The American College of Physicians recently published a guideline entitled Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians
How very confusing these guidelines are. No sooner does NICE change its mind and give acupuncture the thumbs down for low back pain than up pops the American College of Physicians (the largest medical speciality organisation in the USA) to endorse it. Their conclusions are in line with those of two US government agencies that reviewed the evidence in 2016 and found acupuncture to be an effective treatment for chronic back pain (Agency for Healthcare Research and Quality, Feb 2016; Nahin et al, Sept 2016). How can different guidelines, using much the same data, come up with such different answers? Well, guideline recommendations reflect not only the state of the evidence but also how this evidence is interpreted by the people producing them, and this is subject to all kinds of personal and institutional influences. Hence single guidelines cannot really be trusted: as with builders’ quotes you’d be wise to look at several different ones and get a consensus.
Last week’s popular news story has important implications for guidelines on back pain and puts NICE’s decision on acupuncture into an even worse light. Here is some information you could use to help you to understand, inform, debate, complain or whatever else moves you.
A Swedish university study published yesterday concluded that acupuncture may be an effective treatment option for babies that continue to cry when conventional approaches have been unsuccessful.
They recruited healthy infants, aged 2-8 weeks, who were still crying more than 3 hours a day, at least 3 days a week, after having cow’s milk protein excluded from their/their mothers’ diet. In this randomised trial 98 babies had 4 sessions of acupuncture over 2 weeks and 49 had no acupuncture. All of them received gold standard conventional treatment in specialist child health centres. The acupuncture was minimal (very few needles, very shallow insertion, retained for a very short time period), according to usual practice among acupuncturists who specialise in treating infants. Effectiveness was measured in crying time, as recorded in diaries by the parents. Note that parents (and nurses) were both blinded, i.e. they didn’t know whether their baby was getting acupuncture or not, to avoid biasing the results.
In October 2013 I went to a stakeholders workshop to hear about, and discuss, NICE’s plan for an updated guideline on low back pain. The 2009 recommendation of acupuncture has become a key part of BAcC marketing and may have knock-on effects for all of us through increased acceptability in orthodox medical circles. However, the acupuncture recommendation has never gained much of a foothold when it comes to funding primary care services, leaving NICE with egg on its face. This was one of the stated reasons for the guideline update. One solution would be to persuade the NHS to comply with the recommendation; the easier and cheaper option would be simply to uncouple acupuncture.
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