25. July 2017 · Comments Off · Categories: Acupuncture, Back Pain

The American College of Physicians’ new guidelines on the treatment of chronic low back pain strongly recommend the use of acupuncture as a first-line treatment, finding it to be more effective for pain relief and improvement in function than pharmaceutical drugs. The Clinical Guidelines Committee based their recommendations on a systematic review of RCTs covering pharmacological and non-pharmacological treatments for low back pain published up until the end of November 2016 (see below). Clinical outcomes evaluated included reduction of low pain, improvement in function, improvement in quality of life, reduction in disability, number/frequency of back pain episodes, patient satisfaction and adverse effects. The recommendation states that when treating low back pain, doctors should initially select non-pharmacological treatments (exercise, rehabilitation, acupuncture and mindfulness-based stress reduction, which are backed up by moderate-quality evidence, or tai chi, yoga, progressive relaxation, biofeedback, laser therapy, cognitive behavioral therapy and spinal manipulation, which are backed up by low-quality evidence) and that drug treatment should only be considered for patients who do not improve with non-pharmacological interventions. Non-steroidal anti-inflammatory drugs, which were found to have only a small to moderate effect on pain and at best a small effect on function, were recommended over opioids, which the authors concluded should be considered only in patients for whom other therapies have failed because of the substantial harms with which they are associated. The guidelines also recommend acupuncture as a first-line treatment for acute low back pain (along with heat, massage and spinal manipulation), although the evidence for this is considered to be of lower quality.
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-530.

A systematic review of non-pharmacological therapies for low back pain carried out for the American College of Physicians concludes that several of them, including acupuncture and tai chi, are associated with small to moderate effects on pain. Data came from randomised trials of nine non-pharmacological treatment options versus sham treatment, wait list, usual care or each other. Acupuncture was evaluated in 49 trials. The data showed that for acute low back pain, real acupuncture decreased pain intensity more than sham, but had no clear effects on function. Compared with non-steroidal anti-inflammatory drugs (NSAIDs), acupuncture was associated with a slightly greater likelihood of overall improvement at the end of treatment. The evidence for acupuncture’s effects in chronic low back pain was more convincing. Acupuncture was associated with lower pain intensity and better function compared with no acupuncture. Acupuncture also decreased pain intensity more than sham acupuncture immediately after the intervention and through to 12 week follow-up. Compared with medications (NSAIDs, muscle relaxants, or analgesics), acupuncture resulted in greater pain relief and better function immediately after the intervention. Tai chi and mindfulness-based stress reduction were also found to be moderately effective for chronic low back pain.
Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Apr 4;166(7):493-505.

14. February 2017 · Comments Off · Categories: Acupuncture, Back Pain

Evidence identified by a systematic literature review by UK authors suggests that acupuncture represents a cost-effective non-pharmacological treatment option for low back pain (LBP). Analysis of four studies investigating acupuncture for LBP showed that although it was associated with slightly increased costs, incremental cost-effectiveness ratios remained below the commonly cited threshold value of £20,000 per quality-adjusted life year (QALY), suggesting that it represents a cost-effective treatment option.
Cost-Effectiveness of Non-Invasive and Non-Pharmacological Interventions for Low Back Pain: a Systematic Literature Review. Appl Health Econ Health Policy. 2016 Aug 22. [Epub ahead of print].

26. January 2017 · Comments Off · Categories: Acupuncture, Back Pain, Pregnancy

A feasibility study carried out in the UK suggests that acupuncture can add benefit to standard care (SC) for back pain in pregnancy. The pilot randomised trial assigned 125 women with pregnancy-related back pain to one of three treatment arms: SC (self-management advice and physiotherapy), SC plus true acupuncture or SC plus non-penetrating acupuncture. Physiotherapists carried out acupuncture using six to 10 bilateral points selected from an agreed list, including both local paraspinal points and distal points. Between six and eight treatment sessions were offered to participants over a period of six weeks. Patient-reported outcomes (pain, function and quality of life) favoured the addition of acupuncture to SC for pregnancy-related back pain. Analysis of health economic outcomes showed that although SC plus true acupuncture had a higher total cost than SC alone, it also achieved higher QALY (quality-adjusted life-years) gains. No evidence of serious adverse effects on mothers or birth and neonatal outcomes from acupuncture was found.
Evaluating Acupuncture and Standard carE for pregnant women with Back pain (EASE Back): a feasibility study and pilot randomised trial. Health Technol Assess. 2016 Apr;20(33):1-236.

Australian researchers have conducted a study exploring the experience of acupuncture for people with chronic low back pain. This qualitative study used in-depth interviews with 11 people who had received acupuncture for chronic low back pain to identify main themes. The results showed that the core theme was ‘Reclaiming Control’, which was related to the sense of well-being experienced by most of the participants as a result of receiving acupuncture. The other themes included ‘Gaining Sanctuary’, ‘Gaining Trust’ and ‘Working Together’, which reflected the experience of the participants entering an aesthetically appealing, calm and relaxing space, developing confidence in the acupuncturists’ ability to care for them, and negotiating strategies and sharing decision-making with acupuncturists about their care. The authors conclude that clinicians providing acupuncture for low back pain may elicit an immediate sense of calmness in patients which has subsequent benefits for the patient’s well­being, and that the sense of calmness may be enhanced by providing a relaxing physical environment. They further note that the interpersonal processes of establishing trust and shared decision-making are important for clients. Shared decision-making can be improved by considering the explanation of issues and plans to the patient, and especially by developing an understanding of each patient’s worldview and using language that the suits each individual’s healthcare orientation. (The experience of acupuncture care from the perspective of people with chronic low back pain: a grounded theory study. Acupunct Med. 2014 May 1. doi: [Epub ahead of print]). http:/ /www.ncbi.nlm.nih.gov/ pubmed / 24785538

