Does acupuncture reduce pain in adults with acute or chronic low back pain?

Date Last Updated: 03/08/06
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1.         Abstract
2.               Treatment
3.         Background
4.         Objectives
5.         Criteria for including studies
6.         Search strategy
7.         Data collection and evaluation of studies
8.         Description of studies
9.         Methodological quality
10.       Results
11.       Discussion of findings
12.       Conclusions
13.       References
14.      Further Resources

1. Abstract
Low back pain is a major health problem with enormous economic and social costs. Most cases resolve spontaneously, but a proportion persist and become chronic. Traditional treatments include drugs, physical treatment, back exercises and education, but they do not always help. Many people seek alternative treatments, such as acupuncture. Acupuncture is an ancient Chinese medical treatment that involves putting special needles into specific points of the body.

We found three systematic reviews and five additional RCTs of acupuncture for low back pain.

There was some tentative evidence that traditional acupuncture is useful for people who have acute (lasting less than 3 months) low back pain. Acupuncture is an effective treatment for chronic low back pain but the effects are small and it is not certain whether these are maintained for a year or more. It appears to provide an additive effect when added to other treatments for low back pain. It is not associated with serious side effects. Acupuncture appears to be more effective than usual care, but less effective than spinal manipulation.

2. Treatment
Type of treatment: Acupuncture
Indication: Acute or chronic low back pain

3. Background
Low back pain is the most common, most costly and disabling musculoskeletal condition. The rate of low back pain disability has increased since World War II, at a rate that is disproportionate to all other health conditions. In the last year for which statistics are available (July 2004 to June 2005), there were 19,275 ACC compensated claims at a cost of NZ$232,671,000 (www.acc.co.nz/statistics).

The majority of people with low back pain recover within 2 months, but 10 to 20% of these develop chronic low back pain (usually defined as pain and disability persisting more than 3 months). These patients use more than 80% of all health care resources for back trouble (Waddell 1998). The annual prevalence in New Zealand is highest for young males aged 15 to 18 years (44%) with the figures for the 19 to 24 years and 25 to 44 years being 20% and 17% respectively. The prevalence of ever having low back pain, however, is highest in the 45 to 64 year old age group (67%) (McBride 2004).

The main goal in treating low back pain is to decrease pain so that patients can resume their normal activities. Traditional treatments for low back pain include drugs (pain killers, anti-inflammatory drugs and muscle relaxants), physical therapy, back exercises and education about ways to prevent back injury and deal with back pain. Unfortunately, these treatments do not always help. Many people seek alternative treatments, such as acupuncture.

Acupuncture is part of the system of Traditional Chinese Medicine (TCM). In the TCM system, health is seen as a balance between two opposing forces called yin and yang within the body. An imbalance of these is considered to result in ill-health. This imbalance also causes disruption in the flow of �chi� or �vital energy� along pathways in the body known as �meridians�. Acupuncture involves stimulation of points along these meridians. This is done commonly by the insertion of needles into these points which are then manipulated manually or by electrical stimulation. They can also be stimulated by moxibustion, pressure, heat and laser light. This restores the balance between yin and yang, corrects the flow of �chi� along the meridians and restores health to the body and mind.

Some low back pain is caused by myofascial. pain syndrome. In this syndrome, there are painful points in the muscle of the lower back (different from the points identified through TCM), called �trigger points�. Usually, when you press on a trigger point, pain can be felt elsewhere in the body. Dry needling is the insertion of a needle into the trigger points with the purpose of inactivating these points to reduce pain. This is also referred to as an acupuncture treatment.

4. Objectives
The aim of this review is to assess the potential benefits and harms of acupuncture or dry needling for the treatment of low back pain (subacute, acute and chronic).

5. Criteria for including studies

Types of study
Published systematic reviews or randomised controlled trials of acupuncture versus no treatment, placebo/sham acupuncture or other therapeutic interventions, limited to the English language.

Types of participants
Adults (>18 years) with non-specific low back pain and myofascial pain syndrome (pain in the muscle tissue) in the low back region.

