Acupuncture for chronic low back pain in the elderly: results of a large randomized trial

The results of a multicenter randomized clinical trial designed, in part, to close the evidence gaps for Medicare decisions were published in JAMA Network Open: the effectiveness of acupuncture in older adults with chronic low back pain (CLBP) was assessed. The study included 800 participants from four US health care systems; average age was 73.6 years, women - 62%. Participants were randomly assigned to three groups: "usual medical care" (UMC), "standard acupuncture" (SA: 8-15 sessions over 12 weeks + UMC) and "enhanced acupuncture" (EA: the same plus 4-6 maintenance sessions in the next 12 weeks). The primary endpoint was the change in disabling symptoms according to the modified Roland-Morris questionnaire (RMDQ) after 6 months; secondary ones were pain intensity and the proportion of patients with clinically significant improvement (≥30%). Recruitment took place from August 12, 2021 to October 27, 2022; observation ended on November 7, 2023.

Background of the study

Chronic low back pain (CLBP) is a major source of functional limitations in older adults: 39% of adults overall reported back pain in the past 3 months, according to the CDC, and the proportion is particularly high in people ≥65 years old. There has also been a historical increase in chronic disabling back pain specifically: in population-based data, its prevalence increased from the early 1990s to the 2000s. These numbers help explain why older adults are most likely to be at risk for loss of independence due to CLBP.

Classic painkillers have safety limitations in this group of patients (NSAIDs - gastrointestinal and cardiac risks, opioids - falls, sedation, addiction), which is why clinical recommendations have long shifted toward non-drug approaches. Recommendations of the American College of Physicians (ACP) emphasize: treatment of low back pain should begin with non-pharmacological methods, including acupuncture, exercise, manual and behavioral techniques.

This same logic led to a major decision for the US system in 2020: Medicare began covering acupuncture for chronic low back pain as a potential alternative to opioids. The coverage order is up to 12 sessions in 90 days, with an additional 8 sessions if improvement occurs (total maximum 20 in 12 months); if there is no progress, further visits are not covered. This created a practical demand for quality data specifically in older patients.

What did the evidence reviews show before the new RCTs in the elderly? The 2020 Cochrane review and subsequent analyses indicated improved function and modest pain reduction compared with usual care (effects vary and depend on the control - "sham" vs usual care), with serious adverse events rare and typical side effects mild to moderate. But most studies included more "mixed" age samples, leaving the question of whether the results apply to the 70+ population open - and this is what the new multicenter trial addresses.

What was already known at the time this RCT was launched

• CLBP is common in the elderly and significantly limits daily activities; an increasing proportion of chronic disabling pain has been recorded in long-term trends.
• ACP guidelines recommend starting with nonpharmacologic approaches (including acupuncture), and Medicare has covered acupuncture for CLBP since 2020, with limits on the number of sessions and a requirement to demonstrate improvement.

Why new data was needed

• Many older RCTs were conducted in younger cohorts; older people are systematically underrepresented, even though they are more likely to face NSAID/opioid risks.
• The Medicare decision reinforced the practical demand: trials “close to real clinic” are needed (strict protocols, long-term follow-up, evaluation of function, safety and sustainability of effect over a 6-12 month period).

This context helps to correctly interpret the new results: they add an “elderly” link to the existing pyramid of evidence and suggest how to realistically integrate acupuncture into CLBP management pathways in older people.

Key results in figures

Both standard and enhanced acupuncture were statistically significantly superior to usual care in reducing disabling symptoms at 6 months: the adjusted mean difference for SA vs. UMC was -1.0 RMDQ points (95% CI -1.9…-0.1), for EA vs. UMC - -1.5 (95% CI -2.5…-0.6). The advantage over UMC was maintained at 12 months of follow-up. The proportion of patients with clinically significant improvement in RMDQ at 6 months was higher in the acupuncture groups: 39.1% (SA) and 43.8% (EA) vs. 29.4% (UMC); the relative risk of improvement was 1.33 and 1.49, respectively. In terms of pain intensity, EA was superior to SA at 6 months, both groups were superior to UMC. Serious adverse events were rare and comparable between groups; less than 1% of events were “possibly” related to the acupuncture intervention.

What exactly did they do and why is it important?

Sessions were conducted by licensed professionals in community practice according to the expanded STRICTA/CONSORT reporting standards, which increases the transferability of results to a real-life clinic. The choice of the primary endpoint (RMDQ) reflects not just pain as a sensation, but its impact on everyday functioning, which is especially important for patients aged 70+. The study showed a sustained effect up to a year of follow-up without any apparent additional benefit from maintenance sessions beyond the standard course - that is, a "basic" program of 8-15 procedures may be sufficient for clinically significant improvement in some elderly patients. These findings support the discussions about the feasibility of covering acupuncture for chronic low back pain in older age groups.

How to interpret clinical significance

RMDQ differences of 1–1.5 points appear modest in mean values, but the distribution of responses shows that the proportion of patients achieving a “benefit threshold” of ≥30% is significantly higher with acupuncture than with usual care alone. In practice, this means the likelihood of not only a modest reduction in pain, but also a real improvement in daily activities in a significant proportion of elderly patients – with a low incidence of serious adverse events.

Practical summary: who and how it can help

• In older patients (≈70-80 years) with chronic low back pain, especially with high functional limitation, a short course of acupuncture (8-15 sessions over 12 weeks) can be considered as an adjunct to usual care, with an increased likelihood of achieving clinically significant improvement by 6 months.
• If available, 'maintenance' sessions (4-6 more over the next 12 weeks) may further reduce pain intensity at 6 months, although the benefit on functional disability compared with a standard course has not been demonstrated; the choice of strategy should be individualised.

Limitations and accuracy of conclusions

• The effect is expressed at the level of group averages and proportions of “responders”: it is not guaranteed for every patient; individual selection and monitoring of the result are required.
• The study was conducted in US health care systems and with licensed acupuncture practitioners; generalizability of the results to other systems and practice qualities requires caution, and long-term outcomes beyond a one-year horizon remain a subject for further research.

Conclusion

For older patients with chronic low back pain, acupuncture is an effective and safe adjunct to standard care: it increases the chances of clinically meaningful improvement in functional limitations at 6 and 12 months and may further reduce pain intensity, although maintenance sessions beyond the standard course do not appear to provide a convincing “bonus” for the primary functional endpoint. This is an important argument for the judicious inclusion of acupuncture in chronic pain management plans in older adults, particularly where access to quality services is available.

News source: DeBar LL, Wellman RD, Justice M., et al. Acupuncture for Chronic Low Back Pain in Older Adults: A Randomized Clinical Trial. JAMA Network Open. Published online September 12, 2025; 8(9):e2531348. DOI: 10.1001/jamanetworkopen.2025.31348. Registration: NCT04982315.