 

Chronic low back pain (CLBP) is associated with changes in connectivity in the brain’s default mode network (DMN), but acupuncture can reverse these changes as well as provide pain relief. The DMN, which is associated with pain and emotional processing, consists of brain regions that are more active during rest than during active task performance. Previous studies have shown that disruptions of the DMN may underlie the cognitive and behavioural impairments that accompany chronic pain. Chinese scientists used resting-state functional MRI (rsfMRI) to scan the brains of 20 patients with CLBP, before and after four weeks of acupuncture treatment. They compared the scans with those from 10 age- and gender-matched healthy controls. Less connectivity was found within the DMN in patients with CLBP compared with healthy controls (mainly in the dorsolateral prefrontal cortex, medial prefrontal cortex, anterior cingulate gyrus and precuneus). After acupuncture, connectivities in the patients’ DMNs were restored almost to the levels seen in the healthy controls. Furthermore, reductions in clinical pain were correlated with increases in DMN connectivity. (Acupuncture treatment of chronic low back pain reverses an abnormal brain default mode network in correlation with clinical pain relief. Acupunct Med. 2013 Dec 3. doi: 10.1136/ acupmed-2013-010423. [Epub ahead of print]).

Australian authors have concluded that acupuncture is a cost-effective treatment strategy for patients with chronic lower back pain (CLBP). The results of this meta-analysis showed a significant improvement in pain in those receiving acupuncture plus standard care compared with those receiving standard care alone. A non-significant positive effect was found for acupuncture plus standard care compared to sham acupuncture plus standard care. For acupuncture alone versus standard care alone, a significant positive effect was found at week eight, but not at weeks 26 or 52. Using WHO benchmarks, acupuncture was found to be highly cost-effective when used as a complement to standard care for the relief of CLBP. Acupuncture as a substitute for standard care was not found to be cost-effective unless comorbid depression was included. (Cost-effectiveness of Acupuncture for Chronic Nonspecific Low Back Pain. Pain Pract. 2013 Oct 21. doi: 10.1111 /papr.12116. [Epub ahead of print]).

A British research team has found that combining acupuncture with self-care is particularly effective in reducing the symptoms of low back pain. Eighty patients agreed to participate in an evaluation of the Beating Back Pain Service (BBPS), a pilot service, based in a primary and community care setting delivering a combination of acupuncture, self-management and information to patients with chronic low back pain. Patients referred to acupuncture received up to six weekly 30-minute sessions of individualised TCM acupuncture treatment. The results showed that patients using the service experienced statistically significant improvements over time for pain, quality of life, understanding of pain, physical activity and relaxation. These improvements (except relaxation levels) were maintained at three-month follow-up. Patients receiving a combination of acupuncture and self-management sessions produced the most positive results and patient satisfaction with the BBPS was high. (Patient outcomes and experiences of an acupuncture and self-care service for persistent low back pain in the NHS: a mixed methods approach. BMC Complement Altern Med. 2013 Nov 1;13(1):300).

A Cochrane Database systematic review has concluded that current evidence supports acupuncture as a treatment for pelvic and back pain in pregnancy. The authors included 26 randomised trials examining 4093 pregnant women in their review. Moderate-quality evidence suggested that both acupuncture and exercise tailored to the stage of pregnancy can significantly reduce evening pelvic pain and lumbo-pelvic pain compared to usual care alone. In addition acupuncture was found to be significantly more effective than exercise for reducing evening pelvic pain, and was also more effective than physiotherapy at relieving evening lumbo-pelvic pain and disability and improving pain and function, although the effects were small. (Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev. 2013 Aug 1;8:CD001139).

A Chinese research group has found that acupuncture at Hegu L.I.-4 is significantly more effective for the treatment of chronic low back pain (CLBP) than standardised acupuncture, especially in the long term. A total of 187 patients with CLBP were randomised to ‘Hegu acupuncture’, standardised acupuncture or usual care. All received 18 treatments over seven weeks. The results showed that both acupuncture modes were beneficial compared with usual care. Disability scores at eight weeks were 5.3 for Hegu acupuncture, 4.2 for standardised acupuncture and 2.1 for usual care. At 48 weeks, the scores were 5.7 for Hegu acupuncture, 4.6 for standardised acupuncture and 3.3 for usual care. Differences in visual analogue pain scores showed a similar pattern. Statistical analysis showed a significant difference between the two acupuncture groups in favour of Hegu acupuncture, as well as between usual care and both acupuncture groups, in favour of acupuncture. (Hegu acupuncture for chronic low-back pain: a randomized controlled trial. J Altern Complement Med. 2012 Feb;18(2):130-6).

The first pragmatic randomised controlled trial of tai chi for people with low back pain has shown that it can improve pain and disability outcomes in this population. Australian researchers randomised 160 volunteers with persistent non-specific low back pain to either tai chi or a wait-list control group, who continued with their usual health care. The tai chi intervention consisted of 18 forty-minute group sessions over a 10-week period delivered by a qualified instructor. Tai chi was found to reduce the bothersomeness of back symptoms by 1.7 points and pain intensity by 1.3 points (on a 10-point scale). It was also found to improve self-reported disability by 2.6 points on a 24-point scale. (Tai chi exercise for treatment of pain and disability in people with persistent low back pain: a randomized controlled trial. Arthritis Care Res (Hoboken). 2011 Nov;63(11):1576-83).