Types of intervention
Acupuncture or dry needling (where needles are inserted into points of the body with either electrical or hand stimulation) versus no treatment, placebo/sham acupuncture or other treatments.

Types of outcome measures
Intensity of pain (measured on a validated scale), combined measure of improvement, function (measured by specific scales) and return to work. Other less important outcomes were measures of physical examination, health status and other symptoms such as use of medication and adverse events.

6. Search strategy
We searched the following databases in March 2006: Amed, The Cochrane Library, MEDLINE, EMBASE and CINAHL. We also checked the reference lists of publications retrieved by the search for further relevant studies. We searched the ACC website for statistical information on low back claims in New Zealand.

7. Data collection and evaluation of studies
We used the above search strategy to obtain titles and abstracts of studies that were potentially relevant to this review. Where studies met the criteria for inclusion, they were assessed in full text. The quality of each study was evaluated using the SIGN criteria (http://www.sign.ac.uk/methdology/checklists.html) for the evaluation of RCTs and systematic reviews. Where primary studies were included in a good quality systematic review, the systematic review was included, rather than the individual primary studies.

The overall quality of the body of evidence (including all the included studies) was graded according to the CEBM levels of evidence system (http://www.cebm.net/levels_of_evidence.asp).

Relevant data were extracted from the studies selected for inclusion.

8. Description of studies
A Cochrane systematic review, updated in October 2004, was identified. In addition, two other systematic reviews and five additional randomised controlled trials (not included in the systematic reviews) met the criteria for inclusion. The Cochrane review included 35 RCTs, published prior to February 2003. Another systematic review (Manheimer 2005) included 33 RCTs, published prior to August 2004. A systematic review that compared the effectiveness, safety and cost of a number of different therapies for back pain (Cherkin 2003) included older versions of the two previous reviews, an additional evidence synthesis and six RCTs that were included in the previous systematic reviews. The included studies were published between 1995 and 2002. The five additional RCTs were all published in 2005 or 2006.

Summary details of the included studies are as follows:

Systematic reviews

Study details	Participants/studies	Intervention and comparison(s)	Outcomes measured	Comment
Furlan 2004 Cochrane systematic review	Included studies: 35 studies published prior to Feb 2003 N=2861 Adults >18 years with acute or chronic back pain or myofascial pain syndrome	acupuncture or dry needling no treatment, placebo sham procedure or other treatments	pain intensity improvement of symptoms function return to work	The methodological quality of most of the included studies was poor. 3 studies included patients with acute back pain; the remainder had chronic back pain
Manheimer 2005	Included studies: 33 RCTs published prior to Aug 2004 Participants had any type of low back pain	Needle acupuncture Sham acupuncture, other sham treatments, no additional treatment or another active treatment	Short term pain relief (<6 weeks) Long term pain relief (>6 weeks)	Analyses in different subgroups: acute (pain for ≤ 3 months) and chronic (pain >3 months). Subgroup analyses also by type of control group.
Cherkin 2003	Included studies: one meta-analysis, 2 evidence syntheses and 6 RCTs.	Acupuncture Sham treatments, no treatment or other back pain treatments	Pain relief	This review has been superseded by the 2 systematic reviews already mentioned but contains relevant safety data

Randomised controlled trials

Study details

Participants

Intervention and comparison(s)

Outcomes measured

Comment

Brinkhaus 2006

Multicentre trial in Germany

298 people with chronic low back pain for more than 6 months aged 40 to 75 years

Acupuncture

Minimal acupuncture (superficial needling at nonacupuncture points

Waiting list control

Duration: 1 year

Pain intensity at 8, 26 and 52 weeks

Blinding of both acupuncture treatments but some unblinding occurred.

Minimal dropout.

Itoh 2006

Japan

26 consecutive patients with chronic low back pain

17 women, 9 men aged between 65 and 91 years

1. Trigger point acupuncture

2. Sham acupuncture

Duration: 12 weeks

Pain intensity

Crossover trial with a washout period in between.

7 patients dropped out.

