JAMA: Acupuncture Reduces Low Back Disability in Adults Aged 65 and Older

Study design

The BackInAction trial was conducted between August 2021 and November 2023 in four US health systems — Kaiser Permanente among them — and recruited 800 adults aged 65 and older with chronic low back pain (pain for more than three months). Participants were randomized into three arms:

• Usual medical care (UMC): medications, physical therapy, and usual interventions — without acupuncture (n=266)
• Standard acupuncture (SA): 8 to 15 sessions over 12 weeks, plus usual care (n=265)
• Enhanced acupuncture (EA): standard acupuncture plus 4 to 6 maintenance sessions in the following 12 weeks — totaling 12 to 21 sessions (n=269)

The primary outcome was the change in the score of the Roland-Morris Disability Questionnaire (RMDQ — 0 to 24 scale, higher = greater dysfunction). Clinically significant improvement was defined as a reduction ≥ 30% from baseline. Sessions were conducted by licensed and experienced acupuncturists from the community itself — not in an experimental context — which gives the trial high external validity for real practice.

Results

At 6 months, both acupuncture modalities were superior to usual care in low back disability. Standard acupuncture produced an adjusted mean difference (AMD) of -1.0 point in the RMDQ (95% CI: -1.9 to -0.1; p=0.002); enhanced acupuncture reached AMD of -1.5 points (95% CI: -2.5 to -0.6; p=0.002). This benefit was maintained consistently at 12 months: AMD of -1.2 for standard acupuncture and -1.7 for enhanced, both with p=0.002. The proportion of patients with clinically significant improvement (≥ 30%) was 39.1% (standard) and 43.8% (enhanced) versus only 29.4% in the usual-care group. Pain intensity and patient global impression also favored the enhanced acupuncture group over standard at 6 months. Anxiety symptoms improved in both acupuncture groups compared with usual care.

Safety profile

A central aspect for the use of acupuncture in older adults is safety. In this trial, fewer than 1% of participants reported serious adverse events possibly related to the intervention. Mild events — mainly transient discomfort at the insertion site — occurred in 9.7% of patients who received acupuncture. No serious complications were recorded. This comparison is relevant: nonsteroidal anti-inflammatory drugs, widely used for low back pain in older adults, have clinically significant gastrointestinal and cardiovascular event rates in this age group. The principal investigator Dr. Lynn DeBar, of Kaiser Permanente, summarized: "Acupuncture offers a less invasive option with a better safety profile than many conventional treatments for low back pain in older adults."

Context and clinical implications

Chronic low back pain affects approximately one third of adults over 65 and is the leading cause of disability in this age group. First-line pharmacologic treatments — anti-inflammatory drugs and opioids — have limited long-term efficacy and carry amplified risks in older adults: gastrointestinal bleeding, renal failure, falls, and dependence. The BackInAction trial positions acupuncture as a non-pharmacologic alternative with high-quality methodologic evidence for this specific population, published in the highest-impact general medicine journal in the world. The results reinforce the recommendations of guidelines such as those of the American College of Physicians, which already indicated non-pharmacologic interventions as first-line treatment for chronic low back pain.