Tools for Practice


#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).
  • 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
Adverse events not statistically different from sham.1,2 Limitations: Many systematic reviews on acupuncture include mixed acute/chronic back pain; multiple sites of pain reported together, and variable comparator arms. Context
  • 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.
May 16, 2021

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Author(s):

  • Andrew N. Rouble MD CCFP MSc
  • G. Michael Allan MD CCFP
  • Samantha Moe PharmD
  • Stephanie Truelove PhD

1. Kolber MR, Ton J, Thomas B, et al. Can Fam Physician. 2021; 67:e20-30.

2. Mu J, Furlan AD, Lam WY, et al. Cochrane Database Syst Rev. 2020 Dec 11;12:CD013814.

3. Skelly AC, Chou R, Dettori JR, et al. Comparative Effectiveness Review No. 227. AHRQ. Publication No. 20-EHC009. Rockville, MD: Agency for Healthcare Research and Quality; April 2020. DOI: https://doi.org/10.23970/AHRQEPCCER227.

4. Huang JF, Zheng XQ, Chen D, et al. Global Spine J. 2020; 1-18.

5. Xiang Y, He JY, Tian HH, et al. Acupuncture Med. 2020; 38(1):15-24.

6. Yuan QL, Wang P, Liu L, et al. Sci Rep. 2016; 6:30675.

7. Howick J, Hoffmann T. CMAJ. 2018; 190:E908-11.

8. Kirkwood J, Allan GM, Korownyk CS, et al. Can Fam Physician. 2021; 67(1):31-34.

9. PEER. Comparing Treatment Options for Pain. Available at: https://pain-calculator.com/calculators/back-pain/ Accessed: Feb 10, 2021.

Authors do not have any conflicts of interest to declare.