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Three Part Question

[In patients presenting with simple acute low back pain] is [acupuncture better than placebo] at [reducing pain and speeding a return to normal function]

Clinical Scenario

A 35 year old man presents to the emergency department with acute back pain sustained whilst lifting a heavy box. He complains of low lumbar spine pain. There are no neurological symptoms or signs and no "red flags" to indicate a potentially serious cause of his back pain. You diagnose a simple acute low back strain and advise analgesia and mobilisation. He tells you that he knows a local acupuncturist who could see him for acupuncture but wonders if it is worth spending the money. He asks if you are aware of any evidence for it's effectiveness.

Search Strategy

MEDLINE using the OVID interface on ATHENS
AMED using the OVID interface on ATHENS
Cochrane database of systematic reviews via NelH
Medline: [back pain.mp. or exp Back Pain/ or exp Low Back Pain/ or lumbar pain.mp.] and [exp ACUPUNCTURE/ or acupuncture.mp.] and [acute.af.] limit to (humans and english language and abstracts)
AMED and CinAhl: [back pain.mp. or exp Back Pain/ or exp Low Back Pain/ or lumbar pain.mp.] and [exp ACUPUNCTURE/ or acupuncture.mp.] and [acute.af.]
Cochrane: acupuncture back pain

Search Outcome

MEDLINE 22 papers found including 3 systematic reviews by same authors over time.
AMED 32 papers found. No new citations found
CinAhl 21 papers found, no new relevant papers
Cochrane 51 records of which one is directly relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Furlan AD 2004 UNK	Randomized trials of acupuncture (that involves needling) for adults with non-specific (sub)acute or chronic low-back pain, or dry-needling for myofascial pain syndrome in the low-back region. Only the results in patients with acute low back pain are reported here. Sciatica and age <18 years excluded.	Systematic Review	Number of papers found	35 RCTs found. Only 3 specifically looked at acupuncture in acute back pain	The heterogenecity and small numbers in the trials on acute low back pain mean that conclusions are difficullt to draw.
			Quality of papers found	2 independant assessors. 14 high quality, 19 lower quality and 2 fatally flawed
			Acupuncture vs. No treatment for acute back pain	No papers found
			Acupuncture vs sham therapy for acute back pain	One RCT using one session of acupuncture. No difference found in pain or function.
			Acupuncture versus other interventions for acute low-back pain	One trial. Moderate evidence that there is no difference immediately or nin the short term between Naproxen and acupuncture in terms of pain over 10 days. (Kittang 2001)
			Addition of acupuncture to other interventions for acute low-back pain	One low quality RCT (He 1997)limited evidence that the addition of acupuncture and moxibustion to Chinese herbal medicine is more effective than Chinese herbal medicine alone for a global measure of pain and function at the long-term follow-up.

Comment(s)

Acupuncture is a controversial therapy but is gaining acceptance in Western medicine as an adjunct in the treatment of a variety of conditions. This is despite conflicting evidence from controlled trials to support its use. It is commonly advocated in chronic conditions when conventional therapy is perceived as having few answers and it has certainly been advocated in chronic neck and back pain. However, the question faced by clinicians and patients in acute low back pain is different and it is disspointing to find only a small number of well conducted trials to answer the question posed above.

Clinical Bottom Line

There is insufficient evidence to recommend the routine use of acupuncture in acute low back pain.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. AD Furlan, MW van Tulder, DC Cherkin, H Tsukayama, L Lao, BW Koes, BM Berman Acupuncture for dry needling The Cochrane Database of Systematic Reviews Art No CD001351