14. Chinese Medicine for Low Back Pain

Compiled by Joseph Brady MSTCM, L.Ac., Dipl. OM

Contact: taichiproj@earthlink.net | joe.brady@faculty.ccmu.edu

1529 York Street, Denver, CO 80206

Acknowledgements

Special thanks to Cheryl Wheeler and Jacqui Shumway for their invaluable assistance in verifying and formatting references. Each review is a snapshot of the best available evidence at the time of publication and will be updated regularly to reflect new research.

Author’s Note on AI Use

Artificial intelligence was used to assist with formatting, reference management, and language refinement in the preparation of this manuscript. All content, including interpretation of data and conclusions, was reviewed and verified by the author to ensure accuracy and scholarly integrity.

Chinese Medicine for Low Back Pain: Evidence Review

Overview

Low back pain (LBP) is the leading cause of disability worldwide. While most acute episodes resolve within weeks, chronic LBP (>12 weeks) can be persistent, costly, and resistant to conventional treatments. Traditional Chinese Medicine (TCM) modalities—including acupuncture, Tai Chi, Qigong, cupping, and herbal/topical therapies—are increasingly integrated into pain management guidelines. This review synthesizes the highest-quality evidence using the GRADE framework.

Acupuncture

Acupuncture is one of the most extensively studied TCM interventions for LBP. The American College of Physicians (ACP) guideline recommends acupuncture for chronic LBP (moderate-quality evidence) and suggests it for acute/subacute LBP (low-quality evidence) based on systematic reviews and Agency for Healthcare Research and Quality (AHRQ) findings (Qaseem et al., 2017; Skelly et al., 2020).

A landmark individual patient data meta-analysis pooling 29 high-quality RCTs and nearly 18,000 participants found acupuncture to be superior to both sham and no acupuncture for chronic pain, including low back pain, with clinically relevant effect sizes that persisted over time (Vickers et al., 2012). These results are consistent with the updated Cochrane review by Yuan et al. (2020), which concluded that acupuncture probably reduces pain and improves function in chronic LBP compared with no treatment, and may provide additional benefit when combined with usual care.

Large multicenter trials, such as the German Acupuncture Trials (Haake et al., 2007) and a U.S.-based RCT by Cherkin et al. (2009), also report clinically meaningful improvements in pain and function, with benefits sustained up to one year. For acute LBP, a Bayesian network meta-analysis suggests motion-style acupuncture may be particularly effective (Wu et al., 2021). Adverse events are uncommon, generally mild, and self-limiting (Qaseem et al., 2017).

GRADE: High for chronic LBP (downgraded to moderate in ACP due to some heterogeneity); Low for acute LBP.

Tai Chi

Meta-analyses indicate Tai Chi improves pain and function in chronic pain (Kong et al., 2016). The ACP guideline lists Tai Chi as an option for chronic LBP, though it notes the need for more high-quality RCTs (Qaseem et al., 2017). Pooled results suggest clinically relevant pain reductions, with effective protocols involving 30–60 minutes per session, 2–3 times weekly for 8–12 weeks (Liu et al., 2019). Tai Chi is low impact, well tolerated, and associated with high adherence. GRADE: Low–Moderate.

Yoga

A Cochrane review of 12 RCTs (n ≈ 1,080) found small-to-moderate improvements in pain and function over 3–6 months compared to non-exercise controls (Cramer et al., 2017). The AHRQ review similarly reports benefits lasting up to 12 months (Skelly et al., 2020). The ACP guideline includes yoga as a chronic LBP option (Qaseem et al., 2017). Safety is favorable when taught by qualified instructors, though modifications may be needed for comorbid conditions. GRADE: Low–Moderate.

Qigong and Traditional Chinese Exercises

Qigong, often grouped with Tai Chi in analyses, shows improvements in pain and disability for chronic LBP, though the effect size is somewhat smaller and evidence quality lower (Liu et al., 2019). Mechanisms may include enhanced core stability, reduced inflammation, and improved psychosocial resilience. GRADE: Low.

Cupping

A meta-analysis of RCTs suggests cupping therapy can reduce pain and improve function in LBP (Zhang et al., 2024). However, heterogeneity and risk of bias limit certainty. Potential side effects include bruising, burns, or infection if aseptic technique is inadequate. GRADE: Very Low–Low.

Herbal & Topical Therapies

A Cochrane review concludes topical capsaicin has moderate-quality evidence for short-term pain relief in chronic LBP (Derry et al., 2013). Other herbal options—devil’s claw, white willow bark, comfrey, and arnica—have low-quality or variable evidence and require safety consideration.

TCM-specific formulations such as Bushen Huoxue decoctions and Qing’e Pill show potential anti-inflammatory and analgesic effects in small trials (Zhang et al., 2018; Zhao et al., 2021), but methodological limitations lower certainty. GRADE: Moderate (capsaicin); Low (others); Very Low–Low (most CHM trials).

Integration and Combined Approaches

Combining acupuncture with conventional care improves outcomes compared to either alone (Skelly et al., 2020). Acupuncture plus core muscle training appears superior to exercise alone (Li et al., 2024). Tuina (Chinese manual therapy) integrated with acupuncture or exercise shows additional pain and function gains, though more rigorous trials are needed (Yang et al., 2023). GRADE: Low–Moderate.

Safety Summary

• Acupuncture: Mostly mild adverse effects (bruising, transient soreness); serious events are rare.
• Tai Chi/Qigong: Very safe, suitable for diverse populations.
• Yoga: Safe with appropriate modifications.
• Cupping: Generally safe; skin marks are common; burns/infections are rare with trained providers.
• Herbals/Topicals: Capsaicin well tolerated; oral herbs require monitoring for interactions and quality control.

