Low Back Pain  Acupuncture  Herbal Medicine  Magnetic Therapy  Manual Therapies  Movement Therapies  Nutritional Approaches Complementary Approaches Nutritional Approaches Dietary change can be an important component to managing pain and inflammation. This can occur on several levels. Weight loss Many large-scale studies have tried to determine whether there is an association between body weight and low back pain and whether obesity or increased body mass index causes back pain. The general consensus is that there is a statistically positive but weak association between the two. It has also been suggested that obesity may play a part in the chronicity of simple low back pain, promoting the recurrence or increased duration of back pain symptoms (Leboeuf-Yde, 2000, 1999; Hurwitz, 1997). This effect has been attributed to an increase in sedentary lifestyle and the consumption of food high in fat that is common in modern society, a lifestyle that can lead to a reduction in lower extremity and trunk lean body mass and an increase in body fat. In addition studies have shown a higher correlation between body mass and fat distribution and low back pain in women (Han, 1997, Toda, 2000). Improved Blood Flow Caffeine and nicotine are potent vasoconstrictors that limit the supply of blood to muscles (Bazzoli, 1992). Certain foods, nutrients and supplements can alter the underlying cellular metabolic processes that maintain chronic inflammation, degeneration and pain. These usually do not act as immediate pain relievers in the way that pharmaceutical medications do, but generally have to be used consistently over a period of time---often weeks or months--- before they can begin to alter the processes that underlie pain generation. Other supplements can play a supportive role in terms of the relief of the anxiety and depression that can accompany chronic low back pain. Some types of chronic pain may be sustained by inflammatory processes. Theoretically, nutritional approaches could be useful if they reduced the factors that contribute to inflammation, provide supplements that decrease the amount of pro-inflammatory substances, or blocked the interaction between the chemicals produced by the immune system and their receptors in the nervous system. Reducing inflammation Dietary change can be an important component to managing pain and inflammation. This can involve decreasing the intake of foods that have pro-inflammatory substances and increasing foods that have anti-inflammatory properties. Reducing Inflammation and Promoting Analgesia Certain foods, nutrients and supplements can alter the underlying cellular metabolic processes that maintain chronic inflammation, degeneration and pain. These usually do not act as immediate pain relievers in the way that pharmaceutical medications do, but generally have to be used consistently over a period of time--often weeks or months--before they can begin to alter the processes that underlie pain generation. Other supplements can play a supportive role in terms of the relief of the anxiety and depression that can accompany chronic low back pain. Essential Fatty Acids (EFA's) The body uses EFAs to make chemicals that control inflammation. "Essential" means that the body cannot make these substances on its own, and therefore must get them from food or food supplements. There are two main groups of EFAs: Omega-3 fatty acids: These fatty acids include alpha-linolenic acid (ALA) from vegetarian sources, such as flax seeds, and EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), which are found mostly in oily fish such as salmon, mackerel and herring, and sea algae. All members of this class of essential fatty acids have been shown to reduce inflammation. Omega-6 fatty acids: These fatty acids include linoleic acid (LA), which is found in common cooking oils such as corn and safflower; gamma-linolenic acid (GLA) from plant seed oils, such as evening primrose oil, borage and black currant; and arachidonic acid (AA), which is found in high levels in meats. LA and AA generally produce pro-inflammatory substances, while GLA usually converts to anti-inflammatory mediators. Essential fatty acids, especially EPA and GLA, have been shown to help in treating arthritis, particularly rheumatoid arthritis (Leventhal 1993) (Geusens 1994) (Belch 1998). These oils work together through different pathways to both reduce pro-inflammatory prostaglandins and increase anti-inflammatory prostaglandins. They have been show to reduce symptoms and the need for medications in the most severe forms of arthritis. In order to reduce arachidonic acid, an omega-6 that acts as a precursor of inflammatory prostaglandins, it is often recommended that meat and other animal product consumption be decreased. Vitamins Vitamins may possess analgesic and anti-inflammatory properties. When taken properly, they can usually be used long-term because they lack side effects or long-term adverse consequences. They can also be used in combinations and with conventional anti-inflammatory and analgesic agents to enhance their effectiveness (Hanck, 1985). The B vitamins may enhance the effectiveness of prescription anti-inflammatory medications. A combination of vitamin B1, vitamin B6, and vitamin B12 has been reported to help painful spinal conditions and to decrease the amount of pain-reducing and anti-inflammatory medications needed in several small double-blind studies. These studies found that people with painful vertebral syndrome who took a combination of vitamin B1 and B6, at 50 mg each, 250 mcg