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NHS pins its hopes for treating back pain on acupuncture

Unprecedented approval for alternative therapies from health service watchdog

By Jeremy Laurance, Health Editor

Patients with back pain should receive acupuncture through the NHS, the National Institute for Clinical Excellence has recommended in its latest guideline

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Patients with back pain should receive acupuncture through the NHS, the National Institute for Clinical Excellence has recommended in its latest guideline

Tens of millions of pounds are being wasted by the NHS on useless treatments for back pain, money that should be diverted to alternative therapies such as acupuncture and spinal manipulation, a health service watchdog says today.

From among 200 treatments and devices claimed to help a bad back, the National Institute for Clinical Excellence (Nice) has passed judgement on what works and what doesn't. X-rays, ultrasound and steroid injections are out and osteopathy, chiropractic and "needling" are in, it says.

The new guidelines mark a watershed in the treatment of the condition and for Nice itself. It is the first time that the institute has issued a positive recommendation that the NHS provide, and pay for, alternative therapies.

The advice, which NHS trusts will be expected to implement over the coming months, is likely to cause controversy among orthodox clinicians who believe NHS money should be reserved for scientifically proven therapies.

But Nice says a careful review of the evidence shows that acupuncture and spinal manipulation work.

Back pain is among the most common reasons for visits to family doctors (after colds and flu). It affects one in three adults in the UK each year, with an estimated 2.5 million people seeking help from their GP. The NHS spends £1.5bn on treating the condition, and much of that is wasted on worthless treatments, according to Nice.

The standard advice for people who suffer problems with their back has not changed. It is to continue with their normal activities as far as possible and to avoid bed rest.

Most people recover quickly with nothing more elaborate than a couple of paracetamol every four hours to help them keep mobile. The old advice to rest a bad back in bed has been shown to make the condition worse.

The new guideline applies to people with "persistent" low back pain which has lasted for at least six weeks. They should be offered three options: an exercise programme, a course of manual therapy including manipulation or a course of acupuncture. If one treatment option does not work, patients may be offered a second.

The 13-strong Nice panel that drew up the guideline expects acupuncture to be the most popular option, with an estimated annual cost of over £24m in England and Wales.

Manual therapy is expected to cost almost £16m and exercise therapy almost £900,000.

The worst affected patients may be offered up to 100 hours of physical and psychological treatment over eight weeks at a cost of £4,000 a head. But even this expense can be justified when set against long-term costs of existing ineffective treatments, disability benefits and lost production, Nice says.

To pay for the new treatments, the panel estimates that ending the use of steroid and other injections into the back will save more than £33m, stopping MRI scans will save £12m, and a further £1m can be diverted from funds for X-rays. Evidence shows that ordering X-rays can make patients worse, by confirming their invalid status. The overall net cost to the NHS of implementing the guidelines is estimated at just £77,000.

Professor Peter Littlejohns, the clinical and public health director at Nice, said: "Most people will be affected by low back pain at some stage in their lives. The NHS now has evidence-based guidance on how to treat the condition effectively."

Although alternative therapies had been included in previous guidelines for multiple sclerosis, ante-natal care and dementia, the evidence of their worth had been equivocal, he said.

"In this case, the evidence was robust enough to make a positive recommendation," he said.

Martin Underwood, a GP in Coventry and a professor of primary care at the University of Warwick, chaired the expert panel. He said the panel had carefully examined the evidence for the alternative therapies.

"We pulled together the trials, looked at the systematic reviews and in some cases at the original papers. The consistent message coming through was that people who get these treatments do better than those who don't get them."

His claim was challenged by Edzard Ernst, a professor of complementary medicine at the University of Exeter and a leading sceptic about the claimed benefits of alternative medicine.

Professor Ernst said he was most concerned about the use of chiropractic, which is recommended by Nice along with osteopathy, and which involves more extreme manipulation of the spine. Many patients suffered mild side-effects lasting a day or two and there were rare cases of more serious accidents, causing damage to the arteries in the neck, triggering a stroke.

"The Nice panel included three pro-manipulation experts. As a result they are over-optimistic on the benefits and have underestimated the risks [of chiropractic]. A review of spinal manipulation [by the respected Cochrane Library] was much more cautious."

