Berman (2010) - Acupuncture for chronic low back pain

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Berman (2010) - Acupuncture for chronic low back pain
n e w e ng l a n d j o u r na l
m e dic i n e
clinical therapeutics
Acupuncture for Chronic Low Back Pain
Brian M. Berman, M.D., Helene M. Langevin, M.D.,
Claudia M. Witt, M.D., M.B.A., and Ronald Dubner, D.D.S., Ph.D.
This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion
of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies,
the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines,
if they exist, are presented. The article ends with the authors’ clinical recommendations.
A 45-year-old construction worker with a 7-year history of intermittent low back pain
is seen by his family physician. The pain has gradually increased over the past
4 months, despite pain medications, physical therapy, and two epidural corticosteroid
injections. The pain is described as a dull ache in the lumbosacral area with episodic
aching in the posterior aspect of both thighs; it worsens with prolonged standing and
sitting. He is concerned about losing his job, while at the same time worried that continuing to work could cause further pain. The results of a neurologic examination and
a straight-leg–raising test are normal. Magnetic resonance imaging (MRI) shows
evidence of moderate degenerative disk disease at the L4–L5 and L5–S1 levels and a
small midline disk herniation at L5–S1 without frank nerve impingement. The patient wonders whether acupuncture would be beneficial and asks for a referral to a
licensed acupuncturist.
The Cl inic a l Probl em
From the Center for Integrative Medicine,
University of Maryland School of Medicine (B.M.B.), and the University of Maryland Dental School (R.D.) — both in Baltimore; the Department of Neurology and
the Program in Integrative Health, University of Vermont College of Medicine, Burlington (H.M.L.); and the Institute for Social Medicine, Epidemiology, and Health
Economics, Charité University Medical
Center, Berlin (C.M.W.). Address reprint
requests to Dr. Berman at the University
of Maryland School of Medicine, 2200
Kernan Dr., Baltimore, MD 21207, or at
[email protected]
This article was updated on August 25,
2010, at NEJM.org.
N Engl J Med 2010;363:454-61.
Copyright © 2010 Massachusetts Medical Society.
An estimated 70% of persons in Western industrialized countries have back pain
sometime in their lives.1 In the United States, low back pain is one of the most
common reasons for visits to a physician.1-3 Approximately 90% of acute episodes
resolve within 6 weeks. However, 25% or more of patients have recurrent pain within
the next year,4 and chronic low back pain develops in up to 7% of patients.5
The full differential diagnosis of low back pain is extensive, but most of the
causes are infrequently seen in general medical practice.6 Cancer, infection, and inflammatory disorders each account for less than 1% of cases. Structural disorders
of the spine itself, such as compression fractures, spinal stenosis, and disk herniation, are somewhat more common and together account for some 10 to 15% of
cases. However, the most common problem (85% of cases) is “nonspecific” or “idiopathic” low back pain, and it is this disorder that is most often associated with
chronic or recurrent symptoms.
Low back pain results in substantial morbidity. By one estimate, 6.8 million U.S.
adults had physical disability associated with back pain in 1999.7 Patients with back
pain account for more than $90 billion annually in health care expenses, with approximately $26 billion of that amount directly attributable to the treatment of
back pain.8
Pathoph ysiol o gy a nd Effec t of Ther a py
The pathophysiology of chronic low back pain is poorly understood, but is increasingly recognized as complex and multifactorial. Progress in elucidating mechanisms
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clinical Ther apeutics
has been impeded by difficulties in defining suitable animal models that are clearly relevant to the
human disorder and in conducting informative
physiological studies of chronic pain in humans.
Some of the above-mentioned structural abnormalities of the spine are well established as
causes of low back pain. Other abnormalities do
not correlate well with clinical symptoms.6 Findings such as disk herniation and facet-joint degeneration, when associated with central spinal
stenosis or nerve-root impingement, have been
correlated with low back pain, most often in association with sciatica or neurologic deficits. However, there is a high prevalence of such spinal abnormalities in asymptomatic persons,9,10 and such
findings are poor predictors of back pain in long­
itudinal studies.11,12 Muscular and soft-tissue abnormalities have also been described,13,14 but their
role in low back pain remains uncertain.
