A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis

Modulation effects of imagery acupuncture and no-touch double-blinded placebo acupuncture, a cross-over pilot study

Both imagery and acupuncture are the oldest medical practices. Recently, we have developed a new treatment modality, video-guided acupuncture imagery treatment (VGAIT), which combines acupuncture and imagery. In this crossover study, we investigated the modulation effects of video-guided acupuncture imagery treatment compared with placebo acupuncture using no-touch double-blind placebo acupuncture needles and a no-treatment resting control. Pressure pain threshold and electroencephalogram (EEG) data were collected before and after each intervention. 12 healthy participants completed the study. Results showed that pressure pain thresholds were significantly increased after VGAIT compared to the resting control condition. In addition, we found that VGAIT, but not the no-touch placebo acupuncture or the resting control, significantly increased alpha and beta band power. Our findings demonstrate the potential of VGAIT as a remote therapeutic method (e-health treatment option) for pain and the value of no-touch double-blind placebo acupuncture in acupuncture research.

Exploring the rules of related parameters in acupuncture for post-stroke dysphagia based on data mining

Background

Post-stroke dysphagia (PSD) affects the efficacy and safety of swallowing, causing serious complications. Acupuncture is a promising and cost-effective treatment for PSD; however, as the number of randomized controlled trials increases, scientific analysis of the parameters and acupoint prescription is required. Therefore, this study aimed to explore the effects of acupuncture on parameters related to post-stroke dysphagia (PSD).

Methods

We searched the Cochrane Library, PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Database, Chinese Biomedical Literature, and Chongqing VIP Database for randomized controlled trials of acupuncture for PSD in the last 15 years and relevant parameters were analyzed using data mining techniques.

Results

In total, 3,205 records were identified, of which 3,507 patients with PSD were included in 39 studies. The comprehensive analysis demonstrated that the closest parameter combinations of acupuncture on PSD were 0.25 mm × 40 mm needle size, 30 min retention time, five treatments per week, and a 4-week total course of treatment. Additionally, the gallbladder and nontraditional meridians, crossing points, and head and neck sites are the most commonly used acupoint parameters. The core acupoints identified were GB20, RN23, EX-HN14, Gongxue, MS6, SJ17, EX-HN12, EX-HN13, and the commonly used combination of EX-HN12, EX-HN13, GB20, and RN23.

Conclusion

This study analyzed the patterns of PSD-related needling and acupoint parameters to provide evidence-based guidelines for clinical acupuncturists in treating PSD, potentially benefitting affected patients.

Recent trends in acupuncture for chronic pain: A bibliometric analysis and review of the literature

BACKGROUND

Acupuncture has been increasingly used in patients with chronic pain, yet no bibliometric analysis of acupuncture studies for chronic pain exists.

OBJECTIVES

To investigate the characteristics, hotspots and frontiers of global scientific output in acupuncture research for chronic pain over the past decade.

METHODS

We retrieved publications on acupuncture for chronic pain published from 2011 to 2022 from the Science Citation Index Expanded (SCI-expanded) of the Web of Science Core Collection (WoSCC). The co-occurrence relationships of journals/countries/institutions/authors/keywords were performed using VOSviewer V6.1.2, and CiteSpace V1.6.18 analyzed the clustering and burst analysis of keywords and co-cited references.

RESULTS

A total of 1616 articles were retrieved. The results showed that the number of annual publications on acupuncture for chronic pain has increased over time, with the main types of literature being original articles (1091 articles, 67.5 %) and review articles (351 articles, 21.7 %). China had the most publications (598 articles, 37 %), with Beijing University of Traditional Chinese Medicine (93 articles, 5.8 %) and Evidence-based Complementary and Alternative Medicine ranked first (169 articles, 10.45 %) as the most prolific affiliate and journal, respectively. Liang FR was the most productive author (43 articles), and the article published by Vickers Andrew J in 2012 had the highest number of citations (625 citations). Recently, "acupuncture" and "pain" appeared most frequently. The hot topics in acupuncture for chronic pain based on keywords clustering analysis were experimental design, hot diseases, interventions, and mechanism studies. According to burst analysis, the main research frontiers were functional connectivity (FC), depression, and risk.

CONCLUSION

This study provides an in-depth perspective on acupuncture for chronic pain studies, revealing pivotal points, research hotspots, and research trends. Valuable ideas are provided for future research activities.

Effect of Inpatient Integrative Medicine Consultation on 30-Day Readmission Rates: A Retrospective Observational Study at a Major U.S. Academic Hospital

Objectives: The prevalence of inpatient integrative medicine (IM) consult services is increasing among academic health care institutions. The diversity of services between institutions, as well as the novel nature of such interventions, makes it challenging for health care administrators to determine the cost/benefit of adding such a program to their institution. The main purpose of this study was to examine the performance of the new University of California, Los Angeles (UCLA) East-West (EW) consult service as measured by 30-day readmission rates and lengths of stay. Design: This is a retrospective observational case-control study with participants matched to themselves. Setting: UCLA Santa Monica Hospital, a 281-bed academic tertiary care hospital near Los Angeles, California. Subjects: Patients who had received an EW consultation during the inaugural 20 months of the program (2018-2020), and who had been hospitalized in the prior 2 years from the date of their first EW consult. Intervention: Inpatient East-West consultation, which may include counseling, acupuncture and/or trigger point injections depending on medical necessity. Outcome Measures: Thirty-day readmission rates and lengths of hospital admission were compared between the hospitalization that included an EW consult (which included the use of acupuncture and/or trigger point injections when appropriate) and any prior admissions during the 2 years before that EW consult. Secondary outcomes included quantitative analysis of average number of treatments and qualitative assessment of integrative treatment(s) received, conditions treated, and reasons that EW treatment may have been deferred during a consult. Results: One hundred sixty-five unique patients met the study criteria. The EW consultation was associated with clinically relevant, statistically significant decreased 30-day readmission rates (33.0% vs. 4.6%, p < 0.001, odds ratio [OR] 0.10, 95% confidence interval [CI] 0.06-0.17). This effect was similar when limiting the analysis to pain-related admissions (32.3% vs. 3.4%, p < 0.001, OR = 0.07, 95% CI 0.03-0.16). Hospital admissions with EW consults were found to have a statistically significant increased length of stay (7.03 days vs. 5.40 days, p < 0.001). Conclusion: The EW medicine, an example of IM, correlates with a reduced risk of 30-day readmission and with modestly increased lengths of stay.