Dries Hettinga, the head of research at Backcare, a patient support organisation, was a member of the panel and said that there was widespread confusion about treatments for back pain among the public.

"We are contacted by dozens of people each week. There is a huge industry [behind the treatment of back pain] with around 200 different types of treatment and the commonest question is: how do you decide what is effective and what is not? This guideline will be hugely beneficial to patients in setting out the options for treatments available on the NHS."

Stuart Derbyshire, a senior lecturer at the University of Birmingham's School of Psychology, said: "I would be less inclined to offer manipulations and acupuncture even though clinical trials have been successful.

"These things are hard to do in a proper randomised and blinded fashion. But anything that encourages back pain patients to stay active, not go for scans and stay out of the hands of surgeons is generally a good thing."

Case study: 'I can ride a bike again. Last year I couldn't do a thing'

A lifetime of work lifting heavy weights has taken its toll on Tom Barr's back. Last year, the pain was so bad he was crippled – until he got help from an acupuncturist. "I had to slide downstairs on my bottom and do the washing up sitting down. I walked bent over and couldn't go more than 100 yards without a rest," he said.

His son, who lives in the US, was shocked when his father arrived in a wheelchair for a visit and organised a couple of acupuncture sessions. The result was encouraging. "I felt quite a bit better," Mr Barr, 79, said.

He returned home to Ashford, Middlesex and organised sessions with a practitioner registered with the British Acupuncture Council. He had one treatment every fortnight at first, then once every five weeks.

"It has made a difference to my life that is unbelievable. I can ride a bike again and everyone is amazed I can stand up straight. I have just finished painting the front windows and the gate. Last year I couldn't do a thing," Mr Barr said.

Asked if he welcomed the decision that the treatment should be free on the NHS, Mr Barr, said he was happy to pay the £40 cost of the sessions. "It won't suit everybody but it has done it for me, that's all I know."

The British Acupuncture Council said its members were trained to degree standard and adhered to codes of ethics and conduct.

Case study: 'I can ride a bike again. Last year I couldn't do a thing'

Exercise Up to 8 sessions in a supervised group over 12 weeks. A one-to-one programme would be offered if a group approach is not suitable. May include aerobics, muscle strengthening, postural control.

Injections into the back Steroids and other substances are widely administered using this method.

Manual therapy A course involving up to nine sessions over 12 weeks. Includes osteopathy or chiropractic.

X-rays and MRI scans They are often ordered but are of little use, and may make the patient worse. MRI scans should only be used where the patient is being referred for surgery.

Acupuncture A course of 10 sessions lasting up to 12 weeks.

Heat treatments Aimed directly at the discs in the spine, using a variety of methods.

Combined physical and psychological treatment A programme lasting up to 100 hours over a maximum of 8 weeks (for those who are worst affected).

Early surgical intervention There is little evidence that any operation, except spinal fusion, reduces pain.

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Comments

Acupuncture without needles, using patches.
[info]stefansson wrote:
Wednesday, 27 May 2009 at 05:30 am (UTC)
I came to the conclusion that Acupuncture principles were at the basis of all healing. I my case I had a Chronic Back Pain and suffered for many years in my lower Back. After using those patches my pain was gone in about 4 minutes after putting the patches on my back.

