is beneficial for patients with sub-acute and chronic nonspecific LBP in terms of improving symptoms and function. Two studies compared massage to sham treatment reported that massage was superior for pain and function on both short and long-term follow-ups. However, a latest Cochrane review of spinal manipulation in chronic LBP concluded that spinal manipulative therapy results in a small, statistically significant but not clinically significant pain relieve and function in patients with chronic LBP compared with other treatments.[51
To the best of our knowledge, this is the first study investigating the effect of an integrative treatment package on LBP. Furthermore, while most of the studies considered short term beneficial effects of traditional and CAM approach to relieve pain, the long observational period of 6 months allowed us to predict progress of treatment outcomes. However, we were unable to compare the results of our study to others and could not find which treatment of the package is more effective than others.
Our new analysis showed that the older participants in our study benefited more from the LBP integrated package. It means that the more age led to higher HRQOL with less VAS. The prevalence of benign back pain appears to increase with an increasing age, with a peak in the sixth decade. Back pain is one the four most commonly reported symptoms in the elderly[52
] and the prevalence of osteoarthritis, disc degeneration, osteoporosis and spinal stenosis are known to increase with age.[53
] Furthermore, it has been shown that the risk of disabling back pain rises in older age.[55
] In light of this, it is highly desirable to find a safe way for LBP in elderly patients. Since, LBP has such human and financial impacts on society and since the numbers of people aged are increasing our package will be a good suggestion for this group.
Another new finding of the current study was the more benefits of the integrated package in patients with higher BMI. The data for association between obesity and low back pain appears to be controversial[56
] however, there are stronger evidences showing that overweight and obesity are associated with an increased risk of low back pain.[57
] Yet, there is no appropriate therapeutic approach for the obese patient with low back pain. So the more positive result of the integrated package for more obese patients in the current study is favorable.
One more interesting finding of the re-analysis of the results with new method is the similar results in patients with and without the herniated disc surgery. It seems that this package may lead to impressive outcomes even in patient with serious underlying patho-physiology similar other study.[58