Apparently well-designed low back pain AP study produces potentially bad results

May 12, 2009

This study is interesting because it addresses the usual complaint that

these studies don't allow L.Acs to use individually tailored treatments

according to best practice - one of the groups was indeed allowed to do

so. Nevertheless, it was no better than standardized TCM protocol or

*toothpicks*.

So, either all acupuncture is nonspecific, OR perhaps " standard " (i.e.

TCM-based) treatments are really not specific. I certainly noticed

better results after trying out Richard Tan / Master Tung style vs. TCM,

and we don't really know what these folks were using, but as I'm sure

everyone here has seen, results between acupuncturists vary widely, and

referrals to other L.Ac.'s often fail to produce similar results to our

own. But maybe it's all a placebo-spectrum effect (i.e. practitioner -

patient interaction) vs. actual technique. Or, acupuncture is just very,

very hard to do right, and few people are better than mere random

tapping of toothpicks.

-Ben Hawes, L.Ac.

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Trial Fails to Settle Questions About Acupuncture for Low Back Pain

By John Gever, Senior Editor, MedPage Today

Published: May 11, 2009

Reviewed by Dori F. Zaleznik, MD </reviewer.cfm?reviewerid=512>;

Associate Clinical Professor of Medicine, Harvard Medical School,

Boston. Earn CME/CE credit

for reading medical news

</posttest.cfm?testpage=14148 & TBID=14148 & topicid=141>

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Video Source: Group Health Center for Health Studies

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/.

Action Points

------

* 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

<http://www.medpagetoday.com/PainManagement/Migraines/12555>)

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.

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May 12, 2009

What it does say, and everyone apparently misses the real point, is that even

bad acupuncture is twice as good as the best western medicine has to offer

It says something about allopathic/western medicine.

Dr.Don J. Snow, DAOM, MPH, L.Ac.

Chinese Medicine

bhawes

Tue, 12 May 2009 14:14:03 -0600

Apparently well-designed low back pain AP study produces

potentially bad results