Acupuncture treatment of chronic back pain. A double-blind placebo-controlled trial

Placebo Response among Different Types of Sham Acupuncture for Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Low back pain (LBP) is a prevalent and debilitating condition that poses a significant burden on healthcare systems. Acupuncture has been proposed as a promising intervention for LBP, but the evidence supporting its specific effect is insufficient, and the use of sham acupuncture as a control in clinical trials presents challenges due to variations in sham acupuncture techniques and the magnitude of the placebo effect.

OBJECTIVE

To investigate the magnitude of the placebo response of sham acupuncture in trials of acupuncture for nonspecific LBP, and to assess whether different types of sham acupuncture are associated with different responses.

METHODS

Four databases including PubMed, EMBASE, MEDLINE, and the Cochrane Library were searched through April 15, 2023, and randomized controlled trials (RCTs) were included if they randomized patients with LBP to receive acupuncture or sham acupuncture intervention. The main outcomes included the placebo response in pain intensity, back-specific function and quality of life. Placebo response was defined as the change in these outcome measures from baseline to the end of treatment. Random-effects models were used to synthesize the results, standardized mean differences (SMDs, Hedges'g) were applied to estimate the effect size.

RESULTS

A total of 18 RCTs with 3,321 patients were included. Sham acupuncture showed a noteworthy pooled placebo response in pain intensity in patients with LBP [SMD -1.43, 95% confidence interval (CI) -1.95 to -0.91, I2=89%]. A significant placebo response was also shown in back-specific functional status (SMD -0.49, 95% CI -0.70 to -0.29, I2=73%), but not in quality of life (SMD 0.34, 95% CI -0.20 to 0.88, I2=84%). Trials in which the sham acupuncture penetrated the skin or performed with regular needles had a significantly higher placebo response in pain intensity reduction, but other factors such as the location of sham acupuncture did not have a significant impact on the placebo response.

CONCLUSIONS

Sham acupuncture is associated with a large placebo response in pain intensity among patients with LBP. Researchers should also be aware that the types of sham acupuncture applied may potentially impact the evaluation of the efficacy of acupuncture. Nonetheless, considering the nature of placebo response, the effect of other contextual factors cannot be ruled out in this study. (PROSPERO registration No. CRD42022304416).

Biopotential changes of acupuncture points by acupuncture stimulation

Background

The energy flow at acupuncture point is important for understanding the mechanism of acupuncture treatment. However, there are few studies on energy at acupuncture point, and related studies have limitation in explaining the energy flow in all meridians. Thus, we aimed to understand the properties of electrical energy at acupuncture point in twelve meridians by measuring the biopotential at acupuncture and non-acupuncture points.

Methods

For each meridian, twenty subjects were participated, and biopotential was measured at five transport points and their adjacent non-acupuncture points. In each subject, both ‘non-stimulation’ and ‘stimulation’ experiments were conducted in random order. The data were analyzed in two parts: biopotential variability and biopotential difference between acupuncture and non-acupuncture points.

Results

The biopotential variability at acupuncture point was increased by acupuncture stimulation, and it was related to the activation of Qi flow by acupuncture stimulation. The biopotential difference between acupuncture and non-acupuncture points was formed in the direction related to the Qi flow theory, and this biopotential difference tended to decrease by acupuncture stimulation.

Conclusion

The study on biopotential can provide a foundation for research on energy flow mechanism of acupuncture stimulation, and it is expected to overcome limitation of qualitative explanation in traditional medicine.

Acupuncture in chronic aspecific low back pain: a Bayesian network meta-analysis

Background

This Bayesian network meta-analysis investigated the available randomized control trials (RCTs) to point out which acupuncture protocol is the most effective for chronic aspecific low back pain (LBP). Efficacy was measured in terms of pain (Visual Analogic Scale, VAS) and disability (Roland Morris Disability Questionnaire, RMQ), Transcutaneous Electrical Nerve Stimulation (TENS).

Methods

PubMed, Google scholar, Embase, and Scopus were accessed in March 2022. All the RCTs comparing two or more acupuncture modalities for aspecific chronic LBP were accessed. Only studies which investigated the efficacy of acupuncture on patients with symptoms lasting a minimum of 1.5 months, or with at least three episodes in the previous 12 months, were considered eligible. The Review Manager Software (The Nordic Cochrane Collaboration, Copenhagen) was used for the methodological quality assessment. The STATA Software/MP, Version 14.1 (StataCorporation, College Station, Texas, USA), was used for the statistical analyses. The NMA was performed through the STATA routine for Bayesian hierarchical random-effects model analysis.

Results

Data from 44 RCTs (8338 procedures) were retrieved. 56% of patients were women. The mean age of the patients was 48 ± 10.6 years. The mean BMI was 26.3 ± 2.2 kg/m². The individual group (95% confidence interval (CI) 2.02, 7.98) and the standard combined with TENS (95% CI 2.03, 7.97) demonstrated the highest improvement of the RMQ. The VAS score was lower in the standard combined with TENS group (95% CI 3.28, 4.56). Considering the standard acupuncture group, different studies used similar protocols and acupuncture points and the results could thus be compared. The equation for global linearity did not find any statistically significant inconsistency in any of the network comparison.

Conclusion

Verum acupuncture is more effective than sham treatment for the non-pharmacological management of LBP. Among the verum protocols, individualized acupuncture and standard acupuncture with TENS were the protocols that resulted in the highest improvement in pain and quality of life.

Level of Evidence

Level I, Bayesian network meta-analysis of RCTs.

The Universality of Science and Traditional Chinese Medicine: A Philosophical Survey

This paper represents a philosophical appraisal of Traditional Chinese Medicine (TCM) from the point of view of the philosophy of science. As it is generally the case with other versions of Traditional Medicine, rather than a coherent research program Traditional Chinese Medicine constitutes an array of various techniques and practices coupled with a diversity of very different speculative doctrines regarding the physiological structure of certain body parts as well as the purported etiology of disease and malfunction. This chapter starts off by describing some of the theoretical assumptions on which TCM relies with the aim of casting light on whether they, alongside the clinical techniques TCM encompasses, can significantly be considered as a scientific theory comparable with that of conventional medicine. In so doing the chapter examines a plurality of demarcation criteria between science and non-science coming from various existing philosophical frameworks old and new. While, as will be shown, a wealth of research based on RCTs (randomized control trials) points out that TCM´s degree of effectiveness is low, that is not the point this paper intends to make. Instead of such an empirical criticism, the author sustains a comparably stronger epistemic contention, namely: even if the clinical results of TCM fared better than they actually do, that observation alone would not be a good reason to consider this branch of traditional medicine as a scientifically respectable endeavor.

Acupuncture for chronic nonspecific low back pain

BACKGROUND

Chronic nonspecific low back pain (LBP) is very common; it is defined as pain without a recognizable etiology that lasts for more than three months. Some clinical practice guidelines suggest that acupuncture can offer an effective alternative therapy. This review is a split from an earlier Cochrane review and it focuses on chronic LBP.

OBJECTIVES

To assess the effects of acupuncture compared to sham intervention, no treatment, or usual care for chronic nonspecific LBP.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, two Chinese databases, and two trial registers to 29 August 2019 without restrictions on language or publication status. We also screened reference lists and LBP guidelines to identify potentially relevant studies.

