Research Review by Dr. Stephen Burnie©

Date:

Oct. 2007

Study Title:

Acupuncture for chronic low back pain in routine care

Authors:

Weidenhammer W, Linde K, Streng A, Hoppe A, Melchart D

Publication Information:

Clinical Journal of Pain 2007; 23(2): 128-135

Summary:

With clinicians who treat patients with back pain on a regular basis, the use of acupuncture in chiropractic, physiotherapy, and other musculoskeletal practices has become widespread. As a result, large studies examining the effectiveness of acupuncture are now being published.

This study was a retrospective look at a pool of German adults who received publicly funded acupuncture for chronic low back pain from physicians with acupuncture training. Patient records were randomly selected with minimal requirements of a diagnosis of lumbago with sciatica or low back pain lasting more than 6 months with no other diseases affecting the back. Patients were considered eligible if they received up to 15 sessions of acupuncture with a minimum duration of 30 minutes. Of 4032 files chosen from a pool of 227,000 patients who had received acupuncture for chronic low back pain, 2564 were deemed to have sufficient information to be included in this study.

The mean number of acupuncture sessions received by patients was 8.7 with a median duration of the treatment period being 48 days. It is important to note that physicians providing acupuncture were free to suggest or prescribe any other treatments that they felt would be beneficial, which may have confused the results. Overall, 39% of patients received acupuncture treatment alone, with the remainder receiving at least one additional intervention for their back pain. Other interventions included:
  • pain medication prescription (25% of patients)
  • physiotherapy (25%)
  • physical training (22%)
  • relaxation techniques (13%)
  • herbal or homeopathic medicines (9%)
Patient outcomes analyzed in this study included chronicity of pain, pain level, level of depression, and health-related quality of life. These were measured before the first session, after the last session, and 6 months after the first session. After completion of acupuncture and 6 months after the first treatment, large improvements in all outcome measures were found:
  • average pain intensity decreased from 6.3 and 5.2 on a 10-point scale for depressed and non-depressed patients, respectively, by an average of 2.2 and 2.0 points, respectively. These changes lasted for 6 months after starting acupuncture
  • clinically important improvements in functional ability were found in 40% of patients immediately after the acupuncture treatments and 46% of patients at 6 months
  • 54% of patients rated the effects of treatment as good or very good, 31% rated the effects as moderate, and 15% considered the effects slight or insufficient
  • the average number of days with pain in the previous 4 weeks was reduced from 21 days prior to treatment to 10.5 days between the first treatment and 6 months after starting treatment
  • the mean number of days requiring use of pain medication was reduced by about 50%
  • the mean number of days missed from work due to LBP decreased from 11.6 over the 6 month period before starting acupuncture to 7.0 in the 6 months following the first treatment

Conclusions & Practical Application:

This study adds to a growing number of studies supporting the use of acupuncture for patients with chronic low back pain. This article was particularly interesting for more than one reason. Perhaps most compelling is how widespread the use of acupuncture is in Germany, likely due to the fact that it is publicly funded and provided by family physicians (over 10,000 physicians participated in this project as treatment providers to 227,000 patients). It is also interesting because the outcome measures go beyond pain to report other important statistics such as time away from work, medication used, and patient satisfaction with the treatment.

Here is a summary of the important outcomes, all of which favoured the use of acupuncture:
  • decrease of pain between 2.0 and 2.2 on a 10 point scale with results lasting at least 6 months
  • improvements in functional abilities in 46% of patients at 6 months
  • 54% of patients rated the results as good or very good; a further 31% rated the results as moderate
  • reduction in number of painful days over a one month period from 21 days to 10.5 days
  • reduction in use of pain medication by 50%
  • decrease in missed work from 11.6 days to 7 days
Caution must be used when interpreting the results of any single study, and this one has some weaknesses that should be considered. This was not a randomized controlled study, but rather a retrospective observational study. In other words, patient files were examined after the fact rather than enrolling new patients into the study.

The biggest weakness of this design is the lack of a control group with whom to compare results in the acupuncture group. It is possible that patients receiving no treatment (a control) would have fared just as well as those receiving acupuncture due to natural history.

Since these patients had chronic, rather than acute, low back pain we hope this effect has been minimized but there’s no way to know for sure. A second weakness is that patients who did not have complete files were eliminated from the study. Patients experiencing poor results from acupuncture may have dropped out of treatment more often than those receiving good results, possibly inflating the positive results. Finally, the use of other treatments such as physiotherapy and medication in addition to acupuncture may have contaminated the results – i.e. some of the benefits may have been to these interventions rather than the acupuncture itself.

All things considered, the use of acupuncture for chronic low back pain appears to be beneficial and highly regarded by patients. For a condition as difficult to treat as chronic low back pain, manual therapists can take comfort in knowing that acupuncture is gaining a strong body of evidence as an effective component of patient care.