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American College of Physicians guideline likes acupuncture for back pain

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.

The American Physicians made recommendations both for acute and chronic low back pain. For the acute situation they suggest heat treatment has the best evidence, followed by massage, acupuncture and manipulation. For chronic back pain (and this is the situation for most of our patients) they recommend acupuncture and also exercise, multidisciplinary rehabilitation and mindfulness as being best evidenced. Another nine recommended treatments have somewhat less sound evidence. What particularly stands out here is that these are all non-drug treatments; the drugs are held as back-up if the non-drug approaches don’t work. The authors explain that since there is no clear evidence for one treatment being better than another it makes sense to recommend those with the lowest harms and costs. This looks so obvious and eminently sensible that one wonders why such a pragmatic stance is not followed by all guideline bodies.

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