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Acute Pain | Chronic Pain | General

Acupuncture for back pain - 2009 update

 

Clinical bottom line

Acupuncture is no better than a toothpick for treating back pain.

Background

Acupuncture for back pain has been suggested as being appropriate by NICE in the UK (2009), and by some systematic reviews [1]. However, systematic reviews of acupuncture have been shown to be of exceptionally poor quality, and frequently misleading because they include clinical trials of poor reporting quality (leading to bias), inadequate validity (especially with regard to outcomes), and of low size [2]. While 16 of 35 systematic reviews of acupuncture claimed that it worked, application of quality, validity, and size guidelines showed that all 16 made claims that could not be substantiated by the evidence, and that "true" acupuncture was no different to "sham" acupuncture. Yet another examination of acupuncture for pain suggested that any benefits could not be distinguished from bias [3].

The latest systematic review is no different from previous reviews, and makes claims that cannot be substantiated.

Acupuncture is claimed to be better than waiting list controls, or usual care.

Reference

DC Cherkin et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Archives of Internal Medicine 2009 169: 858-866.

Study

This was a large randomised trial comparing four different therapies for adults (18-70 years) in the Western USA receiving care for a back problem. Participants had to have uncomplicated chronic low back pain in the last 3-12 months, and there were a number of obvious exclusions. Bothersomeness had to be scored 3 or greater on a 0-10 scale at entry.

Participants were randomised to treatment using sensible procedures. The four treatments were:

  1. Individualised acupuncture prescribed by diagnostician at the beginning of each visit.
  2. Standardised acupuncture based on a system considered effective by experts.
  3. Simulated acupuncture, involving use of a toothpick that did not puncture the skin.
  4. Usual care chosen by patients and their physicians.

All participants were given a self care book, and all interventions involved patients lying prone in a head rest with an eye mask, and with minimal interaction with therapists to maintain blinding as far as possible.

Treatments were twice weekly for three weeks, and then weekly for four weeks, for 10 treatments in total. Assessments were made at eight, 26, and 52 weeks, using the Roland Morris Disability Questionnaire (RMDQ), bothersomeness, and several other outcomes.

Results

This large trial involved 638 adults, with follow up of 90% or above up to 52 weeks. Participants had an average age of about 47 years, with about 60% being women. About 70% had back pain for at least a year. The average initial RMDQ score was about 10.5 on a 0-24 scale, and average initial bothersomeness score 5 on a 0-10 scale.

The main results were these:

As well as reporting average results, the authors reported the proportion of those with at least a 3/24 point improvement in RMDQ and 2/10 point improvement with Bothersomeness. Figures 1 and 2 show the results at 52 weeks.

Comment

This large, well conducted trial merely confirmed what was already known, that acupuncture using needles was the same as sham acupuncture - in this case a toothpick that did not puncture the skin.

It also confirmed that doing something was better than doing nothing more than usual. Whether this is a simple context effect, a beneficial effect from being involved in a clinical trial, or something extra remains a moot point, but the magnitude of benefits is rather small (Figure 1), and suggests that context effects could be the main generator of benefits.

Figure 1: Percent of patients with at least 3/24 point reduction on RMDQ and at least 2/10 point reduction in bothersomeness at 52 weeks compared with baseline

There is nothing new in these results, but the detail is interesting. For instance, there were statistical differences in the proportion of patients with RMDQ reduction of 3 points or more at 52 weeks for any type of acupuncture over control, but half of those with usual care obtained this level of benefit (not quite equivalent to a moderate improvement).

The additional effect of acupuncture was not great, with no difference in bothersomeness at all. And while there were minor differences in time off work and use of analgesics, there was no significant cost benefit for acupuncture over usual care, though the costs of acupuncture treatment were not included, suggesting that acupuncture could be more costly with minimal additional benefit, especially when considering the known harms of acupuncture [4].

What might be more relevant is previous research indicating that targeting level of care to severity [5] is the best approach.

What we are left with, though, is a conclusion that acupuncture is no better than a toothpick, and roughly the same conclusion the Bandolier came to some years ago.

Other references

  1. J Yuan et al. Effectiveness of acupuncture for low back pain. A systematic review. Spine 2008 33: E887-E900.
  2. CJ Derry et al. Systematic review of systematic reviews of acupuncture published 1996-2005. Clinical Medicine 2006 6:381-386.
  3. SV Madsen et al. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ 2009 338:a3115.
  4. E Ernst, A White. Life-threatening adverse reactions after acupuncture? A systematic review. Pain 1997 71: 123-6.
  5. EM Haland Haldorsen et al. Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. Pain 2002 95: 49-63.