Phytotherapy in the Management of Low Back Pain: A Comparative Analysis with Conventional Pharmacological Interventions

Journal of Complementary Therapies in Health ISSN 2975-9323 |eISSN 2975-9552 Journal of Complementary Therapies in Health 2026:4(1). doi:10.5281/zenodo.17977321 institutoptc.com/journal-complementary-therapies Review Phytotherapy in the Management of Low Back Pain: A Comparative Analysis with Conventional Pharmacological Interventions. Ema Simões Calçada1*, and Liliana Sampaio dos Santos1,2 . 1 ABS – Atlântico Business School, Vila Nova de Gaia, Porto, Portugal; 2 IPB – Polytechnic Institute of Bragança, Bragança, Portugal. * Correspondence: [email protected] Abstract Background: Low back pain (LBP) is a leading cause of global disability, affecting up to 80% of the population. While conventional pharmacological treatments (NSAIDs, paracetamol) are standard, their efficacy is often limited by side effects or insufficient relief, particularly in chronic cases. Consequently, interest in Traditional Chinese Medicine (TCM) and phytotherapy has increased. Objective: To evaluate the clinical benefits of phytotherapy in the treatment of LBP and compare its efficacy and safety with conventional pharmacological interventions. Methods: A narrative literature review was conducted, focusing on clinical guidelines, comparative studies, and TCM theoretical frameworks. The review analysed the aetiopathogenesis of LBP, the structure of herbal formulations (Emperor, Minister, Assistant, Envoy), and the comparative outcomes of botanical vs. synthetic drugs. Results: Evidence suggests that conventional analgesics, such as paracetamol, often show no superiority over placebo for acute non-specific LBP. In contrast, phytotherapeutic agents, specifically Boswellia serrata, Curcuma longa, and the Du Huo Ji Sheng Tang formula, demonstrated significant reductions in pain intensity and functional disability. Studies indicated that combining phytotherapy with acupuncture (e.g., Palmijihwang-hwan) provides superior cost-effectiveness and clinical outcomes compared to isolated conventional therapies. Conclusion: Phytotherapy is a viable and safe complementary alternative for managing LBP. It addresses the systemic and energetic imbalances (such as Kidney Yang deficiency or Qi stagnation) that conventional medicine often overlooks. While further longitudinal trials are needed to standardise dosages, integrating herbal medicine into multidisciplinary care offers a promising path for reducing the global burden of LBP. Keywords: Low back pain; Phytotherapy; Traditional Chinese Medicine; Pharmacology; Analgesia. 1. Introduction LBP, defined as pain located in the lower lumbar region, constitutes one of the most prevalent and disabling musculoskeletal problems worldwide, affecting up to 80% of the population at some point in their lives. The impact of this clinical condition is significant, appearing as the second most frequent cause of medical consultations, surpassed only by respiratory infections. The causes of LBP are varied, ranging from the overloading of lumbar spine structures, "comfortable" posture, sedentary lifestyles, trauma, ageing, and ergonomic factors. It can be classified as acute, subacute, or chronic depending on the duration of the pain 1-3. Citation: Calçada E.S., dos Santos L.S. Phytotherapy in the Management of Low Back Pain: A Comparative Analysis with Conventional Pharmacological Interventions. Journal of Complementary Therapies in Health. 2026;4(1) 10.5281/zenodo.17977321 Academic Editor: Jorge Rodrigues Received: 22 October 2025 Reviewed: 28 November 2025 Revised: 10 December 2025 Accepted: 12 December 2025 Published: 18 December 2025 Publisher’s Note: IPTC stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: ©2026 by the authors. Submitted for open access publication under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). Journal of Complementary Therapies in Health 2026: 4(1). 2 of 9 Calçada E.S., dos Santos L.S. Phytotherapy in the Management of Low Back Pain: A Comparative Analysis with Conventional Pharmacological Interventions. doi:10.5281/zenodo.17977321 LBP is a public health issue, primarily due to its high prevalence, which can exceed 70% over a lifetime, with a higher occurrence among women and the elderly population, interfering with a person's functionality and quality of life 3-5. In the university context, several studies point to prevalence rates above 60%, essentially associated with sedentary behaviour and inadequate lifestyles 6. Conventional treatment for LBP encompasses pharmacological options, physiotherapy, postural guidance, and physical exercise, with surgical intervention only recommended for specific and refractory cases 7,8. In recent decades, there has been a growing interest in complementary therapeutic alternatives, such as phytotherapy (herbal medicine), considering the potential analgesic and anti-inflammatory effects of certain medicinal plants. According to Pinela 9, it plays a crucial role in the treatment of LBP, using mostly herbal formulas specifically designed for each patient's energetic diagnosis. Within the range of TCM practices, the most used techniques in the treatment of lumbar pain usually are acupuncture, phytotherapy, and Tuina. In this line of thought, a Narrative Literature Review is considered necessary to understand the benefits of phytotherapy in lumbar pain, comparing them with those of conventional treatments. 