This review provides some evidence to support acupuncture is better than no treatment, and some forms of conventional therapy, in providing some pain relief. The evidence from this review supports the theory that there is no significant difference between acupuncture and sham/ minimal acupuncture in providing pain relief and improvements in function.
Five studies [14
] found a significant difference in their primary outcome measures- HFAQ, VAS, Roland Morris Disability Questionnaire, McGill Pain Index and Von Korff pain scores when comparing acupuncture, or sham acupuncture, with conventional therapy or no care. Two studies [16
] demonstrated a significant difference between acupuncture treatment and no treatment or routine care at 8 weeks and 3 months. One study [16
] found a significant improvement in pain, function and quality of life after acupuncture treatment compared to routine care at 3 months. Interestingly their study had a non-randomized arm consisting of participants refusing randomization, but requesting acupuncture. This group showed even greater improvements in these outcome measures which could support a degree of psychological response to treatment overestimating the effects of acupuncture. The improvement in pain in patients in the acupuncture group wasn’t significant enough for the patients to reduce the number of analgesics used during the trial as there was no significant difference between groups in analgesics being prescribed.
Two studies [17
] showed conflicting evidence as to whether acupuncture was more effective than conventional treatment. Thomas et al. [19
] showed minimal difference between acupuncture and usual care at 1 year, whereas Haake et al. [17
] found acupuncture better than conventional therapy at 6 months. In both studies the control groups received a variety of interventions with some more evidence based than others making definitive conclusions about acupuncture’s effectiveness over such a broad range of therapies difficult to conclude. Due to high drop-out rates in the study by Thomas et al. [19
], the study may have been underpowered to detect a significant difference.
Three studies [14
] demonstrated no significant difference between acupuncture and minimal/sham acupuncture. There was no difference in pain relief or function over 6 to 12 months. Needle depth insertion varied between studies in both the acupuncture group and sham group. Haake et al. [17
] inserted sham needles very superficially at 1 to 3 millimeters and the acupuncture group’s at 5 to 40 millimeters whereas Brinkhaus et al. [18
] inserted the sham acupuncture needles into a greater depth of 20 to 40 millimeters mimicking the first studies treatment group. Leibing et al. inserted the acupuncture needles to a depth of 10-30 mm compared to 10-20 mm for the sham acupuncture. There appears to be no standardisation of the depth of needle insertion for true acupuncture compared to sham/ minimal acupuncture. The impact of this is difficult to assess as in practice different acupuncture points require different depth of needle insertion depending on their location. These 3 studies [14
] stimulated the inserted needles in the acupuncture groups to achieve De Qi
. All studies found no difference between the acupuncture treatment and the sham treatment questioning if stimulation of needles to achieve De Qi
is necessary to be an effective treatment or indeed if needling specific points along a meridian is necessary, as needle insertion of minimal depth appears to have the same treatment effect.
There was limited standardization of needling techniques within the studies. Three studies [14
] standardized the number of needles used. One study [18
] used 6 to 10 needles in the sham acupuncture group and ten needles in the acupuncture group. The other study [17
] used double the amount of needles at 14 to 20 per treatment in both groups. The details of the needling points used by the physicians were presented in only one study [18
Despite there being no significant difference between acupuncture and sham acupuncture the evidence may advocate that needling soft tissue has a beneficial effect in relieving pain. Acupuncture could then be used as an adjunct to relieve pain, enabling patients to partake in a more rigorous treatment program for their lower back.
There was limited evidence from these studies to support the NICE guidelines recommendations of ten treatments over a twelve week period [1
]. One study [17
] carried out ten sessions in a five week period while two of the studies [16
] offered weekly treatments providing up to 12 to 15 sessions although one study [16
] identified the variation in the number of treatment sessions with some participants receiving 5 sessions compared to other participants in the same study receiving 15 sessions. These studies demonstrated a reduction in pain in the acupuncture groups compared to either no treatment or conventional therapy [16
]. A fourth study [14
] provided 20 sessions of acupuncture or sham acupuncture treatment over 12 weeks with sessions twice weekly initially. There was no evidence from these studies to support acupuncture providing long term pain relief benefit with all significant differences in pain being at 8 weeks to 3 months follow up. Recently published recommendations supported acupuncture as one treatment option for low back pain and suggested 10-12 acupuncture sessions over an 8 week period followed by a review of the patient’s pain, mood and general activity level prior to receiving further acupuncture sessions [2
This review has limitations with only 7 studies reviewed and limited to publications in the last 10 years. There is a broad age variation of participants in these studies. Two studies reviewed participants 18 to 65 years of age [14
] with the other study’s participants ranging up to 86 years of age. This disparity in age range may impact upon the results as those suffering low back pain at 55 years and over may be suffering from degenerative changes. Three studies [16
] ensured the participants had non-specific low back pain for at least 6 months in duration. The fourth study’s participants were suffering low back pain from 4 to 52 weeks encompassing the sub-acute back pain sufferers with the chronic and those suffering additional leg pain [19
]. There is great disparity in the methodologies and the treatment techniques used. The majority of these studies invited participants who wanted acupuncture treatment to join their studies potentially producing a selection bias. These participants may have brought positive expectations thereby influencing the results. The studies were limited to English studies when numerous research has been carried out in various countries such as China. The majority of outcome measures used in these studies were pain related rather a combination of pain scores and functional measures.