#290 Needle in a Pain-Stack: Acupuncture for Chronic Low Back Pain
CLINICAL QUESTION
Does acupuncture improve pain for patients with chronic low back pain?
BOTTOM LINE
The benefit of acupuncture for chronic low back pain is unclear. At best, one in 6 patients will get meaningful pain relief (>=30% reduction in pain) over control. The benefit is reduced to one in 20 when compared to sham acupuncture and disappears when studies of higher quality or longer duration are considered.
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EVIDENCE
Results statistically significant unless indicated.
Focusing on recent systematic reviews (from 2016-2021), acupuncture versus control:
- Systematic review1 [8 randomized control trials (RCT): 4618 patients], reporting proportion of patients attaining meaningful pain reduction (generally ≥30% reduction in pain):
- 54% acupuncture versus 35% control, number needed to treat (NNT) 6 over 4-24 weeks.
- Benefit over control reduced when sham acupuncture procedures (5 RCTs, 1676 patients) used for control: 62% versus 57% control, NNT=20.
- No difference between groups when analyzing studies of longer duration (≥12 weeks, 2 RCTs, 3615 patients), lower risk of bias (4 RCTs, 1457 patients) or larger sample sizes (≥150 participants, 4 RCTs, 4311 patients).
- 54% acupuncture versus 35% control, number needed to treat (NNT) 6 over 4-24 weeks.
- Systematic review2 reporting change on 0-100 pain scale (lower is better), with baseline pain 66:
- Intermediate to long-term pain (at 120-365 days): Sham patients improved to 42 and acupuncture to 38, with acupuncture 4 better.
- Short-term pain (at 8-90 days): Acupuncture 10 points better than sham.
- Four other recent systematic reviews:
- Two found similar scale changes.3,4
- Two used standard mean difference which is difficult to interpret clinically.5,6
- RCTs of acupuncture include differing interventions as the control: Education, waitlist, sham acupuncture, or placebo-TENS, etc. More credible sham controls may improve the success of blinding.7 The placebo/control effect is greater with sham control, resulting in less benefit for the acupuncture intervention compared to control.
- PEER simplified decision aid8 and pain calculator9 can assist with patient-informed decision-making for the management of chronic low back pain.
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