Three types of acupuncture therapy-an individually tailored program, standard therapy and a simulation involving toothpicks at key acupuncture points-appear more effective than usual care for chronic low back pain, according to a report in the May 11 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Back pain costs Americans at least $37 billion annually, according to background information in the article. Many patients with this condition are unsatisfied with traditional medical care and seek help from complementary and alternative care providers, including acupuncturists. “Back pain is the leading reason for visits to licensed acupuncturists, and medical acupuncturists consider acupuncture an effective treatment for back pain,” the authors write.

Several recent studies have suggested that simulated acupuncture, or shallow needling on parts of the body not considered key acupuncture points, appear as effective as acupuncture involving penetrating the skin. To expand on these results, Daniel C. Cherkin, Ph.D., of Group Health Center for Health Studies, Seattle, and colleagues compared four different types of treatment in a randomized clinical trial involving 638 adults (average age 47) with chronic low back pain at Group Health in Seattle and Kaiser Permanente Northern California in Oakland.

During the seven-week treatment period, 157 participants received 10 acupuncture treatments in a manner individually prescribed by a diagnostic acupuncturist; 158 underwent a standardized course of acupuncture treatments considered effective by experts for low back pain; 162 received 10 sessions of simulated acupuncture, in which practitioners used a toothpick inside of an acupuncture needle guide tube to mimic the insertion, stimulation and removal of needles; and 161 received usual care. Participants reported changes in their symptoms and in the amount of dysfunction caused by their back pain by phone after eight, 26 and 52 weeks.

“Compared with usual care, individualized acupuncture, standardized acupuncture and simulated acupuncture had beneficial and persisting effects on chronic back pain,” the authors write. At the eight-week follow-up, 60 percent of the participants receiving any type of acupuncture (individualized, standardized or simulated) experienced a clinically meaningful improvement in their level of functioning, compared with 39 percent of those receiving usual care. At the one-year follow-up, 59 percent to 65 percent of those in the acupuncture groups experienced an improvement in function compared with 50 percent of the usual care group.

Several possible explanations exist for the effectiveness of simulated acupuncture, the authors note. Superficial stimulation of acupuncture points may directly stimulate physiological processes that result in reduced pain and improved function. Alternatively, the improvement may be due to another aspect of the treatment experience, such as interaction with the therapist or a belief that acupuncture will be helpful. “These findings raise questions about acupuncture’s purported mechanisms of action,” they write. “It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or non-specific effects.”

“Our results have important implications for key stakeholders,” they conclude. “For clinicians and patients seeking a relatively safe and effective treatment for a condition for which conventional treatments are often ineffective, various methods of acupuncture point stimulation appear to be reasonable options, even though the mechanism of action remains unclear. Furthermore, the reduction in long-term exposure to the potential adverse effects of medications is an important benefit that may enhance the safety of conventional medical care.”

Arch Intern Med. 2009;169[9]:858-866.

Source
Archives of Internal Medicine

WHEELING, W.Va., May 11 — Acupuncture was more effective than conventional treatment for relieving lower back pain in a randomized trial, but performed no better than poking patients gently with toothpicks.

Roland-Morris Dysfunction Questionnaire scores improved by a mean of 4.4 to 4.5 points with genuine acupuncture compared with a 2.1 point improvement with “usual care” (P<0.001), typically consisting of drugs and physical therapy, according to Daniel C. Cherkin, Ph.D., of the Center for Health Studies in Seattle, and colleagues.

Yet patients receiving the simulated acupuncture also showed mean improvement of 4.4 points, the researchers reported in the May 11 issue of Archives of Internal Medicine.

• Explain to interested patients that controlled trials have demonstrated benefit from acupuncture for certain types of chronic pain compared with conventional treatment, but a placebo effect may account for the finding.
• Explain that this trial used a novel comparison treatment in which needles were not inserted but may still have stimulated acupuncture points.

They concluded that the study supports a therapeutic benefit for acupuncture-point stimulation. But Dr. Cherkin and colleagues said the findings also “raise questions about acupuncture’s purported mechanisms of action.”

The study randomized 638 patients with chronic lower back pain to four treatments: individualized acupuncture, in which experienced acupuncturists determined needle placements for each patient according to their clinical judgment; standardized acupuncture in which eight needles were placed at points established in traditional Chinese medicine as appropriate for lower back pain; usual care; and the simulated acupuncture procedure.

The simulation involved placing a small guide tube against the eight standard acupuncture points and using a toothpick to gently tap and twist against the skin. Dr. Cherkin and colleagues said the sensation is similar to an actual needle insertion but does not break the skin. The procedure was done twice, 10 minutes apart, to simulate needle insertion followed by withdrawal.

Patients in all groups except usual care wore eye masks and their heads were placed in face cradles, blinding them — literally — to the specific mode of treatment.

Treatments lasted seven weeks with the primary evaluation conducted at week eight. Additional follow-ups were performed at weeks 26 and 52.

Mean age of patients was 47, 62% were female, and 68% were white, about two-thirds reported chronic pain for at least one year, and a similar fraction reported medication use in the previous week. Less than a quarter, however, said they had reduced activity or stayed in bed for significant periods recently because of back pain.

On a 10-point scale, the mean expectation that acupuncture would be helpful was 6.7.

Mean Roland-Morris scores at baseline were 10.6 (SD 5.2).

Improvements seen at eight weeks were largely maintained at the later follow-ups. In the case of usual care, an additional one-point improvement over week eight scores was found at week 52, although the total improvement relative to baseline remained smaller than was seen with the three acupuncture-type treatments (P=0.001 after adjusting for age, sex, and baseline score).

Patients in all treatment groups, including usual care, also rated their back pain as significantly less bothersome at weeks eight and 26, but not at the one-year evaluation.

Again, more improvement was seen in the three acupuncture-type groups than with usual care. And again, the simulated procedure seemed just as effective as the two treatments in which needles were used.

Dr. Cherkin and colleagues said the findings echoed those of other trials that found equal efficacy with acupuncture and some kind of sham procedure, with either outperforming usual care. (See Acupuncture Works for Headache But So Does Fake Needling)

They said this could reflect some kind of placebo effect. Or, they speculated, “superficial acupuncture point stimulation directly stimulates physiological processes that ultimately lead to improved pain and function.”

The latter possibility has been supported in earlier studies, including one demonstrating that light touch stimulates “mechanoreceptors” that in turn induce hormonal and emotional reactions related to pain.

Regardless of the mechanism, though, Dr. Cherkin and colleagues said it now appears clear that acupuncture and other similar treatments can be more effective than conventional therapy for lower back pain, especially when ordinary treatment has failed.

“Furthermore, the reduction in long-term exposure to the potential adverse effects of medications is an important benefit that may enhance the safety of conventional medical care,” they wrote.

The study was funded by the National Center for Complementary and Alternative Medicine. Study authors reported no potential conflicts of interest.

Primary source: Archives of Internal Medicine

Source reference:

Cherkin D, et al “A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain” Arch Intern Med 2009; 169: 858-66.

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• Acupuncture Works for Headache But So Does Fake Needling