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Acupuncture for chronic nonspecific low back pain

Abstract

Background

Chronic nonspecific low back pain (LBP) is very common; it is defined as pain without a recognizable etiology that lasts for more than three months. Some clinical practice guidelines suggest that acupuncture can offer an effective alternative therapy. This review is a split from an earlier Cochrane review and it focuses on chronic LBP.

Objectives

To assess the effects of acupuncture compared to sham intervention, no treatment, or usual care for chronic nonspecific LBP.

Search methods

We searched CENTRAL, MEDLINE, Embase, CINAHL, two Chinese databases, and two trial registers to 29 August 2019 without restrictions on language or publication status. We also screened reference lists and LBP guidelines to identify potentially relevant studies.

Selection criteria

We included only randomized controlled trials (RCTs) of acupuncture for chronic nonspecific LBP in adults. We excluded RCTs that investigated LBP with a specific etiology. We included trials comparing acupuncture with sham intervention, no treatment, and usual care. The primary outcomes were pain, back‐specific functional status, and quality of life; the secondary outcomes were pain‐related disability, global assessment, or adverse events.

Data collection and analysis

Two review authors independently screened the studies, assessed the risk of bias and extracted the data. We meta‐analyzed data that were clinically homogeneous using a random‐effects model in Review Manager 5.3. Otherwise, we reported the data qualitatively. We used the GRADE approach to assess the certainty of the evidence.

Main results

We included 33 studies (37 articles) with 8270 participants. The majority of studies were carried out in Europe, Asia, North and South America. Seven studies (5572 participants) conducted in Germany accounted for 67% of the participants. Sixteen trials compared acupuncture with sham intervention, usual care, or no treatment. Most studies had high risk of performance bias due to lack of blinding of the acupuncturist. A few studies were found to have high risk of detection, attrition, reporting or selection bias.

We found low‐certainty evidence (seven trials, 1403 participants) that acupuncture may relieve pain in the immediate term (up to seven days) compared to sham intervention (mean difference (MD) ‐9.22, 95% confidence interval (CI) ‐13.82 to ‐4.61, visual analogue scale (VAS) 0‐100). The difference did not meet the clinically important threshold of 15 points or 30% relative change. Very low‐certainty evidence from five trials (1481 participants) showed that acupuncture was not more effective than sham in improving back‐specific function in the immediate term (standardized mean difference (SMD) ‐0.16, 95% CI ‐0.38 to 0.06; corresponding to the Hannover Function Ability Questionnaire (HFAQ, 0 to 100, higher values better) change (MD 3.33 points; 95% CI ‐1.25 to 7.90)). Three trials (1068 participants) yielded low‐certainty evidence that acupuncture seemed not to be more effective clinically in the short term for quality of life (SMD 0.24, 95% CI 0.03 to 0.45; corresponding to the physical 12‐item Short Form Health Survey (SF‐12, 0‐100, higher values better) change (MD 2.33 points; 95% CI 0.29 to 4.37)). The reasons for downgrading the certainty of the evidence to either low to very low were risk of bias, inconsistency, and imprecision.

We found moderate‐certainty evidence that acupuncture produced greater and clinically important pain relief (MD ‐20.32, 95% CI ‐24.50 to ‐16.14; four trials, 366 participants; (VAS, 0 to 100), and improved back function (SMD ‐0.53, 95% CI ‐0.73 to ‐0.34; five trials, 2960 participants; corresponding to the HFAQ change (MD 11.50 points; 95% CI 7.38 to 15.84)) in the immediate term compared to no treatment. The evidence was downgraded to moderate certainty due to risk of bias. No studies reported on quality of life in the short term or adverse events.

Low‐certainty evidence (five trials, 1054 participants) suggested that acupuncture may reduce pain (MD ‐10.26, 95% CI ‐17.11 to ‐3.40; not clinically important on 0 to 100 VAS), and improve back‐specific function immediately after treatment (SMD: ‐0.47; 95% CI: ‐0.77 to ‐0.17; five trials, 1381 participants; corresponding to the HFAQ change (MD 9.78 points, 95% CI 3.54 to 16.02)) compared to usual care. Moderate‐certainty evidence from one trial (731 participants) found that acupuncture was more effective in improving physical quality of life (MD 4.20, 95% CI 2.82 to 5.58) but not mental quality of life in the short term (MD 1.90, 95% CI 0.25 to 3.55). The certainty of evidence was downgraded to moderate to low because of risk of bias, inconsistency, and imprecision.

Low‐certainty evidence suggested a similar incidence of adverse events immediately after treatment in the acupuncture and sham intervention groups (four trials, 465 participants) (RR 0.68 95% CI 0.46 to 1.01), and the acupuncture and usual care groups (one trial, 74 participants) (RR 3.34, 95% CI 0.36 to 30.68). The certainty of the evidence was downgraded due to risk of bias and imprecision. No trial reported adverse events for acupuncture when compared to no treatment. The most commonly reported adverse events in the acupuncture groups were insertion point pain, bruising, hematoma, bleeding, worsening of LBP, and pain other than LBP (pain in leg and shoulder).