SELECTION CRITERIA

We included only randomized controlled trials (RCTs) of acupuncture for chronic nonspecific LBP in adults. We excluded RCTs that investigated LBP with a specific etiology. We included trials comparing acupuncture with sham intervention, no treatment, and usual care. The primary outcomes were pain, back-specific functional status, and quality of life; the secondary outcomes were pain-related disability, global assessment, or adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the studies, assessed the risk of bias and extracted the data. We meta-analyzed data that were clinically homogeneous using a random-effects model in Review Manager 5.3. Otherwise, we reported the data qualitatively. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 33 studies (37 articles) with 8270 participants. The majority of studies were carried out in Europe, Asia, North and South America. Seven studies (5572 participants) conducted in Germany accounted for 67% of the participants. Sixteen trials compared acupuncture with sham intervention, usual care, or no treatment. Most studies had high risk of performance bias due to lack of blinding of the acupuncturist. A few studies were found to have high risk of detection, attrition, reporting or selection bias. We found low-certainty evidence (seven trials, 1403 participants) that acupuncture may relieve pain in the immediate term (up to seven days) compared to sham intervention (mean difference (MD) -9.22, 95% confidence interval (CI) -13.82 to -4.61, visual analogue scale (VAS) 0-100). The difference did not meet the clinically important threshold of 15 points or 30% relative change. Very low-certainty evidence from five trials (1481 participants) showed that acupuncture was not more effective than sham in improving back-specific function in the immediate term (standardized mean difference (SMD) -0.16, 95% CI -0.38 to 0.06; corresponding to the Hannover Function Ability Questionnaire (HFAQ, 0 to 100, higher values better) change (MD 3.33 points; 95% CI -1.25 to 7.90)). Three trials (1068 participants) yielded low-certainty evidence that acupuncture seemed not to be more effective clinically in the short term for quality of life (SMD 0.24, 95% CI 0.03 to 0.45; corresponding to the physical 12-item Short Form Health Survey (SF-12, 0-100, higher values better) change (MD 2.33 points; 95% CI 0.29 to 4.37)). The reasons for downgrading the certainty of the evidence to either low to very low were risk of bias, inconsistency, and imprecision. We found moderate-certainty evidence that acupuncture produced greater and clinically important pain relief (MD -20.32, 95% CI -24.50 to -16.14; four trials, 366 participants; (VAS, 0 to 100), and improved back function (SMD -0.53, 95% CI -0.73 to -0.34; five trials, 2960 participants; corresponding to the HFAQ change (MD 11.50 points; 95% CI 7.38 to 15.84)) in the immediate term compared to no treatment. The evidence was downgraded to moderate certainty due to risk of bias. No studies reported on quality of life in the short term or adverse events. Low-certainty evidence (five trials, 1054 participants) suggested that acupuncture may reduce pain (MD -10.26, 95% CI -17.11 to -3.40; not clinically important on 0 to 100 VAS), and improve back-specific function immediately after treatment (SMD: -0.47; 95% CI: -0.77 to -0.17; five trials, 1381 participants; corresponding to the HFAQ change (MD 9.78 points, 95% CI 3.54 to 16.02)) compared to usual care. Moderate-certainty evidence from one trial (731 participants) found that acupuncture was more effective in improving physical quality of life (MD 4.20, 95% CI 2.82 to 5.58) but not mental quality of life in the short term (MD 1.90, 95% CI 0.25 to 3.55). The certainty of evidence was downgraded to moderate to low because of risk of bias, inconsistency, and imprecision. Low-certainty evidence suggested a similar incidence of adverse events immediately after treatment in the acupuncture and sham intervention groups (four trials, 465 participants) (RR 0.68 95% CI 0.46 to 1.01), and the acupuncture and usual care groups (one trial, 74 participants) (RR 3.34, 95% CI 0.36 to 30.68). The certainty of the evidence was downgraded due to risk of bias and imprecision. No trial reported adverse events for acupuncture when compared to no treatment. The most commonly reported adverse events in the acupuncture groups were insertion point pain, bruising, hematoma, bleeding, worsening of LBP, and pain other than LBP (pain in leg and shoulder).

AUTHORS' CONCLUSIONS

We found that acupuncture may not play a more clinically meaningful role than sham in relieving pain immediately after treatment or in improving quality of life in the short term, and acupuncture possibly did not improve back function compared to sham in the immediate term. However, acupuncture was more effective than no treatment in improving pain and function in the immediate term. Trials with usual care as the control showed acupuncture may not reduce pain clinically, but the therapy may improve function immediately after sessions as well as physical but not mental quality of life in the short term. The evidence was downgraded to moderate to very low-certainty considering most of studies had high risk of bias, inconsistency, and small sample size introducing imprecision. The decision to use acupuncture to treat chronic low back pain might depend on the availability, cost and patient's preferences.

Systematic review and meta-analysis of effects of acupuncture on pain and function in non-specific low back pain

OBJECTIVE

To assess the effectiveness of acupuncture for non-specific low back pain (NSLBP) through systematic review of published randomised controlled trials (RCTs).

METHODS

Studies were identified in electronic databases from their inception to February 2018, and were grouped according to the control interventions. The outcomes of interest were pain intensity and disability. Methodological quality was evaluated using the Cochrane risk-of-bias criteria and the Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) checklist. The review was reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

25 trials (n=7587 participants) were identified and included in a meta-analysis. The results showed that acupuncture was more effective at inducing pain relief than: no treatment (standardised mean difference (SMD) -0.69, 95% CI -0.99 to -0.38); sham acupuncture in the immediate term (SMD -0.33, 95% CI -0.49 to -0.18), short term (SMD -0.47, 95% CI -0.77 to -0.17), and intermediate term (SMD -0.17, 95% CI -0.28 to -0.05); and usual care in the short term (SMD -1.07, 95% CI -1.81 to -0.33) and intermediate term (SMD -0.43, 95% CI -0.77 to -0.10). Also, adjunctive acupuncture with usual care was more effective than usual care alone at all time points studied. With regard to functional improvement, the analysis showed a significant difference between acupuncture and no treatment (SMD -0.94, 95% CI -1.57 to -0.30), whereas the other control therapies could not be assessed.

CONCLUSION

We draw a cautious conclusion that acupuncture appears to be effective for NSLBP and that acupuncture may be an important supplement to usual care in the management of NSLBP.

Individual recovery expectations and prognosis of outcomes in non-specific low back pain: prognostic factor review

BACKGROUND

Low back pain is costly and disabling. Prognostic factor evidence can help healthcare providers and patients understand likely prognosis, inform the development of prediction models to identify subgroups, and may inform new treatment strategies. Recent studies have suggested that people who have poor expectations for recovery experience more back pain disability, but study results have differed.

OBJECTIVES

To synthesise evidence on the association between recovery expectations and disability outcomes in adults with low back pain, and explore sources of heterogeneity.

SEARCH METHODS

The search strategy included broad and focused electronic searches of MEDLINE, Embase, CINAHL, and PsycINFO to 12 March 2019, reference list searches of relevant reviews and included studies, and citation searches of relevant expectation measurement tools.

