MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

In 2010, NICE recommended acupuncture for chronic low back pain (cLBP). Acupuncturists were of course delighted; the British Acupuncture Council, for instance, stated that they fully support NICE’s (National Institute for Health and Clinical Excellence) decision that acupuncture be made available on the NHS for chronic lower back pain. Traditional acupuncture has been used for over 2,000 years to alleviate back pain and British Acupuncture Council members have for many many years been successfully treating patients for this condition either in private practice or working within the NHS. In effect, therefore, these new guidelines are a rubber stamp of the positive work already being undertaken as well as an endorsement of the wealth of research evidence now available in this area.

More critical experts, however, tended to be surprised about this move and doubted that the evidence was strong enough for a positive recommendation. Now a brand-new meta-analysis sheds more light on this important issue.

Its aim was to determine the effectiveness of acupuncture as a therapy for cLBP. The authors found 13 RCTs which matched their inclusion criteria. Their results show that, compared with no treatment, acupuncture achieved better outcomes in terms of pain relief, disability recovery and better quality of life. These effects were, however, not observed when real acupuncture was compared to sham acupuncture. Acupuncture achieved better outcomes when compared with other treatments. No publication bias was detected.

The authors conclude that acupuncture is an effective treatment for chronic low back pain, but this effect is likely to be produced by the nonspecific effects of manipulation.

In plain English, this means that the effects of acupuncture on cLBP are most likely due to placebo. Should NICE be recommending placebo-treatments and have the tax payer foot the bill? I think I can leave it to my readers to answer this question.

6 Responses to Should NICE recommend placebos?

  • Only honestly, with informed consent, and in the cheapest and most minimal form that is effective. If sham acupuncture is as effective as acupuncture, then sending patients to someone who will make unfounded claims about qi and meridians is immoral quackery.

    It could be that sham and ‘real’ acupuncture has some effect beyond placebo, with the needle affecting patient’s perceptions of back-pain, but it is important not to dress this up with misleading stories.

    One difficulty with this is that there may be few people willing to train to become a sham accupuncturist!

    • Randal – “…sending patients to someone who will make unfounded claims about qi and meridians is immoral quackery.”

      A more honest/accurate statement would be “I’m ignorant of other medical systems, including their technical language and treatment models. They are based in a scientific model that I haven’t taken the time to understand. I’ll send you to someone who knows what they are talking about. For me to do otherwise would be immoral quackery.”

  • Edzard,

    In your 2005 meta-analysis your team found acupuncture to be significantly better than sham for low back pain (http://www.ncbi.nlm.nih.gov/pubmed/15838072). Can you address the weaknesses, changes, or different strengths of evidence which make the newer study showing no difference than sham to be a more authoritative conclusion?

    • the non-penetrating needles which best control for placebo have only become available recently. so the difference between the two analyses is essentially that our 2005 review was based on data which was more biased and therefore false positive. simple!?

  • “In plain English, this means that the effects of acupuncture on cLBP are most likely due to placebo. Should NICE be recommending placebo-treatments and have the tax payer foot the bill?”

    Should nice recommend and pay for a treatment, placebo or not that can have the same effect on the brain as opioids?

  • The authors said: “In line with behavioural data that show decreased pain responses under placebo, pain-related activity in the spinal cord is strongly reduced under placebo.
    “These results provide direct evidence for spinal inhibition as one mechanism of placebo analgesia and highlight that psychological factors can act on the earliest stages of pain processing in the central nervous system.”
    The team said their work was clinically significant because it opens up new ways for assessing the effectiveness of and possible site of action of new treatments for various forms of pain, including chronic pain”.
    The findings were published in the journal Science.
    A placebo, the giving out of a sham medicine, is used in medical research to test the effectiveness of new treatments. It allows researchers to compare and contrast the actual performance of a new drug or treatment.
    However researchers began to find that the fake medicines could actually have an effect.

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