Acupuncture for Chronic Low Back Pain Reviewed

Laurie Barclay, MD

July 28, 2010

July 28, 2010 — Recent evidence and management principles concerning the use of acupuncture for chronic low back pain are reviewed in an article published in the July 29 issue of the New England Journal of Medicine.

"Acupuncture is a therapeutic intervention characterized by the insertion of fine, solid metallic needles into or through the skin at specific sites," write Brian M. Berman, MD, from the University of Maryland School of Medicine in Baltimore, and colleagues. "The technique is believed to have originated in China, where it has remained a fundamental component of a system of [medicine that] espouses an ancient physiological system (not based on Western scientific empiricism) in which health is seen as the result of harmony among bodily functions and between body and nature. Internal disharmony is believed to cause blockage of the body's vital energy, known as qi, which flows along 12 primary and 8 secondary meridians."

Tenderness on palpation is thought to be evidence of blockage of qi, and inserting acupuncture needles at specific points along the meridians is believed to restore the proper flow of qi. The analgesic effects of acupuncture appear to be based on neural innervation, because they are completely blocked by local anesthesia at needle-insertion sites. Furthermore, acupuncture stimulates the release of endogenous opioids in brainstem, subcortical, and limbic structures, as well as producing mechanical stimulation of connective tissue and other effects on local tissues. Despite these effects, the mechanisms underlying chronic pain relief by acupuncture are not completely understood.

Acupuncture is seldom regarded as the first choice of treatment, in part because randomized controlled clinical trials and large meta-analyses have not proven it to be more effective than sham acupuncture in relieving low back pain. However, it may be useful as part of a multidisciplinary approach to the management of chronic low back pain, along with physical therapy, pain medication, and/or exercise.

"Acupuncture is a regulated discipline, and patients should be referred only to practitioners who are licensed by the state in which they practice," the review authors write. "A diploma from the National Certification Commission for Acupuncture and Oriental Medicine is a requirement for licensure in most states. Physicians may practice acupuncture in the United States after completing one of several medical acupuncture programs."

Before embarking on any treatment regimen, all patients with chronic or recurrent low back pain should have a thorough diagnostic workup to rule out cancer, infection, or other serious spinal disease mandating specific medical or surgical intervention. Contraindications to acupuncture include coagulation and bleeding disorders, use of anticoagulants, severe psychiatric disease, and local skin infections or trauma. Electroacupuncture should not be used at the site of pacemakers or other implanted electrical devices. Pregnant women may undergo acupuncture, but not at specific acupuncture points known to be especially sensitive to needle insertion or at acupuncture points in the abdominal regions.

In traditional Chinese medicine, ancillary procedures such as palpation of the radial artery and other areas, tongue examination, and use of herbal medications may accompany needle insertion, but the effect of these procedures is poorly documented. Selection of insertion points for each patient at each treatment is based on the history and physical examination, but there are certain commonly used acupuncture points for low back pain. Different practitioners and acupuncture schools use varying depths of needle insertion (6.4 - 38.1 mm) and diameter (0.1 - 0.3 mm), length (12.7 - 76.2 mm), and number (4 - 20) of needles used.

Needles are left in place for 15 to 30 minutes while the patient relaxes, and the needles often are stimulated manually to produce de qi (a dull, localized, ache) and "needle grasp," a tugging sensation noted by the acupuncturist as the needle moves against connective tissue. Additional needle stimulation may be achieved with electrical current (electroacupuncture), moxibustion (burning the herb artemisia vulgaris at the end of the acupuncture needle), or heat.

One treatment is considered to be insufficient, and recent trials of acupuncture for low back pain used at least 12 acupuncture sessions, often starting with 2 sessions a week and tapering off after 4 weeks to once weekly, with booster treatments sometimes used monthly or every other month. Acupuncture should be discontinued if there are no apparent effects after 10 to 12 sessions.

Major adverse effects occur rarely with acupuncture, and significant minor adverse events, such as needle-site pain, nausea and vomiting, dizziness, or fainting occur in less than 0.1% of patients. Nonserious adverse events may include needle-site pain in 3% of patients, hematoma in 3%, bleeding in 1%, and orthostatic symptoms in 0.5%.

"There is continuing debate in the medical community regarding the role of the placebo effect in acupuncture," the review authors write. "The most recent well-powered clinical trials of acupuncture for chronic low back pain showed that sham acupuncture was as effective as real acupuncture. The simplest explanation of such findings is that the specific therapeutic effects of acupuncture, if present, are small, whereas its clinically relevant benefits are mostly attributable to contextual and psychosocial factors, such as patients' beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient."

Joint clinical practice guidelines from the American College of Physicians and the American Pain Society recommend that clinicians consider acupuncture as one possible treatment option for patients with chronic low back pain refractory to self-care (level of supporting evidence, fair). According to the North American Spine Society, acupuncture offers better short-term pain relief and functional improvement than no treatment, and adding acupuncture to other treatments is more effective than other treatments alone, but high-quality, randomized controlled trials are still needed comparing acupuncture with no treatment and with sham acupuncture.

The UK National Institute for Health and Clinical Excellence has also endorsed acupuncture as a treatment option for patients with low back pain lasting more than 6 weeks, with up to 10 sessions of acupuncture during a period of 12 weeks.

"The National Certification Commission for Acupuncture and Oriental Medicine and the American Academy of Medical Acupuncture are potential resources for finding a qualified local practitioner," the review authors conclude. "At the end of treatment, we would assess the patient's response, particularly his level of pain, mood, and general activity level, and make a determination about whether he should receive additional acupuncture treatments."

One of the review authors reports being a member of the board of directors of Stromatec and receiving grant support and payment for travel and accommodation expenses from Stromatec. The other study authors have disclosed no relevant financial relationships.

N Engl J Med. 2010;363:454-461.

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