Stimulated by Heo et al 2020, and Choo et al 2021.
EA – electroacupuncturekey to acronyms
LBP – low back pain
SR – systematic review
UC – usual care
QoL – quality of life
CAM – complementary and alternative medicine
I was attracted to Heo et al because it involved EA and was published in the BJA, which I don’t often see publishing acupuncture trials. On closer inspection it is quite an unusual population and question, at least for the English language literature.
I did a quick search on PubMed for papers that mention “back surgery” in the title and have a text word starting with either acup* or electroacup*
There were 8 papers in total and the 6 most recent ones all came from South Korea within the last 5 years. 5 out of 6 came from the same group. First an SR on the subject, followed by a protocol for a pilot study, then a prospective cohort, another protocol (corresponding to the current multicentre trial), the pilot study, and finally this latest trial that caught my eye.
It sounds as though this team went through the right steps in clinical research: see what is out there (SR), pilot your idea in one centre, and then do the definitive multicentre study, with protocols published before each trial.
When I say definitive study, I am perhaps overstating the case, the trial was adequately powered but was still not huge with just 108 participants. But note that the comparison is pragmatic – EA was added to usual care (UC). There was no sham group, so no need to worry about the size of the difference between normal and gentle needling.
The EA group received twice weekly sessions for 4 weeks, with paraspinal points at L3, L4 and L5 plus up to 9 additional points according to symptoms. EA was applied at 50Hz at L3 and L5 for 15 mins.
Both groups received UC which included an education programme and physical therapy. The latter was performed twice a week for 4 weeks and involved 15 minutes of interferential current therapy plus superficial heat therapy. So, the acupuncture was in addition to a reasonably intense programme of hands on treatment.
You can see this in the results, as both groups improve over the course of treatment and follow up, but the EA group has significantly less pain and greater function at the primary outcome. This difference is no longer significant 2 months after the treatment course. Interestingly there is no difference in the quality of life (QoL) measure (EQ-5D) at any time point. This may be a reflection of the fact that this trial was relatively small and was powered to measure a difference in VAS pain rather than QoL.
But this discrepancy reminds me of another trial in chronic pain where the opposite occurred. Acupuncture was combined with physical therapy in a three arm trial, and whilst it measured no appreciable difference in the pain outcome between real acupuncture, sham acupuncture and physical therapy alone (all groups had physical therapy), there was a significant benefit in both real and sham acupuncture groups in terms of QoL.
The second paper I am highlighting is from the US, and it studies the increase in CAM utilisation by back pain patients in Oregon following an extension of medical insurance (Medicaid) in 2016 to include evidence based CAM services for back pain.
Whilst there was a steady rise in utilisation of CAM from the start of 2014 to the end of 2018, the change of policy seems to have had the biggest influence on the use of acupuncture and chiropractic, although much greater proportions of back pain patients use physical therapy and massage than either of the former treatments.
1 Heo I, Shin B-C, Cho J-H, et al. Multicentre randomised controlled clinical trial of electroacupuncture with usual care for patients with non-acute pain after back surgery. Br J Anaesth Published Online First: 16 December 2020. doi:10.1016/j.bja.2020.10.038
2 Choo EK, Charlesworth CJ, Gu Y, et al. Increased Use of Complementary and Alternative Therapies for Back Pain Following Statewide Medicaid Coverage Changes in Oregon. J Gen Intern Med Published Online First: 14 January 2021. doi:10.1007/s11606-020-06352-6
3 Cho Y-H, Kim C-K, Heo K-H, et al. Acupuncture for acute postoperative pain after back surgery: a systematic review and meta-analysis of randomized controlled trials. Pain Pract Off J World Inst Pain 2015;15:279–91. doi:10.1111/papr.12208
4 Hwang M-S, Heo K-H, Cho H-W, et al. Electroacupuncture as a complement to usual care for patients with non-acute pain after back surgery: a study protocol for a pilot randomised controlled trial. BMJ Open 2015;5:e007031. doi:10.1136/bmjopen-2014-007031
5 Lee J, Shin J-S, Lee YJ, et al. Long-Term Course of Failed Back Surgery Syndrome (FBSS) Patients Receiving Integrative Korean Medicine Treatment: A 1 Year Prospective Observational Multicenter Study. PloS One 2017;12:e0170972. doi:10.1371/journal.pone.0170972
6 Shin B-C, Cho J-H, Ha I-H, et al. A multi-center, randomized controlled clinical trial, cost-effectiveness and qualitative research of electroacupuncture with usual care for patients with non-acute pain after back surgery: study protocol for a randomized controlled trial. Trials 2018;19:65. doi:10.1186/s13063-018-2461-6
7 Heo I, Hwang M-S, Hwang E-H, et al. Electroacupuncture as a complement to usual care for patients with non-acute low back pain after back surgery: a pilot randomised controlled trial. BMJ Open 2018;8:e018464. doi:10.1136/bmjopen-2017-018464