More recent investigations focus on alterations
in the central nervous system, detected with various imaging methods, that are associated with
chronic low back pain.15 Studies using functional
MRI have shown alterations in cerebral activation,16,17 and anatomical studies have shown
changes in regional volume and density in the
brain.18-20 It has been suggested that these alterations may reflect or contribute to changes in central nervous system processing of sensory stimuli.
However, the specific findings of these studies
have not been entirely consistent with one another, and it is not clear whether the observed alterations are a cause or a consequence of chronic
low back pain.
In addition, psychological and behavioral factors, including fear of movement, appear to play
an important role in patients with chronic low
back pain.21-24 Such patients have been shown to
have altered brain-activation patterns at subcortical and cortical sites associated with emotion
and postural control.25-28 Studies comparing psychosocial variables with anatomical findings have
shown the former to have greater predictive value
than the latter.11,12
Acupuncture is a therapeutic intervention characterized by the insertion of fine, solid metallic
needles into or through the skin at specific
sites.29,30 The technique is believed to have originated in China, where it has remained a fundamental component of a system of medical theory
and practice that is often termed “traditional
Chinese medicine.” Although a number of different techniques or schools of acupuncture prac-
tice have arisen, the approach used in traditional
Chinese medicine appears to be the most widely
practiced in the United States.31
Traditional Chinese medicine espouses an ancient physiological system (not based on Western
scientific empiricism) in which health is seen as
the result of harmony among bodily functions
and between body and nature. Internal disharmony is believed to cause blockage of the body’s
vital energy, known as qi, which flows along 12
primary and 8 secondary meridians (Fig. 1). Blockage of qi is thought to be manifested as tenderness on palpation. The insertion of acupuncture
needles at specific points along the meridians is
supposed to restore the proper flow of qi.
Efforts have been made to characterize the effects of acupuncture in terms of the established
principles of medical physiology on which Western medicine is based. These efforts remain inconclusive, for several reasons. First, the majority
of studies have been conducted in animals, and
it is difficult to relate findings from such studies
to effects in humans. Second, acupuncture has
been shown to activate peripheral-nerve fibers of
all sizes, rendering a systematic study of responses complex. Third, the acupuncture experience is
dominated by a strong psychosocial context, including expectations, beliefs, and the therapeutic
Despite these limitations, some physiological
phenomena associated with acupuncture have
been identified. Local anesthesia at needle-insertion sites completely blocks the immediate analgesic effects of acupuncture, indicating that these
effects are dependent on neural innervation.35
Acupuncture has been shown to induce the release of endogenous opioids in brain-stem, subcortical, and limbic structures.36,37 In the rat,
electroacupuncture has been shown to induce pituitary secretion of adrenocorticotropic hormone
and cortisol, leading to systemic antiinflammatory effects.38 Functional MRI studies in humans
have shown immediate effects of prolonged acupuncture stimulation in limbic and basal forebrain areas related to somatosensory and affective functions that are known to be involved in
pain processing.39 Results on positron-emission
tomography have shown that acupuncture increases μ-opioid–binding potential for several days
in some of the same brain areas.40 Acupuncture
also has effects on local tissues, including mechanical stimulation of connective tissue,41 release of adenosine at the site of needle stimu­
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n e w e ng l a n d j o u r na l
m e dic i n e
ory regarding the effect of acupuncture on mechanisms of chronic pain.
Cl inic a l E v idence
A number of clinical trials have evaluated the efficacy of acupuncture for chronic low back pain.
A meta-analysis in 2008, which involved a total
of 6359 patients,44 showed that real acupuncture
treatments were no more effective than sham
acupuncture treatments. There was nevertheless
evidence that both real acupuncture and sham
acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy
for low back pain. These conclusions were supported by a subsequent meta-analysis from the
Cochrane Back Review Group.45 Details of several of the major recent clinical trials that were
included in these meta-analyses are provided in
the Supplementary Appendix, available with the
full text of this article at NEJM.org.46-50
In a large German study, 1162 patients with
a history of chronic low back pain for a mean of
8 years were randomly assigned to real acupuncture, sham acupuncture, or conventional therapy
(a combination of drugs, physical therapy, and
exercise).47 Acupuncture treatments consisted of
needle insertions at standardized acupuncture
points plus some additional points chosen by
the practitioner. Brief manual manipulation was
used to stimulate the needles after insertion.
