Acupuncture was better than no acupuncture but did not differ from minimal (sham) acupuncture for chronic low back pain at 8 weeks
Q In patients with chronic low back pain, is acupuncture better than minimal (sham) or no acupuncture for reducing pain?
randomised controlled trial (Acupuncture Randomised Trial in Low Back Pain).
blinded (patients who received acupuncture and minimal acupuncture).
Follow up period:
30 private practices and hospital outpatient units in Germany.
301 patients 40–75 years of age (mean age 59 y, 68% women) who had chronic low back pain for >6 months, mean pain intensity ⩾40 on a 100 mm visual analogue scale (VAS) in the previous 7 days, and used only oral non-steroidal anti-inflammatory drugs in the 4 weeks before treatment. Exclusion criteria were protrusion or prolapse of ⩾1 intervertebral disc and neurological symptoms; radicular pain; previous vertebral column surgery; infectious spondylopathy; spondylolysis or spondylolisthesis; low back pain caused by inflammatory, malignant, or autoimmune disease; congenital spine deformities; compression fracture caused by osteoporosis; spinal stenosis; Chinese medicine diagnoses requiring moxibustion; or acupuncture in the past 12 months.
acupuncture (n = 147), minimal (sham) acupuncture (n = 75), or a waiting list (n = 79). Acupuncture and sham acupuncture groups involved 12 30-minute treatments by specialised acupuncture physicians over 8 weeks. Acupuncture comprised needling of ⩾4 local points bilaterally, extraordinary points (Huatojiaji and Shiqizhuixia), and ⩾2 distant points. Physicians were instructed to achieve de qi (irradiated feeling) if possible and to manually stimulate needles at least once. Minimal (sham) acupuncture comprised bilateral needling of ⩾6 of 10 predefined non-acupuncture points away from the lower back (where the patient had pain), using superficial insertion with fine needles 20–40 mm long. De qi and manual stimulation were avoided. The waiting list group received acupuncture 8 weeks after randomisation.
included change in low back pain intensity on a 100 mm VAS (0–100, 0 = no pain, 100 = worst pain) and adverse effects.
Patient follow up:
94% (intention to treat analysis).
The acupuncture group had a greater mean decrease in low back pain intensity (score on VAS) than the no acupuncture (waiting list) group (difference in change between groups 21.7, 95% CI 13.9 to 30) but did not differ from the sham acupuncture group. 22 serious adverse events were reported: 13 in the acupuncture group, 4 in the sham acupuncture group, and 5 in the waiting list group.
In patients with chronic low back pain, acupuncture reduced pain intensity more than no acupuncture but did not differ from minimal (sham) acupuncture at 8 weeks.
- Gareth Parsons, RGN, MSc
The study by Brinkhaus et al addressed concerns about the quality of randomisation and sample sizes raised in a previous systematic review on the therapeutic use of acupuncture.1 The study showed that both acupuncture and sham acupuncture reduced pain more than no treatment. However, some important questions remain unanswered.
Is acupuncture no better than sham acupuncture? This could be resolved by using a crossover design with a suitable “washout” period.2 Researchers could also increase the number of patients to improve the power of the study. The possibility also exists that the sham design may be flawed. Addressing such flaws is difficult because shams can produce stimuli that may cause analgesia. Recently, Pariente et al used positron emission tomography to show that sham acupuncture elicited activity in areas of the brain involved in modulation of pain and found a stronger, different effect with the de qi (pronounced duh-CHEE: the tingling effect of needle placement) thought to be produced by true acupuncture.3 This could explain why acupuncture and sham acupuncture did not differ in the study by Brinkhaus et al. Finally, many people use acupuncture in the belief that it will help. These beliefs might explain the neurological responses observed by Pariente et al3 and some of the apparent treatment effects in the study by Brinkhaus et al.
It is difficult to recommend acupuncture for chronic low back pain based solely on the findings of the study by Brinkhaus et al. Many patients are familiar with other methods of pain management.4 Brinkhaus et al did not compare acupuncture with other methods of pain management and because acupuncture treats pain and not the underlying problem, comparisons with other treatments are needed. Acupuncture is not risk free, and although most adverse events are minor, serious events have been recorded, admittedly often as a result of poor practice.5
For correspondence: Dr B Brinkhaus, Institute of Social Medicine, Epidemiology, and Health Economics, Charité University Medical Center, Berlin, Germany.
Source of funding: German Social Health Insurance Companies.