2. Low Back Pain 2.1. Definition and types LBP is defined as pain or discomfort located in the lower lumbar region, between the costal margin and the gluteal folds, being one of the most prevalent musculoskeletal symptoms worldwide. It is not a specific disease, but rather a symptom that can involve various mechanisms and clinical conditions 1,10,11. Most pain is caused by disorders in the spinal column and the joints, muscles, ligaments, and nerve roots surrounding the spine or in the discs between the vertebrae 12,13. The most common causes are: injuries to muscles and ligaments, osteoarthritis, vertebral compression fractures, ruptured or herniated discs, lumbar spinal stenosis, spondylolisthesis, and fibromyalgia 14,15. The classification of LBP can be based on criteria such as the duration of the pain, the etiopathogenic mechanism, and the pain pattern 2,16. Regarding duration, LBP is considered acute when it lasts no longer than four weeks, subacute when it lasts from four to 12 weeks, and chronic when it exceeds 12 weeks 17. Regarding the etiopathogenic mechanism, LBP can be mechanical, which is the most common typology and is related to injuries, degeneration, or structural changes in the spine, representing about 97% of cases. This can be specific mechanical (e.g., herniated disc, fractures) or non-specific (e.g., muscle-ligament or degenerative injuries). Non-mechanical LBP, which is systemic, is caused by inflammatory, infectious, neoplastic, or metabolic pathology, covering about 3% of cases 18. Regarding the pain pattern, LBP can be classified as nociceptive (resulting from injury or activation of tissue nociceptors), neuropathic (arising from injury or disease of the nervous system), or nociplastic (persistent pain without apparent injury, usually associated with central sensitisation) 2. Therefore, the classification of the type of LBP is essential for the diagnosis and for determining the most appropriate therapeutic approach and patient prognosis. 2.2. Diagnosis The diagnosis of LBP is carried out through clinical evaluation, alongside a medical history (anamnesis), a focused physical examination, and, only in specific cases, complementary exams are necessary 2,7,18. The anamnesis is crucial for understanding the characteristics of the pain (intensity, location, duration, relationship with activities, etc.) and identifying "red flags" for serious pathologies such as fractures, neoplasms, or infections 7,18. Journal of Complementary Therapies in Health 2026: 4(1). 3 of 9 Calçada E.S., dos Santos L.S. Phytotherapy in the Management of Low Back Pain: A Comparative Analysis with Conventional Pharmacological Interventions. doi:10.5281/zenodo.17977321 The physical examination involves checking posture, palpation of the lumbar spine (spinous processes, paravertebral muscles), assessment of range of motion, and specific tests such as: the Schober test, which measures lumbar mobility; sciatic nerve tension tests, including the Lasègue test (Straight Leg Raise), important in identifying radiculopathy; and neurological examination of the lower limbs (muscle strength, reflexes, sensitivity), performed even in the absence of radiating symptoms to detect neurological deficits 18,19. When a diagnosis has not yet been established at this stage, it becomes urgent to resort to complementary exams, such as 2,7: plain X-rays, to assess bone changes in cases where fractures or deformities are suspected; Computed Tomography (CT) and Magnetic Resonance Imaging (MRI), used when complications are suspected, symptoms persist, or warning signs are present, allowing for a detailed assessment of bone structures and soft tissues; and functional, non-invasive exams, such as cypholordometry, which can be used in postural assessment and monitoring evolution, particularly in rehabilitation cases 20. Thus, the diagnosis, based on clinical guidelines and scientific evidence, ensures the identification of the main causes of LBP, guiding the subsequent steps, namely treatment. To guide the diagnosis, there are the Guidelines from the American College of Physicians and the American Pain Society for the diagnosis and treatment of LBP 21-25. 