Back pain is one of the most common health problems in developed countries. More than 50% of adults are bothered by back pain each year (22
) and 70% to 80% of adults are afflicted by it at some time in their lives (23
). Moreover, back pain may persist substantially longer than previously thought. In a recent study of persons with a new episode of back pain, about a third of patients still have back symptoms a year after their episode began (24
). Once back pain becomes chronic, it appears to persist (25
Back pain is the most costly ailment of working-age adults, with an estimated $26 billion spent annually in the U.S. on the direct costs of personal medical care for back pain (26
) and an estimated $19.8 billion lost because of back-related lost worker productivity (27
). Despite a vast array of treatments, both conventional and complementary, no clear consensus exists on how to treat this problem (28
). Eisenberg (30
) found that most people with back problems considered complementary and alternative medical care to be superior to conventional care for back pain.
Although acupuncture appears to confer benefits as an adjunctive treatment to usual medical care for persons with back pain, it is neither superior to sham acupuncture, massage or chiropractic (31
). One study found it superior to guideline driven best conventional care (11
). Acupuncture is also a safe treatment and appears to be cost effective.
Manheimer et al (32
) performed a meta-analysis on 22 trials of acupuncture for chronic back pain published before September 2004. Although the largest and newest trials were not included in this analysis, they found that in the short term, acupuncture was statistically and clinically superior to sham acupuncture (standardized mean difference = 0.58, 95% CI=0.36–0.80; 4 trials with 343 patients) and no additional treatment (standardized mean difference = 0.69, 95% CI=0.4–0.98; 8 trials with 586 patients). They concluded that insufficient data existed to draw conclusions about acupuncture’s short term effectiveness compared with most other treatments. Finally, they noted that their results were preliminary, there was lots of heterogeneity in the trials and the publication of results from ongoing major trials would have a major effect on the evidence.
) performed the most recent systematic review of acupuncture needling for chronic back pain, including studies published through July 2006. They included 19 trials (median = 60 patients per study and 4998 patients total; range = 20 to 3093 patients/study), most of which included needle acupuncture only. The review compared acupuncture to no treatment (3 trials), to sham acupuncture (7 trials), to other therapies (4 trials) and as an adjunctive treatment to other care (7 trials). They evaluated improvements in both pain and functional status over a variety of time periods: immediately after treatment (< 1 week), and in the short (up to 3 months), intermediate (3 to 12 months) and longer term (> 1year). Immediately after treatment, three trials found acupuncture appears more effective than no treatment in improving pain relief and functional status.
Acupuncture was rarely superior to sham acupuncture for pain relief (i.e., in one of six trials immediately post-treatment, in two of three trials for short term outcomes and in none of four trials with intermediate outcomes and in the one trial with long-term outcomes). Functional status among persons receiving acupuncture and sham acupuncture was similar at short-term follow-ups.
Among four trials comparing acupuncture to other treatments, massage proved superior to acupuncture in reducing pain and improving functional status at 1 year, chiropractic proved superior to acupuncture in reducing pain and improving functional status in the short term, and the two studies comparing acupuncture and TENS were inconsistent.
Acupuncture was evaluated as an adjunctive treatment in seven trials. The primary treatments were exercise (2 trials), usual or standard care (3 trials), physiotherapy (1 trial), and orthopedic care (1 trial). In all trials for virtually all follow-up periods, those receiving adjunctive acupuncture did better than the others.
One additional large trial (n=1162) has been published since then (11
). This trial also found acupuncture clearly superior to guideline driven best conventional care, but not superior to sham acupuncture, for at least 6 months. Nearly twice as many people receiving acupuncture or sham acupuncture showed clinically relevant response as in the conventional care group. While some studies have shown that persons receiving acupuncture who are optimistic about its effectiveness do better than others (33
), other studies have not (4
Acupuncture appears to be a relatively safe treatment for persons with back pain, with only 6 – 8% of over 13,000 such patients reporting side effects in 12 trials and one large observational study (10
). Most of the side effects were minor (e.g., increased back pain, drowsiness, dizziness, local bleeding). No deaths, permanent disability or hospitalizations were reported. This adverse event profile is similar to that of some large prospective studies evaluating the safety of acupuncture in routine practice (36
Both of the trials of acupuncture for back pain that included cost-effectiveness analyses found costs were greater in the acupuncture group than in usual care as a result of the cost of acupuncture (10
). However, those costs were relatively modest and the average incremental gains per quality adjusted life year were substantially lower than internationally accepted thresholds for cost-effectiveness. Authors of both studies concluded that acupuncture is a cost-effective intervention for back pain.