Back pain is one of the most common reasons people see a physician, with nearly three-quarters of people in Western countries experiencing back pain at some point in their lives. According to some estimates, patients with low back pain account for more than $90 billion in annual health care expenses in the United States.
The causes for back pain are complex and multifaceted, and about 85 percent of cases will be defined as "nonspecific," meaning a direct cause cannot be found. Back pain is also one of the most common reasons for acupuncture appointments. But should physicians consider recommending acupuncture to these patients?
In a feature article published in the July 29 edition of the New England Journal of Medicine, researchers examine the current studies into acupuncture for low back pain and make treatment recommendations for a sample patient.
"Many studies in the past few years have found a benefit to acupuncture for low back pain, particularly when added to conventional therapy," says lead author Brian Berman, MD, director of the University of Maryland Center for Integrative Medicine and a professor of family and community medicine at the University of Maryland School of Medicine.
He adds, "Our review examined recent studies involving thousands of patients. However, questions still remain about the role of the placebo effect in acupuncture, particularly since many clinical trials showed that sham acupuncture could be as effective as real acupuncture."
The reviewers suggested more research into acupuncture for low back pain is needed, specifically looking at the environment in which acupuncture is performed to evaluate whether a psychological or emotional bias may be contributing to patients reporting improvement. They also recommend additional studies to evaluate sham acupuncture without needles penetrating the skin, to see if the benefits of acupuncture may be achieved without an invasive procedure.
Most acute back pain goes away in about six weeks. However, 25 percent of patients report recurring pain within a year, and 7 percent develop chronic low back pain.
For physicians contemplating whether to suggest acupuncture for their back pain patients, the article gives current recommendations from the American College of Physicians, the American Pain Society and the North American Spine Society for incorporating acupuncture into a treatment plan.
The authors report that it is essential for all patients with chronic or recurrent back pain to undergo a careful diagnostic evaluation before selecting a course of therapy. Certain conditions, such as cancer or infection, may preclude certain patients from receiving acupuncture treatment.
As part of the review, the researchers examined the case of a hypothetical 45-year-old man who had years of low back pain, but was not receiving adequate relief from his current treatments. He had concerns about losing his job as a construction worker and wondered whether acupuncture could help him.
Based on the patient's evaluation, which included MRI and a clinical examination, and the evidence for the potential benefits for acupuncture, the team would suggest a course of 10 to 12 acupuncture treatments over a period of eight weeks with a qualified practitioner.
"In a case such as this, we would first want to reassure the patient that the clinical exam and MRI showed no evidence of a serious underlying condition such as cancer or spinal infection. In addition to acupuncture, we would encourage this patient to stay active and consider a stretching and strengthening exercise program," explains Berman.
The idea to use acupuncture with standard treatments such as pain medicines and physical therapy is one of the keys to "integrative medicine," a growing field of medicine looking at combining conventional and complementary treatments where there is evidence about safety and effectiveness.
"Dr. Berman and his team at the University of Maryland Center for Integrative Medicine are international leaders in the field of integrative medicine; they are among the many innovative, world-class researchers at the University of Maryland School of Medicine. This article is just one example of the center's mission to provide scientifically valid information to help physicians and patients make informed decisions about complementary therapies," says E. Albert Reece, MD, PhD, MBA, vice president for medical affairs, University of Maryland, and dean, University of Maryland School of Medicine.
Other researchers on the New England Journal article include Helene Langevin, MD, Program in Integrative Health, University of Vermont College of Medicine, Burlington; Claudia Witt, MD, Institute for Social Medicine, Epidemiology and Health Economics, Charite University Medical Center, Berlin; and Ronald Dubner, DDS, PhD, University of Maryland School of Dentistry, Baltimore.
Founded in 1991, the University of Maryland Center for Integrative Medicine was the first program within a U.S. academic medical center to investigate complementary and alternative medicine through research, patient care and education. It has been a National Institutes of Health Center of Excellence for Research of Complementary Medicine for the past 15 years.
The center's main research interests have included arthritis, pain and inflammatory conditions. Its researchers published results of a large clinical trial in the Annals of Internal Medicine in 2004 showing that acupuncture is a safe and effective adjunctive treatment for pain from osteoarthritis of the knee.