SELECTION CRITERIA

We included low back pain prognosis studies from any setting assessing general, self-efficacy, and treatment expectations (measured dichotomously and continuously on a 0 - 10 scale), and their association with work participation, clinically important recovery, functional limitations, or pain intensity outcomes at short (3 months), medium (6 months), long (12 months), and very long (> 16 months) follow-up.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and all reported estimates of unadjusted and adjusted associations between expectations and related outcomes. Two review authors independently assessed risks of bias using the Quality in Prognosis Studies (QUIPS) tool. We conducted narrative syntheses and meta-analyses when appropriate unadjusted or adjusted estimates were available. Two review authors independently graded and reported the overall quality of evidence.

MAIN RESULTS

We screened 4635 unique citations to include 60 studies (30,530 participants). Thirty-five studies were conducted in Europe, 21 in North America, and four in Australia. Study populations were mostly chronic (37%), from healthcare (62%) or occupational settings (26%). General expectation was the most common type of recovery expectation measured (70%); 16 studies measured more than one type of expectation. Usable data for syntheses were available for 52 studies (87% of studies; 28,885 participants). We found moderate-quality evidence that positive recovery expectations are strongly associated with better work participation (narrative synthesis: 21 studies; meta-analysis: 12 studies, 4777 participants: odds ratio (OR) 2.43, 95% confidence interval (CI) 1.64 to 3.62), and low-quality evidence for clinically important recovery outcomes (narrative synthesis: 12 studies; meta-analysis: 5 studies, 1820 participants: OR 1.89, 95% CI 1.49 to 2.41), both at follow-up times closest to 12 months, using adjusted data. The association of recovery expectations with other outcomes of interest, including functional limitations (narrative synthesis: 10 studies; meta-analysis: 3 studies, 1435 participants: OR 1.40, 95% CI 0.85 to 2.31) and pain intensity (narrative synthesis: 9 studies; meta-analysis: 3 studies, 1555 participants: OR 1.15, 95% CI 1.08 to 1.23) outcomes at follow-up times closest to 12 months using adjusted data, is less certain, achieving very low- and low-quality evidence, respectively. No studies reported statistically significant or clinically important negative associations between recovery expectations and any low back pain outcome.

AUTHORS' CONCLUSIONS

We found that individual recovery expectations are probably strongly associated with future work participation (moderate-quality evidence) and may be associated with clinically important recovery outcomes (low-quality evidence). The association of recovery expectations with other outcomes of interest is less certain. Our findings suggest that recovery expectations should be considered in future studies, to improve prognosis and management of low back pain.

The Effect of Acupuncture on Post-Operative Oral Surgery Pain: A Pilot Study

An important problem with acupuncture research has been the difficulty in designing appropriate control groups. This pilot study attempted to resolve this problem. Ten patients with third molar extractions were assigned to an acupuncture group (n=7) or a placebo acupuncture group (n=3). Pain intensity and length of time to reach moderate pain after dental surgery were recorded by standard patient self-report. Results indicate that subjects treated with acupuncture reported longer pain-free duration times (mean 212min vs 65min) and experienced a 56.5% mean pain reduction compared to those who received placebo acupuncture. Even though the limited sample size reduced statistical power, this pilot study provides a model for placebo acupuncture control that will be utilised in future large-scale clinical acupuncture studies.

The Methodology of Controlled Trials of Acupuncture

The double-blind controlled trial methodology cannot be straightforwardly applied to trials of acupuncture. The double-blind condition, where the clinician is ignorant of the treatment allocation, cannot be sensibly maintained in trials of acupuncture or other physical treatments. The definition of an appropriate control group is also a difficult matter. The great majority of controlled trials of acupuncture so far conducted are seriously flawed by the use of a placebo control that itself has therapeutic effects. Recently more appropriate control groups have been developed, notably mock TENS, which is inert, and minimal acupuncture, which has only a very slight specific effect. As trials can only be single blind, if is especially important to monitor the adequacy of the control procedure, to ensure that it is perceived as being as effective as the true treatment. It is suggested that this can be achieved by assessing the: credibility of the two treatment procedures.

Controlled trials of acupuncture should therefore be single blind, and employ a control condition that has no more than minimal specific effects, but is nevertheless seen as a credible, bona fide treatment by patients.

A randomized controlled clinical trial evaluating quality of life when using a simple acupressure protocol in women with primary dysmenorrhea

OBJECTIVE

To evaluate a simple acupressure protocol in LIV3 and LI4 acupoints in women with primary dysmenorrhea.

METHODS

This paper reports a randomized, single blinded clinical trial. 90 young women with dysmenorrhea were recruited to three groups to receive 20min acupressure every day in either LIV3 or LI4, or placebo points. Acupressure was timed five days before menstruation for three successive menstrual cycles. On menstruation, each participant completed the Wong Baker faces pain scale, and the quality of life short form -12 (QOL SF-12).

RESULTS

Intensity and duration of pain between the three groups in the second and third cycles during the intervention (p<0.05) differed significantly. Significant differences were seen in all domains of QOL except for mental health (p=0.4), general health (p=0.7) and mental subscale component (p=0.12) in the second cycle, and mental health (p=0.9), and mental subscale component (p=0.14) in the third cycle.

CONCLUSION

Performing the simple acupressure protocol is an effective method to decrease the intensity and duration of dysmenorrhea, and improve the QOL. Registration ID in IRCT: IRCT2016052428038N1.

Acupuncture for musculoskeletal pain: A meta-analysis and meta-regression of sham-controlled randomized clinical trials

The aims of this systematic review were to study the analgesic effect of real acupuncture and to explore whether sham acupuncture (SA) type is related to the estimated effect of real acupuncture for musculoskeletal pain. Five databases were searched. The outcome was pain or disability immediately (≤1 week) following an intervention. Standardized mean differences (SMDs) with 95% confidence intervals were calculated. Meta-regression was used to explore possible sources of heterogeneity. Sixty-three studies (6382 individuals) were included. Eight condition types were included. The pooled effect size was moderate for pain relief (59 trials, 4980 individuals, SMD -0.61, 95% CI -0.76 to -0.47; P < 0.001) and large for disability improvement (31 trials, 4876 individuals, -0.77, -1.05 to -0.49; P < 0.001). In a univariate meta-regression model, sham needle location and/or depth could explain most or all heterogeneities for some conditions (e.g., shoulder pain, low back pain, osteoarthritis, myofascial pain, and fibromyalgia); however, the interactions between subgroups via these covariates were not significant (P < 0.05). Our review provided low-quality evidence that real acupuncture has a moderate effect (approximate 12-point reduction on the 100-mm visual analogue scale) on musculoskeletal pain. SA type did not appear to be related to the estimated effect of real acupuncture.

Responder analyses in randomised controlled trials for chronic low back pain: an overview of currently used methods

PURPOSE

To provide an overview and a critical appraisal of the use of responder analyses in published randomised controlled trials (RCTs) of interventions for chronic low back pain (LBP). The methodology used for the analyses, including the justification, as well as the implications of responder analyses on the conclusions was explored.