Cost-effectiveness analysis of acupuncture compared with usual care for acute non-specific low back pain: secondary analysis of a randomised controlled trial

OBJECTIVE

To assess the cost-effectiveness of a single treatment session of acupuncture, when applied in addition to usual care for acute low back pain (ALBP).

METHODS

Secondary analysis of a multicentre randomised controlled trial in Norwegian general practice. In total, 171 participants with ALBP ⩽14 days were randomised to a control group (CG) receiving usual care or to an acupuncture group (AG) receiving one additional session of Western medical acupuncture alongside usual care. Primary outcome measures for this cost-effectiveness analysis were quality-adjusted life years (QALYs), health care costs and societal costs at days 28 and 365, the incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB). The NMB was calculated on the basis of the Norwegian cost-effectiveness threshold of NOK 275,000 (USD 35,628) per QALY gained. Missing data were replaced by multiple chained imputation.

RESULTS

Eighty-six participants in the CG and 81 in the AG were included in the analysis. We found no QALY gain at day 28. At day 365, the incremental QALY of 0.035 was statistically significant. The differences in health care costs and societal costs were not statistically significant. Three out of four calculations led to negative ICERs (cost saving) and positive NMBs. For the health care perspective at day 365, the ICER was USD -568 per QALY and the NMB was USD 1265, with 95.9% probability of acupuncture being cost-effective.

CONCLUSION

To our knowledge, this is the first cost-effectiveness analysis of acupuncture for ALBP. The findings indicate that acupuncture may be cost-effective from a 1-year perspective, but more studies are needed.

TRIAL REGISTRATION NUMBER

NCT01439412 (ClinicalTrials.gov).

Acupuncture for Low-Back Pain

Low-back pain affects 84% of the world's population. At present, no method of treatment can be considered as the method of choice. Acupuncture is effective, scientific, cost-effective, and free from major side-effects. Three illustrative cases, showing the beneficial effects of acupuncture are presented. Attention is drawn to the possible presence of underlying sacroiliac-joint dysfunction, which could masquerade as sciatica, hip pain, and/or groin pain.

The Intersection of Dissemination Research and Acupuncture: Applications for Chronic Low Back Pain

Dissemination research is the study of distributing information and intervention materials to a specific clinical practice or public health audience. Acupuncture, a healthcare practice involving the stimulation of certain body points, often with thin needles, is considered an evidence-based treatment for low back pain (LBP), but is underutilized in the United States.

Body: We will use the example of acupuncture for LBP to identify opportunities to leverage dissemination research to increase utilization of acupuncture. Deficits in the awareness or knowledge of acupuncture may limit its adoption by patients and other stakeholders. Thus, we summarize methods to gather data on stakeholder awareness and knowledge of acupuncture for LBP, i.e., audience research. Engaging multiple stakeholder audiences (e.g., health system leaders, primary care providers, patients), is needed to generate knowledge on promising dissemination strategies for each audience. Audience segmentation is important for identifying population subgroups for whom adoption of acupuncture may require a more intensive or tailored dissemination strategy. To illustrate potential audience ‘segments’, our research discussion focused on developing dissemination strategies by age (i.e., older adults – those age 65 years or older, and younger adults – those under age 65 ). This decision was prompted by Medicare’s recent policy covering acupuncture for chronic LBP. We leverage current knowledge of barriers and facilitators of acupuncture use to discuss how further tailoring of dissemination strategies might optimize adoption of acupuncture in both groups of adults. Experimental study designs could then be used to compare the effectiveness of such strategies to increase awareness, knowledge, or adoption of acupuncture.

Conclusions: Conducting dissemination research may improve awareness and knowledge of acupuncture, and ultimately the adoption of acupuncture in biomedical settings. We anticipate that the concepts highlighted in this manuscript will also be helpful for those disseminating information about other complementary and integrative health approaches.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.

Acupuncture Treatment Modulates the Connectivity of Key Regions of the Descending Pain Modulation and Reward Systems in Patients with Chronic Low Back Pain

Chronic low back pain (cLBP) is a common disorder with unsatisfactory treatment options. Acupuncture has emerged as a promising method for treating cLBP. However, the mechanism underlying acupuncture remains unclear. In this study, we investigated the modulation effects of acupuncture on resting state functional connectivity (rsFC) of the periaqueductal gray (PAG) and ventral tegmental area (VTA) in patients with cLBP. Seventy-nine cLBP patients were recruited and assigned to four weeks of real or sham acupuncture. Resting state functional magnetic resonance imaging data were collected before the first and after the last treatment. Fifty patients completed the study. We found remission of pain bothersomeness in all treatment groups after four weeks, with greater pain relief after real acupuncture compared to sham acupuncture. We also found that real acupuncture can increase VTA/PAG rsFC with the amygdala, and the increased rsFC was associated with decreased pain bothersomeness scores. Baseline PAG-amygdala rsFC could predict four-week treatment response. Our results suggest that acupuncture may simultaneously modulate the rsFC of key regions in the descending pain modulation (PAG) and reward systems (VTA), and the amygdala may be a key node linking the two systems to produce antinociceptive effects. Our findings highlight the potential of acupuncture for chronic low back pain management.

[Acupuncture for pain and allergic rhinitis-from clinical experience to evidence]

BACKGROUND

Acupuncture is a traditional Chinese medicine therapy method that is also frequently used in the western world. It has been the subject of intensive scientific research over the past two decades.

AIM OF THE WORK

To describe the efficacy, therapy safety, and health economic relevance of acupuncture for chronic pain disorders and allergic diseases.

MATERIAL AND METHODS

In the context of a review (narrative review) the relevant literature was selected, presented, and interpreted.

RESULTS

Acupuncture is effective in chronic pain disorders such as chronic knee joint pain in osteoarthritis, migraine, tension headache, chronic lumbar spine pain, chronic cervical spine pain, shoulder pain, dysmenorrhea, and fibromyalgia under routine conditions. In addition, specific efficacy is shown in most chronic pain indications. Acupuncture is also effective in patients with allergic diseases. In large clinical studies, acupuncture has proven to be a relatively safe therapy, but severe complications (e.g. pneumothorax cases, hepatitis B) also occur in rare instances. Acupuncture is usually associated with higher therapy costs, but is considered a cost-effective treatment strategy for pain disorders.