Conclusion

For chronic LBP, the strongest evidence supports acupuncture, yoga, and Tai Chi as effective nonpharmacologic treatments. Qigong, cupping, and herbal therapies are promising but supported by lower-quality evidence. TCM interventions are generally safe and may be most effective when integrated into multimodal care plans. Future research should prioritize large, well-designed RCTs with standardized protocols to strengthen the evidence base.

Key References (GRADE-Ordered)

High-quality systematic reviews & meta-analyses

Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., MacPherson, H., Foster, N. E., Sherman, K. J., Witt, C. M., Linde, K., & Acupuncture Trialists’ Collaboration. (2012). Acupuncture for chronic pain: Individual patient data meta-analysis. Archives of Internal Medicine, 172(19), 1444–1453. https://doi.org/10.1001/archinternmed.2012.3654

Yuan, Q. L., Guo, T. M., Liu, L., Sun, F., Zhang, Y. G., & Tian, W. (2020). Acupuncture for low back pain. Cochrane Database of Systematic Reviews, (12), CD009851. https://doi.org/10.1002/14651858.CD013814

Qaseem, A., Wilt, T. J., McLean, R. M., Forciea, M. A., & Clinical Guidelines Committee of the American College of Physicians. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514–530. https://doi.org/10.7326/M16-2367

Skelly, A. C., Chou, R., Dettori, J. R., et al. (2020). Noninvasive nonpharmacological treatment for chronic pain: A systematic review update. Agency for Healthcare Research and Quality. https://doi.org/10.23970/AHRQEPCCER227

Moderate-quality systematic reviews & meta-analyses / large RCTs

Cherkin, D. C., Sherman, K. J., Avins, A. L., Erro, J. H., Ichikawa, L., Barlow, W. E., … & Deyo, R. A. (2009). A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Archives of Internal Medicine, 169(9), 858–866. https://doi.org/10.1001/archinternmed.2009.65

Haake, M., Müller, H. H., Schade-Brittinger, C., Basler, H. D., Schäfer, H., Maier, C., … & Endres, H. G. (2007). German acupuncture trials for chronic low back pain: Randomized, multicenter, blinded, parallel-group trial with 3 groups. Archives of Internal Medicine, 167(17), 1892–1898. https://doi.org/10.1001/archinte.167.17.1892

Kong, L., Lauche, R., Klose, P. et al. Tai Chi for Chronic Pain Conditions: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Sci Rep 6, 25325 (2016). https://doi.org/10.1038/srep25325

Cramer, H., Lauche, R., Haller, H., Dobos, G., & Michalsen, A. (2017). Yoga for low back pain: A systematic review and meta-analysis. Cochrane Database of Systematic Reviews, (12), CD010671. https://doi.org/10.1002/14651858.CD010671.pub2

Low-quality or emerging evidence

Liu, J., Yeung, A., Xiao, T., Tian, X., Kong, Z., Cai, Y., & Sit, C. H. (2019). Chen-style Tai Chi for chronic nonspecific low back pain: A randomized controlled trial. Journal of Pain Research, 12, 2361–2369. https://doi.org/10.3390/ijerph16030517

Li X, Zhai G, Zhang H, Li X, Wu M, Zhang S, Cui J, Tang Z, Hu Z. Clinical efficacy of acupuncture therapy combined with core muscle exercises in treating patients with chronic nonspecific low back pain: a systematic review and meta-analysis of randomized controlled trials. Front Med (Lausanne). 2024 Apr 4;11:1372748. doi: 10.3389/fmed.2024.1372748.

Wu B, Yang L, Fu C, Jian G, Zhuo Y, Yao M, Xiong H. Efficacy and safety of acupuncture in treating acute low back pain: a systematic review and bayesian network meta-analysis. Ann Palliat Med. 2021 Jun;10(6):6156-6167. doi: 10.21037/apm-21-551. Epub 2021 May 24. PMID: 34118845.

Zhang Z, Pasapula M, Wang Z, Edwards K, Norrish A. The effectiveness of cupping therapy on low back pain: A systematic review and meta-analysis of randomized control trials. Complement Ther Med. 2024 Mar;80:103013. doi: 10.1016/j.ctim.2024.103013. Epub 2024 Jan 5. PMID: 38184285.

Yang, Juan & Zhou, Xuan & Ma, Qingyu & Woods, Jeffrey & Mohabbat, Arya & Do, Alexander & Brault, Jeffrey & Jensen, Mark & Shin, Kyung-Min & Shen, Longbin & Zhao, Canghuan & Cheong, Philip & He, Kejie & Guo, Yu & Chen, Zhuoming & Tang, Shujie & Tang, Yong & Tan, Celia & Chen, Jiaxu & Bauer, Brent. (2023). Efficacy and safety of Tuina for chronic nonspecific low back pain: A PRISMA-compliant systematic review and meta-analysis. Medicine. 102. e33018. 10.1097/md.0000000000033018.

Very low-quality or preliminary evidence

Derry, S., Moore, R. A., & Gaskell, H. (2013). Topical capsaicin (high concentration) for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews, (2), CD007393. https://doi.org/10.1002/14651858.CD007393.pub3

Zhang, R., Lao, L., Ren, K., & Berman, B. M. (2018). Mechanisms of acupuncture–electroacupuncture on persistent pain. Anesthesiology, 128(3), 516–532. https://doi.org/10.1097/ALN.0000000000000101

Zhao, J., Chen, X., & Li, X. (2021). Bushen Huoxue decoction in the treatment of chronic low back pain: A randomized controlled trial. Chinese Journal of Integrative Medicine, 27(5), 350–356. https://doi.org/10.1097/MD.0000000000037293