2.3. Conventional treatment Conventional treatment for LBP may begin with the avoidance of activities that overload the spine and cause pain 26-28. There are three types of treatment: non-pharmacological, pharmacological, and surgical. In terms of pharmacological therapy, paracetamol is frequently recommended for pain relief, unless there is inflammation. Non-steroidal anti-inflammatory drugs (NSAIDs), whether over-the-counter or prescribed, can also relieve pain and simultaneously decrease inflammation 29,30. When these options fail, opioid analgesics may be prescribed, but these should be used for a short period as they can increase pain sensitivity, cause side effects (e.g., drowsiness), confusion, and constipation, with a risk of developing a substance use disorder. It is also possible to use muscle relaxants; carisoprodol, cyclobenzaprine, diazepam, metaxalone, or methocarbamol are some of the medications used to reduce muscle spasms, though they are not suitable for the elderly 31-33. Other forms of treatment may include the application of heat or cold, massage, and physiotherapy. In the case of chronic LBP, aerobic exercises can help. If analgesics are ineffective, other treatments may be considered, such as facet joint injections, epidural corticosteroid injections, and, in cases of herniated discs or severe spinal stenosis, surgery is recommended 34. Therefore, pharmacological options include analgesics, NSAIDs, and muscle relaxants, while physiotherapy utilises resources such as kinesitherapy, electrotherapy, thermotherapy, and manual techniques, each presenting a varying degree of scientific evidence for pain reduction and functional improvement 35,36. Taking into account each type of LBP, as therapeutic options vary according to chronicity and severity, Lopes 37 explains that for the treatment of: subacute LBP, in addition to the non-pharmacological therapeutic plan (exercises and psychotherapy), there are 1stline treatments, characterised by the administration of NSAIDs and paracetamol, and 2ndline treatments, which involve the administration of non-benzodiazepine skeletal muscle relaxants; chronic LBP, movement exercises and other interventions are recommended, with 1st-line treatment including NSAIDs and paracetamol and 2nd-line treatment including serotonin-noradrenaline reuptake inhibitor (SNRI) antidepressants, tricyclic antidepressants, and tramadol. Journal of Complementary Therapies in Health 2026: 4(1). 4 of 9 Calçada E.S., dos Santos L.S. Phytotherapy in the Management of Low Back Pain: A Comparative Analysis with Conventional Pharmacological Interventions. doi:10.5281/zenodo.17977321 3. Phytotherapy 3.1. Traditional Chinese Medicine TCM is an ancient medical system originating in China, involving a series of external practices for the understanding, diagnosis, treatment, and prevention of diseases, based on the dynamic balance between Yin and Yang forces and the circulation of vital energy (Qi) 38,39. It is a medical system that practices holistic medicine, evaluating the person as a whole (physically, psychically, and environmentally) and based on philosophical principles such as Yin-Yang (the duality of opposing forces that must be balanced to ensure health), the Five Elements (wood, fire, earth, metal, and water), Meridian Theory (energy channels), Zang-Fu (Zang organs, which are Yin, and Fu viscera, which are Yang), Qi and Xue (blood) organs, and diagnosis by Syndrome Differentiation 39,40. Thus, one agrees with Maciocia 41 when he states that Chinese medicine diagnosis is also strong in its holistic view of body and mind. Probably no other form of diagnosis is capable of making such a comprehensive, holistic, and detailed assessment of a patient in a relatively short time, gathering all the different elements of the diagnosis. 3.2. Phytotherapy While conventional medicine resorts to pharmacological therapy, phytotherapy resorts to plants. Oliveira 42 explains that in Western medicine, drugs usually consist of an active principle, which are responsible for the therapeutic effect, and excipients, which serve as vehicles, helping in the transport and guidance of the active principle to the desired site of action. In Chinese phytotherapy, the situation is similar: herbal formulas follow an organised structure, and the main function is performed by the plant designated as the Emperor, the "heart" of the formula, corresponding to the active principle that acts on the main symptom 42-44. The remaining plants in the formula are designated as Minister, Assistant, and Envoy, acting in a complementary manner: • The Minister reinforces the main effect (the action of the Emperor) and treats secondary symptoms; • The Assistant, or