DISCUSSION

As a nonpharmacological procedure, acupuncture is becoming increasingly important in pain and allergy therapy and is therefore increasingly included in current guidelines. In further studies, the efficacy of acupuncture should be determined in other indications and the mechanisms of action of this therapy method should be investigated.

Sleep Apnea Multilevel Surgery (SAMS) trial protocol: a multicenter randomized clinical trial of upper airway surgery for patients with obstructive sleep apnea who have failed continuous positive airway pressure

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a serious and costly public health problem. The main medical treatment, continuous positive airway pressure, is efficacious when used, but poorly tolerated in up to 50% of patients. Upper airway reconstructive surgery is available when medical treatments fail but randomized trial evidence supporting its use is limited. This protocol details a randomized controlled trial designed to assess the clinical effectiveness, safety, and cost-effectiveness of a multilevel upper airway surgical procedure for OSA.

METHODS

A prospective, parallel-group, open label, randomized, controlled, multicenter clinical trial in adults with moderate or severe OSA who have failed or refused medical therapies. Six clinical sites in Australia randomly allocated participants in a 1:1 ratio to receive either an upper airway surgical procedure consisting of a modified uvulopalatopharyngoplasty and minimally invasive tongue volume reduction, or to continue with ongoing medical management, and followed them for 6 months.

RESULTS

Primary outcomes: difference between groups in baseline-adjusted 6 month OSA severity (apnea-hypopnea index) and subjective sleepiness (Epworth Sleepiness Scale). Secondary outcomes: other OSA symptoms (e.g. snoring and objective sleepiness), other polysomnography parameters (e.g. arousal index and 4% oxygen desaturation index), quality of life, 24 hr ambulatory blood pressure, adverse events, and adherence to ongoing medical therapies (medical group).

CONCLUSIONS

The Sleep Apnea Multilevel Surgery (SAMS) trial is of global public health importance for testing the effectiveness and safety of a multilevel surgical procedure for patients with OSA who have failed medical treatment.

CLINICAL TRIAL REGISTRATION

Multilevel airway surgery in patients with moderate-severe Obstructive Sleep Apnea (OSA) who have failed medical management to assess change in OSA events and daytime sleepiness. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366019&isReview=true Australian New Zealand Clinical Trials Registry ACTRN12614000338662, prospectively registered on 31 March 2014.

Cost-effectiveness of acupuncture versus standard care for pelvic and low back pain in pregnancy: A randomized controlled trial

Objective

To assess the cost-effectiveness of acupuncture for pelvic girdle and low back pain (PGLBP) during pregnancy.

Design

Pragmatic-open-label randomised controlled trial.

Setting

Five maternity hospitals

Population

Pregnant women with PGLBP

Method

1:1 randomization to standard care or standard care plus acupuncture (5 sessions by an acupuncturist midwife).

Main outcome measure

Efficacy: proportion of days with self-assessed pain by numerical rating scale (NRS) ≤ 4/10. Cost effectiveness (societal viewpoint, time horizon: pregnancy): incremental cost per days with NRS ≤ 4/10. Indirect non-healthcare costs included daily compensations for sick leave and productivity loss caused by absenteeism or presenteeism.

Results

96 women were allocated to acupuncture and 103 to standard care (total 199). The proportion of days with NRS ≤ 4/10 was greater in the acupuncture group than in the standard care group (61% vs 48%, p = 0.007). The mean Oswestry disability score was lower in the acupuncture group than with standard care alone (33 versus 38, Δ = 5, 95% CI: 0.8 to 9, p = 0.02). Average total costs were higher in the control group (€2947) than in the acupuncture group (€2635, Δ = —€312, 95% CI: -966 to +325), resulting from the higher indirect costs of absenteeism and presenteeism. Acupuncture was a dominant strategy when both healthcare and non-healthcare costs were included. Costs for the health system (employer and out-of-pocket costs excluded) were slightly higher for acupuncture (€1512 versus €1452, Δ = €60, 95% CI: -272 to +470).

Conclusion

Acupuncture was a dominant strategy when accounting for employer costs. A 100% probability of cost-effectiveness was obtained for a willingness to pay of €100 per days with pain NRS ≤ 4.

The Evidence on Acupuncture for Knee Osteoarthritis – Editorial Summary on the Implications for Health Policy

Decisions on whether a health service should provide a particular treatment are based on the evidence on three questions: 1) whether the treatment can work, ie it is biologically active; 2) whether the treatment is safe and effective in daily practice; and 3) whether it is economically worthwhile. Evidence presented at the Kyoto conference shows that acupuncture for osteoarthritis of the knee has a biological effect, has a large clinical effect in practice, has negligible risk, and has a cost effectiveness which is well within the usual acceptable limit. On the present evidence, acupuncture is likely to offer an alternative to treatment with non-steroidal anti-inflammatory drugs (NSAIDs).

An Observational Study on the Costs and Consequences of Acupuncture for the Management of Chronic Low Back Pain in Korean Patients

Objectives

To investigate the consequences and costs of acupuncture in general medical practice for patients with chronic low back pain (CLBP) in Korea.

Methods

A multicentre observational study was performed. Outpatients with CLBP who received at least one acupuncture session in a Korean Medicine clinic during the study period were included and followed up for 3 months. All patients received regular acupuncture treatments in accordance with the doctors’ discretion. The consequences in terms of effects included condition-specific outcomes and preference-based outcome. For cost analysis, the cumulative resource use for direct medical costs at each research clinic during the study period and direct patient data using the self-reported healthcare utilisation questionnaires were used.

Results

A total of 157 patients were eligible to participate and 105 were finally included. Significant improvements in condition-specific and preference-based measures were observed after acupuncture treatment. An average of approximately $146 (£93) per patient was reported for direct medical costs in each clinic for 1 month and $231 (£148) for 3 months. Other medical expenses related to CLBP were reduced during this period.

Conclusions

The use of acupuncture to manage CLBP in general clinical practice in Korea inexpensively improved pain, functional disability and quality of life. The study results are meaningful and consistent with the results of previous trials performed in other European countries but the power of the study is not strong, having major design weaknesses. A large-scale cohort or registry based on practice may be helpful to strengthen the evidence of the cost-effectiveness of acupuncture.