Sham acupuncture consisted of shallow insertion of needles at non-acupuncture points without stimulation. The primary outcome was a
treatment response, defined as either a 33% improvement on the Von Korff Chronic Pain Grade
Scale or a 12% improvement on the Hannover
Functional Ability Questionnaire. At 6 months,
there was no significant difference between the
response rate with real acupuncture (47.6%) and
the rate with sham acupuncture (44.2%; P = 0.39),
Figure 1. Acupuncture Meridians.
but both real and sham acupuncture were sigTwelve of the major acupuncture meridians are associated with a specific
nificantly better than conventional therapy
internal organ (e.g., heart, lung, or spleen), and an additional eight meridians are considered to be vessels or reservoirs of energy (qi) not associated
(27.4%; P<0.001 for both comparisons).
with internal organs. Shown are the governing vessel (GV) meridian (black),
A large trial in Germany,50 3093 patients with
the urinary bladder (UB) meridian (green), and the gallbladder (GB) meridian
chronic low back pain for a mean of 7 years were
randomly assigned to receive either acupuncture
or no acupuncture in addition to usual medical
lation,42 and increases in local blood flow.43 care. The primary end point was back function,
However, the various observations that have been as assessed with the use of the Hannover Funcmade are not sufficient to permit a unified the- tional Ability Questionnaire, which generates a
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clinical Ther apeutics
score ranging from 0 to 100, with 100 representing perfect back function. At 3 months, the mean
back-function score in the acupuncture group had
increased from 61.8 to 74.5 (a mean increase of
12.1 points), and the mean score in the control
group had increased from 63.3 to 65.1 (a mean
increase of 2.7 points), for a difference in mean
between-group improvement of 9.4 points (95%
confidence interval, 8.3 to 10.5; P<0.001).
Cl inic a l Use
Acupuncture is considered to be a form of alternative or complementary medicine, and as noted
above, it has not been established to be superior
to sham acupuncture for the relief of symptoms
of low back pain. As a result, it is not often regarded as the first choice of therapy. However,
since extensive clinical trials have suggested that
acupuncture may be more effective than usual
care, it is not unreasonable to consider acupuncture before or together with conventional treatments, such as physical therapy, pain medication,
and exercise. Many pain specialists incorporate
acupuncture into a multidisciplinary approach to
the management of chronic low back pain.
Acupuncture is a regulated discipline, and patients should be referred only to practitioners who
are licensed by the state in which they practice.
A diploma from the National Certification Commission for Acupuncture and Oriental Medicine is
a requirement for licensure in most states. Physicians may practice acupuncture in the United
States after completing one of several medical
acupuncture programs.
It is essential that all patients with chronic or
recurrent low back pain undergo a careful diagnostic evaluation before selecting a course of
therapy. Patients with serious spinal disease, such
as cancer or infection, are not appropriate candidates for acupuncture and require specific medical or surgical intervention as dictated by the
underlying disorder. Clinical practice guidelines
emphasize clinical “red flags,” such as a neurologic deficit, unexplained weight loss, fever, and
structural deformity.51 Imaging is recommended
for patients older than 50 years of age and for
those with signs or symptoms suggesting systemic disease.52
Contraindications to acupuncture include clotting and bleeding disorders (e.g., hemophilia and
advanced liver disease), warfarin use, severe psy-
chiatric conditions (e.g., psychosis), and local skin
infections or trauma to the skin (e.g., burns).53
In addition, electroacupuncture should be avoided at the site of implanted electrical devices, such
as pacemakers. Acupuncture is not contraindicated during pregnancy. However, some specific
acupuncture points are known to be especially
sensitive to needle insertion; these sites, as well
as acupuncture points in the abdominal regions,
should be avoided in pregnant women.54
In the traditional practice of acupuncture,
needle insertion itself may be accompanied by a
variety of ancillary procedures, including palpation of the radial artery and other areas of the
body, examination of the tongue, and recommendation of herbal medications. All of these steps
are based on the application of principles of traditional Chinese medicine, as opposed to Western
physiological and medical concepts. To what extent such procedures may contribute to the psychological milieu of acupuncture is unknown, and
only a few studies have examined the context in
which acupuncture treatment is delivered.32,55
During an acupuncture session for low back
pain, the patient lies prone on a treatment couch,
with the sites of intended needle insertion exposed. Acupuncturists typically individualize the
selection of insertion points for each patient at
each treatment session on the basis of the history
and physical examination. Nonetheless, there are
certain commonly used acupuncture points for
low back pain, which are listed in Table 1 and
shown in Figure 2.56,57 A practitioner may modify the treatment protocol by adding supplemental points. The depth of needle insertion (6.4 to
38.1 mm) and the diameter (0.1 to 0.3 mm),
length (12.7 to 76.2 mm), and number (4 to 20)
of needles used all vary among practitioners and
acupuncture schools.
