Acupuncture for low back pain

Clinical Inquiries question

Is acupuncture effective in improving pain relief for low back pain?

Evidence-based answer

Acupuncture is an effective treatment for relief from low back pain, even when compared with other interventions (sham acupuncture, usual care, or no treatment), with stronger effects observed immediately after treatment. Clinically significant reduction in pain is more reliably observed in chronic rather than acute low back pain (strength of recommendation: A, based on systematic review and meta-analysis of randomized controlled trials [RCTs]).

Evidence summary

The literature search was completed between January and July 2019. Findings are outlined in Table 1.^1–4 A 2015 systematic review and meta-analysis¹ of 31 RCTs (N = 6656) comparing acupuncture with other treatments (sham acupuncture, no treatment, transcutaneous electrical nerve stimulation, medications, usual care) found that acupuncture was clinically superior to sham acupuncture in pain reduction for patients with chronic low back pain (CLBP)—defined as lasting longer than 3 months—immediately after (standardized mean difference [SMD] of −0.49, 95% CI −0.76 to −0.21) and up to 3 months following (SMD = −0.45, 95% CI −0.76 to −0.14) treatment. Further, acupuncture provided more pain relief in CLBP compared with no treatment (SMD = −0.73, 95% CI −0.96 to −0.49) and usual care, which typically consisted of nonacupuncture care like physical therapy, massage, and medication (mean difference [MD] of −11.47, 95% CI −19.33 to −3.61, I² = 59.9%) immediately following treatment. Analysis of studies comparing acupuncture with medications and transcutaneous electrical nerve stimulation treatment found no significant differences in pain reduction.¹ Effects on pain and function were reported on a 100-point visual analogue scale (VAS).

Table 1.

Summary of the evidence for acupuncture for low back pain

STUDY TYPE	POPULATION	OUTCOMES*
Systematic review and meta-analysis1 (31 RCTs)	N = 6656 Age 17–90 y 40% male, 60% female Excluded LBP caused by trauma, infection, fracture, tumour, fibromyalgia, cauda equina syndrome	Acupuncture clinically superior to sham acupuncture in immediate pain reduction for chronic LBP (SMD = −0.49, 95% CI −0.76 to −0.21) Acupuncture clinically superior to sham acupuncture 3 mo following treatment for chronic LBP (SMD = −0.45, 95% CI −0.76 to −0.14) Acupuncture clinically superior compared with no treatment for chronic LBP (SMD = −0.73, 95% CI −0.96 to −0.49) Acupuncture clinically superior compared with usual care in immediate pain reduction for chronic LBP (MD = −11.47, 95% CI −19.33 to −3.61, I2 = 59.9%)
Appraisal of systematic reviews2 (16 systematic reviews of RCTs)	N = 11 682 Age > 18 y	Acupuncture statistically but not clinically superior to sham acupuncture or usual care in immediate pain reduction for acute LBP (MD = −9.38, 95% CI −17.00 to −1.76, P = .02, I2 = 27%) Acupuncture clinically superior to sham acupuncture or usual care in immediate pain reduction for chronic LBP (WMD = −5.88, 95% CI −11.20 to −0.55, at 1 mo; and WMD = −17.79, 95% CI −25.50 to −10.0, at 3 mo)
Systematic review3 (17 RCTs)	N = 7958 Age > 18 y Excluded LBP related to cancer, infection, inflammatory arthropathy, trauma, fracture, pregnancy, neurologic deficits Included radicular and nonradicular pain	Acupuncture statistically superior to sham acupuncture in immediate pain reduction for chronic LBP (WMD = −16.76, 95% CI −33.3 to −0.19) Acupuncture statistically superior to sham acupuncture 3 mo following treatment for chronic low back (WMD = −9.55, 95% CI −16.5 to −2.58) Acupuncture statistically superior compared with medications for chronic LBP (WMD = −10.56 on 0- to 100-point scale, 95% CI −20.34 to −0.78) and improved function (3 trials, SMD = −0.36, 95% CI −0.67 to −0.04) Seven RCTs studying immediate effects on pain reduction (4 trials, SMD = −0.72, 95% CI −0.94 to −0.49) and function (3 trials, SMD = −0.94, 95% CI −1.41 to −0.47) favoured acupuncture over control with no acupuncture

LBP—low back pain, MD—mean difference, RCT—randomized controlled trial, SMD—standardized mean difference, WMD—weighed mean difference.

