Across the globe, industrialized nations suffer from low back pain. In the United States alone, the yearly healthcare costs associated with this condition reaches over $100 billion per year. Up to 70 percent of all adults in the advanced nations suffer from the condition at some point in time during the course of their life. Unfortunately, there is no consistency in effectiveness when using acupuncture for low back pain. However, pain in the lower back that does not extend down to the legs is often treated by non-surgical measures, including bodywork, but none has been clinically proven superior to another.
The findings were discovered with a variety of medical databases using their records stretching back from their inception up to 2014. Numerous targeted bodywork techniques were included that were used to treat a plethora of dysfunctions associated with the hip and lower back region. These treatments include acupuncture but are not limited to such while the conditions range from sciatica to lumbago.
The team of Lizhou Liu, Leon Marie, and Jondong Wang worked independently from one another, cross-referencing full-papers, while working through disagreements in methodology to provide a robust assessment of different studies. However, the preferred points of data were random controlled tests as those would provide the most reliable results when determining whether or not acupuncture served as an effective method on non-invasive treatment for both long and short-term back pain.
Efficacy was measured based on the effect on pain relief, overall improvement, functional improvement, and effectiveness rate which compares the degree of improvement within a similar group—in this instance, those suffering from the condition. The specific style of treatment was not monitored, instead preferring to include all acupuncture for lower back pain procedures.
The team was primarily interested in defining the acupuncture style and whether the treatment worked as well as a methodological quality of the studies. They also included the examination of the descriptive characteristics, the approaches of data analysis, and the conclusions or main findings. This method was utilized for both English and non-English sources. To make the meta-analysis more accurate, studies were given a rating between low and high. These ratings were based on the specific data point’s use of the Jedad Scale and the PEDro scale.
Moreover, the data was weighted by low drop-out rates and high follow-up rates, then cross-referenced with other group tests to determine the weighting’s magnitude. The Standard for Reporting Interventions in Clinical Trials of Acupuncture helped determine external validity as were assessments of individual adequacy in systematic reviews. When determining the value of the studies, the team used The Assessment of Multiple Systematic Reviews which informed the quality assessment of the study for reliability and validity. Two of the reviewers cross-referenced their independent reviews to assign a score that determined the degree of agreement in quality. A score below 4 is low quality while a score 8 or above was high quality. Everything in between is considered moderate and the grades determined the strength of evidence.
The studies reviewed were too different and needed to be placed into three subgroups. Variations in control groups, the time between a patient’s follow-up, and the length of time the patient suffered low back pain served to define the groups. The length of time afflicted was separated by those who were afflicted for more than 3 months and those afflicted for less than 3 months. Studies were also distinguished based on whether the patients received legitimate acupuncture or a false treatment which involved non- or superficial penetration and was not physiologically responsive. The outcome was another factor separated by pain relief and functional improvement or overall improvement and effectiveness rate. Finally, the time between follow-ups ranged from less than 3 months for short-term and more than 1 year for long-term.
To ensure that the studies included in the meta-analysis are the most valuable, the team removed the low-quality studies which allowed application of the results for clinical fields to be more relevant. This also helped group the magnitudes for the different control groups and focus specifically on patients of received acupuncture treatment for the condition.
With over 1000 records accumulated from almost 800 different publications including 70 papers met the standards for review. However, most of the papers were not acceptable leaving only 20 acceptable full-text articles for inclusion. After excluding four reviews from a single journal and three others from journal articles, only 75 percent of the remaining reviews were included in the final analysis. A meta-analysis composed of thirteen different systematic reviews produced a best-evidence synthesis and two studies for both qualitative and quantitative analyses. However, one of the independent reviewers focused exclusively on qualitative analyses. The sources were English-speaking, Chinese, and Japanese in origin—though primarily in English. Unfortunately, the studies were inconsistent in regards to the quality of random controlled tests. The studies covered long-term, short-term, and a mixture of both long and short-term trials. However, the Chinese studies focused exclusively on disc herniation in for both specific and nonspecific back pain.
