Recently, acupuncture, an important part of traditional Chinese medicine, has been recommended as one of the favourable nonpharmacologic therapies for low back pain by American College of Physicians. Two reports published on journal of Ann Intern Med in February 2017 by Chou et al., 2017, and Qaseem et al., 2017 made the recommendation.

Lower back pain is one of the most common reasons for clinic visits in the United States. It is associated with increased healthcare costs as well as lost wages and decreased work productivity. Acute back pain generally lasts less than 4 weeks and usually resolves on its own. Subacute low back pain is defined as lasting 4 to 12 weeks, while chronic back pain lasts over 12 weeks. Up to 30% of patients report persistent low back pain up to 1 year after experiencing an acute episode. One in five report substantial limitations in activity, according to background information in the articles.

To develop the guideline, the ACP reviewed randomized controlled trials and systematic reviews of studies evaluating noninvasive, nondrug, and drug therapy for low back pain in adults. To be included, studies had to be published in English between January 2008 and November 2016. The authors identified earlier studies using the 2007 ACP/American Pain Society systematic reviews. The agency evaluated outcomes including reduction or elimination of back pain and number of back pain episodes, improvement in back-specific function, improvement in health-related quality of life, reduction in work disability, patient satisfaction, and adverse events. The guidelines and evidence reviews also underwent peer review and a public comment period.

In the report acupuncture was evaluated in 49 trials. Of these studies, 11 (n= 1163; range, 40 to 300) were in a systematic review of acupuncture for acute or subacute low back pain (58) and 32 (n= 5931; range, 16 to 2831) in a systematic review of acupuncture for chronic low back pain (59), and 6 additional trials were identified (n=864; range, 80 to 275) (see report). The systematic reviews categorized 22% and 45% of trials as low risk of bias; 3 additional trials were rated as good, 2 as fair, and 1 as poor quality.

For acute low back pain, a systematic review found that acupuncture decreased pain intensity more than sham acupuncture with nonpenetrating needles (2 trials: mean difference, 9.38 on a

0-to 100-point VAS [CI, 1.76 to 17.0]) (see report). Two other trials reported inconsistent effects on pain intensity (see report). Compared with nonsteroidal anti-inflammatory drugs, acupuncture was associated with a slightly greater likelihood of overall improvement at the end of treatment (5 trials: relative risk, 1.11 [CI, 1.06 to 1.16]).

For chronic low back pain, the systematic review found that acupuncture was associated with lower pain intensity (4 trials: SMD, 0.72 [CI, 0.94 to – 0.49]) and better function (3 trials: SMD, 0.94 [CI, 1.41 to 0.47]) immediately after the intervention compared with no acupuncture (see report). Mean effects on pain ranged from 7 to 24 points on a 0- to 100-point scale; for function, 1 trial reported an 8-point difference on a 0- to 100-point scale and 2 trials reported differences of 0.8 and 3.4 points on the RDQ. In the long term, 2 trials showed small or no clear differences. Acupuncture also decreased pain intensity more than sham acupuncture immediately after the intervention (4 trials: WMD, 16.76 [CI, 33.3 to 0.19]) and through 12 weeks (3 trials: WMD, 9.55 [CI, 16.5 to 2.58]), with no differences in function. Five trials that could not be pooled or were not included in the review reported results consistent with these findings (see report). The systematic review found that compared with medications (nonsteroidal anti-inflammatory drugs, muscle relaxants, or analgesics), acupuncture resulted in greater pain relief (3 trials: WMD, 10.56 on a 0- to 100-point scale [CI, 20.34 to 0.78]) and better function (3 trials: SMD, 0.36 [CI, 0.67 to 0.04]) immediately after the intervention.

Overall, the new guidelines emphasize conservative treatment. First-line therapy should incorporate nondrug therapies. New evidence supports acupuncture in acute low back pain alongside with massage, or spinal manipulation; and tai chi and acupuncture in chronic low back pain alongside exercise, multidisciplinary rehabilitation, yoga, motor control exercise, progressive relaxation. Nonsteroidal anti-inflammatories (NSAIDs) or muscle relaxants should be considered when nondrug therapy fails. The guidelines strongly discourage the use of opioids.

“For treatment of chronic low back pain, clinicians should select therapies that have the fewest harms and lowest costs because there were no clear comparative advantages for most treatments compared with one another. Clinicians should avoid prescribing costly therapies; those with substantial potential harms, such as long-term opioids (which can be associated with addiction and accidental overdose); and pharmacologic therapies that were not shown to

be effective, such as [tricyclic antidepressants] and [selective serotonin reuptake inhibitors],” write Amir Qaseem, MD, PhD, MHA, chair of the ACP guidelines committee, and colleagues.

Reference

Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt ED. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Apr 4;166 (7):493-505.

Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2017 Apr 4;166 (7):514-530.

Grateful acknowledgements are due to R Chou and A Qaseem and colleagues (this paper was based on their articles in Ann Intern Med, titled: Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline and Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians.) as well as to Bai-Yun Zeng for his work in preparing this briefing paper.