Evaluating Acupuncture and Standard carE for pregnant women with Back pain (EASE Back): a feasibility study and pilot randomised trial

BACKGROUND

Many pregnant women experience low back pain. Acupuncture appears to be a safe, promising intervention but evidence is needed about its clinical effectiveness and cost-effectiveness.

OBJECTIVES

To assess the feasibility of a future large randomised controlled trial (RCT) testing the additional benefit of adding acupuncture to standard care (SC) for pregnancy-related back pain.

DESIGN

Phase 1: a questionnaire survey described current care for pregnancy-related back pain. Focus groups and interviews with midwives, physiotherapists and pregnant women explored acceptability and feasibility of acupuncture and the proposed RCT. Phase 2: a single-centre pilot RCT. Participants were identified using six methods and randomised to SC, SC plus true acupuncture or SC plus non-penetrating acupuncture.

PARTICIPANTS

Phase 1: 1093 physiotherapists were surveyed and 15 midwives, 21 physiotherapists and 17 pregnant women participated in five focus groups and 20 individual interviews. Phase 2: 125 women with pregnancy-related back pain participated.

INTERVENTIONS

SC: a self-management booklet and onward referral for one-to-one physiotherapy (two to four sessions) for those who needed it. SC plus true acupuncture: the self-management booklet and six to eight treatments with a physiotherapist comprising true (penetrating) acupuncture, advice and exercise. SC plus non-penetrating acupuncture: the self-management booklet and six to eight treatments with a physiotherapist comprising non-penetrating acupuncture, advice and exercise.

MAIN OUTCOME MEASURES

Pilot RCT outcomes included recruitment rates, treatment fidelity, follow-up rate, patient-reported pain and function, quality of life and health-care resource use. Birth and neonatal outcomes were also assessed. Staff overseeing outcome data collection were blind to treatment allocation.

RESULTS

Phase 1: 629 (57.5%) physiotherapists responded to the survey, 499 were experienced in treating pregnancy-related back pain and reported 16 advice and 18 treatment options. Typical treatment comprised two to four individual sessions of advice and exercise over 6 weeks. Acupuncture was reported by 24%. Interviews highlighted the impact of back pain and paucity of effective interventions. Women and midwives strongly supported a RCT and expressed few concerns. Physiotherapists' concerns about acupuncture in pregnancy informed a training programme prior to the pilot RCT. Phase 2: We recruited 125 of 280 potentially eligible women (45%) in 6 months and randomised 41 to SC and 42 each to the SC plus true acupuncture and SC plus non-penetrating acupuncture arms. Analysis was conducted with 124 participants (41, 42 and 41, respectively) as one participant was randomised in error. Three of six recruitment methods were the most successful. In total, 10% of women (n = 4) randomised to SC alone accessed one-to-one physiotherapy and received an average of two treatments. The average number of treatments was six for both SC plus true acupuncture and SC plus non-penetrating acupuncture. Treatments were in line with protocols. Eight-week follow-up was 74%. Patient-reported outcomes (pain, function and quality of life) favoured the addition of acupuncture. There was no evidence of serious adverse events on mothers or birth and neonatal outcomes. The Pelvic Girdle Questionnaire was found to be an appropriate outcome measure for a future trial.

CONCLUSIONS

A future main RCT is feasible and would be welcomed by women and clinicians. Longer-term follow-up and further follow-up efforts are recommended for a main trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49955124.

FUNDING

This project was funded by the National Institute of Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 33. See the NIHR Journals Library website for further project information.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Comparison of the Cost-utility Analysis of Electroacupuncture and Nonsteroidal Antiinflammatory Drugs in the Treatment of Chronic Low Back Pain

INTRODUCTION AND OBJECTIVE

Chronic low back pain (CLBP) is among the most common and important reasons for visiting a spine surgeon by patients; it is the second cause of visiting a doctor. Low back pain can cause considerable suffering and is a major financial burden in the society. There are many different methods available for the treatment of CLBP. This study aimed to compare the cost-utility of electroacupuncture (EA) and nonsteroidal antiinflammatory drugs (NSAIDs), as two common treatment methods for patients with CLBP.

METHODS

This study was conducted on 100 patients suffering from CLBP. Cases were randomly selected from patients referring to two hospitals and four acupuncture clinics in Tehran. Forty-one patients received EA, and 59 patients were prescribed NSAIDs. The EuroQol five dimensions questionnaire was used to calculate quality-adjusted life-year. For calculating the total cost of the two treatment methods, face to face interview with patients was conducted by the researchers (using specific basic literature questionnaire), neurologists, and spine surgeons. The study perspective was social (direct and indirect costs calculated).

RESULTS

The mean age for EA group was 41 ± 2.3 years, and for NSAIDs group, it was 38.0 ± 4.4 years. The average of the utility of patients under treatment by EA and NSAIDs was estimated as 0.70 and 0.627, respectively. The difference in utility between the two groups was significant (p ≤ 0.05). The total cost of EA and NSAIDs was estimated as 461.48 ± 57.8$ and 497.77 ± 85.2$ for one year (2016), respectively, which was also significant (p ≤ 0.05).

CONCLUSION

The results indicate a significant difference between EA and NSAIDs in cases of both utility and total cost. The findings demonstrate that EA is more cost-effective than NSAIDs, as therefore can be considered as an alternative treatment for CLBP, with reasonable cost-utility.

An economic evaluation of Alexander Technique lessons or acupuncture sessions for patients with chronic neck pain: A randomized trial (ATLAS)

Objectives

To assess the cost-effectiveness of acupuncture and usual care, and Alexander Technique lessons and usual care, compared with usual GP care alone for chronic neck pain patients.

Methods

An economic evaluation was undertaken alongside the ATLAS trial, taking both NHS and wider societal viewpoints. Participants were offered up to twelve acupuncture sessions or twenty Alexander lessons (equivalent overall contact time). Costs were in pounds sterling. Effectiveness was measured using the generic EQ-5D to calculate quality adjusted life years (QALYs), as well as using a specific neck pain measure–the Northwick Park Neck Pain Questionnaire (NPQ).

Results

In the base case analysis, incremental QALY gains were 0.032 and 0.025 in the acupuncture and Alexander groups, respectively, in comparison to usual GP care, indicating moderate health benefits for both interventions. Incremental costs were £451 for acupuncture and £667 for Alexander, mainly driven by intervention costs. Acupuncture was likely to be cost-effective (ICER = £18,767/QALY bootstrapped 95% CI £4,426 to £74,562) and was robust to most sensitivity analyses. Alexander lessons were not cost-effective at the lower NICE threshold of £20,000/QALY (£25,101/QALY bootstrapped 95% CI -£150,208 to £248,697) but may be at £30,000/QALY, however, there was considerable statistical uncertainty in all tested scenarios.

