Spinal Pain

douleurs rachidiennes : évaluation de l'acupuncture

1. Systematic Reviews and Meta-Analysis

☆☆☆	Evidence for effectiveness and a specific effect of acupuncture.
☆☆	Evidence for effectiveness of acupuncture.
☆	Limited evidence for effectiveness of acupuncture.
Ø	No evidence or insufficient evidence.

1.1. Generic Acupuncture

1.1.1. Vickers 2018 ★★★

Vickers AJ, Vertosick EA, Lewith G et al, Acupuncture Trialists' Collaboration. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain. 2018 May;19(5):455-474. [168043]

Purpose	Our objective was to update an individual patient data meta-analysis to determine the effect size of acupuncture for 4 chronic pain conditionss.
Methods	We searched MEDLINE and the Cochrane Central Registry of Controlled Trials randomized trials published up until December 31, 2015. We included randomized trials of acupuncture needling versus either sham acupuncture or no acupuncture control for nonspecific musculoskeletal pain, osteoarthritis, chronic headache, or shoulder pain. Trials were only included if allocation concealment was unambiguously determined to be adequate. Raw data were obtained from study authors and entered into an individual patient data meta-analysis.
Results	The main outcome measures were pain and function. An additional 13 trials were identified, with data received for a total of 20,827 patients from 39 trials. Acupuncture was superior to sham as well as no acupuncture control for each pain condition (all P < .001) with differences between groups close to .5 SDs compared with no acupuncture control and close to .2 SDs compared with sham. We also found clear evidence that the effects of acupuncture persist over time with only a small decrease, approximately 15%, in treatment effect at 1 year. In secondary analyses, we found no obvious association between trial outcome and characteristics of acupuncture treatment, but effect sizes of acupuncture were associated with the type of control group, with smaller effects sizes for sham controlled trials that used a penetrating needle for sham, and for trials that had high intensity of intervention in the control arm. We conclude that acupuncture is effective for the treatment of chronic pain, with treatment effects persisting over time. Although factors in addition to the specific effects of needling at correct acupuncture point locations are important contributors to the treatment effect, decreases in pain after acupuncture cannot be explained solely in terms of placebo effects. Variations in the effect size of acupuncture in different trials are driven predominantly by differences in treatments received by the control group rather than by differences in the characteristics of acupuncture treatment.
Perspective	Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain..

1.1.2. Yuan 2015 ★★

Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional Chinese Medicine for Neck Pain and Low Back Pain: A Systematic Review and Meta-Analysis. 2015;PLoS One. 2015 Feb 24;10(2):e0117146. doi: 10.1371/journal.pone.0117146. eCollection 2015.[141558]

Purpose	Neck pain (NP) and low back pain (LBP) are common symptoms bothering people in daily life. Traditional Chinese medicine (TCM) has been used to treat various symptoms and diseases in China and has been demonstrated to be effective. The objective of the present study was to review and analyze the existing data about pain and disability in TCM treatments for NP and LBP.
Methods	Studies were identified by a comprehensive search of databases, such as MEDLINE, EMBASE, and Cochrane Library, up to September 1, 2013. A meta-analysis was performed to evaluate the efficacy and safety of TCM in managing NP and LBP.
Results	Seventy five randomized controlled trials (n = 11077) were included. Almost all of the studies investigated individuals experiencing chronic NP (CNP) or chronic LBP (CLBP). We found moderate evidence that acupuncture was more effective than sham-acupuncture in reducing pain immediately post-treatment for CNP (visual analogue scale (VAS) 10 cm, mean difference (MD) = -0.58 (-0.94, -0.22), 95%confidence interval, p = 0.01), CLBP (standardized mean difference = -0.47 (-0.77, -0.17), p = 0.003), and acute LBP (VAS 10 cm, MD = -0.99(-1.24, -0.73), p< 0.001). Cupping could bemore effective than waitlist in VAS (100mm)(MD = -19.10 (-27.61, -10.58), p < 0. 001) for CNP or medications (e.g. NSAID) for CLBP (MD = -5.4 (-8.9, -0.19), p = 0.003). No serious or life-threatening adverse effects were found.
Conclusion	Acupuncture, acupressure, and cupping could be efficacious in treating the pain and disability associated with CNP or CLBP in the immediate term. Gua sha, tai chi, qigong, and Chinese manipulation showed fair effects, but we were unable to draw any definite conclusions, and further research is still needed. The efficacy of tuina and moxibustion is unknown because no direct evidence was obtained. These TCM modalities are relatively safe.