METHODS

A convenience sample of four systematic reviews evaluating 162 RCTs of interventions for chronic LBP was used to identify individual trials. Randomised trials were screened by two reviewers and included if they performed and reported a responder analysis (i.e. the proportion of participants achieving a pre-defined level of improvement). The cutoff value for responders, the period of follow-up, and the outcome measure used were extracted. Information on how RCT authors justified the methodology of their responder analyses was also appraised.

RESULTS

Twenty-eight articles (17%) using 20 different definitions of responders were included in this appraisal. Justification for the definition of responders was absent in 80% of the articles. Pain was the most frequently used domain for the definition of response (50%), followed by back-specific function (30%) and a combination of pain and function (20%). A reduction in pain intensity ≥50% was the most common threshold used to define responders (IQR 33-60%).

CONCLUSIONS

Few RCTs of interventions for chronic LBP report responder analyses. Where responder analyses are used, the methods are inconsistent. When performing responder analyses authors are encouraged to follow the recommended guidelines, using empirically derived cutoffs, and present results alongside mean differences.

Analysis of scientific truth status in controlled rehabilitation trials

RATIONALE, AIMS AND OBJECTIVES

Systematic reviews, meta-analyses and clinical guidelines (reviews) are intended to inform clinical practice, and in this sense can be thought of as scientific truthmakers. High-quality controlled trials should align to this truth, and method quality markers should predict truth status. We sought to determine in what way controlled trial quality relates to scientific truth, and to determine predictive utility of trial quality and bibliographic markers.

METHOD

A sample of reviews in rehabilitation medicine was examined. Two scientific truth dimensions were established based on review outcomes. Quality and bibliographic markers were extracted from associated trials for use in a regression analysis of their predictive utility for trial truth status. Probability analysis was undertaken to examine judgments of future trial truth status.

RESULTS

Of the 93 trials included in contemporaneous reviews, overall, n = 45 (48%) were true. Randomization was found more in true trials than false trials in one truth dimension (P = 0.03). Intention-to-treat analysis was close to significant in one truth dimension (P = 0.058), being more commonly used in false trials. There were no other significant differences in quality or bibliographic variables between true and false trials. Regression analysis revealed no significant predictors of trial truth status. Probability analysis reported that the reasonable chance of future trials being true was between 2 and 5%, based on a uniform prior.

CONCLUSIONS

The findings are at odds with what is considered gold-standard research methods, but in line with previous reports. Further work should focus on scientific dynamics within healthcare research and evidence-based practice constructs.

Acupuncture for chronic low back pain in long-term follow-up: a meta-analysis of 13 randomized controlled trials

Chronic low back pain is one of the most common reasons that people seek medical treatment, and the consequent disability creates a great financial burden on individuals and society. The etiology of chronic low back pain is not clear, which means it is often refractory to treatment. Acupuncture has been reported to be effective in providing symptomatic relief of chronic low back pain. However, it is not known whether the effects of acupuncture are due to the needling itself or nonspecific effects arising from the manipulation. To determine the effectiveness of acupuncture therapy, a meta-analysis was performed to compare acupuncture with sham acupuncture and other treatments. Overall, 2678 patients were identified from thirteen randomized controlled trials. The meta-analysis was performed by a random model (Cohen's test), using the I-square test for heterogeneity and Begg's test to assess for publication bias. Clinical outcomes were evaluated by pain intensity, disability, spinal flexion, and quality of life. Compared with no treatment, acupuncture achieved better outcomes in terms of pain relief, disability recovery and better quality of life, but these effects were not observed when compared to sham acupuncture. Acupuncture achieved better outcomes when compared with other treatments. No publication bias was detected. Acupuncture is an effective treatment for chronic low back pain, but this effect is likely to be produced by the nonspecific effects of manipulation.

Complementary and alternative medicine treatments for low back pain

Complementary and alternative medicine, often referred to as integrated medicine, is often used for the treatment of low back pain. This article presents 6 therapies (ie, behavioral treatment, acupuncture, manipulation, prolotherapy, neuroreflexotherapy, and herbal treatments), which are discussed in terms of the specifics of the modality, as well as the empirical evidence related to their effectiveness.

A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain

Background. Back pain is a common problem and a major cause of disability and health care utilization. Purpose. To evaluate the efficacy, harms, and costs of the most common CAM treatments (acupuncture, massage, spinal manipulation, and mobilization) for neck/low-back pain. Data Sources. Records without language restriction from various databases up to February 2010. Data Extraction. The efficacy outcomes of interest were pain intensity and disability. Data Synthesis. Reports of 147 randomized trials and 5 nonrandomized studies were included. CAM treatments were more effective in reducing pain and disability compared to no treatment, physical therapy (exercise and/or electrotherapy) or usual care immediately or at short-term follow-up. Trials that applied sham-acupuncture tended towards statistically nonsignificant results. In several studies, acupuncture caused bleeding on the site of application, and manipulation and massage caused pain episodes of mild and transient nature. Conclusions. CAM treatments were significantly more efficacious than no treatment, placebo, physical therapy, or usual care in reducing pain immediately or at short-term after treatment. CAM therapies did not significantly reduce disability compared to sham. None of the CAM treatments was shown systematically as superior to one another. More efforts are needed to improve the conduct and reporting of studies of CAM treatments.

An international expert survey on acupuncture in randomized controlled trials for low back pain and a validation of the low back pain acupuncture score

BACKGROUND

Acupuncture is a promising treatment approach in patients with chronic low back pain (cLBP) but little is known about the quality of acupuncture in randomized controlled trials (RCT) of acupuncture cLBP. -

OBJECTIVE

To determine how international experts (IES) rate the quality of acupuncture in RCTs of cLBP; independent international validation of the Low Back Pain Acupuncture Score (LBPAS).

METHODOLOGY

Fifteen experts from 9 different countries outside China were surveyed (IES). They were asked to read anonymized excerpts of 24 RCTs of cLBP and answer a three-item questionnaire on how the method of acupuncture conformed to 1) Chinese textbook standards, 2) the expert?s personally preferred style, and 3) how acupuncture is performed in the expert?s country. Likert scale rating, calculation of the mode for each answer, and Spearman?s rank correlation coefficient between all three answers and the LBPAS were calculated.

RESULTS

On comparison with Chinese textbook standards (question 1), 6 RCTs received a good rating, 8 trials a fair and 10 trials a poor or very poor rating. 5 of the 6 trials rated good, received at least a good rating also in question 2 or 3. We found a high correlation of 0.85 (p<0.0001) between the IES and LBPAS ratings for question 1 and question 2, and a correlation of 0.66 (p<0.0001) for question 3.

CONCLUSION

The international expert survey (IES) revealed that only 6 out of 24 (25%) RCTs of acupuncture for cLBP were rated "good" in respect to Chinese textbook acupuncture standards. There were only small differences in how the acupuncture quality was rated in comparison to Chinese textbook acupuncture, personally preferred and local styles of acupuncture. The rating showed a high correlation with the Low Back Pain Acupuncture Score LBPAS.