Conclusions

In comparison with usual care, acupuncture is likely to be cost-effective for chronic neck pain, whereas, largely due to higher intervention costs, Alexander lessons are unlikely to be cost-effective. However, there were high levels of missing data and further research is needed to assess the long-term cost-effectiveness of these interventions.

Study of acupuncture for low back pain in recent 20 years: a bibliometric analysis via CiteSpace

Background

Acupuncture has been applied to relieve low back pain (LBP) in many countries. However, a bibliometric analysis of the global use of acupuncture for LBP is rare.

Objective

The aim of this study was to demonstrate the state of the art and trends concerning the global use of acupuncture for LBP in recent 20 years.

Methods

Literature relating to acupuncture for LBP from 1997 to 2016 was retrieved from Web of Science. CiteSpace was used to analyze country/institution, cited journals, authors/cited authors, cited references, and keywords. An analysis of counts and centrality was used to reveal publication outputs, countries/institutions, core journals, active authors, foundation references, hot topics, and frontiers.

Results

A total of 958 references were obtained, and the total number of publications continually increased over the investigated period. Journal articles (662) were the most frequently occurring document type. The most productive country and institution in this field was the USA (342) and Harvard University (47), respectively. The J Altern Complem Med (69) was the most productive journal, and Pain (636) was the most cocited journal, which reflected the nature of the research. The Haake’s (2007) article (cocitation counts: 130) and the Cherkin’s (2001) article (centrality: 0.59) were the most representative and symbolic references, with the highest cocitation number and centrality, respectively. Cherkin was the most influential author, with the highest number of publications of 25 and a cocitation number of 226. The four hot topics in acupuncture for LBP were research method, evaluation, economy, and comprehensive therapy. The three frontier topics were intervention, test reliability, and prevalence.

Conclusion

This study provides an insight into acupuncture for LBP and valuable information for acupuncture researchers to identify new perspectives on potential collaborators and cooperative institutions, hot topics, and research frontiers.

Cost-Effectiveness of Non-Invasive and Non-Pharmacological Interventions for Low Back Pain: a Systematic Literature Review

BACKGROUND

Low back pain (LBP) is a major health problem, having a substantial effect on peoples' quality of life and placing a significant economic burden on healthcare systems and, more broadly, societies. Many interventions to alleviate LBP are available but their cost effectiveness is unclear.

OBJECTIVES

To identify, document and appraise studies reporting on the cost effectiveness of non-invasive and non-pharmacological treatment options for LBP.

METHODS

Relevant studies were identified through systematic searches in bibliographic databases (EMBASE, MEDLINE, PsycINFO, Cochrane Library, CINAHL and the National Health Service Economic Evaluation Database), 'similar article' searches and reference list scanning. Study selection was carried out by three assessors, independently. Study quality was assessed using the Consensus on Health Economic Criteria checklist. Data were extracted using customized extraction forms.

RESULTS

Thirty-three studies were identified. Study interventions were categorised as: (1) combined physical exercise and psychological therapy, (2) physical exercise therapy only, (3) information and education, and (4) manual therapy. Interventions assessed within each category varied in terms of their components and delivery. In general, combined physical and psychological treatments, information and education interventions, and manual therapies appeared to be cost effective when compared with the study-specific comparators. There is inconsistent evidence around the cost effectiveness of physical exercise programmes as a whole, with yoga, but not group exercise, being cost effective.

CONCLUSIONS

The identified evidence suggests that combined physical and psychological treatments, medical yoga, information and education programmes, spinal manipulation and acupuncture are likely to be cost-effective options for LBP.

Psychometric properties of the Hebrew version of the Oswestry Disability Index

BACKGROUND

Low back pain (LBP) is one of the most common health complaints, with lifetime prevalence rates as high as 84%. The Oswestry Disability Index (ODI) is often the measure of choice for LBP in both research and clinical settings and, as such, has been translated into 29 languages and dialects. Currently, however, there is no validated version of Hebrew-translated ODI (ODI-H).

OBJECTIVE

To examine the psychometric properties of the ODI-H.

METHODS

Cross-culturally appropriate translation into Hebrew was conducted. A convenience sample of 115 participants (Case Group) with LBP and 68 without LBP (Control Group) completed the ODI-H, SF-36 Health Survey, and two Visual Analog Scales (VAS).

RESULTS

Internal consistency was α = 0.94 and test-retest reliability for 18 participants repeating the ODI-H was 0.97. No floor or ceiling effects were noted for Cases, although there was a floor effect for the Control Group. Scores were significantly different for the two groups, indicating discriminant validity. Concurrent validity was reflected by significant correlations with SF-36 scores, particularly the Physical Functioning and Bodily Pain subscales (-0.83 and -0.79, respectively) and with the VAS (0.84 and 0.79).

CONCLUSIONS

The ODI-H is a valid and reliable measure of low back pain-related disability for the Hebrew-speaking public.

Acupuncture for chronic pain and depression in primary care: a programme of research

Background

There has been an increase in the utilisation of acupuncture in recent years, yet the evidence base is insufficiently well established to be certain about its clinical effectiveness and cost-effectiveness. Addressing the questions related to the evidence base will reduce uncertainty and help policy- and decision-makers with regard to whether or not wider access is appropriate and provides value for money.

Aim

Our aim was to establish the most reliable evidence on the clinical effectiveness and cost-effectiveness of acupuncture for chronic pain by drawing on relevant evidence, including recent high-quality trials, and to develop fresh evidence on acupuncture for depression. To extend the evidence base we synthesised the results of published trials using robust systematic review methodology and conducted a randomised controlled trial (RCT) of acupuncture for depression.