After insertion of the needles, the patient is
advised to relax and rest with the needles left in
place, typically for 15 to 30 minutes. Frequently,
the needles are stimulated manually by the practitioner in order to elicit a dull, localized, aching
sensation that is termed de qi, as well as “needle
grasp,” a tugging sensation perceived by the acupuncturist and caused by mechanical interaction
between the needle and connective tissue.58 The
practitioner may further stimulate the needle with
electrical current (electroacupuncture), moxibustion (burning the herb artemisia vulgaris at the
end of the acupuncture needle), or heat.
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Table 1. Acupuncture Points Commonly Used in the Treatment of Chronic
Low Back Pain.*
Point Name†
UB 23 (shenshu)
At the level of the lower border of the spinous process
of the second lumbar vertebra, 1.5 cun lateral to
GV 4
UB 25 (dachangshu)
At the level of the lower border of the spinous process
of the fourth lumbar vertebra, 1.5 cun lateral to
GV 3
GV 3 (yaoyangguan)
Below the spinous process of the fourth lumbar vertebra, at the level with the iliac crest
UB 40 (weizhong)
At the midpoint of the transverse crease of the
popliteal fossa, between the tendons of the biceps
femoris muscle and the semitendinosus muscle
GB 30 (huantiao)
At the junction of the lateral third and medial two
thirds of the distance between the greater trochanter and the sacral hiatus
*Data are adapted from Cheng.56 GB denotes gallbladder, GV governing vessel, and UB urinary bladder.
†Acupuncture points are conventionally identified in one of two ways: by the
meridian on which they are located and the numerical position on that meridian or by their Chinese name. Both are listed here (e.g., the acupuncture point
shenshu is the 23rd acupuncture point on the UB meridian).
‡A measurement that is traditionally used to locate acupuncture points in proportion to the patient’s body is called cun. It is equivalent to the width of the
interphalangeal joint of the middle finger when it is flexed.
The number and frequency of acupuncture
treatments vary; however, most practitioners do
not consider one treatment to be adequate. In the
recent trials of acupuncture for low back pain,
a minimum of 12 sessions of acupuncture were
administered, often starting with 2 sessions a
week and tapering off after 4 weeks to once weekly.46,47,49,50 Booster treatments, monthly or every
other month, are sometimes used in follow-up.
However, if no effects are evident after 10 to 12
sessions, treatment should be discontinued.59 The
cost of acupuncture treatment varies across the
country and may range from $65 to $125 per
session. Medicare and Medicaid do not cover acupuncture; however, the proportion of third-party
plans providing coverage increased from 32% in
2002 to 47% in 2004.60
A dv er se Effec t s
Major adverse effects of acupuncture appear to be
rare. Two prospective surveys, covering a total of
more than 60,000 acupuncture sessions, did not
reveal any serious adverse events.61,62 Significant
minor adverse events, all occurring in less than
0.1% of cases, included needle-site pain, nausea
m e dic i n e
and vomiting, and dizziness or fainting. In another survey, which included 9429 physicians performing more than 760,000 sessions of acupuncture, two instances of pneumothorax, one
exacerbation of depression, an acute hypertensive
crisis, a vasovagal reaction, and an asthma attack
with hypertension and angina were reported.63
Nonserious adverse events included needle-site
pain in 3% of patients, hematoma in 3%, bleeding in 1%, and orthostatic symptoms in 0.5%.
In a German study involving more than 2 million acupuncture treatments in 229,230 patients,
8.6% reported at least one adverse event, and 2.2%
reported one that required treatment.64 The most
common adverse effects were bleeding or hematoma (6.1%) and pain (1.7%). Two patients had a
pneumothorax. One adverse event, a nerve injury
in a lower limb, persisted for 180 days.