A systematic review on the effectiveness of complementary and alternative medicine for chronic non-specific low-back pain

The purpose of this systematic review was to assess the effects of spinal manipulative therapy (SMT), acupuncture and herbal medicine for chronic non-specific LBP. A comprehensive search was conducted by an experienced librarian from the Cochrane Back Review Group (CBRG) in multiple databases up to December 22, 2008. Randomised controlled trials (RCTs) of adults with chronic non-specific LBP, which evaluated at least one clinically relevant, patient-centred outcome measure were included. Two authors working independently from one another assessed the risk of bias using the criteria recommended by the CBRG and extracted the data. The data were pooled when clinically homogeneous and statistically possible or were otherwise qualitatively described. GRADE was used to determine the quality of the evidence. In total, 35 RCTs (8 SMT, 20 acupuncture, 7 herbal medicine), which examined 8,298 patients, fulfilled the inclusion criteria. Approximately half of these (2 SMT, 8 acupuncture, 7 herbal medicine) were thought to have a low risk of bias. In general, the pooled effects for the studied interventions demonstrated short-term relief or improvement only. The lack of studies with a low-risk of bias, especially in regard to SMT precludes any strong conclusions; however, the principal findings, which are based upon low- to very-low-quality evidence, suggest that SMT does not provide a more clinically beneficial effect compared with sham, passive modalities or any other intervention for treatment of chronic low-back pain. There is evidence, however, that acupuncture provides a short-term clinically relevant effect when compared with a waiting list control or when acupuncture is added to another intervention. Although there are some good results for individual herbal medicines in short-term individual trials, the lack of homogeneity across studies did not allow for a pooled estimate of the effect. In general, these results are in agreement with other recent systematic reviews on SMT, but in contrast with others. These results are also in agreement with recent reviews on acupuncture and herbal medicine. Randomized trials with a low risk of bias and adequate sample sizes are direly needed.

Comparison of the Effectiveness of Acupuncture Treatment and Local Anaesthetic Injection for Low Back Pain: A Randomised Controlled Clinical Trial

Objective

To compare the effectiveness of repeated acupuncture stimulation and local anaesthetic injection at the most painful points in patients with low back pain.

Method

This randomised controlled clinical trial involved 26 patients with low back pain randomly allocated to either an acupuncture group (n = 13) or a local anaesthetic injection group (n = 13). Both acupuncture and anaesthetic injection were performed at two to five of the most painful points on the lower back once weekly for 4 weeks. In the acupuncture group, a 0.18 mm diameter stainless steel needle was inserted to a depth of 10–20 mm and manual stimulation was applied. In the local anaesthetic injection group, a 0.5 mm diameter needle was inserted to a depth of 10–20 mm and a local anaesthetic was injected. Participants evaluated pain using a Visual Analogue Scale immediately before and after the first treatment, before each subsequent treatment, and at 2 weeks and 4 weeks after completion of treatment.

Results

There was a significant difference between the two groups in the change in Visual Analogue Scale pain scores (p<0.01), with acupuncture providing more favourable results than local anaesthetic injection. The reduction in pain score from baseline calculated at each time period was significantly different between the two groups after the first (p<0.05) and final (p<0.01) treatments, and during the follow-up period (after 2 weeks (p<0.01) and 4 weeks (p<0.05)).

Conclusion

Both injection and acupuncture relieved pain, but acupuncture was superior for the immediate and sustained effects, suggesting that it is a useful treatment for low back pain. The difference in the effects may be attributable to differences in the mechanism of pain suppression.

Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials

OBJECTIVE

Estimates of treatment effects reported in placebo-controlled randomized trials are less subject to bias than those estimates provided by other study designs. The objective of this meta-analysis was to estimate the analgesic effects of treatments for non-specific low back pain reported in placebo-controlled randomized trials.

METHODS

Medline, Embase, Cinahl, PsychInfo and Cochrane Central Register of Controlled Trials databases were searched for eligible trials from earliest records to November 2006. Continuous pain outcomes were converted to a common 0-100 scale and pooled using a random effects model.

RESULTS

A total of 76 trials reporting on 34 treatments were included. Fifty percent of the investigated treatments had statistically significant effects, but for most the effects were small or moderate: 47% had point estimates of effects of <10 points on the 100-point scale, 38% had point estimates from 10 to 20 points and 15% had point estimates of >20 points. Treatments reported to have large effects (>20 points) had been investigated only in a single trial.

CONCLUSIONS

This meta-analysis revealed that the analgesic effects of many treatments for non-specific low back pain are small and that they do not differ in populations with acute or chronic symptoms.

Effectiveness of acupuncture for low back pain: a systematic review

STUDY DESIGN

A systematic review of randomized controlled trials (RCTs).

OBJECTIVE

To explore the evidence for the effectiveness of acupuncture for nonspecific low back pain (LBP).

SUMMARY OF BACKGROUND DATA

Since the most recent systematic reviews on RCTs on acupuncture for LBP, 6 RCTs have been published, which may impact on the previous conclusions.

METHODS

Searches were completed for RCTs on all types of acupuncture for patients with nonspecific LBP published in English. Methodologic quality was scored using the Van Tulder scale. Trials were deemed to be high quality if they scored more than 6/11 on the Van Tulder scale, carried out appropriate statistical analysis, with at least 40 patients per group, and did not exceed 20% and 30% dropouts at short/intermediate and long-term follow-up, respectively. High quality trials were given more weight when conducting the best evidence synthesis. Studies were grouped according to the control interventions, i.e., no treatment, sham intervention, conventional therapy, acupuncture in addition to conventional therapy. Treatment effect size and clinical significance were also determined. The adequacy of acupuncture treatment was judged by comparison of recommendations made in textbooks, surveys, and reviews.

RESULTS

Twenty-three trials (n = 6359) were included and classified into 5 types of comparisons, 6 of which were of high quality. There is moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief. There is strong evidence that acupuncture can be a useful supplement to other forms of conventional therapy for nonspecific LBP, but the effectiveness of acupuncture compared with other forms of conventional therapies still requires further investigation.

CONCLUSION

Acupuncture versus no treatment, and as an adjunct to conventional care, should be advocated in the European Guidelines for the treatment of chronic LBP.

Imperfect placebos are common in low back pain trials: a systematic review of the literature

The placebo is an important tool to blind patients to treatment allocation and therefore minimise some sources of bias in clinical trials. However, placebos that are improperly designed or implemented may introduce bias into trials. The purpose of this systematic review was to evaluate the adequacy of placebo interventions used in low back pain trials. Electronic databases were searched systematically for randomised placebo-controlled trials of conservative interventions for low back pain. Trial selection and data extraction were performed by two reviewers independently. A total of 126 trials using over 25 different placebo interventions were included. The strategy most commonly used to enhance blinding was the provision of structurally equivalent placebos. Adequacy of blinding was assessed in only 13% of trials. In 20% of trials the placebo intervention was a potentially genuine treatment. Most trials that assessed patients' expectations showed that the placebo generated lower expectations than the experimental intervention. Taken together, these results demonstrate that imperfect placebos are common in low back pain trials; a result suggesting that many trials provide potentially biased estimates of treatment efficacy. This finding has implications for the interpretation of published trials and the design of future trials. Implementation of strategies to facilitate blinding and balance expectations in randomised groups need a higher priority in low back pain research.

