NICE rejects acupuncture for low back pain

Of all types of alternative medicine, acupuncture is the one that has received the most approval from regular medicine. The benefit of that is that it’s been tested more thoroughly than most others. The result is now clear. It doesn’t work. See the evidence in Acupuncture is a theatrical placebo.

This blog has documented many cases of misreported tests of acupuncture, often from people have a financial interests in selling it. Perhaps the most egregious spin came from the University of Exeter. It was published in a normal journal, and endorsed by the journal’s editor, despite showing clearly that acupuncture didn’t even have much placebo effect.

Acupuncture got a boost in 2009 from, of all unlikely sources, the National Institute for Health and Care Excellence (NICE). The judgements of NICE and the benefit / cost ratio of treatments are usually very good. But the guidance group that they assembled to judge treatments for low back pain was atypically incompetent when it came to assessment of evidence. They recommended acupuncture as one option. At the time I posted “NICE falls for Bait and Switch by acupuncturists and chiropractors: it has let down the public and itself“. That was soon followed by two more posts:

NICE fiasco, part 2. Rawlins should withdraw guidance and start again“,

and

“The NICE fiasco, Part 3. Too many vested interests, not enough honesty“.

At the time, NICE was being run by Michael Rawlins, an old friend. No doubt he was unaware of the bad guidance until it was too late and he felt obliged to defend it.

Although the 2008 guidance referred only to low back pain, it gave an opening for acupuncturists to penetrate the NHS. Like all quacks, they are experts at bait and switch. The penetration of quackery was exacerbated by the privatisation of physiotherapy services to organisations like Connect Physical Health which have little regard for evidence, but a good eye for sales. If you think that’s an exaggeration, read "Connect Physical Health sells quackery to NHS".

When David Haslam took over the reins at NICE, I was optimistic that the question would be revisited (it turned out that he was aware of this blog). I was not disappointed. This time the guidance group had much more critical members.

The new draft guidance on low back pain was released on 24 March 2016. The final guidance will not appear until September 2016, but last time the final version didn’t differ much from the draft.

Despite modern imaging methods, it still isn’t possible to pinpoint the precise cause of low back pain (LBP) so diagnoses are lumped together as non-specific low back pain (NSLBP).

The summary guidance is explicit.

“1.2.8 Do not offer acupuncture for managing non-specific low back 7 pain with or without sciatica.”
 

The evidence is summarised section 13.6 of the main report (page 493).There is a long list of other proposed treatments that are not recommended.

Because low back pain is so common, and so difficult to treat, many treatments have been proposed. Many of them, including acupuncture, have proved to be clutching at straws. It’s to the great credit of the new guidance group that they have resisted that temptation.

Among the other "do not offer" treatments are

• imaging (except in specialist setting)
• belts or corsets
• foot orthotics
• acupuncture
• ultrasound
• TENS or PENS
• opioids (for acute or chronic LBP)
• antidepressants (SSRI and others)
• anticonvulsants
• spinal injections
• spinal fusion for NSLBP (except as part of a randomised controlled trial)
• disc replacement

At first sight, the new guidance looks like an excellent clear-out of the myths that surround the treatment of low back pain.

The positive recommendations that are made are all for things that have modest effects (at best). For example “Consider a group exercise programme”, and “Consider manipulation, mobilisation”. The use of there word “consider”, rather than “offer” seems to be NICE-speak -an implicit suggestion that it doesn’t work very well. My only criticism of the report is that it doesn’t say sufficiently bluntly that non-specific low back pain is largely an unsolved problem. Most of what’s seen is probably a result of that most deceptive phenomenon, regression to the mean.

One pain specialist put it to me thus. “Think of the billions spent on back pain research over the years in order to reach the conclusion that nothing much works – shameful really.” Well perhaps not shameful: it isn’t for want of trying. It’s just a very difficult problem. But pretending that there are solutions doesn’t help anyone.

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