A r e a s of Uncer ta in t y
There is continuing debate in the medical community regarding the role of the placebo effect in
acupuncture. As noted above, the most recent wellpowered clinical trials of acupuncture for chronic low back pain showed that sham acupuncture
was as effective as real acupuncture. The simplest
explanation of such findings is that the specific
therapeutic effects of acupuncture, if present, are
small, whereas its clinically relevant benefits are
mostly attributable to contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the
part of the patient.34,65,66 These studies also seem
to indicate that needles do not need to stimulate
the traditionally identified acupuncture points or
actually penetrate the skin to produce the anticipated effect. On the other hand, acupunctureneedle stimulation has analgesic effects in studies in animals, and a number of imaging studies
in humans have shown changes in limbic structures after traditional acupuncture that are distinct from changes after sham acupuncture, even
though the active and sham treatments have equivalent analgesic effects.32,40,67 These findings suggest that it is difficult to design a sham procedure
that is both believable to patients and physiologically inactive.
Future studies should focus on the association
between the acupuncture procedure and the psychosocial context within which it is applied —
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clinical Ther apeutics
for example, by comparing acupuncture performed
in a neutral environment with that performed in
the context of traditional ancillary techniques. It
may also be important to try to identify the optimal candidate for acupuncture on the basis of
individual beliefs, expectations, and psychological profile and to study the relative effectiveness
of acupuncture in comparison with other nonpharmacologic approaches, such as cognitive behavioral approaches, relaxation therapy, massage
therapy, and biofeedback. Finally, we recommend
that additional studies further evaluate the efficacy of sham acupuncture without skin penetration, since it may be possible to achieve the
benefits of acupuncture without an invasive procedure.
Shenshu (UB 23)
Dachangshu (UB 25)
Yaoyangguan (GV 3)
Weizhong (UB 40)
Huantiao (GB 30)
Guidel ine s
The American College of Physicians and the
American Pain Society have issued joint clinical
practice guidelines recommending that clinicians
consider acupuncture as one possible treatment
option for patients with chronic low back pain
who do not have a response to self-care.68,69 The
level of supporting evidence for this recommendation was characterized as fair, and it was noted
that recommendations may change as new studies become available.
Furthermore, the North American Spine Society recently concluded that acupuncture provides
better short-term pain relief and functional improvement than no treatment and that the addition of acupuncture to other treatments provides
a greater benefit than other treatments alone.70
This review also identified a need for additional
high-quality, randomized, controlled trials comparing acupuncture with no treatment and with
sham acupuncture. Finally, the U.K. National Institute for Health and Clinical Excellence has recommended acupuncture as a treatment option for
patients with low back pain. As a result, the U.K.
National Health Service now provides a maximum of 10 sessions of acupuncture over a period
of 12 weeks for people with low back pain that
has persisted for more than 6 weeks.71
Figure 2. Acupuncture Points Used in the Treatment of Chronic Low
Back Pain.
Shown are the locations of acupuncture points that are commonly used in
the treatment of chronic low back pain, including UB 23 (shenshu), UB 25
(dachangshu), GV 3 (yaoyangguan), UB 40 (weizhong), and GB 30 (huantiao).
GB denotes gallbladder, GV governing vessel, and UB urinary bladder.
clinical examination and MRI showed no evidence of a serious underlying condition requiring
specific therapy, such as cancer or spinal infection. We would encourage him to stay active in
order to improve function and to consider a tailored stretching and strengthening exercise program. He has specifically requested a referral for
acupuncture, and we would suggest a course of
10 to 12 treatments over a period of 8 weeks from
a licensed acupuncturist or a physician trained in
medical acupuncture. The National Certification
Commission for Acupuncture and Oriental Medicine and the American Academy of Medical Acupuncture are potential resources for finding a
qualified local practitioner. At the end of treatment, we would assess the patient’s response,
R ec om mendat ions
particularly his level of pain, mood, and general
The patient in the vignette has chronic back pain activity level, and make a determination about
that has not responded to a number of medical whether he should receive additional acupuncture
treatments. First, we would reassure him that the treatments.
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n e w e ng l a n d j o u r na l
Dr. Langevin reports being a member of the board of directors of Stromatec and receiving grant support and payment for
travel and accommodation expenses from Stromatec. No other
potential conflict of interest relevant to this article was reported.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
m e dic i n e
We thank Eric Manheimer, M.S., and Lixing Lao, Ph.D., of the
University of Maryland Center for Integrative Medicine, Susan
Hartnoll, B.A., of the Institute for Integrative Health, Gary Kaplan, D.O., of the Kaplan Clinic, and James Swyers, M.A., for
their comments and advice on the manuscript and Katrina Farber for her administrative assistance.
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