Methods and results

We synthesised the evidence from high-quality trials of acupuncture for chronic pain, consisting of musculoskeletal pain related to the neck and low back, osteoarthritis of the knee, and headache and migraine, involving nearly 18,000 patients. In an individual patient data (IPD) pairwise meta-analysis, acupuncture was significantly better than both sham acupuncture (p < 0.001) and usual care (p < 0.001) for all conditions. Using network meta-analyses, we compared acupuncture with other physical therapies for osteoarthritis of the knee. In both an analysis of all available evidence and an analysis of a subset of better-quality trials, using aggregate-level data, we found acupuncture to be one of the more effective therapies. We developed new Bayesian methods for analysing multiple individual patient-level data sets to evaluate heterogeneous continuous outcomes. An accompanying cost-effectiveness analysis found transcutaneous electrical nerve stimulation (TENS) to be cost-effective for osteoarthritis at a threshold of £20,000 per quality-adjusted life-year when all trials were synthesised. When the analysis was restricted to trials of higher quality with adequate allocation concealment, acupuncture was cost-effective. In a RCT of acupuncture or counselling compared with usual care for depression, in which half the patients were also experiencing comorbid pain, we found acupuncture and counselling to be clinically effective and acupuncture to be cost-effective. For patients in whom acupuncture is inappropriate or unavailable, counselling is cost-effective.

Conclusion

We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed. When all trials are analysed, TENS is cost-effective. Promising clinical and economic evidence on acupuncture for depression needs to be extended to other contexts and settings. For the conditions we have investigated, the drawing together of evidence on acupuncture from this programme of research has substantially reduced levels of uncertainty. We have identified directions for further research. Our research also provides a valuable basis for considering the potential role of acupuncture as a referral option in health care and enabling providers and policy-makers to make decisions based on robust sources of evidence.

Trial registration

Current Controlled Trials ISRCTN63787732.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Comparison of treatment effects on lateral epicondylitis between acupuncture and extracorporeal shockwave therapy

Background

Lateral epicondylitis is one of the most common overuse injuries, and has been reported to reduce function and affect daily activities. There is no standard therapy for lateral epicondylitis. In Hong Kong, acupuncture and extracorporeal shockwave therapy (ESWT) have been popular in treating lateral epicondylitis in recent years.

Objective

This study is to compare the treatment effects of acupuncture and ESWT on lateral epicondylitis.

Methods

In this study, we evaluated 34 patients (34 elbows) with lateral epicondylitis. Seventeen patients were treated by 3-week ESWT, one session per week. Another 17 were treated by 3-week acupuncture therapy, two sessions per week. The outcome measures included pain score by visual analogue scale, maximum grip strength by Jamar dynamometer, and level of functional impairment by disability of arms, shoulders, and hands questionnaire. Participants were assessed at three time points: baseline; after treatment; and 2-week follow-up.

Results

The two treatments showed no significant difference at any assessment time-point. Both treatment groups had significant improvement in pain score in longitudinal comparisons. No significant difference was found in maximum grip strength and functional impairment in either treatment group, but a trend of improvement could be observed. In addition, improvement in pain relief stopped when treatment ended for either groups.

Conclusions

The treatment effects of acupuncture and ESWT on lateral epicondylitis were similar. The pain relief persisted for at least two weeks after treatment.

Identifying back pain subgroups: developing and applying approaches using individual patient data collected within clinical trials

Background

There is good evidence that therapist-delivered interventions have modest beneficial effects for people with low back pain (LBP). Identification of subgroups of people with LBP who may benefit from these different treatment approaches is an important research priority.

Aim and objectives

To improve the clinical effectiveness and cost-effectiveness of LBP treatment by providing patients, their clinical advisors and health-service purchasers with better information about which participants are most likely to benefit from which treatment choices. Our objectives were to synthesise what is already known about the validity, reliability and predictive value of possible treatment moderators (patient factors that predict response to treatment) for therapist-delivered interventions; develop a repository of individual participant data from randomised controlled trials (RCTs) testing therapist-delivered interventions for LBP; determine which participant characteristics, if any, predict clinical response to different treatments for LBP; and determine which participant characteristics, if any, predict the most cost-effective treatments for LBP. Achieving these objectives required substantial methodological work, including the development and evaluation of some novel statistical approaches. This programme of work was not designed to analyse the main effect of interventions and no such interpretations should be made.

Methods

First, we reviewed the literature on treatment moderators and subgroups. We initially invited investigators of trials of therapist-delivered interventions for LBP with > 179 participants to share their data with us; some further smaller trials that were offered to us were also included. Using these trials we developed a repository of individual participant data of therapist-delivered interventions for LBP. Using this data set we sought to identify which participant characteristics, if any, predict response to different treatments (moderators) for clinical effectiveness and cost-effectiveness outcomes. We undertook an analysis of covariance to identify potential moderators to apply in our main analyses. Subsequently, we developed and applied three methods of subgroup identification: recursive partitioning (interaction trees and subgroup identification based on a differential effect search); adaptive risk group refinement; and an individual participant data indirect network meta-analysis (NWMA) to identify subgroups defined by multiple parameters.

Results

We included data from 19 RCTs with 9328 participants (mean age 49 years, 57% females). Our prespecified analyses using recursive partitioning and adaptive risk group refinement performed well and allowed us to identify some subgroups. The differences in the effect size in the different subgroups were typically small and unlikely to be clinically meaningful. Increasing baseline severity on the outcome of interest was the strongest driver of subgroup identification that we identified. Additionally, we explored the application of Bayesian indirect NWMA. This method produced varying probabilities that a particular treatment choice would be most likely to be effective for a specific patient profile.

Conclusions

These data lack clinical effectiveness or cost-effectiveness justification for the use of baseline characteristics in the development of subgroups for back pain. The methodological developments from this work have the potential to be applied in other clinical areas. The pooled repository database will serve as a valuable resource to the LBP research community.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme. This project benefited from facilities funded through Birmingham Science City Translational Medicine Clinical Research and Infrastructure Trials Platform, with support from Advantage West Midlands (AWM) and the Wolfson Foundation.

Acupuncture for chronic neck pain: a protocol for an updated systematic review

BACKGROUND

This study aims to investigate the efficacy and safety of acupuncture for patients with chronic neck pain.

METHODS

The MEDLINE, EMBASE, CENTRAL, CINAHL, and the Chinese Biomedical Literature Database, the China National Knowledge Infrastructure, VIP Information, and Wanfang Data databases will be searched from their inception to present. Randomised controlled trials (RCTs) of acupuncture (assessed as the sole treatment or as an adjunct treatment) for chronic neck pain will be included. The primary outcome is chronic neck pain measured by the visual analogue scale (VAS), McGill Pain Questionnaire, or short-form McGill Pain Questionnaire. The secondary outcomes will include the functional recovery, health-related quality of life, psychological improvements related to the reduction of pain, and adverse events. Two authors will perform the study selection, data extraction, and quality assessment independently. Any disagreements will be resolved through discussion with a third author. Methodological quality of the included trials will be evaluated by the Cochrane risk-of-bias criteria, and the Standards for Reporting Interventions in Controlled Trials of Acupuncture checklist will be used to assess completeness of reporting.

