HITTING THE HEADLINES

18 Sep 2006

Acupuncture for low back pain

Acupuncture is more effective for back pain than standard NHS treatment, reported three newspapers (15 September 2006). The newspapers were largely accurate in their reports of a well-conducted trial. The study found only a small benefit of acupuncture, and further research is needed.

·    On 15th September 2006 three newspapers (1-3) reported that acupuncture is more effective for treating back pain than standard NHS treatment.

·    The reports were based on an open, randomised controlled trial and cost effectiveness analysis of 241 participants with persistent non-specific (cause unknown) lower back pain (4, 5). The authors found weak evidence to suggest that acupuncture is more effective than usual care for reducing low back pain at 12 months, but stronger evidence for a small benefit of acupuncture at 24 months.

·    The newspapers were largely accurate in their reports of the study. The Independent (1) correctly pointed out that the benefit seen with acupuncture was small. While the study was well-conducted, and the authors' conclusions are likely to be reliable, further research is needed.

Evaluation of the evidence base for the use of acupuncture for the relief of low back pain

Where does the evidence come from?

The research was carried out by Dr MacPherson and colleagues based at the Foundation for Traditional Chinese Medicine, York, and the School of Health and Related Research, University of Sheffield, UK. The research was funded by the UK NHS Executive health technology programme.

What were the authors' objectives?

To determine whether a short course of traditional acupuncture improves longer term outcomes for individuals with persistent non-specific low back pain in primary care. The cost-effectiveness of acupuncture for lower back pain was also examined.

What was the nature of the evidence?

The study was an open, randomised controlled trial of 241 adults with non-specific low back pain of 4-52 weeks duration. Assessment of pain was carried out using the bodily pain dimension of the SF-36 health status questionnaire (scored 0 to 100 with 100 representing no pain) at 12 and 24 months. Other measures included the Oswestry pain disability index, the McGill present pain index, and the seven remaining dimensions of the SF-36. In addition, the authors measured treatment satisfaction, concerns about back pain, current use of analgesics, and back pain in the last year. Safety was assessed by monitoring adverse events reported at acupuncture sessions or during follow up.

What interventions were examined in the research?

Patients were randomly assigned to receive either a short course of traditional acupuncture or usual care only. Acupuncture care consisted of up to 10 individualised treatment sessions (mean 8.1) over three months. All patients continued to receive care from their general practitioner. Usual care consisted of NHS treatment according to their general practitioner's assessment of need. Half of patients receiving usual care received physiotherapy or manipulation during the first three months. Other interventions included drugs and recommended back exercises.

What were the findings?

There was no statistically significant difference between groups for the SF-36 pain outcome at 12 months (acupuncture: 64/100 versus usual care: 58.3/100). At 24 months, the acupuncture group showed a statistically significant greater reduction in pain than the usual care group, with an estimated difference of eight points (acupuncture: 67.8/100 versus usual care: 59.5/100). There were no statistically significant differences between treatment groups for scores on the Oswestry pain disability index or the McGill present pain index at 12 or 24 months. At three months patients receiving acupuncture were significantly more likely to be very satisfied with their treatment and overall care than patients receiving usual care. At 24 months, patients receiving acupuncture were significantly less likely to need analgesics for low back pain, and were less worried about their back pain problem than 12 months ago, but there was no statistically significant difference in the numbers experiencing low back or leg pain in the previous 12 months. No serious adverse events were reported in the acupuncture group. Cost effectiveness analysis revealed that total costs to the NHS during the two year study period were higher on average for the acupuncture group (£460) than for the usual care group (£345); however, acupuncture appeared to be cost effective in the long-term.

What were the authors' conclusions?

There is weak evidence for an effect of acupuncture on non-specific low back pain at 12 months, but stronger evidence of a small benefit at 24 months. Referral to a qualified acupuncturist for a short course of treatment appears to be safe and acceptable to patients with low back pain.

How reliable are the conclusions?

Appropriate methods were used to randomise patients to treatment groups, and groups were generally similar at baseline. As this was a pragmatic trial, usual care rather than sham acupuncture was used as a control which may increase the risk of bias as it was not possible to blind the patients or treatment providers. However, the researchers investigated the effects of patients' prior beliefs about acupuncture and found no evidence to suggest that improvement could be due to the patients' beliefs about acupuncture, rather than the acupuncture itself. Validated outcome measures were used, but relied on patients' self-reports. This can lead to recall bias, and can particularly be a problem when participants are not blind to treatment or are reporting subjective outcomes such as pain. All patients were accounted for and analysed according to the groups to which they were randomised. Factors that might affect the results other than the interventions, such as duration of current back pain episode, baseline pain score and clustering by acupuncturist were accounted for in the analysis. The authors' conclusions seem appropriate, however, it should be noted that the treatment effect seen with acupuncture was small, and further research is needed.

Systematic reviews

Information staff at CRD searched for systematic reviews relevant to this topic. Systematic reviews are valuable sources of evidence as they locate, appraise and synthesize all available evidence on a particular topic. There was one related systematic review identified on the Cochrane Database of Systematic Reviews (CDSR)(6) and four on the Database of Abstracts of Reviews of Effects (DARE)(7-10).

References and resources

1. Acupuncture more effective for treating back pain than traditional methods on the NHS. The Independent, 15 September 2006, p28.

2. Why acupuncture is better for back pain than a trip to the GP. Daily Mail, 15 September 2006, p47

3. Acupuncture is best remedy for back pain. Daily Express, 15 September 2006, p4.

4. Thomas KJ, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell MJ, Roman M, Walters SJ, Nicholl J. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ doi:10.1136/bmj.38932.806134.7C (published 15 September 2006).

5. Ratcliffe J, Thomas KJ, MacPherson H, Brazier J. A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis. BMJ doi:10.1136/bmj.38932.806134.7C (published 15 September 2006).

6. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001351. DOI: 10.1002/14651858.CD001351.pub2.

7. Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Annals of Internal Medicine 2005;142(8):651-663. [DARE Abstract]

8. Henderson H. Acupuncture: evidence for its use in chronic low back pain. British Journal of Nursing 2002;11(21):1395-403. [DARE Abstract]

9. Strauss A J. Acupuncture and the treatment of chronic low-back pain: a review of the literature. Chiropractic Journal of Australia 1999;29(3):112-118. [DARE Abstract]

10. Ernst E, White A R. Acupuncture for back pain: a meta-analysis of randomized controlled trials. Archives of Internal Medicine 1998;158(20):2235-2241. [DARE Abstract]

11. NHS Centre for Reviews and Dissemination. Acupuncture. Effective Health Care Bulletin 2001;7(2).

12. Thomas K J, MacPherson H, Ratcliffe J, Thorpe L, Brazier J, Campbell M, et al. Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. Health Technology Assessment 2005;9(32).

Consumer information

British Acupuncture Council

The British Medical Acupuncture Society

BackCare: the charity for healthier backs

Previous Hitting the Headlines summaries on this topic

Acupressure 'best for lower back pain'. Hitting the Headlines archive, 17 February 2006.

Is routine physiotherapy effective for low back pain? Hitting the Headlines archive, 24 September 2004.

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