Authors’ conclusions

We found that acupuncture may not play a more clinically meaningful role than sham in relieving pain immediately after treatment or in improving quality of life in the short term, and acupuncture possibly did not improve back function compared to sham in the immediate term. However, acupuncture was more effective than no treatment in improving pain and function in the immediate term. Trials with usual care as the control showed acupuncture may not reduce pain clinically, but the therapy may improve function immediately after sessions as well as physical but not mental quality of life in the short term. The evidence was downgraded to moderate to very low‐certainty considering most of studies had high risk of bias, inconsistency, and small sample size introducing imprecision. The decision to use acupuncture to treat chronic low back pain might depend on the availability, cost and patient’s preferences.

Plain language summary

Acupuncture for chronic non‐specific low‐back pain (LBP)

Review question

Does acupuncture safely reduce pain and improve back‐related function and quality of life for people with chronic nonspecific LBP?

Background

Most people have experienced chronic LBP. Some of them choose acupuncture to relieve their pain and other symptoms.

Search date

The evidence is current to 29 August 2019.

Study characteristics.

We reviewed 33 trials (37 articles) with 8270 participants. The trials were carried out in Europe, Asia, North and South America. The studies compared acupuncture with sham (placebo), no treatment and usual care.

Key results

Compared with sham, acupuncture may not be more effective in reducing pain immediately after treatment. Acupuncture perhaps did not appear to improve back‐specific function immediately after treatment, or may not enhance quality of life in the short term.

Acupuncture was better than no treatment for pain relief and functional improvement immediately after treatment.

Compared with usual care, acupuncture did not appear to significantly clinically reduce pain, but seemed more effective in improving function immediately after treatment. Acupuncture did not improve quality of life in the short‐term.

The incidence of adverse events may be similar between acupuncture and sham, and between acupuncture and usual care. Adverse effects related to acupuncture were considered minor or moderate.

Certainty of the evidence

The certainty of the evidence ranged from very low to moderate. Many trials showed a high risk of bias due to problems with masking the acupuncturists or participants. This may affect the participants reported outcomes and trialists computed effects. Some outcomes were based on small samples, resulting in inconsistency and imprecision of results.

Authors’ conclusions

Implications for practice

The very low to low‐certainty evidence with sham controls provides evidence that acupuncture seems not to be more effective than sham in treating chronic nonspecific low back pain (LBP). In clinical practice, the decision to use acupuncture to treat chronic LBP may depend on treatment availability, cost, and, importantly, participant or provider preference. Moderate‐certainty evidence showed that acupuncture provided more immediate pain relief than no treatment for people with persistent pain. Very low to moderate‐certainty evidence provided no significant results between acupuncture and usual care. The majority of the evidence from the other three comparisons (acupuncture versus another intervention, one technique of acupuncture versus another, and acupuncture plus an intervention versus the same intervention alone) suggested that acupuncture brought no additional clinical benefits, and that no one acupuncture technique was clinically better than another. The certainty of this evidence was either very low or low, due to poor methodology and small samples.

Although there was low‐certainty evidence for adverse events in the main comparisons, the incidence of such events was generally similar between acupuncture and sham or usual care, consistent with the findings of many other systematic reviews. Therefore, we consider acupuncture might be a safe treatment for people with chronic LBP.

Implications for research

Future studies should seek to minimize the risk of bias through appropriate blinding practices, co‐intervention strategies, and intention‐to‐treat (ITT) analyses. Finding a way to effectively mask acupuncturists and participants will reduce primary bias, and enable trials to differentiate the physiological (specific) and psychological (nonspecific) effects of acupuncture treatment. Overall, we highly recommend that future clinical trials follow the Consolidated Standards of Reporting Trials (CONSORT) checklist to improve research methodology in this field (Schulz 2010).

Many of the included trials did not fully meet the STRICTA guidelines, particularly in their failure to report the details of needling techniques (MacPherson 2010). Therefore, we strongly suggest that future researchers carefully consult the STRICTA checklist when designing and reporting acupuncture treatment protocols, as this will make their studies more informative.

Next, the trials reviewed did not investigate the types of people who would benefit most from the use of acupuncture to manage chronic LBP. Therefore, we recommend that future trials compare outcomes classified by pain duration and baseline pain intensity; for example, measuring LBP experienced for less than one year versus more than one year, or measuring baseline pain on a 10‐point visual analogue scale (VAS) between four and seven points and higher than seven. Additional methodological research in this field is also necessary, particularly to explore the potential influence of patients’ preferences and expectations on outcomes. Finally, the included trials provided relatively little information on the effectiveness of combined interventions involving acupuncture in managing chronic nonspecific LBP. Future trials testing such interventions will provide very useful evidence for clinical practice.

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