Li 2005

China

60 people with non specific low back pain

1. Acupuncture with moxibustion

2. Physiotherapy treatments (using light, electricity and heat)

Duration: 6 months

Pain relief

Function

Relapse rate

Not blinded

Muller 2005

Australia

69 people >17 years of age with neck and back pain for a minimum of 13 weeks

1. Acupuncture

2. Medication (Celebrex or Vioxx and paracetamol)

3. Spinal manipulation

Duration: 1 year

Pain frequency

Pain intensity

Quality of life

One year follow up of a trial included in the Cochrane systematic review

Not blinded

Thomas 2005

241 people aged 18 to 65 years with non specific low back pain of 4 to 52 weeks duration

1. Acupuncture

2. Usual care (mixture of physiotherapy, medication and back exercises)

Duration: 2 years

Pain score (from SF 36)

Cost utility

Disability score

Other quality of life measures

Medication use

Pain free months in last year

Worry about back pain

Satisfaction

Safety and acceptability of acupuncture

Setting was primary care.

9. Methodological quality
The included studies were evaluated using the SIGN criteria. The systematic reviews were of good quality but most of the included studies had low methodological quality. Two of the RCTs were good quality, two were fair quality and one RCT could not be evaluated for quality because it was not available.

10. Results
The Cochrane systematic review assessed the effects of acupuncture for acute and chronic low back pain separately. There was no conclusion for acute low back pain because there were only three RCTs with small sample sizes and low methodological quality. For chronic low back pain, acupuncture gave significantly more pain relief and functional improvement compared to no treatment after short term follow up. Acupuncture gave significantly more pain relief than sham treatment (placebo) after short term follow up but there were no differences between groups for improvement in function. The effects were not maintained at longer-term follow up. There was also evidence that when acupuncture was added to other treatments, there was additional reduction of pain and improvement in function compared to the use of the other treatments by themselves. However, the effects of acupuncture were only small (for example, a reduction in pain of 32% with acupuncture compared to a reduction in pain of 23% with sham treatment and 6% with no treatment).

The review by Manheimer also confirmed the results of the Cochrane systematic review. It found that acupuncture was significantly more effective at reducing chronic low back pain than no treatment or sham treatment in the short term (up to 6 weeks). No conclusion could be reached for acute low back pain because of sparse data. There was no evidence to suggest that acupuncture was more effective than other treatments commonly used for chronic low back pain. They concluded that pain relief seemed to be sustained over the longer term but that this conclusion was uncertain. The other systematic review (with a smaller number of included studies) also confirmed the results of the Cochrane review.

One of the RCTs compared acupuncture with minimal acupuncture and no acupuncture at 8, 26 and 52 weeks in patients with chronic back pain. It reported that acupuncture was more effective in improving pain than no acupuncture treatment but there were no differences between acupuncture and minimal acupuncture. Thus, this trial did not confirm the findings of both systematic reviews which did find a difference between �real� acupuncture and �pretend� or �sham� acupuncture.

Another RCT (long term follow-up of one of the trials in the Cochrane systematic review) compared the effects of acupuncture with medication and spinal manipulation on a number of different pain outcomes 12 months after treatment in patients with chronic back pain. They reported that spinal manipulation appeared to be more effective than either medication or acupuncture.

Another RCT compared the effects of traditional acupuncture (by 6 acupuncturists) with �usual care� in patients with chronic back pain at 3, 12 and 24 months. They found that at both 12 and 24 months there was clinically significant improvement in the acupuncture group when compared with the usual care group and at 24 months acupuncture was significantly more effective at reducing pain than usual care. They reported no benefits relating to function or disability. They also found that GP referral to a service offering traditional acupuncture was cost effective for reducing back pain over a 2 year period.

One RCT found that trigger point acupuncture had greater short term effects on chronic low back pain in older people than sham acupuncture. The RCT of unknown quality found that acupuncture combined with moxibustion reduced disability and relapse rate when compared with physiotherapy treatment. These two RCTs had small numbers.

Acupuncture was associated with very few side effects in all the studies.

11. Discussion of findings
There was some evidence that acupuncture is useful for people who have acute (lasting less than 3 months) low back pain but this finding may be due to chance.