of vitamin B12, and 50-75 mg of the nonsteroidal anti-inflammatory drug diclofenac experienced a statistically significant reduction in pain and increase in spinal movement compared to the group that received diclofenac alone (Vetter 1988). Vitamin B12 alone has also been shown to have analgesic and anti-inflammatory effects and may have a role in the treatment of back pain. A recent study confirmed the use of intramuscular vitamin B12 injections as a safe and effective treatment for generalized low back pain or sciatic pain of mechanical origin. The study showed a statistically significant improvement in pain and disability and decreased use of acetaminophen for pain relief (Mauro, 2000). Vitamin D is a fat-soluble family of compounds known as vitamins D1, D2 and D3. It is made in the skin through the action of sunlight, and is added to milk. The biologically active form of vitamin D is a hormone known as calcitriol. In recent years, scientific studies have looked at the role of vitamin D in the immune system and its apparent ability to suppress inflammatory T cell activity (Deluca 2001). Results suggest an important role for vitamin D in autoimmune disorders such as rheumatoid arthritis (Nagpal, 2001). Vitamin D is also involved in the functioning of healthy nerves and muscles by regulating the level of calcium in the blood. Calcium is vital for normal nerve impulse transmission and muscle contraction. Antioxidants Free radicals are substances that are created in the body through various chemical reactions. They have the capability to injure cells and the body has various mechanisms to inactivate them. Antioxidants are agents that work to reduce the levels of free radicals. The therapeutic use of antioxidants such as vitamin C and vitamin E may be important interventions in reducing tissue damage (Packer, 1992) (Goldfarb, 1999). A high intake of vitamin C reduced risk of cartilage loss and disease progression in 640 people with osteoarthritis (McAlindon, 1996) Alpha-lipoic acid, an anti-oxidant, given intravenously appears to significantly decrease neuropathic symptoms such as pain, burning, and numbness in patients with some types of neuropathy (DeZiegler 1997). In Germany, alpha-lipoic acid is an approved medical treatment for peripheral neuropathy, a common complication of diabetes. The richest food source of alpha-lipoic acid is red meat. Quercitin is a member of the flavonoid group, naturally occurring antioxidant substances found in fruits, vegetables, and tea. It inhibits the release of histamine and other inflammatory mediators, decreasing the inflammatory response in all mucous membranes. In recent studies, it has been shown to inhibit some inflammatory enzymes, such as lipid peroxidases, and decrease leukotriene (another inflammatory molecule) formation. Thus, it may be helpful in a variety of inflammatory responses, including injury, bursitis, and rheumatoid arthritis. (Wang, 2000) (Formica, 1995). Enzymes Proteolytic enzymes, including bromelain, papain, trypsin, and chymotrypsin, may be helpful in healing injuries because of their anti-inflammatory activity--in addition to their more commonly recognized action in digestion. Three double-blind studies have investigated the effects of a combination of trypsin and chymotrypsin for seven to ten days on severe low back pain. One of the studies reported small, statistically significant improvements for some measures in people with degenerative arthritis of the lower spine (Hingorani 1968). A second trial on people with sciatica-type leg pain showed significant improvement in several measures in one trial (Gaspardy 1971). The third study found very few differences in improvement compared to placebo (Gibson 1975). Bromelain, a complex enzyme of pineapple also known to have anti-inflammatory actions, may also help to reduce pain. When taken orally in combination with trypsin and rutin, it has shown effectiveness for treating osteoarthritis (Taussig, 1988). Bromelain can cause gastrointestinal disturbances or diarrhea, and allergic reactions to bromelain can occur rarely. In addition, bromelain may have certain interactions with various herbs, supplements and drugs, such as increasing the risk of bleeding when using anticoagulant/antiplatelet drugs or herbs. It is important to discuss the use of bromelain with a knowledgeable health professional. Minerals Minerals, such as zinc and copper may help in wound healing and in reducing pain and inflammation (Honkanen 1991, Lansdown 1996). In animal studies, magnesium alone had a significant analgesic effect on neuropathic pain and also increased the analgesic effect of low-dose morphine in conditions of persistent pain (Begon 2002). Glucosamine and Chondroitin Recent clinical trials have shown the statistically significant effectiveness of compounds such as chondroitin sulfate, diacerhein and glucosamine sulfate for the treatment of pain and inflammation of osteoarthritis (Towheed, 2001). It is noted that the onset of action takes about 4 to 6 weeks, but the symptomatic effect is maintained after stopping the treatment for periods of 4 to 8 weeks. Glucosamine sulfate has demonstrated a beneficial structural effect in osteoarthritis of the knee and diacerhein in osteoarthritis of the hip (Hochberg, 2001). This effect on both symptoms and structure suggest these substances could be helpful in degenerative joint disease of the low back, although this has not yet been substantiated in clinical trials. There is more evidence to substantiate the use of glucosamine than chondroitin sulfate.