Evidence-informed management of chronic low back pain with needle acupuncture

The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue to The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Effect sizes of non-surgical treatments of non-specific low-back pain

Numerous randomized trials have been published investigating the effectiveness of treatments for non-specific low-back pain (LBP) either by trials comparing interventions with a no-treatment group or comparing different interventions. In trials comparing two interventions, often no differences are found and it raises questions about the basic benefit of each treatment. To estimate the effect sizes of treatments for non-specific LBP compared to no-treatment comparison groups, we searched for randomized controlled trials from systematic reviews of treatment of non-specific LBP in the latest issue of the Cochrane Library, issue 2, 2005 and available databases until December 2005. Extracted data were effect sizes estimated as Standardized Mean Differences (SMD) and Relative Risk (RR) or data enabling calculation of effect sizes. For acute LBP, the effect size of non-steroidal anti-inflammatory drugs (NSAIDs) and manipulation were only modest (ES: 0.51 and 0.40, respectively) and there was no effect of exercise (ES: 0.07). For chronic LBP, acupuncture, behavioral therapy, exercise therapy, and NSAIDs had the largest effect sizes (SMD: 0.61, 0.57, and 0.52, and RR: 0.61, respectively), all with only a modest effect. Transcutaneous electric nerve stimulation and manipulation had small effect sizes (SMD: 0.22 and 0.35, respectively). As a conclusion, the effect of treatments for LBP is only small to moderate. Therefore, there is a dire need for developing more effective interventions.

Regional myofascial pain: diagnosis and management

This chapter defines and describes the condition that is known by the term myofascial trigger point pain syndrome. An outline is given of the current state of knowledge of the pathophysiology of myofascial trigger points, including the latest details from needle microdialysis in near real-time. The clinical features of this pain syndrome are summarised in general terms and the reliability of the clinical diagnosis is discussed. The clinical evidence for and against the common therapeutic interventions used in the management of myofascial pain is reviewed in detail and some tentative conclusions are reached with respect to needling therapies.

Relief of low back pain immediately after acupuncture treatment--a randomised, placebo controlled trial

BACKGROUND

The purpose of this study was to examine the immediate effect of single acupuncture stimulation to the most painful point in patients with low back pain.

METHOD

A randomised, evaluator-blinded, sham controlled clinical trial was conducted in which 31 patients with low back pain were randomly allocated to either an acupuncture group (n = 15) or a sham acupuncture group (n = 16). Both acupuncture and sham acupuncture were performed at the most painful point on the lower back of the subjects. For the acupuncture group, a stainless steel needle was inserted to a depth of 20 mm and manually stimulated (sparrow pecking method) for 20 seconds, while for the sham treatment a guide tube without a needle was placed at the point and tapped on the skin. Changes in low back pain were evaluated with a visual analogue scale (VAS) and the Schober test. Participants were also asked if they felt the needling sensation or not. The therapy and the evaluation were independently performed by two different acupuncturists.

RESULTS

VAS score and the Schober test score showed significant improvement after treatment as compared with the sham group (P = 0.02, 0.001, respectively). There were no significant differences in the needling sensation between the acupuncture and sham group.

CONCLUSION

These results suggest that acupuncture at the most painful point gives immediate relief of low back pain.

Acupuncture treatment for opiate addiction: A systematic review

A review of the efficacy of acupuncture as treatment for opiate addiction, covering 33 years of reported literature in western scientific journals, was systematically undertaken. Some abstracts from Chinese language journals were also briefly reviewed. Supportive evidence often came from non-controlled nonblinded methodologies. When well-designed clinical trials (randomized, controlled, single-blind methodologies) were used, there was no significant evidence for acupuncture being a more effective treatment than controls. Some of the current supportive evidence for efficacy came from Chinese journals that have not been translated into English yet.

Complementary and alternative therapies for low back pain

The support for the principles of evidence-based medicine has increased within the field of complementary and alternative medicine (CAM). The objective of this chapter is to determine the effectiveness of CAM therapies compared to placebo, no intervention, or other interventions for acute/subacute and chronic non-specific low back pain (LBP). Results from Cochrane reviews on acupuncture, botanical medicine, massage, neuroreflexotherapy, and spinal manipulation have been used. The results showed that acupuncture is more effective than no treatment or sham treatment for chronic LBP but that there are no differences in effectiveness compared with other conventional therapies. Specific botanical medicines can be effective for acute episodes of chronic non-specific LBP in terms of short-term improvement in pain and functional status; long-term efficacy was not assessed. Massage seems more beneficial than sham treatment for chronic non-specific LBP but effectiveness compared with other conventional therapies is inconclusive. Neuroreflexotherapy appears to be more effective than sham treatment or standard care for chronic non-specific LBP. Spinal manipulation was more effective than sham manipulation or ineffective therapies, and equally effective as other conventional therapies. In summary, the results on CAM therapies for (acute episodes of) chronic LBP are promising but more evidence on the relative cost-effectiveness compared to conventional treatments is needed.

Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the cochrane collaboration

OBJECTIVES

To assess the effects of acupuncture and dry-needling for the treatment of nonspecific low back pain.

BACKGROUND

Low back pain is usually a self-limiting condition that tends to improve spontaneously over time. However, for many people, back pain becomes a chronic or recurrent problem for which a large variety of therapeutic interventions are employed.

SEARCH STRATEGY

We updated the searches from 1996 to February 2003 in CENTRAL, MEDLINE, and EMBASE. We also searched the Chinese Cochrane Centre database of clinical trials and Japanese databases to February 2003.

SELECTION CRITERIA

Randomized controlled trials of acupuncture (that involved needling) or dry-needling for adults with nonspecific acute/subacute or chronic low back pain.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed methodologic quality (using the criteria recommended by the Cochrane Back Review Group) and extracted data. The trials were combined using meta-analysis methods or levels of evidence when the data reported did not allow statistical pooling.

RESULTS

Thirty-five randomized clinical trials were included: 20 were published in English, 7 in Japanese, 5 in Chinese, and 1 each in Norwegian, Polish, and German. There were only 3 trials of acupuncture for acute low back pain. These studies did not justify firm conclusions because of their small sample sizes and low methodologic quality. For chronic low back pain, there is evidence of pain relief and functional improvement for acupuncture compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and in short-term follow-up. There is also evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, the effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low back pain. No clear recommendations could be made about the most effective acupuncture technique.

CONCLUSIONS

The data do not allow firm conclusions regarding the effectiveness of acupuncture for acute low back pain. For chronic low back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and "alternative" treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low back pain. Because most of the studies were of lower methodologic quality, there is a clear need for higher quality trials in this area.

The effectiveness of electroacupuncture versus electrical heat acupuncture in the management of chronic low-back pain

DESIGN

Forty-two (42) subjects suffering from chronic low-back pain were matched with the nature of their occupations and then randomly allocated into: (1) an electroacupuncture group (EA); (2) an electrical heat acupuncture (EH) group or; (3) a control group.

INTERVENTIONS

Subjects in the EA group and the EH group received treatment for 20 minutes on a total of 6 acupuncture points. Treatment was delivered twice per week for 4 weeks (a total of 8 sessions). Back exercise was taught to all subjects including the control group as a home program.

OUTCOMES MEASURES

A numerical rating scale of pain (NPRS), straight leg raise (SLR), and Roland Morris Disability Questionnaire (RMDQ) were recorded.