DISCUSSION

The results of this systematic review will provide the latest evidence of the efficacy of acupuncture in treating chronic neck pain, which will benefit both practitioners and policymakers.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015017178.

Does Acupuncture Treatment Affect Utilization of Other Hospital Services at an Urban Safety-Net Hospital?

BACKGROUND

Little is known regarding the interaction between acupuncture and biomedical healthcare among vulnerable patient populations. In particular, the association between acupuncture and total cost of healthcare has not been characterized.

METHODS

Total hospital system visits and associated charges were retrospectively reviewed among patients who received acupuncture at a large safety-net hospital system from 2007 to 2014. Inclusion criteria were Medicare or Medicaid insurance coverage, older than age 18 years, and one or more on-site acupuncture appointments. Patients were stratified into five groups based on the number of acupuncture visits: 1-3, 4-6, 7-9, 10-12, or 13-15 treatments. The total number of biomedical hospital visits and total associated charges were compared 6 months before and 6 months after initiation of acupuncture.

RESULTS

A total of 329 patients met our inclusion criteria. Although not statistically significant, there appeared to be an association between acupuncture treatment and a decrease in total hospital charges. The group receiving 1-3 acupuncture treatments showed a per-patient average increase in total charges in the 6-month period after acupuncture ($1771.34; p = 0.38). The patients who received 7-9 treatments showed the largest average decrease in total charges ($8967.24; p = 0.17).

CONCLUSION

This study shows a previously unreported aggregate relationship between number of treatments and total healthcare charges in a single urban safety-net hospital. Given the sample size available and the heterogeneity of the patient population, no statistically significant associations could be established between initiation of acupuncture treatment and charges. However, some suggestive patterns were observed. Further prospective studies with a matched-group control are warranted to further explore this relationship. Additional study across wider locations is warranted to best guide practitioners and hospitals in designing efficacious, high-value integrative medicine programs.

Unanticipated Insights into Biomedicine from the Study of Acupuncture

Research into acupuncture has had ripple effects beyond the field of acupuncture. This paper identifies five exemplars to illustrate that there is tangible evidence of the way insights gleaned from acupuncture research have informed biomedical research, practice, or policy. The first exemplar documents how early research into acupuncture analgesia has expanded into neuroimaging research, broadening physiologic understanding and treatment of chronic pain. The second describes how the acupuncture needle has become a tool to enhance biomedical knowledge of connective tissue. The third exemplar, which illustrates use of a modified acupuncture needle as a sham device, focuses on emergent understanding of placebo effects and, in turn, on insights into therapeutic encounters in treatments unrelated to acupuncture. The fourth exemplar documents that two medical devices now in widespread use were inspired by acupuncture: transcutaneous electrical nerve stimulators for pain control and antinausea wrist bands. The final exemplar describes how pragmatic clinical trial designs applied in acupuncture research have informed current general interest in comparative effectiveness research. In conclusion, these exemplars of unanticipated outcomes of acupuncture research comprise an additional rationale for continued support of basic and clinical research evaluating acupuncture and other under-researched therapies.

Factors affecting decision-making of patients choosing acupuncture in a public hospital

BACKGROUND

With increasing evidence to support its practice, acupuncture has been integrated within many hospitals around the world. The purpose of this study is to understand the factors affecting decision making of patients as they select acupuncture treatment for their medical conditions and symptoms within a public hospital.

METHODS

A qualitative study consisting of in depth interviews with 14 patients was conducted. All patients attended an acupuncture clinic within a public hospital. Data collected was analysed via thematic analysis.

RESULTS

Four main factor groups affecting decision making of patients were identified- factors affecting the level and value of patient-centric care, the confidence and trust patients place within the acupuncture service, the presence of collaborative efforts between acupuncturists and Western medicine practitioners, and the knowledge, culture and belief society has regarding the role of acupuncture and Western medicine. All participants interviewed had more than one factor group present as enablers toward their eventual selection of acupuncture for ailment management. It was also noted that although the majority of participants had sufficient knowledge regarding acupuncture, there were a select few who had misperceptions or no knowledge regarding certain aspects of acupuncture.

CONCLUSIONS

There may be certain patterns in the way patients choose to utilise acupuncture services in public hospitals. Further studies should also be carried out in other public hospitals to analyse the factor groups identified further.

Efficacy of acupuncture and electroacupuncture in patients with nonspecific low back pain: study protocol for a randomized controlled trial

BACKGROUND

Previous studies have shown that acupuncture and electroacupuncture (EA) are effective in the treatment of patients with low back pain. However, there is little evidence to support the use of one intervention over the other. The aim of this study is to compare the effect of acupuncture and electroacupuncture in the treatment of pain and disability in patients with chronic nonspecific low back pain.

METHODS/DESIGN

The study design is a randomized controlled trial. Patients with nonspecific chronic low back pain of more than three months duration are recruited at Rehabilitation Center of Taboao da Serra - SP (Brazil). After examination, sixty-six patients will be randomized into one of two groups: acupuncture group (AG) (n = 33) and electroacupuncture group (EG) (n = 33). Interventions will last one hour, and will happen twice a week for 6 weeks. The primary clinical outcomes will be pain intensity as measured and functional disability.

SECONDARY OUTCOMES

quality of pain, quality of life. perception of the overall effect, depressive state, flexibility and kinesiophobia. All the outcomes will be assessed will be assessed at baseline, at treatment end, and three months after treatment end. Significance level will be determined at the 5 % level. Results of this trial will help clarify the value of acupuncture and electroacupuncture as a treatment for chronic low back pain and if they are different.

DISCUSSION

Results of this trial will help clarify the value of acupuncture needling and electroacupuncture stimulation of specific points on the body as a treatment for chronic low back pain.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02039037 . Register October 30, 2013.

Implementing stratified primary care management for low back pain: cost-utility analysis alongside a prospective, population-based, sequential comparison study

STUDY DESIGN

Within-study cost-utility analysis.

