Letter to the Editor: Response

We would like to thank the authors of the letter to the editor titled “Other Interventions in Approach to Lumbar Disorders” for reading and providing a commentary to stimulate further discussion regarding the treatment-based classification (TBC) approach to individuals with low back disorders. In the letter to the editor, the authors identify the omission of other possible alternative interventions, including acupuncture, for individuals with lumbar disorders. While we believe that alternative interventions do have a place in the management of individuals with low back disorders, further research is required to determine which characteristics identify individuals most likely to respond to these interventions. The main purpose of a TBC is to identify a priori which patients with low back pain are most likely to respond to a particular intervention.2 In 2 randomized clinical trials, individuals matched to the corresponding interventions had superior outcomes with respect to pain and function compared with those receiving standardized or unmatched interventions.1,3 Subgrouping patients who respond to a particular intervention improves clinical decision making and leads to improved clinical outcomes, shorter duration of care, and decreased economic burden to the patient and health care.1 We believe that this is an important distinction. There are numerous interventions that have reported benefits in the management of individuals with low back disorders, including massage therapy, acupuncture, surgery, injections, and cognitive behavioral retraining.4-7 However, when these interventions are applied to a heterogeneous group of patients with low back pain, the clinical effect sizes tend to be modest. Although some research has reported positive benefits for acupuncture in the management of low back pain, there are little data available about patient characteristics that would predict the best response to this intervention. Witt and colleagues attempted to identify predictive criteria to identify patients who responded favorably to routine medical care plus acupuncture treatment.8 In this study, data were pooled from 4 previous randomized controlled trials including individuals with knee/hip pain, low back pain, neck pain, and headache. Four predictor criteria were found that would indicate a favorable response to acupuncture: female sex, living in a multiperson household, failure of other therapies, and previously positive experience with acupuncture.8 While these data do not provide clear decision making regarding patients with low back disorders only, they do provide an initial outline of patients that may be suitable for adding acupuncture treatment to routine medical care. Furlan and colleagues reviewed and reported on the body of literature regarding the use of acupuncture for low back pain and were unable to draw “firm conclusions” regarding its use in acute low back pain, but they did state that it is better than sham treatments for pain relief in the chronic low back pain populations.5 The authors further state, “Acupuncture is not more effective than other conventional or alternative treatments.” We feel that additional research is necessary to clarify which characteristics clearly identify individuals with low back disorders that respond to acupuncture. Until that research is derived and validated, we believe that is appropriate to leave acupuncture and other alternative treatment options outside of the TBC algorithm.