1.1.3. Vickers 2012 ★★★

Vickers AJ, Cronin AM, Maschino AC, et al; Acupuncture Trialists’Collaboration. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med 2012;172:1444-53. [157530]

Purpose	We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain.
Methods	We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 5 RCTs, with a total of 3488 patients analyzed.
Results	In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and noacupuncture control for each pain condition (P< 0,001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13-0.33)SDs lower than sham controls for back and neck pain; the effect sizes in comparison to noacupuncture controls were 0.55 (95% CI, 0.51-0.58),SDs.These results were robust to a variety of sensitivity analyses, including those related to publication bias.
Conclusion	Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo (Conclusions sur la douleur chronique en général).

1.1.4. Furlan 2012 ★★

Furlan AD, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L, Gagnier J, Ammendolia C, Dryden T, Doucette S, Skidmore B, Daniel R, Ostermann T, Tsouros S. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med. 2012. [168178].

Background	Back pain is a common problem and a major cause of disability and health care utilization. Purpose. To evaluate the efficacy, harms, and costs of the most common CAM treatments (acupuncture, massage, spinal manipulation, and mobilization) for neck/low-back pain.
Methods	Data Sources: records without language restriction from various databases up to February 2010. Data Extraction: the efficacy outcomes of interest were pain intensity and disability. Data Synthesis: reports of 147 randomized trials and 5 nonrandomized studies were included. CAM treatments were more effective in reducing pain and disability compared to no treatment, physical therapy (exercise and/or electrotherapy) or usual care immediately or at short-term follow-up. Trials that applied sham-acupuncture tended towards statistically nonsignificant results. In several studies, acupuncture caused bleeding on the site of application, and manipulation and massage caused pain episodes of mild and transient nature.
Conclusions	CAM treatments were significantly more efficacious than no treatment, placebo, physical therapy, or usual care in reducing pain immediately or at short-term after treatment. CAM therapies did not significantly reduce disability compared to sham. None of the CAM treatments was shown systematically as superior to one another. More efforts are needed to improve the conduct and reporting of studies of CAM treatments.

1.2. Special outcome

1.2.1. Lu 2011 (quality of life) ★★

Lu SC, Zheng Z, Xue CC. Does acupuncture improve quality of life for patients with pain associated with the spine? A systematic review. Evid Based Complement Alternat Med. 2011;301767. [158473].

Background	This paper aimed to evaluate the effectiveness of acupuncture for qualities of life (QoL) in patients suffering from pain associated with the spine (PAWS). Acupuncture has been shown to reduce pain severity, but its effect on QoL is unknown.
Methods	PubMed, CINAHL, and Cochrane Central Register of Controlled Trials as well as EMBASE were searched. Published randomized controlled trials on PAWS comparing acupuncture with waiting-list or sham interventions were considered.
Results	Eight out of 186 trials were included. For physical functioning, acupuncture was better than waiting-list at immediate and short-term followups; and was better than sham interventions at immediate assessment (SMD = 0.40. 95% CI 0.06 to 0.74). For mental functioning, acupuncture was better than waiting-list at short-term followup and sham interventions at intermediate-term followup (SMD = 0.27. 95% CI 0.03 to 0.51). A similar effect was observed on pain reduction. Discrepancies in point selection for relieving anxiety and insufficient training of trial acupuncturists were also identified.
Conclusions	Acupuncture has a moderate effect on the improvement of physical functioning and pain for PAWS patients in the short term; but the effect for mental functioning is small and delayed. Future trials should address point selection and consistency in the qualifications of trial acupuncturists.