OBJECTIVE

To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within risk-defined patient subgroups (that is, patients at low, medium, and high risk of persistent disabling pain).

SUMMARY OF BACKGROUND DATA

Individual-level data collected alongside a prospective, sequential comparison of separate patient cohorts with 6-month follow-up.

METHODS

Adopting a cost-utility framework, the base case analysis estimated the incremental LBP-related health care cost per additional quality-adjusted life year (QALY) by risk subgroup. QALYs were constructed from responses to the 3-level EQ-5D, a preference-based health-related quality of life instrument. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses examined alternative methodological approaches, including a complete case analysis, the incorporation of non-back pain-related health care use and estimation of societal costs relating to work absence.

RESULTS

Stratified care was a dominant treatment strategy compared with usual care for patients at high risk, with mean health care cost savings of £124 and an incremental QALY estimate of 0.023. The likelihood that stratified care provides a cost-effective use of resources for patients at low and medium risk is no greater than 60% irrespective of a decision makers' willingness-to-pay for additional QALYs. Patients at medium and high risk of persistent disability in paid employment at 6-month follow-up reported, on average, 6 fewer days of LBP-related work absence in the stratified care cohort compared with usual care (associated societal cost savings per employed patient of £736 and £652, respectively).

CONCLUSION

At the observed level of adherence to screening tool recommendations for matched treatments, stratified care for LBP is cost-effective for patients at high risk of persistent disabling LBP only.

LEVEL OF EVIDENCE

2.

The reasons for using acupuncture for pain relief

Background:

Acupuncture has recently received considerable attention around the world due to its cost-effectiveness, few side effects, and well-established analgesic properties.

Objectives:

The present study aimed to identify the factors that might lead to using acupuncture for pain relief.

Patients and Methods:

This qualitative study was conducted using conventional content analysis method. The study population included eight patients and six highly experienced acupuncturists, who were able to express their opinion and were willing to take part in the study. The inclusion criteria for patients were being under treatment with acupuncture for pain relief or a history of treatment during the last year and age > 18 years. All highly trained acupuncturists with minimum of one-year active experience were included. The data were collected via semi-structured in-depth interviews. Categories were extracted through inductive analysis and codes and eventually, themes emerged. Data rigor was assured by data collection triangulation, participants’ variety, and external and members’ check.

Results:

Initially, 1311 primary codes were extracted, then the related codes were divided into 127 subcategories according to their similarities, and after reduction and integration process, 16 categories were developed from subcategories and eventually five themes were determined, including conventional medicine limitation, efficacy of acupuncture, external promoters, internal promoters, and acupuncture inhibitors.

Conclusions:

The important factors that affect choosing acupuncture for pain relief included conventional medicine limitations, external promoters, internal promoters, acupuncture efficacy, and acupuncture inhibitors. More interest can be drawn to this technique by basic planning to enhance some of the underlying factors and eliminate obstacles to its further applicability.

Evaluating the economics of complementary and integrative medicine

Healthcare in the United States is expensive and becoming more so every year. Policy and decision makers increasingly need information on costs, as well as effectiveness and safety, in order to formulate health-care strategies that are both clinically effective and financially responsible.

Many people believe the benefits of complementary and integrative medicine (CIM) exceed its costs. Surveys have shown that a substantial portion of the US population uses CIM and pays directly for that use.^1–4 The most recent estimates show that total US out-of-pocket expenditures for CIM were $34 billion—11% of all US out-of-pocket healthcare expenditures.¹ However, if CIM is to be considered in broader healthcare strategies, its economic impact must be determined.

Theoretically, CIM seems a good candidate for cost-effectiveness, and even cost savings, because it avoids high technology, offers inexpensive and noninvasive remedies, encourages healthy lifestyle change, and focuses on the whole person, all of which may improve health beyond the targeted disease or condition. However, to many in the conventional health-care system, CIM is seen only as an “add on” expense. What must be demonstrated via economic evaluation are the healthcare costs that can be avoided through the use of CIM.

CIM offers the potential for several avenues of cost reduction. The first is as a direct replacement for the usual conventional therapy for a condition. The second is in terms of lower future healthcare utilization both in general (through treating the whole person) and for the targeted disease or condition. A third avenue to cost reduction is through reducing productivity loss for employers. A reduction in costs to employers does not directly reduce healthcare costs (unless the employer is itself a health-care facility); however, both are costs to society. Productivity losses can be reduced through improved employee health, and potentially through the improved employee well-being and empowerment offered by CIM.

Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis

STUDY DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs).

OBJECTIVE

To evaluate the totality of evidence in relation to the effectiveness of acupuncture for nonspecific chronic low back pain (NSCLBP).

SUMMARY OF BACKGROUND DATA

Acupuncture has become a popular alternative for treating clinical symptoms of NSCLBP. A number of RCTs have examined the effectiveness of acupuncture in the treatment of NSCLBP.

METHODS

A systematic literature search was completed without date or language restrictions up to May 2012. Studies included in the review were RCTs that examined all forms of acupuncture that adhered to the Traditional Acupuncture Theory for treating NSCLBP. Outcome measures included impairment, activity limitation, and participation restriction. The methodological quality of the studies was examined using the Cochrane risk of bias tool.

RESULTS

Thirty-two studies were included in the systematic review, of which 25 studies presented relevant data for the meta-analysis. Acupuncture had a clinically meaningful reduction in levels of self-reported pain (mean difference =-16.76 [95% confidence interval, -33.33 to -0.19], P = 0.05, I = 90%) when compared with sham, and improved function (standard mean difference =-0.94 [95% confidence interval, -1.41 to -0.47], P < 0.00, I = 78%) when compared with no treatment immediately postintervention. Levels of function also clinically improved when acupuncture in addition to usual care, or electroacupuncture was compared with usual care alone. When acupuncture was compared with medications (NSAIDs, muscle relaxants, and analgesics) and usual care, there were statistically significant differences between the control and the intervention groups but these differences were too small to be of any clinical significance. There was no evidence in support of acupuncture over transcutaneous electrical nerve stimulation.

CONCLUSION

This systematic review demonstrates that acupuncture may have a favorable effect on self-reported pain and functional limitations on NSCLBP. However, the results should be interpreted in the context of the limitations identified, particularly in relation to the heterogeneity in the study characteristics and the low methodological quality in many of the included studies.

LEVEL OF EVIDENCE

1.