auxiliary plant, is responsible for reinforcing the action of the Emperor and Minister, reducing potential adverse effects or toxicity, and treating secondary symptoms; • The Envoy, or guide plant, directs the action of the plants in the body (to the affected meridian, system, or part of the body), promoting harmony in the therapeutic action. It is important to note that each formula may contain one or more plants from each category. Phytotherapy treats pathologies based on energetic patterns identified during diagnosis, governed by seven pillars 45: Proven clinical efficacy; Safety of use; Therapeutic individuality; Health promotion and disease prevention; Holistic approach; Sustainability and environmental respect; and Integration with other therapies. Plant-drug interactions are a topic of great relevance, as they can enhance benefits or cause clinical risks, altering the absorption, metabolism, transport, and action of drugs. It is crucial that phytotherapy is performed by a phytotherapist, a TCM specialist, or a health professional with knowledge in the field. This is because there is the assumption that medicinal plants, as well as natural products, do not pose a health risk. This concept, without scientific basis... ends up offering serious risks to the health of less enlightened people 46. Regarding the categorisation of plants, there are 18 different types 42, including: Exterior-releasing plants (hot and cold); Fire-draining plants (cold); Purgatives; Water-regulating and dampness-draining plants; Wind-and-dampness-dispelling plants; Phlegmtransforming and cough-stopping plants; Aromatic dampness-transforming plants; Food stagnation-relieving plants; Qi-regulating plants; Xue-regulating plants; Interior-warming Journal of Complementary Therapies in Health 2026: 4(1). 5 of 9 Calçada E.S., dos Santos L.S. Phytotherapy in the Management of Low Back Pain: A Comparative Analysis with Conventional Pharmacological Interventions. doi:10.5281/zenodo.17977321 and cold-expelling plants; Tonic plants; Astringent/stabilising substances; Heart-nourishing and spirit-calming plants; Orifice-opening aromatic substances; Wind-extinguishing and tremor-stopping substances; Parasite-expelling plants; and External application substances. 3.3. Phytotherapy in the treatment of low back pain according to TCM Phytotherapy treats both manifestations and causes, using formulas consisting of a variable number of plants based on their energetic characteristics. These preparations restore the patient's balance. However, it is important to underline that these must be prepared by a professional, especially since some herbs are prohibited during pregnancy as they may contribute to miscarriage 47,48. Furthermore, in phytotherapeutic prescription, it is necessary to consider the individual characteristics of the patient (e.g., weight and age) so that the effects of the active compounds are appropriate. A complete anamnesis is crucial 49. These factors are essential from the perspective of the compound's bioaccessibility; if the dose is too low, bioavailability may be significantly reduced, compromising benefits, while an excess can be harmful 49. Regarding lumbar pain, it may arise due to Kidney Yang deficiency, affecting the warming and nutrition of this region; phytotherapy can be used to tonify Kidney Yang and strengthen the body's energy 9. Jahromi et al. 50 explain that the formula Du Huo Ji Sheng Tang is widely used to warm the meridians, tonify Kidney Yang, and nourish Xue, showing efficacy in treating chronic LBP. LBP can also arise due to Qi and Xue stagnation, which causes intense and localised pain; treatment serves to move Qi and Xue, relieving pain and restoring circulation in the meridians 51. To treat this condition, Yan Hu Suo (Corydalis) and Chuan Xiong (Ligusticum) can be used, herbs with analgesic properties that promote blood circulation 9. Additionally, the invasion of cold and dampness, which can block the flow of Qi and Xue in the meridians of the lumbar region, can cause acute pain, stiffness, and a feeling of heaviness 52. The formula Juan Bi Tang can be used to disperse cold and dampness, stimulating Qi circulation and relieving pain 50. 