Article: Pain Management Review of Accupuncture

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Manual Therapies and Acupuncture for Low Back and Neck Pain

Disclosures

Jennie C. Tsao, PhD

In the symposium "Manual Therapies and Acupuncture for Low Back and Neck Pain,[1]" a panel of experts evaluated the use of complementary and manual therapies for back and neck pain. Dr. Cynthia Myers, from the University of California at Los Angeles, discussed a recent study[2] from a nationally representative US sample that found that 33% of those surveyed had back or neck pain in the past year, and of these, 29% used alternative therapy without conventional care and 24% used both complementary and conventional care. Factors associated with the use of complementary therapies include having pain at more than 1 site, being female, and age (use peaked in the fifth decade). Most commonly used therapies were chiropractic (20%), massage (14%), and relaxation (12%). Massage and chiropractic were perceived as helpful by 65% and 61% of respondents, respectively, whereas conventional care was perceived as helpful by 27%.

Dr. Karen Sherman from the Group Health Cooperative, Seattle, Washington, described the practice of acupuncture, massage, and chiropractic by licensed providers for back pain, and reviewed the evidence for effectiveness, safety, and cost-effectiveness of these interventions. Data were drawn from surveys of therapists[3] and systematic reviews, including randomized, controlled trials of patients with low back pain.[4] For acupuncture, most practitioners (92%) used the Traditional Chinese Medicine approach, with two-thirds including heat and self-care recommendations. Evidence for effectiveness of acupuncture remains unclear, despite newer studies of better quality. Studies indicate that acupuncture resulted in very few serious adverse events. Costs of subsequent back care were similar in patients receiving acupuncture vs self-care over a 1-year period.

For massage, most therapists used deep tissue (83%) or Swedish (81%) techniques as well as self-care recommendations (86%). A recent Cochrane review concluded that there is moderate evidence that massage improves pain intensity and quality for patients with subacute low back pain and that massage improves pain intensity and function in patients with chronic low back pain.[5] Massage is generally safe if done properly.[6] Costs of subsequent back care were lower in patients receiving massage vs acupuncture and self-care over a 1-year period.

For chiropractic, most therapists used spinal adjustment (87%) and fewer recommended self-care (28%). The general conclusion from newer studies is that spinal manipulation is not better than other standard care for low back pain. A systematic review[7] found no serious adverse events following spinal manipulation. When compared with an educational booklet, chiropractic treatment did not reduce the cost of back care 2 years post treatment, and it was not different from physical therapy in costs or effectiveness.

Anita Gross, of the McMaster University School of Rehabilitation Sciences in Hamilton, Ontario, Canada, presented the results of a systematic review[8] to determine whether conservative management of mechanical neck disorders leads to clinical improvement. Long-term benefits were found for a multimodal approach (mobilization and/or manipulation combined with exercise), strengthening exercises, epidural injection, and intravenous injection of glucocorticoid. The evidence supporting a multimodal approach was strong, although the magnitude of improvement in pain/functioning was relatively small, despite high patient-perceived effectiveness. Moderate evidence of benefit was found for "vertigo" exercises, intermittent traction, low-level laser therapy, local anesthetic injections, and subcutaneous injections in trials with short-term follow-up. Limited evidence was found for stretching exercises, water pillows, and orthopaedic pillows. Unknown effectiveness (conflicting evidence) was found for massage, manipulation and mobilization combined, short-wave diathermy, ultrasound, pulsed electromagnetic field therapy, galvanic current, and acupuncture. Cold/ice, heat, infrared light, spray and stretch, diadynamic currents, microcurrents, transcutaneous electrical nerve stimulation, magnetic necklaces, rest, collars for whiplash-associated disorders II or III, and mobilization or manipulation done alone are unlikely to be beneficial.

References

1. Myers C, Sherman K, Gross A. Manual therapies and acupuncture for low back and neck pain. Program and abstracts of the 23rd Annual Meeting of the American Pain Society; May 6-9, 2004; Vancouver, British Columbia, Canada. Symposium 313.

2. Wolsko PM, Eisenberg DM, Davis RB, Kessler R, Phillips RS. Patterns and perceptions of care for treatment of back and neck pain: results from a national survey. Spine. 2003;28:292-297.

3. Cherkin DC, Deyo RA, Sherman KJ, et al. Characteristics of licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. J Am Board Fam Pract. 2002;15:378-390.

4. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG, Ernst E. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med. 2003;138:898-906.

5. Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low-back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 2002;27:1896-1910.

6. Ernst E. The safety of massage therapy. Rheumatology (Oxford). 2003;42:1101-1106.

7. Ernst E. Prospective investigations into the safety of spinal manipulation. The safety of massage therapy. J Pain Symptom Manage. 2001;21:238-242.

8. Gross AR, Kay T, Hondras M, et al. Manual therapy for mechanical neck disorders: a systematic review. Man Ther. 2002;7:131-149.