New Evidence on Acupuncture for Low Back Pain

Evidence-based medicine requires periodic review of published studies to see what's new. In this article, the results of six random-controlled trials (RCTs) on acupuncture for low back pain (LBP) were reviewed. This brings us up-to-date on the latest evidence regarding acupuncture as an effective treatment tool for LBP.

Only six new trials were included in this systematic review. These six were published in the last two years since the previous systematic review was performed. There were many more studies done (1,606 with 40 of them random controlled trials) but they had to be high-quality to qualify as acceptable evidence. Only the six included were considered high enough quality to be selected.

High-quality means each study had at least 40 subjects per group. The number of people who dropped out of the study did not exceed 20 to 30 per cent (based on length of follow-up). And proper analysis of the data was conducted.

Among the studies considered, all types of treatment comparisons were made. For example, acupuncture was compared with sham treatment. Acupuncture was compared with no treatment. Some looked at the results of acupuncture compared to traditional methods. Other studies compared acupuncture alone versus acupuncture combined with traditional (conventional) therapy.

In each study, the treatment procedures were checked for adequacy. In layman's terms we would say the technique used had to be up to snuff. In other words, the protocol used had to match what was published in textbooks, taught in up-to-date programs, and practiced in advanced clinical settings. Details of acupuncture treatment such as points selected for needling, number of points needled, length of time needles were kept in, and number of sessions were evaluated.

The results were measured in different ways as well. But the most typical outcome measures were pain intensity, function, disability, general health status, and return to work (yes versus no, length of time off work). There was moderate evidence that acupuncture was better than no treatment. At the same time, sham acupuncture worked just as well as true acupuncture. Sham acupuncture means the needles were not placed at true acupuncture points, they were only inserted a little way into the skin, and they were not stimulated (moved or twisted) like true acupuncture needles would be.

There was moderate evidence that acupuncture was effective for short-term relief of pain. Relief of pain was directly linked with improved function, so it was inferred that acupuncture also improved function. There was conflicting evidence for pain relief over a longer (intermediate) amount of time.

When acupuncture was compared with other treatment (e.g., electrical stimulation, medication, massage), there was a wide range of results. Massage produced better short- and long-term results for improved function and pain relief. There was no difference between acupuncture and self-care. There was evidence that acupuncture combined with conventional therapy had the best results. But problems with study design and fewer than 40 patients in a group weakened the evidence.

The main difference in findings from the last systematic review to this current, updated review is a strengthening or confirmation that acupuncture treatment is favored over no treatment at all. Likewise, combining acupuncture with other more conventional therapies also provides good results. Comparing acupuncture against conventional therapy (an either/or situation), the evidence is not conclusive. The one change brought by the new evidence is that sham acupuncture may be just as good as true acupuncture. In the past, acupuncture was favored over sham treatment.

This type of systematic review update helps direct research. New data can be reported and conflicting data analyzed further. In this case, the reason for no difference between acupuncture and sham treatment must be examined in greater detail.

Future studies will have to address the best way to choose control groups. What constitutes an acceptable sham treatment? Should the same needles be used? Are special nonpenetrating needles needed? How far from the true acupuncture meridians can needles be inserted for sham treatment? These and other questions must be considered.

And along with re-evaluating control groups and sham treatment approaches, the patients themselves must be reviewed in the study design. Should patients with all types of back pain be included in one group? Should researchers separate those with back pain from those with back and sciatica (leg pain)? How much improvement is enough to say the treatment was successful (improved, much improved, very much improved)?

What constitutes real change? A 20 - 30 - or 50 per cent decrease in pain? What should the cut-off point be for meaningful clinical improvement? Even though there are still many questions to be answered, as a result of this updated systematic review, the European Guidelines for nonspecific back pain will include acupuncture as an effective treatment for chronic low back pain. There is enough evidence that acupuncture is cost effective when compared with other treatments.

Jing Yuan, PhD, et al. Effectiveness of Acupuncture for Low Back Pain. A Systematic Review. In Spine. Vol. 33. No. 23. Pp. E887-E900.

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