Acupuncture for low back pain

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Acupuncture for low back pain

• Hugh MacPherson
• Senior Research Fellow
• Department of Health Sciences
• hm18_at_york.ac.uk

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Numbers of practitioners

• 50,000 Complementary Alternative (CAM)
  practitioners
• 10,000 acupuncture practitioners - approx
• 2500 doctors (BMAS)
• 2500 physios (AACP)
• 2500 acupuncturists (BAcC)
• 2500 Chinese shop practitioners (unregulated)
• House of Lords Report

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Effectiveness gaps in primary care

• Based on survey of GP perceptions (n78)
• Musculoskeletal 95
• Depression 45
• Eczema 36
• Chronic pain 32
• Irritable bowel 32
• Fisher 2004

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Why use the randomised controlled trial (RCT) for
evidence of effectiveness?

• Key reasons are
• Control for natural history of the disease
  (people tend to recover anyway)
• Attribute change to intervention (minimise bias)

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Comparing pragmatic and explanatory RCT
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Acupuncture versus sham acupuncture short-term
(lt6 weeks outcome)
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Acupuncture versus no treatment short-term (lt6
weeks outcome)
Source Manheimer et al Ann In Med 2005
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Acupuncture versus no treatment long-term (gt6
weeks outcome)
Source Manheimer et al Ann In Med 2005
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Overall improvement
Source Manheimer et al Ann In Med 2005
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GERAC randomised controlled trials
LBP
OA Knee
Scharf et al, Ann Int Med 2006
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sham intervention vs. no treatment
Hrobjartsson A, Götzsche P. Cochrane Library
2006 ART Mig Linde K. et al. JAMA
20052932118 ART TTH Melchart D et al. BMJ
2005331376 ART LBP Brinkhaus et al. Arch
Intern Med 2006166450 ART OAK Witt et al.
Lancet 2005366136
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The UK perspective

• Health Technology Assessments call for
  proposals 1997
• Does acupuncture have long term effectiveness in
  the management of pain in primary care?

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We set out to test the hypothesis that.

• . primary care patients in the UK with
  persistent low back pain, when referred for up to
  10 acupuncture sessions, gain more relief from
  pain than those offered usual management only,
  for equal or less cost.

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Inclusion/exclusion

• INCLUSION Patients aged 20 to 65 with current
  episode at least 4 weeks duration
• EXCLUSION A current episode of back pain of more
  than 12 months duration, possible serious spinal
  pathology

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Baseline demographics
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Baseline demographics
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Acupuncture treatments provided

• Average 8 treatments per patient, usually weekly
• Average 10 needles per treatment
• Individualised point selection
• Auxiliary techniques and advice

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Underlying principles of acupuncture

• Diagnosis of imbalance
• Catalyst for change
• Leads to self-healing
• Goal of longer-term impact

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Treatments received during 3 three months
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SF-36 Bodily Pain score at 3 months adjusted
for baseline
Diff 5 pts P 0.129
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SF-36 Bodily Pain score at 12 months adjusted
for baseline
Diff 6 pts P 0.111
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SF-36 Bodily Pain score at 24 months adjusted
for baseline
Diff 8 pts P 0.003
Source Thomas et al BMJ 2006
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Practitioner approach(based on interviews)

• a complex intervention
• individualised care
• new understandings
• actively involving patients
• a long term approach

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At randomisationDo you believe that
acupuncture can help your low back pain?
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At randomisationDo you believe that
acupuncture can help your low back pain?
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Worry about back pain at 24 months (compared to
baseline)
Diff. between groups Plt0.001
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Heterogeneity of acupuncturists
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NHS and total social costs (mean cost/patient at
24 months)
Estimated cost per QALY gained 4,241Source
Ratcliffe et al BMJ 2006
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Conclusions

• The evidence suggests that acupuncture is
  effective for low back pain
• In primary care in the UK, a short course of
  individualised acupuncture confers clinical and
  cost benefits at 24 months
• The evidence supports appropriate commissioning
  of acupuncture for low back pain in primary care

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Acknowledgements re back pain trial

• NCCHTA
• Patients
• Acupuncturists
•  
• Patient representative
• David Laverick
• Advisory Board
• Trevor Sheldon (chair)
• Sally Bell?Syer

• Research Team
•  
• Kate Thomas (PI)
• Lucy Thorpe
• Mark Roman
• Julie Ratcliffe
• John Brazier
• Mike Fitter
• Mike Campbell
• Ann Morgan
• Liz Oswald
• Helen Wilkinson
• Jon Nicholl