^*Cohen’s 3 levels of rating of clinical importance4: Small is a WMD < 10% of the scale, an SMD or d score < 0.5, or a relative risk of < 1.25 or > 0.8 (depending on whether the report referred to risk of benefit or the risk of harm); medium is a WMD from 10%–20% of the scale, an SMD or d score from 0.5–0.8; or a relative risk between 1.25 and 2.0 or between 0.5 and 0.8; and large is a WMD > 20% of the scale, an SMD or d score > 0.8, or a relative risk > 2.0 or < 0.5.

A 2015 appraisal of 16 systematic reviews of RCTs (N = 11 682) comparing acupuncture with sham acupuncture, no treatment, or acupuncture plus conventional treatment, which included physical therapy, exercise, and medication, revealed inconsistent evidence of benefit in acute low back pain—defined as lasting less than 3 months—with studies supporting statistically but not clinically relevant pain relief immediately after intervention (MD = −9.38, 95% CI −17.00 to −1.76; P = .02; I² = 27%). Acupuncture was consistently found to provide superior pain relief for CLBP lasting greater than 3 months in the short term (weighted mean difference [WMD] of −5.88, 95% CI −11.20 to −0.55, at 1 month; and WMD = −17.79, 95% CI −25.50 to −10.07, at 3 months).² Effects on pain and function were reported on a 100-point VAS, the Roland Morris Disability Questionnaire, the Oswestry Disability Index, and the Quebec Back Pain Disability Scale, which were consolidated by distribution-based methods to determine clinical relevance.

A 2016 systematic review (N = 7958) including 7 RCTs of acupuncture versus sham acupuncture for CLBP lasting longer than 3 months found that acupuncture significantly reduced pain intensity immediately (4 trials, WMD = −16.76, 95% CI −33.3 to −0.19) and 12 weeks after treatment (3 trials, WMD = −9.55, 95% CI −16.5 to −2.58). Seven RCTs studying immediate effects on pain reduction (4 trials, SMD = −0.72, 95% CI −0.94 to −0.49) and function (3 trials, SMD = −0.94, 95% CI −1.41 to −0.47) favoured acupuncture over control with no acupuncture. Compared with medications (nonsteroidal anti-inflammatory drugs, muscle relaxants, or analgesics), acupuncture provided greater pain relief (3 trials, WMD = −10.56 on a 0− to 100-point scale, 95% CI −20.34 to −0.78) and improved function (3 trials, SMD = −0.36, 95% CI −0.67 to −0.04).³ Effects on pain and function were reported on a 100-point VAS and the Roland Morris Disability Questionnaire.

Common limitations in the appraised studies were small numbers of trials and methodologic heterogeneity regarding acupuncture techniques, number and duration of treatments, and type of sham acupuncture used.^1–3 One review noted that sham acupuncture as a control was particularly problematic because neither noninsertion nor superficial insertion at nonacupoints is fully physiologically inert.²

Recommendations from others

The American College of Physicians issued a clinical practice guideline recommending acupuncture as a first-line therapy for acute and chronic nonradicular low back pain along with other nondrug therapy including stretching, heat application, massage, and manual spinal manipulation.⁵ The National Institutes of Health’s National Center for Complementary and Integrative Health considers acupuncture to be a safe treatment when done by trained acupuncturists using sterile needles.⁶

Clinical Inquiries are author-formulated questions that are answered with the best available current evidence, written by family medicine residency faculty and their residents through the Family Physician Inquiries Network. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (www.cebm.net). The Family Physicians Inquiries Network Clinical Inquiries series in Canadian Family Physician is coordinated by Rick Guthmann, MD, MPH, Editor-in-Chief for the series. If interested in submitting questions or writing answers for this series, go to www.fpin.org or e-mail ci@fpin.org.

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