Is Acupuncture Effective for Lower Back Pain?
Mu, J., Furlan, A. D., Lam, W. Y., Hsu, M. Y., Ning, Z., & Lao, L. (2020). Acupuncture for chronic nonspecific low back pain. The Cochrane database of systematic reviews, 12(12), CD013814. https://doi.org/10.1002/14651858.CD013814
Prior MRI studies have found physiological evidence that the brain releases pain-modulating chemicals during acupuncture. However, it is unclear if the benefits would reach clinical significance, and whether the positive effects are a result of placebo. Also, it is unknown if acupuncture is more cost-effective than other interventions.
Hence, this systematic review assessed the effects of acupuncture compared to sham intervention, no treatment, or usual care for chronic nonspecific LBP. Outcomes of interest include pain, back‐specific function and quality of life (QoL).
What they did
The researchers included only randomized controlled trials (RCTs) that examined the effects of acupuncture on chronic nonspecific LBP, which was defined as pain lasting more than three months without a specific cause. There were 33 studies included with 8270 participants in total, with the mean age being 41.6 years old and mean duration of LBP was 5.3 years. Males represented 42% of the participants.
What they found
Acupuncture vs Sham Acupuncture
- Very low-certainty evidence: acupuncture did not provide superior improvement in back-specific function compared to sham in the immediate term.
- Low-certainty evidence: acupuncture offers greater pain relief in the immediate term and improvement in QoL in the short term compared to sham. However, the difference was not clinically significant.
Acupuncture vs No Treatment
- Moderate-certainty evidence: acupuncture has a clinically superior effect on pain relief and back function than no treatment in the immediate term, but the effect did not carry on to the short term.
Acupuncture vs Usual Care
- Low-certainty evidence: acupuncture is not superior in reducing pain but does improve back-specific function in the immediate term when compared with usual care.
- Moderate-certainty evidence: acupuncture has a clinically superior effect on physical health-related but not mental health-related quality of life in the short term.
- Acupuncture has a similar incidence of adverse events immediately after treatment as the sham intervention groups and usual care groups.
- No trial reported adverse events for acupuncture when compared to no treatment.
- most commonly reported adverse events were insertion point pain, bruising, hematoma, bleeding, worsening of LBP, and pain other than LBP
*Short-term = Immediately after to 7 days after intervention
Immediate term = 8th day to 3rd month after intervention
Usual care = primary care, medication, physiotherapy, and exercise
- In the immediate term, acupuncture is clinically ineffective in improving back-specific function when compared to sham, but clinically effective when compared to usual care and no treatment at all.
- In the short term, acupuncture is effective in improving QoL when compared to sham. Acupuncture is also superior in improving physical QoL but not mental QoL when compared to usual care.
- In the immediate term, acupuncture is clinically effective in improving pain compared to no treatment, but clinically ineffective when compared to sham and usual care.
- Acupuncture did not have higher incidence of adverse events when compared to no treatment at all and usual care.
- Many studies had high risk of performance bias due to lack of blinding of the acupuncturist or patient. A few studies have high risk of detection, attrition, reporting or selection bias.
- Many studies did not report the specific acupuncture protocol, making it difficult to recommend a specific acupuncture technique.
The fact that acupuncture did not outperform sham acupuncture suggests that placebo may have contributed to pain modulation. This means that patient’s receptivity and beliefs towards acupuncture influences the likelihood of a positive outcome. Patient’s opinions should therefore be consulted before administering it.
Since acupuncture produced superior improvement in pain and back function compared to no treatment at all, it may be useful for patients who are non-compliant to other forms of treatment. However, given that the effects of acupuncture only lasts for the immediate term, education and counselling is still necessary to increase patient compliance towards the primary treatment modality.