Investigating Acupuncture and Manual Therapy for Low Back Pain

Abstract
Background
Low Back Pain (LBP) is the principal cause of disability globally (Buchbinder et al. 2018; Hartvigsen et al. 2018). Research and packages of care have strived to reduce levels of LBP, but globally it continues to rise (Foster et al. 2018). There is debate as to the role of acupuncture in LBP care pathways and research on acupuncture is of varying quality and not conclusive (SAR, 2018). Previous research of acupuncture has not effectively used trial design to produce high quality, robust and convincing evidence.
Aims
To investigate if acupuncture and manual therapy are indicated as appropriate treatments for the treatment of LBP and consider if their combination may be viable and effective.
To determine the international LBP recommendations for acupuncture and manual therapy.
To establish which RCT design could best evaluate acupuncture and manual therapy for the treatment of LBP and to trial this in a pilot study.
To ascertain if high-quality research compares and combines acupuncture with manual therapy for LBP.
Methods
To review the international clinical practice guidelines and their approach to acupuncture and manual therapy for LBP. To consider a range of clinical trial designs and establish a preferred design. To conduct a trial investigating acupuncture and manual therapy alone and in combination for LBP, using a cohort study with nested factorial RCT. To conduct a systematic review, comparing acupuncture with manual therapy for LBP.
Results
Further evidence is indicated in the study of acupuncture and manual therapy for LBP. Clinical practice guidelines are inconsistent in their interpretation of evidence and the recommendation of acupuncture. A cohort study with nested factorial RCT is an effective design for recruitment, retention and to evaluate acupuncture and manual therapy for LBP. 97% of participants accepted the interventions offered and 100% of individuals completed the RCT interventions and 100% returned (97% completion of primary outcomes measures) of follow-up questionnaires. Zero attrition was achieved with this pilot study (95% CI 0.0, 6.3). Manual therapy may be superior (-1.4, 95% CI -3.8, 1.0, P=0.24) to usual care, but the results are not statistically significant. Manual therapy appears favourable in an SR and meta-analysis of manual therapy versus acupuncture; the results were limited by the methodological quality of the studies included.
Conclusions
A full-scale definitive trial of acupuncture and manual therapy using a cohort design, with nested factorial RCT is needed.