Low Back Pain and Sciatica
© AACMA 2016
What Does the Research Say About Acupuncture and Low Back Pain?
In a systematic review of 32 randomised controlled trials for acupuncture treatment of chronic non-specific low back pain, acupuncture was superior (both statistically and clinically significant) to sham acupuncture in pain reduction and improved function immediately after treatment (3). Acupuncture was equivalent but not superior to usual care in pain and function, but acupuncture plus usual care was superior to usual care alone (3). The reviewers rated the evidence level of their review as Level of Evidence 1 (3). A systematic review of 11 randomised controlled trials on acute low back pain, acupuncture was superior to NSAIDS for improving symptoms (small effect), and superior to sham for pain but not function (4). A narrative review of non-invasive and alternative treatments for chronic low back pain rated the evidence for the effectiveness of acupuncture as high and for acupressure as moderate (5).
A review of 16 systematic reviews found that acupuncture alone, or when added to usual care, provided short-term improvement in pain and function for chronic low back pain (medium to large clinical effects) and hence ‘should be advocated in routine clinical practice’ (6). For acute low back pain, the reviewers could not make firm conclusions about the effectiveness of acupuncture due the inclusion of only two systematic reviews (6). Two studies found that acupuncture is likely to be cost-effective for low back pain or chronic non-specific low back pain, respectively (7, 8).
Acupuncture was rated as effective for both acute and chronic low back pain by ‘The Acupuncture Evidence Project’. The level of evidence was rated at the highest level, ‘evidence of positive effect’ for chronic low back pain; and at the second highest level, ‘evidence of potential positive effect’ for acute low back pain (1).
What are the limitations of this Research? When reviews separate the evidence on chronic low back pain from acute low back pain, as was done in the recent review by the US Agency for Healthcare Research and Quality, the evidence became clearer. It was found that there is moderate quality evidence for the effectiveness of acupuncture in chronic low back pain for both pain intensity and function, but only low quality evidence for pain intensity and function in acute low back pain (9). There is mounting evidence that sham/placebo controls used in acupuncture trials are not inert, which is likely to lead to a consistent underestimation of the true effect size of acupuncture Acupuncture is effective for treating chronic low back pain with ‘positive effect’, and effective for acute low back pain at the level of ‘potential positive effect (1). © AACMA 2016 interventions. This means that acupuncture is likely much more effective than the current evidence indicates. For this reason both the Scottish Intercollegiate Guidelines Network (SIGN) guideline for the Management of Chronic Pain and the National Institutes of Health in the US recommend that future studies on acupuncture and pain should be focussed on pragmatic trials rather than randomised controlled trials (10). Notwithstanding these limitations level I evidence still supports the effectiveness of acupuncture for low back pain (1).
Clinical Guidelines that Recommend Acupuncture for Low Back Pain In ‘Acute Pain Management: Scientific Evidence’ published by the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine in 2015, NHMRC Level 1 evidence was identified for acupuncture treatment of back pain (11). The Scottish Intercollegiate Guidelines Network (SIGN) guideline for the Management of Chronic Pain (2013), recommended acupuncture for chronic low back pain (Grade A recommendation) (10). Sciatica: Twice as Effective as Conventional Care Sciatica may occur with or without low back pain and is most commonly caused by a bulging lumbar disc, but may also be caused by other pathology (12). A network meta-analysis comparing 21 different therapies for sciatica rated acupuncture as the second-best therapy in terms of pain intensity and global effect (13). Acupuncture was clearly superior to exercise therapy and radio frequency treatment (13).
1. McDonald J, Janz S. The Acupuncture Evidence Project: A Comparative Literature Review.: Australian Acupuncture and Chinese Medicine Association Ltd,; 2016.
2. World Health Organization. Chapter 6: Priority diseases and reasons for inclusion Priority Medicines for Europe and the World Update Report. Geneva: World Health Organization; 2013.
3. Lam M, Galvin R, Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis. Spine. 2013 Nov 15;38(24):2124-38.
4. Lee JH, Choi TY, Lee MS, Lee H, Shin BC, Lee H. Acupuncture for acute low back pain: a systematic review. The Clinical journal of pain. 2013 Feb;29(2):172-85.
5. Wellington J. Noninvasive and alternative management of chronic low back pain (efficacy and outcomes). Neuromodulation : journal of the International Neuromodulation Society. 2014 Oct;17 Suppl 2:24-30.
6. Liu L, Skinner M, McDonough S, Mabire L, Baxter GD. Acupuncture for low back pain: an overview of systematic reviews. Evidence-based complementary and alternative medicine : eCAM. 2015;2015:328196.
7. Andronis L, Kinghorn P, Qiao S, Whitehurst DG, Durrell S, McLeod H. Cost-Effectiveness of Non-Invasive and Non-Pharmacological Interventions for Low Back Pain: a Systematic Literature Review. Applied health economics and health policy. 2016 Aug 22.
8. Taylor P, Pezzullo L, Grant SJ, Bensoussan A. Cost-effectiveness of Acupuncture for Chronic Nonspecific Low Back Pain. Pain practice : the official journal of World Institute of Pain. 2014 Sep;14(7):599-606.
9. Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. AHRQ Comparative Effectiveness Reviews. Noninvasive Treatments for Low Back Pain. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016.
10. Scottish Intercollegiate Guidelines Network. Management of Chronic Pain (SIGN publication no. 136). Scottish Intercollegiate Guidelines Network (SIGN); 2013.
11. Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J. Acute pain management: scientific evidence, fourth edition, 2015. The Medical journal of Australia. 2016 May 2;204(8):315-7.
12. Lewis R WN, Matar HE, et al. The Clinical Effectiveness and Cost-Effectiveness of Management Strategies for Sciatica: Systematic Review and Economic Model. Health Technology Assessment, No 1539. Southampton (UK): NIHR Journals Library; 2011.
13. Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network metaanalyses. The spine journal : official journal of the North American Spine Society. 2015 Jun 1;15(6):1461-77.
Acupuncture is effective for treating chronic low back pain with ‘positive effect’, and effective for acute low back pain at the level of ‘potential positive effect (1).
Acupuncture is twice as effective as standard care for sciatica, and more effective than all other interventions other than injecting a biological agent (13).