NPC Archive Item: NICE guidance for low-back pain: acupuncture is an option, but should this be real or simulated?

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1st July 2009

NICE has issued a clinical guideline on the early management of persistent or recurrent low back pain. The guideline includes recommendations for assessment and imaging, provision of information and education to patients, drug and non-drug treatment options, and referral criteria for surgery. A recent study supports the guidance with regard to acupuncture as an option for first-line treatment, but suggests no difference in effectiveness between real or simulated acupuncture.

Health professionals involved in the management of patients with low back pain should familiarise themselves with and follow the NICE guideline. A quick reference guide is available. Treatment should take into account patient’s needs and preferences. First-line non-drug options for consideration are: a structured exercise programme; a course of manual therapy, including spinal manipulation; or a course of acupuncture. Details of the methods and the evidence used to develop the guidance can be found in the full guideline.

NICE clinical guideline 88 covers the early treatment of persistent or recurrent low back pain, defined as non-specific back pain that has lasted for longer than six weeks, but less than 12 months. It includes recommendations for assessment and imaging, provision of information and education to patients, options for non-pharmacological and pharmacological treatments, and referral for surgery. In this blog we summarise the treatment options and consider a recent clinical trial which adds to evidence for the effectiveness of acupuncture, which is one of the treatment options recommended in the NICE guideline.

What are the treatment options?
An exercise programme, a course of manual therapy, or a course of acupuncture should be offered initially according to patient preference. If one of these options does not result in satisfactory improvement, consider offering another one.

  • Exercise: Patients with low back pain should be advised to stay physically active and exercise. A structured exercise programme should be considered (up to a maximum of eight sessions over a period of up to 12 weeks).
  • Manual therapy: This includes spinal manipulation, spinal mobilisation, or massage, and should comprise a maximum of nine sessions over a period of up to 12 weeks. It can be provided by a number of appropriately trained practitioners.
  • Acupuncture: A course should include a maximum of 10 sessions over a period of up to 12 weeks. See the section below regarding the clinical evidence for acupuncture and the possible use of sham acupuncture as an alternative.

For patients who have received at least one less intensive treatment option, and have high disability and/or significant psychological distress, referral for a combined physical and psychological treatment programme, comprising about 100 hours over a maximum of eight weeks, should be considered. This programme should include a cognitive behavioural approach and exercise.

What about drug treatment?
Drug treatment should be provided as appropriate to manage pain and to maintain physical activity.

Regular paracetamol is the first-line treatment option. Non-steroidal anti-inflammatory drugs (NSAIDs) and/or weak opioids can be considered if paracetamol alone provides insufficient pain relief. It is important to consider the risk of side effects, especially in older people and other people at increased risk of side effects. An NSAID (or COX-2 inhibitor) should be chosen on an individual basis taking into consideration gastrointestinal and cardiovascular risk (see MeReC Extra 30). For those over the age of 45, NSAIDs (or COX-2 inhibitors) should be co-prescribed with a proton-pump inhibitor, choosing the one with the lowest acquisition cost.

Where other medications provide insufficient pain relief, a tricyclic antidepressant can be considered. A low dose should be given initially, increasing this up to a maximum antidepressant dose until a therapeutic effect is achieved or side effects are not tolerated. Note that selective serotonin reuptake inhibitors (SSRIs) should not be used for treating pain.

Short-term treatment with strong opioids can be considered for those patients in severe pain, but if prolonged treatment is required patients should be referred for specialist assessment.

What is the clinical evidence for acupuncture?
The systematic review (search updated July 2008) detailed in the NICE full guideline, identified evidence to support the use of acupuncture needling (solid needling) for reducing pain and improving function. However, no evidence of an effect on psychological distress was found.

The clinical evidence reviewed for the NICE guideline also suggests that seeing an acupuncturist is better than usual care, but there is not much difference between acupuncture and sham acupuncture. Results of a recent study (level of evidence 2 [limited-quality patient-oriented evidence] according to the SORT criteria) support this view.

In this randomised controlled trial of 638 people with chronic low back pain, similar benefits were identified for individualised acupuncture, standardised acupuncture and simulated acupuncture (use of a tooth pick in a needle guide tube). All were statistically significantly better in relieving back dysfunction than usual care after eight weeks of treatment (improvements in Roland-Morris Disability questionnaire score [range 0 to 23] 4.4, 4.5, 4.4 vs. 2.1, respectively; P<0.001). The proportion of patients experiencing a three point increase or higher were greater in the real and simulated acupuncture groups compared with usual care (at 8 weeks 60% vs. 39%, P<0.001). Use of medications in the real and simulated acupuncture groups was also significantly reduced compared with usual care (at 8 weeks 47% vs. 59%, P=0.01).

No adverse events were reported in the simulated acupuncture group, whereas approximately 4% of people receiving real acupuncture experienced moderate adverse events possibly related to treatment (mostly short-term pain). In one case there was a severe reaction (pain lasting a month).

This study raises interesting questions over the mechanism of action of acupuncture, and why simulated acupuncture, in which there is no puncturing of the skin, would appear to be just as effective. The NICE guideline does not recommend the specific form of acupuncture to use, but does point out in its full guideline that sham acupuncture is used as an active form of treatment by some practitioners, and that this should be considered as a possible treatment.

Study details
Cherkin DC, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med 2009;169:858–66

This study was sponsored by the National Institute of Health and the National Centre for Complementary and Alternative Medicine, USA.

Further information on the management of low back pain can be found in the back pain section of NPC.

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