RESULTS

There were significant reduction of NPRS within the EA (p = 0.000), EH (p = 0.000), and control (p = 0.013) groups across sessions. Significant between-group differences were shown in session 4 (p = 0.006), session 8 (p = 0.001), and 1-month follow-up sessions (p = 0.001). Posthoc tests showed that the NPRS of the EH group was significantly lower than that of the EA group and the control group by session 4 (p = 0.004). After session 8, the NPRS of both the EA group (p = 0.003) and the EH group (p = 0.001) were significantly lower than that of the control group. Such a difference was maintained at least up to the 1-month follow-up. Only the EA group had significant improvement in the measurement of SLR across sessions (p = 0.000). The between-group difference reached significance level in session 8 (p = 0.001) and at 1-month follow-up (p = 0.002). Posthoc tests showed that EA group had significantly greater gain than the EH group and the control group. For the RMDQ score, the improvement was statistically significant within each of the three groups over time (p = 0.000). However, the between-group difference did not reach statistical significance.

CONCLUSIONS

Our findings suggest that 4 sessions of EH treatment over 2 weeks produced significantly greater reduction in the NPRS than that of the EA or the control. However, EA produced greater improvement in SLR and reduction in RMDQ score than that of the EH and the control.

Acupuncture and dry-needling for low back pain

BACKGROUND

Although low-back pain is usually a self-limiting and benign disease that tends to improve spontaneously over time, a large variety of therapeutic interventions are available for its treatment.

OBJECTIVES

To assess the effects of acupuncture for the treatment of non-specific low-back pain and dry-needling for myofascial pain syndrome in the low-back region.

SEARCH STRATEGY

We updated the searches from 1996 to February 2003 in CENTRAL, MEDLINE, and EMBASE. We also searched the Chinese Cochrane Centre database of clinical trials and Japanese databases to February 2003.

SELECTION CRITERIA

Randomized trials of acupuncture (that involves needling) for adults with non-specific (sub)acute or chronic low-back pain, or dry-needling for myofascial pain syndrome in the low-back region.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed methodological quality (using the criteria recommended by the Cochrane Back Review Group) and extracted data. The trials were combined using meta-analyses methods or levels of evidence when the data reported did not allow statistical pooling.

MAIN RESULTS

Thirty-five RCTs were included; 20 were published in English, seven in Japanese, five in Chinese and one each in Norwegian, Polish and German. There were only three trials of acupuncture for acute low-back pain. They did not justify firm conclusions, because of small sample sizes and low methodological quality of the studies. For chronic low-back pain there is evidence of pain relief and functional improvement for acupuncture, compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and at short-term follow-up. There is evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain. No clear recommendations could be made about the most effective acupuncture technique.

AUTHORS' CONCLUSIONS

The data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back pain. For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and "alternative" treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain. Because most of the studies were of lower methodological quality, there certainly is a further need for higher quality trials in this area.

The effectiveness of relaxation acupoint stimulation and acupressure with aromatic lavender essential oil for non-specific low back pain in Hong Kong: a randomised controlled trial

OBJECTIVES

To assess the effect of acupoint stimulation with electrodes combined with acupressure using an aromatic essential oil (lavender) as an add-on-treatment on pain relief and enhancing the physical functional activities among adults with sub-acute or chronic non-specific low back pain.

DESIGN

Randomised controlled trial.

SETTING

The community centre, Old-Aged Home and Women Workers Association, Hong Kong.

INTERVENTION

8-session relaxation acupoint stimulation followed by acupressure with lavender oil over a 3-week period. The control group received usual care only.

OUTCOME MEASURES

Changes from baseline to the end of treatment were assessed in pain intensity (by Visual Analogue Scale) and duration; lateral fingertip-to-ground distance in centimetres; walking time and interference on daily activities.

RESULTS

The baseline VAS scores for the intervention and control groups were 6.38 (S.E.M. = 0.22) and 5.70 (S.E.M. = 0.37) out of 10, respectively ( P=0.24 ). One week after the end of treatment, the intervention group had 39% greater reduction in VAS pain intensity than the control group ( P=0.0001 ), improved walking time ( P=0.05 ) and greater lateral spine flexion range ( P=0.01 ).

CONCLUSIONS

Our results show that 8-sessions of acupoint stimulation followed by acupressure with aromatic lavender oil were an effective method for short-term LBP relief. No adverse effects were reported. To complement mainstream medical treatment for sub-acute LBP, the combined therapy of acupoint stimulation followed by acupressure with aromatic lavender oil may be one of the choices as an add-on therapy for short-term reduction of LBP.

Electroacupuncture for Tension-type Headache on Distal Acupoints Only: A Randomized, Controlled, Crossover Trial

OBJECTIVE

To investigate the efficacy of electroacupuncture, applied to distal acupoints only, for tension-type headache.

BACKGROUND

Electroacupuncture is commonly used for tension-type headache, but when applied to distal acupoints only, evidence of its efficacy is lacking.

DESIGN

A randomized, single-blinded, sham-controlled, crossover clinical trial. Methods.-The trial had 5 stages: baseline (2 weeks), phases I and II (each 4 weeks), washout period (2 weeks), and follow-up (3 months after phase II). Forty patients were randomly assigned to either group A or group B. Group A received real electroacupuncture during phase I, then sham electroacupuncture in phase II. Group B received the treatments in reverse order. Outcome measures were headache frequency and duration, pain intensity using a visual analog scale, mechanical pain threshold, headache disability, and sickness impact. Data were analyzed by univariate 2-way analysis of variance.

RESULTS

Thirty-seven patients completed the trial. There were no significant differences between the 2 groups at baseline. At the end of phase I, group A, but not group B, demonstrated significant improvement in mean (standard error of the mean [SEM]) headache frequency (3.0 per month [0.3] versus 12.0 per month [1.7]), duration (13.3 hours [3.5] versus 32.0 hours [6.2]), pain intensity (32.8 mm [4.1] versus 47.5 mm [2.7]), pain threshold (right side, 2.9 kg/second [0.1] versus 0.9 kg/second [0.1]; left side, 2.4 kg/second [0.1] versus 1.1 kg/second [0.1]), headache disability score (6.0 [1.0] versus 16.3 [1.6]), and sickness impact score (288.7 [48.0] versus 687.1 [77.2]). For each parameter, significant differences also were demonstrated for both groups between baseline and phase II, and baseline and follow-up. There were no significant differences between the groups at the end of follow-up (P >.05).

CONCLUSION

Electroacupuncture to distal points alone is effective for short-term symptomatic relief of tension-type headache.

Sham interventions in randomized clinical trials of acupuncture—a review

BACKGROUND AND OBJECTIVES

For non-drug interventions such as acupuncture, it is difficult to establish placebo or sham controls that are both inert and indistinguishable. We reviewed sham-controlled clinical trials of acupuncture to investigate (a) which types of sham interventions have been used in the past; (b) in what respects true and sham interventions differed; and (c) whether trials using different types of sham yielded different results.

METHODS

47 randomized controlled trials comparing true and sham acupuncture interventions for pain and a variety of other conditions were identified from systematic reviews and through a search in PubMed. Details of patients, interventions, sham interventions and outcomes were extracted in a standardized manner.

