Katharina Rhein, cand. med. Lic. Acupuncture;
Sandro Graca, MSc, Lic TCM, FABORM
Editor’s Note: This is the latest column from the Society for Acupuncture Research (www.acupunctureresearch.org). Visit the SAR online columnist page for access to previous articles.
Chronic low back pain (CLBP) is the leading cause of disability worldwide, and more than one-third of U.S. adults ages 65 and older experience this condition. The U.S. spends more than $134 billion annually on back and neck pain treatment, with over 30% of these costs incurred by older adults covered primarily by Medicare.
Conventional treatments – including pharmacological therapies and invasive procedures – provide limited functional benefit and pose substantial risks for older adults with multiple health conditions.
In 2020, Medicare began covering acupuncture for CLBP, but no large-scale studies had examined its effectiveness or cost-effectiveness specifically for Medicare-eligible older adults. The BackInAction trial addressed this critical evidence gap through coordinated clinical effectiveness and economic evaluation studies.
Overview of the Studies
DeBar, et al.,1 conducted a pragmatic three-arm randomized clinical trial of 800 adults ages 65 and older with nonspecific CLBP of at least three months duration, drawn from four large U.S. health systems. Participants were randomized to: usual medical care (UMC) alone; UMC plus standard acupuncture (SA: 8-15 sessions over 12 weeks); or UMC plus enhanced acupuncture (EnA: the same initial course plus 4-6 maintenance sessions over the following 12 weeks).
Treatments were delivered by more than 50 experienced community-based licensed acupuncturists using manual needling only, following a pragmatic protocol aligned with current Medicare coverage parameters. The primary outcome was change in Roland–Morris Disability Questionnaire (RMDQ) score at six months, with follow-up at three and 12 months; secondary outcomes included pain intensity and the proportion achieving at least 30% improvement in disability.
Using the same population, Herman, et al.,2 evaluated one-month healthcare use, costs, and cost-effectiveness for 672 participants, from healthcare-sector and Medicare perspectives.
Key Findings
Both standard and enhanced acupuncture produced significantly greater improvements in back pain–related disability at six months than usual medical care alone, and these benefits persisted at 12 months. At six months, adjusted mean RMDQ change scores favored SA and EnA over UMC, with no meaningful difference between the two acupuncture dosing strategies.
The proportion of patients achieving at least 30% improvement in disability was higher with acupuncture (about 39% for SA and 44% for EnA) compared with UMC (about 29%), and this advantage was maintained at one year. Pain intensity and global impression-of-change measures also showed consistent benefit for both acupuncture groups over UMC.
Serious adverse events were uncommon and similar across groups, with fewer than 1% judged possibly related to acupuncture, confirming a good safety profile in this older, multimorbid population.
From an economic perspective, EnA reduced back pain-related healthcare-sector costs by an average of $491 per participant over one year compared with UMC, largely through reduced hospitalizations and other non-acupuncture services. Standard acupuncture added roughly $759 per participant in healthcare costs versus UMC, but its cost per quality-adjusted life-year (QALY) gained was $52,897 – well below the commonly used $100,000 per QALY threshold for a cost-effective intervention. EnA was both less costly and more effective than UMC, yielding a QALY gain of 0.037 and an 18.5 percentage-point increase in the proportion of participants achieving clinically meaningful improvement.
Sensitivity analyses supported the overall conclusion that adding acupuncture to usual care is likely to be cost-effective – and in the case of the enhanced schedule, potentially cost saving – for Medicare-type payers.
Clinical Relevance for Acupuncture Practitioners
Taken together, these coordinated studies provide strong, practice-relevant evidence that acupuncture needling is both clinically effective and economically attractive for older adults with CLBP in real-world health system settings. A pragmatic course of up to 15 sessions over 12 weeks, delivered by community-based acupuncturists, meaningfully improves function and pain beyond usual medical care, with sustained benefit at one year and minimal safety concerns.
The extended schedule that includes 4-6 maintenance sessions – mirroring current Medicare coverage allowances – appears particularly valuable, as it not only maintains clinical benefit, but also can offset other healthcare use and costs.
For clinicians and professional advocates, these findings directly address policymakers’ questions about real-world outcomes and value for older adults, strengthening arguments for appropriate reimbursement, reducing supervisory and billing barriers, and supporting the integration of acupuncture into multidisciplinary care pathways for chronic back pain in later life.
Conclusion
Acupuncture provides clinically meaningful and likely cost-effective treatment for older adults with chronic low back pain when added to usual medical care. While implementation details will vary across health systems, these results support acupuncture as a safe, effective first-line option that can improve outcomes and potentially reduce overall healthcare spending for this population.
References
- DeBar LL, Wellman RD, Justice M, et al. Acupuncture for chronic low back pain in older adults: a randomized clinical trial. JAMA Netw Open, 2025;8(9):e2531348.
- Herman PM, Mann S, DeBar LL, et al. Cost-effectiveness of acupuncture needling for older adults with chronic low back pain. Spine, 2026;51(3):E65-E75.