http://www.lifewavecure.com
CAM for back pain
[info]stepheng1 wrote:
Wednesday, 27 May 2009 at 05:38 am (UTC)
Well done NICE in tackling head-on the widespread problem of low back pain with an evidence based decision. Back pain is an area that conventional medicine has limited means to deal with and there are risks from surgery and prolonged exposure to painkillers and anti-inflammatory drugs. The inevitable negativity from the sceptical Professor Ernst should not prevent this decision being taken on-board by the nation's GPs. Millions of days of patient suffering and days off work will potentially be saved by this wise decision.
Low back pain and acupuncture
[info]mtvmalta wrote:
Wednesday, 27 May 2009 at 06:33 am (UTC)
I am sure NICE is correct as low back pain has a major psychological element in it as a rule and placebos are just the kind of treatment that works in these circumstances. When I say there is a strong psychological element I do not mean that the pain is imagined but, for example, that it tends to stop people moving about which is what they need to improve
treating back pain with acupuncture
[info]kakhengtan wrote:
Wednesday, 27 May 2009 at 07:24 am (UTC)
Back pain is a confusing condition, which must be defined accurately. Whether it is caused by slip disc, muscle ache, nerve problem etc... Doctors must scan and check carefully the cause before suggesting any cure such as chiropractic or acupuncture. I have a slip disc/prolapse, my acupuncturist ( a very famous one in Kuala Lumpur) would not treat me, instead he advised me to see a medical doctor, who will prescribe muscle relaxant such as norgesic, which worked well in reducing the pain and nervy sensation. But it does not cure a slip disc! But I am told paracetimo/pandanol in norgesic may clog up my kidney with stones. I do taichi every morning as an exercise to help myself in terms of alertness and mobility.
It is rather appalling for Institute for Clinical Excellence (Nice) to simply suggest alternative treatment just because doctors could not provide effective treatment. It should not include pro-alternative treatment in your scientific committee, Professor Ernst and Stuart Derbyshire should be in the panel. Please do more research before suggesting any placebo treatment, even it seems to help. Please examine idea such as forcing the disc back into its original position works at all. Double blind tests please!
Re: treating back pain with acupuncture
[info]robertcrowleydc wrote:
Wednesday, 27 May 2009 at 10:48 am (UTC)
Numerous double blind studies have been performed legitimizing the use of chiropractic for treatment of low back pain in many well respected peer-reviewed jounals including Spine.
I have been a chiropractor for 7 years and have worked within a clinic along side orthopaedic surgeons, medical doctors and physiotherapists in the United States. There is a time and place for every modality. Conservative therapies, such as chiropractic manipulation and physiotherapy are effective a large percentage of the time. As chiropractors, we perform appropriate examinations including complete neurological and orthopaedic exams in order to make a proper diagnosis. When improvement is not made we are trained to make the proper referral to a patient's GP or specialist. Chiropractors are also trained to order appropriate tests, such as MRI scans when clinically indicated. The main difference between us and medical physicians is our method of treatment does not include pharmaceuticals or surgical methods.
Re: treating back pain with acupuncture
[info]kakhengtan wrote:
Thursday, 28 May 2009 at 07:46 am (UTC)
Many so-called complimentary treatments cannot offer scientific diagnosis, even though they try to borrow scientific instruments/methods such as x-ray and MRI in their work, for which they have no qualified training, but they would claim employment of "proper instruments/methods). In the case of mild back pain with anomalous or unknown cause, probably due to muscle sprain or stress, the so-called complimentary treatments are no better than popping pain killers. For slip disc no one should attempt the so-called complimentary treatments as they would only complicates, if not, worsen the condition. Many claims of the so-called complimentary treatments are not verifiable, even they claim of double blind tests, which are doubtful and difficult for handy work, they either test the skill of the practitioners or the condition of the victims. At most the treatments are effects of placebo, not a real cure of the cause of the sickness.
I have grown up in environment that can only offer voodoo or vooshu, acupuncture, 'traditional medicine", and now enjoying real scientific medicines based on atomic and molecular theories, real physics and chemistry, biology and maths. Practitioners of the so-called complimentary treatments who have not studied these sciences should not claim to provide treatments under the cover of relieving pains. If the so-called complimentary treatments are effective, why do we waste money in building hospitals and universities, and demand young people to spend 8 years studying sciences and medicines. Let us close them down. The practitioners of the so-called complimentary treatments should be awarded professorships and Nobel prizes!!
Not always the answer
[info]leonore35 wrote:
Wednesday, 27 May 2009 at 07:33 am (UTC)
When I was in Korea I developed a back problem and was treated with acupunctute, heat pads and some kind of plaster. Nothing worked when I got back home I was diagnosed after a scan with stenosis
I had an operation and have been without problems for abot 15 years
Chiropractic & Acupuncture are both fraudulent treatments designed to make money for charlatans.
[info]williamgrogan wrote:
Wednesday, 27 May 2009 at 08:52 am (UTC)
Chiropractic and Acupunctureare based on utter nonsense and magic, Chiropractic on non existent "subluxations" and Acupuncture on non existent "meridian energy lines". When a British Acupuncture Council spokesman claims, Acupuncturists are "trained to degree standard"; what are they trained in? There are no recognised or evidence based acupuncture points, so how can anyone be trained where and when to stick the needles, never mind how long to put them in for? In trials, where and when and who did the sticking of the needles had no effect on outcome. At best Acupuncture is a con on sick people that makes then think they are better by deceiving them. I was also horrified that NICE is trying to avoid MRI scans; MRI found my back pain was caused by a very specific hernia that presses on the nerve in my back. Exercise, particularly walking, keeps my pain away.
Re: Chiropractic & Acupuncture are both fraudulent treatments designed to make money for charlatans.
[info]hywelthomas wrote:
Wednesday, 27 May 2009 at 12:34 pm (UTC)
This is an odd one. I agree with you that it's nonsense, but if such placebos are more effective and cheaper for many, it may not necessarily be a bad thing. It may be financially prudent to treat with placebos initially.

