Whether it was intended as a Valentine’s Day gift to the acupuncture profession or not, on February 14 the American College of Physicians (ACP), issued new clinical guideline recommending acupuncture among other noninvasive and nonpharmacologic therapies for acute, subacute and chronic low back pain. “Nonpharmacologic” describes a treatment that does not entail taking drugs.
With this clinical guideline, acupuncture takes another step toward the mainstream of medical care.
At its website (www.acponline.org), the ACP writes that it “is a national organization of internists, the largest medical-specialty organization, and second-largest physician group in the United States. Our 148,000 members include internists, internal medicine subspecialists, medical students, residents, and fellows.”
The ACP states that its goal in issuing a clinical guideline “is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.” As such, clinical recommendations are taken seriously by U.S. internists and other physicians.
The guideline, the first revision addressing low back pain since 2007, consists of three recommendations, along with the strength of the evidence-based claim in each case:
Recommendation 1: “Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat. . . , massage, acupuncture, or spinal manipulation. . . . If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants. . . . (Grade: strong recommendation)”
Recommendation 2: “For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction. . . , tai chi, yoga, motor control exercise, progressive relaxation, electromyography, biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation. . . . (Grade: strong recommendation)
Recommendation 3: “In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as a first-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)”
Acute low back pain is less than 4 weeks in duration, subacute is 4 to 12 weeks, and chronic is greater than 12 weeks). Radicular low back pain is due to nerve root impingement and is associated with lower extremity pain, numbness, tingling or weakness. The public commonly refers to it as sciatic pain. The practice guideline does not address radicular low back pain because evidence is equivocal.
The guideline notes that most episodes of acute back pain are self-limiting: many patients do not seek medical care and the pain resolves on its own. “For patients who do seek medical care, pain, disability and return to work typically improve rapidly in the first month. However, up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode, and 1 in 5 report substantial limitations in activity.”
The ACP guideline reports that “low back pain is one of the most common reasons for physician visits in the United States.” In 2006, “the total costs attributable to low back pain in the United States were estimated at $100 billion.”
Additional key recommendations
Some additional key recommendations are:
Since acute and subacute low pain tends to resolve, patients are better off with short-term regimens of nonsteroidal anti-inflammatories (NSAIDs, like aspirin, Motrin, Advil and Celebrex) and skeletal muscle relaxants (SMRs, like Flexeril), combined with nonpharmacologic treatments like acupuncture, massage, yoga and the like.
Patients with chronic low back pain should initially initiate nonpharmacologic (i.e., non-drug) treatment like acupuncture, exercise, multidisciplinary rehabilitation, and others.
Nonpharmacologic interventions are considered as first-line options in patients with chronic low back pain because fewer harms are associated with these types of therapies than with pharmacologic options.
Patients with chronic low back pain who see no improvement with nonpharmacologic treatment should be encouraged to use NSAIDs before initiating treatment with opioids.
“Opioids should be considered the last treatment option . . . and should be considered only in patients for whom other therapies have failed because they are associated with substantial harms. . . [including] increased nausea, dizziness, constipation, vomiting, somnolence and dry mouth.”
This is welcome news to the acupuncture profession. Acupuncturists have long been aware of the benefits of acupuncture in addressing low back pain and, in my own experience, this includes radicular or sciatic pain. Some physicians I’ve spoken to are open to acupuncture while others have been dismissive. In the latter case, this includes, “If it helps, that’s great,” which is code for “if it helps it’s all in your mind.” While I think there are multiple reasons for this dismissive attitude, the ACP Practice Guideline will perhaps persuade some physicians to take acupuncture more seriously.
If you have questions about how acupuncture can help you or someone you know, please do not hesitate to contact me.
The complete practice guideline may be found at < http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice>.
© 2017 William Weinstein