Only short-term follow-up studies, those of 3 months or less, could be assessed due to a lack of consistent follow-up definition within the systematic reviews. Those reviews were then split further between 6-week follow-up intervals and 3-month follow-up intervals. However, only those studies which exclusively included acupuncture for low back pain as the other heterogeneous results could confound the meta-analysis. In the end, only four pain relief and functional improvement with short follow-up control groups qualified.
For short-term pain reviews, the meta-analysis judged false and legitimate acupuncture techniques. For pain relief, the reviews did not give consistent results. Some of the reviews identified no difference between legitimate and false techniques. However, other reviews found a statistically relevant correlation. For functional improvement, again no difference between false and legitimate techniques was found either for short-term low back pain.
The studies on long-term back pain also examined the difference in result between false and legitimate techniques, though the definition for false techniques varied from review to review. Pain relief among the higher quality studies showed a positive effect for legitimate techniques while moderate and lower quality studies presented no difference. However, regardless of the quality of the study, none of the tests showed a difference between false and legitimate techniques in regards to functional improvement. Moreover, while there was no clear consensus on the definition of what no treatment, legitimate techniques showed better results than no treatment at all, and legitimate techniques when used in conjunction with conventional treatment proved more effective than conventional treatment alone.
When studying systematic reviews to determine the efficacy of legitimate techniques found that false techniques were not as effective for the treatment of long-term back pain relief in the short-term, but there was no clinically relevant difference in improvement for functional limitations. However, for short-term back pain relief, there was no consistency in results to suggest that false techniques provided any benefit over legitimate techniques. Moreover, legitimate techniques demonstrated better results for pain relief and functional limitations over no treatment.
Since so few of the reviews met the acceptable quality standard, the meta-analysis identified some common areas of improvement. To start, more weight should be given to studies that pass the assessment of multiple systematic reviews. Furthermore, exclusion of poor quality results also provided a method for improving the results of the meta-analysis. However, the use of the assessment of multiple systematic reviews presents strictly a qualitative as opposed to a quantitative method for analysis. Moreover, assessment of multiple systematic reviews makes weighting the individual data difficult. As such, including further measures to be included in conjunction with assessment of multiple systematic reviews may account for these issues.
The use of treating with false techniques as a control may be questionable. In this instance, false techniques involve the use of unsharpened needles. Moreover, these techniques may also involve a misalignment with the specific pressure points the legitimate techniques demand. However, this latter divergence may actually be an adequate control as the principle of using legitimate technique for the condition relies on the precise application of the technique along the meridian system.
Still, that touching the skin produces neuro and endocrinological reactions may confound false techniques as a control altogether. As TCM places emphasis on the mind-body system and seeks to integrate care holistically, the evidence suggests it does not. Also, most patients who suffer from the condition are treated using self-reported analyses which in and of itself offers all forms of treatment the possibility of being psychologically influenced.
Every measure of this meta-analysis sought to reduce the possibility of biases through all steps. The studies spanned country, language, and cultural origin using independent, systematic and comprehensive approaches. The researchers themselves likewise include members from different backgrounds with diverse educational disciplines who have also trained to use the assessment of multiple systematic reviews standard. Next, the meta-analysis itself was differentiated to account for control comparisons, heterogeneous influencing outcome measures, and chronicity. The systematic reviews then underwent a formal analysis methodology to ensure scientific robustness and reliability. Finally, both statistical and clinical relevance was examined to increase applicability.
No conclusive efficacy regarding the use of legitimate techniques of acupuncture for low back pain in the short-term could be found. However, the sample size included only two acceptable studies. But in regards to long-term low back pain, legitimate techniques can be recommended over no treatment or false techniques and when used in conjunction with conventional therapies. Future studies are suggested to better understand the effects of legitimate techniques for both short-term and long-term back pain, especially in comparison to false techniques.
Half a dozen reviews indicate legitimate techniques to be effective for pain relief and functional improvement than no treatment. Furthermore, legitimate techniques have been shown in another half dozen studies to complement traditional treatments. However, further study is necessary to fully understand the value of legitimate techniques—especially compared to false techniques for short-term lower back pain—and it is recommended that more high-quality studies of legitimate techniques are conducted. Regardless, the possibility of using the treatment of acupuncture for low back pain offers promise and is far from being discredited.
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