Any mention of chiropractic is a bit scary. Other nonsenses like homeopathy and reflexology are in themselves harmless (except in that people may avoid real treatments for real diseases), but chiraporactic certainly seems like the dangerous one to me. People with qualifications from unregulated non-medical bodies manipulating the spine / neck ... shudder.

I don't suffer back problems really. My lower back has siezed up for a few days. I saw an osteopath the first time, which may have helped a little, but other times I've just let time be the healer. Certainly I've found anecdotally that walking helped, so that's what I do : walk.
Re: Chiropractic & Acupuncture are both fraudulent treatments designed to make money for charlatans.
[info]tyfumatt wrote:
Wednesday, 27 May 2009 at 02:25 pm (UTC)
....Small point, but, I think, a necessary one... In this country, Chiropractors ARE in fact regulated by an independant government body. In order to initially register with the GCC, a prospective candidate must be able to demonstrate succesful completion of a four-year full time master's degree currently offered by two mainstream universities, and the obvious and necessary criminal record checks. They also have to abide by a stringent and enforcable code of conduct, mandated by the GCC, before they are even allowed to practice. Once on the register, chiropractors have to re-apply each year, and to do so must demonstrate a minimum of 30 hours of peer-reviewed continuing professional development, or face automatic removal from the register. It is a legal offence to imply knowledge of, treat or parctice as a chiropractor, even if properly trained, unless one is currently registered, and such offenders face criminal proceedings, which is rigidly enforced,... rightly, to protect the public.

One of the reasons that Chiropractic training and monitoring is so rigorous, is fairly obvious:- that manipulating structures in the body requires absolutely accurate diagnosis..Chiropractors are trained to recognise when this is appropriate, and more importantly, when it is not....First, do no harm.....

Some public perception is that it's like the wild west out there.....Happily, it is not, and has been regulated for many years now.

My own ignorance, several years ago, led me to believe that chiropractors obtained their qualifications from the back of a cereal packet, or something similar. I was dragged, kicking and screaming to see a chiropractor, much against my better judgment, and had all my prejudices dispelled in very short order (six weeks). It works, and it is very closely monitored to be safe and effective.
About time for NICE
[info]mind_ful wrote:
Wednesday, 27 May 2009 at 09:05 am (UTC)
ABsolutely brilliant. There is so much evidence in support of CAM that it is a crime a few bigotted nay sayers have been allowed to pursue their propoganda and prevent the public from benefitting from these wonderful tried and tested methods. Maurice Laing, who funded profesor ernst's chari at exeter would be thrilled today. He set up the chair to help others benefit as he had done from osteopathy. Instead the occupant has apparantly done all he can to remove CAM fro the NHS and to hep the drug companies sell more steriods - or so it seems. Maurice would be happy again to read this from NICE after years of turning in his grave no doubt!
Re: About time for NICE
[info]richardjeff wrote:
Wednesday, 27 May 2009 at 05:09 pm (UTC)
There is support for some CAM. Certainly not a blanket endorsement. Homeopathy just does not work on anything and I'd guess the same for many others, but homoeopathy has had lots of studies and the properly controlled ones all find the same. It doesn't do anything more than a placebo would.