RESULTS

In two trials the sham intervention consisted of superficial needling of the true acupuncture points, four trials used true acupuncture points which were not indicated for the condition being treated, in 27 trials needles were inserted outside true acupuncture points, five trials used placebo needles and nine trials used pseudo-interventions such as switched off-laser acupuncture devices. True and sham interventions often differed in a variety of other variables, such as manipulation of needles, depth of insertion, achievement of an irradiating needling sensation (de-chi), etc. There was no clear association between the type of sham intervention used and the results of the trials.

CONCLUSION

Randomized trials investigating the specific effects of acupuncture have used a great variety of sham interventions as controls. Summarizing all the different sham interventions as "placebo" controls seems misleading and scientifically unacceptable.

Acupuncture in clinical neurology

BACKGROUND

A majority of people in the United States use alternative or complementary therapy at some point in their lives, and acupuncture is among the most frequently used modalities. Many United States medical schools offer courses in alternative medicine, and a growing number of insurers offer coverage for alternative therapies. This paper critically reviews our current knowledge about the safety and efficacy of acupuncture for neurologic conditions.

REVIEW SUMMARY

Acupuncture is a safe procedure when performed by trained professionals. Complications from acupuncture are rare and mainly related to negligence of sterile technique. Studies of the therapeutic value of acupuncture are fraught with challenging methodologic problems, including the choice of a placebo, a suitable control treatment, and the technique of stimulation applied. Clinical trials of the use of acupuncture for pain syndromes (headache, neck, and back pain), stroke rehabilitation, Parkinson's disease, multiple sclerosis, and substance abuse are reviewed.

CONCLUSIONS

Based on the current literature, no definitive recommendation can be made regarding the efficacy of acupuncture for common pain syndromes including headache, and neck and back pain. Better quality clinical trials fail to demonstrate efficacy for the use of acupuncture as part of a rehabilitation program following stroke or as a treatment for drug addiction. Acupuncture may have a role in the treatment of sleep disturbance associated with Parkinson's disease but was not efficacious for the primary symptoms of either Parkinson's disease or multiple sclerosis. In light of increasing public interest and use of alternative therapies, this review may be helpful in promoting more discussion between patients and physicians about the use of acupuncture.

Trigger point--acupuncture point correlations revisited

In 1977, Melzack and colleagues examined the possible correspondence of acupuncture points and trigger points for the treatment of pain. They claimed a 71% correspondence between these two classes of points. Their findings have influenced many researchers and practitioners but have not been examined since 1977. The current study explores the claim of a 71% correspondence between these two classes of points through a more extensive examination of the acupuncture literature.

OBJECTIVES

To investigate the claim of a 71% correspondence of acupuncture points and trigger points for the treatment of pain.

METHODS

The study involved a review of acupuncture texts published since 1977, focusing on five textbooks for the in-depth analyses and a broader range of texts for the more general analyses.

RESULTS

If trigger points correspond to any class of acupuncture points it would have to be to the a shi points rather than the "channel" or "extra" points with which the 1977 study attempted to find correlation. Approximately 35% of recommended acupuncture points in the treatment of pain are distant from the site of the pain, making assumptions about the infrequency of use of distant acupuncture points for pain suspect. Sixty-one percent (61%) of the acupuncture points that the 1977 study examined for the treatment of pain are not recommended at all for the treatment of pain, and 44% are not recommended in the treatment of any problem, while only 19% of the acupuncture points are frequently recommended for pain and 20% for all conditions. For the acupuncture points that corresponded in the 1977 study, the equivalent numbers are: 60% not recommended at all for pain, 47% not recommended for anything, 18% commonly recommended for pain, and 16% commonly recommended for anything.

CONCLUSION

The claimed 71% correspondence of trigger points to acupuncture points is conceptually not possible. Furthermore, even putting this conceptual problem aside, no more than 40% of the acupuncture points that the 1977 study examined could correlate for the treatment of pain, and more likely, only approximately 18%-19% correlate rather than the 71% that was claimed. However, this study found a probable correspondence of trigger points to a different class of acupuncture points, the a shi points, which appears to be an important finding. Researchers and clinicians who have assumed the conclusions of the 1977 study to be correct will need to reexamine the impact of the current findings on any claims that are dependent on the conclusions of that study.

Acupuncture: evidence for its use in chronic low back pain

Back pain is a major economic burden in the UK, with increasing numbers of patients seeking complementary therapies, such as acupuncture, as a means to supplement traditional medical treatments. Studies to date have produced conflicting results relating to the efficacy of acupuncture and thus this systematic review will provide a concise summary of the clinical scenario in Western countries. A search of various electronic databases identified 11 articles consisting of three case studies, five randomized controlled trials, and two cross-over trials. Systematic examination of these articles did not provide definitive evidence to support or refute the use of acupuncture in the treatment of low back pain. In an era of increasing demands for evidence-based practice and professional accountability, the absence of irrefutable scientific evidence places nurses and medics in a vulnerable position.

Does acupuncture improve the orthopedic management of chronic low back pain--a randomized, blinded, controlled trial with 3 months follow up

This prospective, randomised controlled trial, with three parallel groups, patient and observer blinded for verum and sham acupuncture and a follow up of 3 months raises the question: "Does a combination of acupuncture and conservative orthopedic treatment improve conservative orthopedic treatment in chronic low back pain (LBP). 186 in-patients of a LBP rehabilitation center with a history of LBP >or=6 weeks, VAS >or=50mm, and no pending compensation claims, were selected; for the three random group 4 weeks of treatment was applied. 174 patients met the protocol criteria and reported after treatment, 124 reported after 3 months follow up. Patients were assorted 4 strata: chronic LBP, <or=0.5 years, 0.5-2 years, 2-5 years, >or=5 years. Analysis was by intention to treat. Group 1 (Verum+COT) received 12 treatments of verum acupuncture and conservative orthopedic treatment (COT). Group 2 (Sham+COT) received 12 treatments of non-specific needling and COT. Group 3 (nil+COT) received COT alone. Verum- and Sham acupuncture were blinded against patient and examiner. The primary endpoints were pain reduction >or=50% on VAS 3 months after the end of the treatment protocol. Secondary endpoints were pain reduction >or=50% on VAS and treatment efficacy on a four-point box scale directly after the end of the treatment protocol and treatment efficacy after 3 months. In the whole sample a pain relief of >or=50% on VAS was reported directly after the end of treatment protocol: Verum+COT 65% (95%CI 51-77%), Sham+COT 34% (95%ci 22-49%), nil+COT 43% (95%ci 29-58%) - results are significant for Verum+COT over Sham+COT (P<or=0.02). The results after 3 months are: Verum+COT 77% (95%ci 62-88%), Sham+COT 29% (95%ci 16-46%), nil+Cot 14% (95%ci 4-30%) - effects are significant for Verum+COT over Sham+COT (P<or=0.001) and for Verum+COT over nil+COT (P<0.001). No difference was found in the mobility of the patients nor in the intake of NSAID diclofenac. Our conclusion is that acupuncture can be an important supplement of conservative orthopedic treatment in the management of chronic LBP.