Stimulated by NG193.[1]
NICE – National Institute for Health & Care Excellence
key to acronyms
cLBP – chronic low back pain
MSK – musculoskeletal
GERAC – German acupuncture trials (large 3 arm trials with ~1000 patients in each)
MCID – minimum clinical important difference
LA – local anaesthetic
CRPS – complex regional pain syndrome
RFD – radiofrequency denervation.
It is nearly 10 years since we have seen any positive recommendation for acupuncture in NICE guidelines,[2] so it is a great relief to see the evidence scales tilting in favour of acupuncture for chronic pain today.
Whilst low back pain (LBP) is one of the most common varieties of chronic pain in the population, research on this was excluded because this was reviewed in the infamous NG59 (see To NICE – there appears to be a glaring orthodox bias in NG59). At first, I thought it was rather artificial to exclude one type of MSK pain, but since the effect size of acupuncture over sham in cLBP is lower than in all other MSK conditions, this decision actually favoured acupuncture.
…this decision actually favoured acupuncture.
It is probably true that acupuncture is less efficacious and less effective in cLBP than in chronic neck pain, but the data in meta-analyses probably exaggerates this because of the results in the GERAC trial in cLBP.
The GERAC trials were large comparative effectiveness trials of acupuncture compared with guideline based conventional care as well as having a sham acupuncture arm. I have summarised these previously,[3] but importantly, whilst there was one for cLBP,[4] there was no GERAC trial for neck pain.
The GERAC trial on cLBP demonstrated that both acupuncture and sham (superficial off-point segmental needling) were 50% better than guideline based standard care in Germany, but there was a very small difference between real and sham. Since there were 300 patients in each arm of this trial, the comparison of acupuncture versus sham in meta-analysis for cLBP is artificially brought down by this data, whereas the results for neck pain are not.
This means that the big data has an effect size of less than 0.2 for acupuncture over sham in cLBP, but more than 0.8 for acupuncture over sham in neck pain.[5]
The truth probably lies somewhere in between…
The truth probably lies somewhere in between with acupuncture being a bit better for neck pain, but there is no real doubt that it is effective in back pain as well.
So, back to these guidelines, and the critical pooled data was for acupuncture versus sham for pain at 3 months or less. 13 trials were included with a total of 1230 patients, and the pooled mean difference was 1.41 on a 0 to 10 pain scale. The equivalent critical figure from NG59 was 0.8 (see Exercise not acupuncture recommended by NICE for low back pain). The pooled trials were for neck pain,[6–8] shoulder pain,[9] myofascial pain,[10–13] fibromyalgia,[14–17] and chronic pelvic pain,[18] and used a variety of different sham controls, so there was notable clinical heterogeneity. Despite this there was downgrading of evidence for inconsistency because the statistical heterogeneity could not be explained by the pre-specified subgroup analyses. I did comment on this point!
The first recommendation under management of chronic pain is for exercise, and the guideline included a lot of research for exercise, but they could only manage to pool data from 9 trials and 528 patients in the largest comparison, which was aerobic exercise versus usual care. The mean difference here was 6.97, but this is presented on a 0 to 100 scale, so it is less than half the effect we see in acupuncture versus sham.
There is no sham controlled data for exercise presented, and again exercise does not meet the usual standard of MCID, which is 10 on a 0 to 100 scale or 1 on a 0 to 10 scale. Exercise seems destined to be recommend by NICE no matter how bad the evidence, but the same is not true for other interventions, and this guideline fails to recommend many interventions that are part of current standard practice in the NHS.
“do not initiate…”
Pain management programmes are not recommended, but perhaps more dramatic than that, a whole raft of drugs come under the banner of “do not initiate…”:
- antiepileptics including gabapentinoids
- antipsychotics
- benzodiazepines
- trigger point injections with steroids or LA
- ketamine
- topical or intravenous LA
- NSAIDs
- opioids
- paracetamol
There are a couple of exceptions for clinical trials in CRPS.
It strikes me that pain clinics in the NHS will be left with very little to do, apart from the RFD for back pain that was recommend in NG59 of course. I have also commented on that recommendation on here (see Burning nerves with needles in back pain – stop the burning, just use the needles!).