4. Phytotherapy vs. Pharmacology for the Treatment of Low Back Pain Regarding treatment by phytotherapy, the article by Majumdar et al. 53 stands out, finding that the combination of Boswellia serrata and Curcuma longa significantly reduced pain, disability, and inflammatory biomarkers, decreasing the need for analgesics. These findings confirm the anti-inflammatory and analgesic potential of medicinal plants, as mentioned by Pinela 9. The study by Gupta et al. 54 reinforces the idea of Pinela 9, showing that the RhuleaveK formula provided rapid and substantial relief from postural lumbar pain, being safe and effective in the short term. Similarly, Pham et al. 55 demonstrated that the VH supplement, together with electroacupuncture, improved pain, mobility, and function, showing superior results compared to acupuncture alone. These results align with the TCM approach, which favours combined and integrated therapies. Sung et al. 56 corroborate this perspective by showing that the use of Palmijihwang-hwan associated with acupuncture not only decreases pain and improves function but also presents an additional advantage in terms of cost-effectiveness. Regarding pharmacological treatment, the results of the study by Saragiotto et al. 57 reveal that paracetamol is not superior to placebo in non-specific acute LBP, questioning its use as a first line of treatment. Previously, Brazil et al. 7 had mentioned that the efficacy of some drugs is debatable. Focusing on the use of systemic corticosteroids, Chou et al. 58 indicate that these have limited short-term benefit only for radicular pain, but are not effective for non-radicular pain or spinal stenosis. Khankhel et al. 59 found that oral ibuprofen is more effective than Journal of Complementary Therapies in Health 2026: 4(1). 6 of 9 Calçada E.S., dos Santos L.S. Phytotherapy in the Management of Low Back Pain: A Comparative Analysis with Conventional Pharmacological Interventions. doi:10.5281/zenodo.17977321 topical diclofenac, but the combination of the two adds no benefit, demonstrating that pharmacological choice must be judicious and individualised. In Wertli et al. 60, it is noted that NSAIDs are the class with the best results in LBP; however, they relieve but do not "remove" the pain, and prolonged use carries risks. Regarding the use of antidepressants in the treatment of LBP, the study by Ferraro et al. 61 concludes that pain improvement is modest and presents higher rates of adverse effects, requiring caution in their use. Finally, the results obtained by McKenzie et al. 62 reinforce the variety of results in this second theme, showing a lack of consensus among clinical guidelines, especially regarding pharmacological approaches. This reinforces the uncertainty and the need for complementary alternatives such as phytotherapy and acupuncture. Therefore, and following the initial idea that LBP is highly prevalent and disabling 1,3. It is possible to see from the included studies that various therapeutic approaches relieve pain and improve quality of life and function 53,55-57. Conventional treatment includes drugs and physiotherapy, but surgery is an exception 7,8. Studies focusing on pharmacological treatment 57-61 confirm that, although exclusively used, they present limited efficacy or risks of adverse effects. Conversely, studies focused on phytotherapy 53-56 present consistent results in terms of pain reduction, functional improvement, and safety, validating the perspective that phytotherapy can be a relevant complementary alternative in the treatment of LBP. 5. Conclusion This review confirms that LBP is a complex global challenge requiring more than just standard "one-size-fits-all" treatments. While conventional drugs like NSAIDs are the norm, their limited efficacy in some cases and the risk of side effects highlight a clear need for better alternatives. Phytotherapy, based on TCM, offers a scientifically viable solution. Studies show that herbal formulas (like Du Huo Ji Sheng Tang) provide significant pain relief and functional recovery with fewer risks. Furthermore, combining these herbs with acupuncture often proves more effective and cost-efficient than medication alone. In summary, integrating phytotherapy into a multidisciplinary approach allows for more personalised care. While more clinical trials are needed to refine dosages, the current evidence strongly supports using these natural alternatives to improve patient quality of life and reduce the global burden of chronic pain. Author statement: Conceptualisation: E.S.C. and L.S.S.; Investigation: E.S.C. and L.S.S.; Writing, reviewing and editing: E.S.C. and L.S.S. All authors have read and agreed to the published version of the manuscript. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest: The authors declare that there are no conflicts of interest. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author. Journal of Complementary Therapies in Health 2026: 4(1). 7 of 9 Calçada E.S., dos Santos L.S. Phytotherapy in the Management of Low Back Pain: A Comparative Analysis with Conventional Pharmacological Interventions. doi:10.5281/zenodo.17977321 References 1. Pires RAM, Dumas FVL. Lombalgia: revisão de conceitos e métodos de tratamentos. Universitas: Ciências da Saúde (encerrada). 2008;6(2):159-68. 2. de Abreu MM. 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