However Acupuncture, Chiropractic and Osteopathy doe sometimes produce verifiable results though the explanation of why is as yet unclear. Don't go and think all CAM is good. Most do nothing but earn many for the therapist, some might be harmful but some do work.
chiropractor
[info]snowdonwatcher wrote:
Wednesday, 27 May 2009 at 10:12 am (UTC)
I went to one of them.
I paid him & he did some manipulation of my back. "Come back in a week for your next session".
I went again, paid & had the same treatment.

He said "you will see an improvement soon, just come back again next week".

After several weeks (he always said the same things) I started to see where this was going, give him money, each week & he is onto a regular little earner. I would not touch a Chiropractor with a bargepole.

I might add he was a member of the official body etc, letters after his name etc, so one assumes he was supposed to know what he was on about!
Nuts you creeps NHS provide, and pay for this. AIDs Not CHECKED YET
[info]famulla wrote:
Wednesday, 27 May 2009 at 11:09 am (UTC)
Oh, how I hate the politicians???
When you read this in a piece meal the reading is, it is going to happen, privately for and for Nice itself. Nuts you creeps NHS provide, and pay for this.
The new guidelines mark a watershed in the treatment of the condition and for Nice itself. It is the first time that the institute has issued a positive recommendation that the NHS provide, and pay for, alternative therapies.
I thank you
Firozali A.Mulla
Select carefully and some CAM can be excellent.
[info]richardjeff wrote:
Wednesday, 27 May 2009 at 04:56 pm (UTC)
Complimentary and Alternative treatments are a bit of a rag bag and each form of treatment for each kind of complaint must be considered separately. For example, no scientific or properly controlled study has found homeopathy to work in any instance for virtually anything yet this was adopted on the margins of the NHS for years. On the other hand Acupuncture does produce significant results for a number of complaints. Equally so does Chiropractor and Osteopathy though how much is "cure" and how much temporary symptomatic relief is sometimes hard to assess. Those who blindly endorse all CAMs are foolish but in among the nonsense are some good therapeutic treatments even if exactly how they work is not yet fully understood.
Acupuncture
[info]loveursoul wrote:
Wednesday, 27 May 2009 at 07:41 pm (UTC)
At last ! Complementary therapy is finally being given the credit it deserves. Often giving the symptom pills or medication is not the answer to finding the cure, quite often time and direction is. For many reasons the NHS sometimes does not have the time to treat the symptom properly wheras complementary therapists do. Acupuncture is just one of the options available to do this.
Until now complementary therapy has not been given the credit it deserves due to lack of knowledge and understanding, it is so good that finally eyes are being opened and acknowledgement is being given!.

Loveursoul is a new website being set up to help people find the right complementary therapy in their area based upon the symptoms they have. It will also record an indivduals therapy history providing valuable reference for any future needs. Contact us at www.loveursoul.co.uk
NICE guidelines and Ernst
[info]niaowen wrote:
Wednesday, 27 May 2009 at 08:16 pm (UTC)
I can't believe that once again the tin pot one man band Ernst who has made a lucrative career from rubbishing complimentary therapy and in particular chiropractic in spite of all the clinical evidence has been wheeled out again to rant against today's newly published NICE guidelines for low back pain. It suggests lazy journalism where one so called "expert" is allowed media coverage far beyond what he deserves and unbalanced reporting. I call upon the public to implore Dr Ernst to quietly go away and stop ranting!!!! Please provide the public with views from genuine experts without their own agendas.
Re: NICE guidelines and Ernst
[info]ojeronimo wrote:
Wednesday, 27 May 2009 at 11:16 pm (UTC)
The stance of opposing complementary therapies taken by Prof Ernst is rather strange. According to an interview he gave in 2003 his father was physician in charge of a European health spa offering a range of complementary therapy treatments. What implication might one draw from this anomaly?

Back pain
[info]catfishspy wrote:
Thursday, 25 June 2009 at 09:13 am (UTC)
l suffer from sciatica and treating back pain with acupuncture is a stupid idea, thats why critical illness life insurance pays for propper treatment which really does help.
Back Pain
[info]bedsonlegs wrote:
Friday, 2 October 2009 at 10:14 am (UTC)
l suffer from sciatica, somtimes it is really chronic, l was advised to buy a memory foam mattress so l could get a good nights sleep, and memory mattresses do make a difference.


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