References
1 Recommendations | Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain | Guidance | NICE. https://www.nice.org.uk/guidance/ng193/chapter/Recommendations (accessed 7 Apr 2021).
2 Recommendations | Headaches in over 12s: diagnosis and management | Guidance | NICE. https://www.nice.org.uk/guidance/cg150/chapter/Recommendations (accessed 9 Jan 2021).
3 Cummings M. Modellvorhaben Akupunktur–a summary of the ART, ARC and GERAC trials. Acupunct Med 2009;27:26–30. doi:10.1136/aim.2008.000281
4 Haake M, Müller H-H, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med 2007;167:1892–8. doi:10.1001/archinte.167.17.1892
5 Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain 2018;19:455–74. doi:10.1016/j.jpain.2017.11.005
6 Birch S, Jamison RN. Controlled Trial of Japanese Acupuncture for Chronic Myofascial Neck Pain: Assessment of Specific and Nonspecific Effects of Treatment. Clin J Pain 1998;14:248–55. doi:10.1097/00002508-199809000-00012
7 Liang Z, Zhu X, Yang X, et al. Assessment of a traditional acupuncture therapy for chronic neck pain: a pilot randomised controlled study. Complement Ther Med 2011;19 Suppl 1:S26-32. doi:10.1016/j.ctim.2010.11.005
8 White P, Lewith G, Prescott P, et al. Acupuncture versus Placebo for the Treatment of Chronic Mechanical Neck Pain. Ann Intern Med 2004;141:911. doi:10.7326/0003-4819-141-12-200412210-00007
9 Molsberger AF, Schneider T, Gotthardt H, et al. German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) – a pragmatic, controlled, patient-blinded, multi-centre trial in an outpatient care environment. Pain 2010;151:146–54. doi:10.1016/j.pain.2010.06.036
10 Chou L-W, Hsieh Y-L, Chen H-S, et al. Remote Therapeutic Effectiveness of Acupuncture in Treating Myofascial Trigger Point of the Upper Trapezius Muscle. Am J Phys Med Rehabil 2011;90:1036–49. doi:10.1097/PHM.0b013e3182328875
11 Couto C, de Souza ICC, Torres ILS, et al. Paraspinal Stimulation Combined With Trigger Point Needling and Needle Rotation for the Treatment of Myofascial Pain. Clin J Pain 2014;30:214–23. doi:10.1097/AJP.0b013e3182934b8d
12 Ilbuldu E, Cakmak A, Disci R, et al. Comparison of Laser, Dry Needling, and Placebo Laser Treatments in Myofascial Pain Syndrome. PhotomedLaser Surg 2004;22:306–11. doi:10.1089/pho.2004.22.306
13 Tekin L, Akarsu S, Durmuş O, et al. The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial. Clin Rheumatol 2013;32:309–15. doi:10.1007/s10067-012-2112-3
14 Harris RE, Tian X, Williams DA, et al. Treatment of Fibromyalgia with Formula Acupuncture: Investigation of Needle Placement, Needle Stimulation, and Treatment Frequency. J Altern Complement Med 2005;11:663–71. doi:10.1089/acm.2005.11.663
15 Karatay S, Okur SC, Uzkeser H, et al. Effects of Acupuncture Treatment on Fibromyalgia Symptoms, Serotonin, and Substance P Levels: A Randomized Sham and Placebo-Controlled Clinical Trial. Pain Med 2018;19:615–28. doi:10.1093/pm/pnx263
16 Uğurlu FG, Sezer N, Aktekin L, et al. The effects of acupuncture versus sham acupuncture in the treatment of fibromyalgia: a randomized controlled clinical trial. Acta Reumatol Port 2017;42:32–7.
17 Vas J, Santos-Rey K, Navarro-Pablo R, et al. Acupuncture for Fibromyalgia in Primary Care: A Randomised Controlled Trial. Acupunct Med 2016;34:257–66. doi:10.1136/acupmed-2015-010950
18 Lee SWH, Liong ML, Yuen KH, et al. Validation of a Sham Acupuncture Procedure in a Randomised, Controlled Clinical Trial of Chronic Pelvic Pain Treatment. Acupunct Med 2011;29:40–6. doi:10.1136/aim.2010.003137
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