1.2.2. Smith 2000 Φ

Smith LA, Oldman AD, McQuay HJ,Moore RA. Teasing apart quality and validity in systematic reviews: an example from acupuncture trials in chronic neck and back pain. Pain. 2000;83:119-132. [86317]

Background	The objectives of the study were (1) to carry out a systematic review to assess the analgesic efficacy and the adverse effects of acupuncture compared with placebo for back and neck pain and (2) to develop a new tool, the Oxford Pain Validity Scale (OPVS). to measure validity of findings from randomized controlled trials (RCTs), and to enable ranking of trial findings according to validity within qualitative reviews.
Methods	Data Sources: Data Synthesis Published RCTs (of acupuncture at both traditional and non-traditional points) were dentified from systematic searching of bibliographic databases (e.g. MEDLINE) and reference lists of retrieved reports. Pain outcome data were extracted with preference given to standardized outcomes such as pain intensity. Information on adverse effects was also extracted. All included trials were scored using a five-item 0-16 point validity scale (OPVS). The individual RCTs were ranked according to their OPVS score to enable more weight to be placed on the trials of greater validity when drawing an overall conclusion about the efficacy of acupuncture for relieving neck and back pain. Statistical analyses were carried out on the OPVS scores to assess the Relationship between trial finding (positive or negative) and validity. Thirteen RCTs met the inclusion criteria. Five trials concluded that acupuncture was effective, and eight concluded that it was not effective for relieving back or neck pain. There was no obvious difference between the findings of trials using traditional and non-traditional points. Using the new OPVS scale. the validity scores of the included trials ranged from 4 to 14. There was no significant relationship between OPVS score and trial finding (positive versus negative).
Conclusions	Authors' conclusions did not always agree with their data. We drew our own conclusions (positive/negative) based on the data presented in the reports. Reanalysis using our conclusions showed a significant relationship between OPVS score and trial finding, with higher validity scores associated with negative findings. OPVS is a useful tool for assessing the validity of trials in qualitative reviews. With acupuncture for chronic back and neck pain, we found that the most valid trials tended to be negative. There is no convincing evidence for the analgesic efficacy of acupuncture for back or neck pain.

2. Cost-Effectiveness Analysis

See corresponding item

3. Clinical Practice Guidelines

3.1. AIM Specialty Health (USA) 2019 ⊕

Spine Surgery. Musculoskeletal Program Clinical Appropriateness Guidelines. AIM Specialty Health. 2019;:42P. [198043].

Cervical Decompression With or Without Fusion/ Cervical Disc Arthroplasty/ Lumbar Disc Arthroplasty/ Lumbar Discectomy, Foraminotomy, and Laminotomy/ Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)/ Lumbar Laminectomy. Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including but not limited to the following: [Alternative therapies such as acupuncture]. The requirement for a period of conservative treatment as a prerequisite to a surgical procedure is waived when there is evidence of progressive nerve or spinal cord compression resulting in a significant neurologic deficit, or when myelopathy, weakness, or bladder disturbance is present.

3.2. Canadian Medical Association (CMA, Canada) 2017 ⊕

Lignes directrices canadiennes relatives à l’utilisation des opioïdes pour le traitement de la douleur chronique non cancéreuse, Canadian Medical Association. 2017:110P. [196698].

Recommandation 1: Lorsqu’on envisage le traitement d'un patient atteint de douleur chronique non cancéreuse nous recommandons l’optimisation de la pharmacothérapie non opioïde et du traitement non pharmacologique plutôt qu’un essai d’opioïdes (Recommandation Forte).
Le tableau 2 énumère certains des traitements spécifiques disponibles pour la prise en charge de la douleur chronique non cancéreuse ainsi que les données probantes appuyant chacun de ces traitements .
Douleurs dorsales, ostéo-arthrite du genou, douleurs cervicales, fibromyalgie, céphalées graves ou migraines. Qualité des données probantes : Faible ou très faible. Thérapies dont l’efficacité est appuyée par certaines données probantes : acupuncture, yoga, massothérapie, manipulation rachidienne, manipulation ostéopathique, tai-chi et approches de relaxation peuvent aider certains patients à gérer leur douleur.

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