Medical Acupuncture on the wrong side of NICE
The last Cochrane review which considered the role of Medical Acupuncture (MA) in the treatment of Low Back Pain (LBP) was carried out by Furlan et al in 2005. In this review verum MA was shown to be efficacious (more effective than ‘sham’) in providing short term pain relief. A good result from research point of view.
The NICE guidelines for the treatment of LBP published in 2009 were partly based on the abovementioned review as well as the GERAC trial which showed MA (including ‘sham’) to be more than twice as effective as conventional treatment in the primary outcome measures. In the GERAC trial, verum MA was not shown to be significantly more effective than ‘sham’ needling however there was a small trend in favour of verum needling.
But is ‘sham’ a credible form of placebo for use in RCT’s? Those who understand the proposed mechanisms basis for MA would argue that a needle inserted into the skin (even more so when needling muscle tissue) will evoke specific physiological effects over and above the placebo effect, regardless of point location. As such, how can we miss the point?, except when interpreting RCT’s based on ‘sham’ needling that is.
Anyway, roll on 2016 and the efficacy for MA in the treatment of LBP is now in doubt which has been used by certain members of the NICE committee to successfully have MA removed as a recommended treatment for LBP according to the latest update (CG59).
But why the misplaced emphasis on efficacy when evaluating MA in the treatment of LBP? Surely it would make more sense to focus on the question is MA effective, not does inserting a needle at location A have a stronger effect than inserting at location B? This seems be a fairly pointless exercise, especially if for example the ‘sham’ needle is within the same spinal segment as the active needle.
The NICE committee considered effectiveness when making recommendations for exercise therapy and manual therapy in the treatment of LBP according to CG59. None of these treatments have been shown to have strong efficacy, however convention ensures these treatments continue to be recommended. There seems to be a bias against MA which will no doubt deny patients access to this highly effective technique.
What might be future directions in MA research? A good place to start would be to stop comparing like with like and instead compare MA to anti-inflammatories for example. Better still, consider the role of MA as part of an integrated care package for those with LBP which is arguably how this technique should and is used by many in clinical practice.