There is good evidence that traditional acupuncture is an effective treatment for chronic back pain over the short term (up to 3 months after treatment) and it appears to provide an additive effect when added to other treatments. The beneficial effects of acupuncture were found when this treatment was compared with either no treatment of sham (pretend) treatment. One of the RCTs did not confirm this result, however, and found that there were no differences between acupuncture and �minimal� acupuncture at 1 year. This could be partly explained because there were differences in pain levels between the groups before the study started.

It is uncertain whether the beneficial effects are maintained after 3 months but both systematic reviews found a strong trend and the results of 1 RCT published more recently (comparing acupuncture with no treatment [waiting list]) suggests that the beneficial effects of acupuncture are maintained at 1 year after treatment. More research is needed to confirm the effects of acupuncture long term.

There is less evidence for a benefit in improving function. Both systematic reviews found that acupuncture had a beneficial effect on improving function only in the trials where it was compared with no treatment. No significant differences were found between real and sham acupuncture for improving function.

The systematic reviews found no evidence of a difference between acupuncture and other commonly used treatments for low back pain such as massage, spinal manipulation, medication and TENS. This has been challenged by a more recent RCT of good quality that compared acupuncture with �usual care� (which included a mixture of physiotherapy, medication and back exercises) at 1 and 2 years after treatment. Although both treatments were effective at reducing pain (but not improving function), acupuncture was more effective than usual care. Another RCT has suggested the spinal manipulation is more effective than acupuncture or medication long term (1 year after treatment) but this conclusion was based only on the patients who actually received the treatment (analysis of compliers) rather than the intention to treat analysis. In intention to treat analysis, both spinal manipulation and acupuncture appeared to reduce pain more effectively than medication. More research is required to determine which of a number of treatments that are commonly used to reduce low back pain is the most effective.

12. Conclusion
There is level two evidence from the studies included in this review that acupuncture is effective at reducing chronic low back pain in the short term (up to 3 months after treatment) although the benefit may be small. There is level three evidence that this benefit is maintained up to 2 years after treatment (although further research is required to confirm this). There is level three evidence that acupuncture is more effective than usual care (which includes a mixture of physiotherapy, medication and back exercises). There is level three evidence that spinal manipulation is more effective than acupuncture for chronic low back pain. There is insufficient evidence to determine the relative benefits of acupuncture when compared with any other treatments for low back pain. There is level four evidence that acupuncture may reduce pain in people with acute low back pain.

13. References

Brinkhaus B, Witt CM, Jena S, Linde K, Streng A, Wagenpfeil S et al. Acupuncture in patients with chronic low back pain. Arch Intern Med 2006; 166: 450-7.

Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the effectiveness, safety and cost of acupuncture, massage therapy and spinal manipulation for back pain. Ann Intern Med 2003; 138: 898-906.

Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW et al. Acupuncture and dry needling for low back pain. The Cochrane Database of Systematic Reviews 2005, Issue 1.

Itoh K, Katsumi Y, Hirota S, Kitakoji H. Effects of trigger point acupuncture on chronic low back pain in elderly patients � a sham-controlled randomized trial. Acupuncture in Medicine 2006; 24(1): 5-12.

Li N, Wu B, Wang CW. Comparison of acupuncture-moxibustion and physiotherapy in treating chronic non-specific low back pain. Zhongguo Linchuang Kangfu 2005; 9(2): 186-7.

Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Ann Intern Med 2005; 142: 651-63.

Muller R, Giles LGF. Long-term follow-up of a randomized clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes. J Manipulative Physiol Ther 2005; 28: 3-11.

Thomas KJ, 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).

14. Further Resources

McBride D, Begg D, Herbison P, Buckingham K. Low back pain in young New Zealanders. NZ Med J 2004; 117(1203).

Accident Compensation Corporation website: www.acc.co.nz/statistics/

Waddell G. The clinical course of low back pain. In: Waddell G, editor. The back pain revolution. 1st edition, Edinburgh: Churchill Livingstone; 1998, pp 103-17.

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