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May 11, 2009

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Acupuncture found to beat “usual” care for back pain

May 11, 2009
Courtesy JAMA/Archives Journals 
and World Science staff

Three types of ac­u­punc­ture ther­a­py—in­clud­ing one de­scribed as only “sim­u­lat­ed” ac­u­punc­ture—ap­peared more ef­fec­tive than usu­al care for chron­ic low back pain in a new stu­dy, re­search­ers re­port.

The study ap­pears in the May 11 is­sue of the re­search jour­nal Ar­chives of In­ter­nal Med­i­cine.
Back pain costs Amer­i­cans at least $37 bil­lion an­nu­al­ly, ac­cord­ing to the re­search­ers. Many pa­tients with this con­di­tion are un­sat­is­fied with tra­di­tion­al med­i­cal care and turn to al­ter­na­tive tech­niques, in­clud­ing acu­punc­ture.

Nor­mal ac­u­punc­ture is a tra­di­tion­al Chin­ese tech­nique in­volv­ing in­sert­ing thin nee­dles in­to the skin at se­lected points to treat var­i­ous ail­ments. Prac­ti­tion­ers say this pro­ce­dure helps br­ing the bo­dy’s en­er­gy in­to bal­ance. West­ern sci­en­tists tend to be skep­ti­cal of such ideas, argu­ing that the sup­posed en­ergy fields have never been seen or mea­sured. None­the­less, some stud­ies have in­di­cat­ed that for what­ev­er rea­son, ac­u­punc­ture is help­ful for some con­di­tions.

The new study is reviving ques­tions about how acu­punc­ture works. 

“Back pain is the lead­ing rea­son for vis­its to li­censed acupunc­tur­ists, and med­i­cal acupunc­tur­ists con­sid­er ac­u­punc­ture an ef­fec­tive treat­ment for back pain,” the au­thors of the Archives re­port wrote.

Cu­ri­ous­ly, 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. 

The new study in­clud­ed an in­di­vid­ually tai­lored ac­u­punc­ture pro­gram, stand­ard ac­u­punc­ture ther­a­py and a sim­ula­t­ion in­volv­ing tooth­picks at key ac­u­punc­ture points 

The re­search­ers, Dan­iel C. Cherkin of Group Health Cen­ter for Health Stud­ies, Se­at­tle, and col­leagues, com­pared four dif­fer­ent types of treat­ment in a ran­dom­ized clin­i­cal tri­al in­volv­ing 638 adults of av­er­age age 47. All had chron­ic low back pain and un­der­went a seven-week treat­ment.

Dur­ing that 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, all forms of real and si­mu­lated ac­u­punc­ture “had ben­e­fi­cial and per­sist­ing ef­fects,” the au­thors wrote. At the eight-week fol­low-up, 60 per­cent of the par­ti­ci­pants re­ceiv­ing any type of ac­u­punc­ture ex­pe­ri­enced a clin­ic­ally mean­ing­ful im­prove­ment, com­pared with 39 per­cent of those re­ceiv­ing usu­al care, the study found. At the one-year fol­low-up, 59 per­cent to 65 per­cent of those in the ac­u­punc­ture groups re­ported an im­prove­ment in func­tion com­pared with 50 per­cent in the “u­su­al care” group.

There are sev­er­al pos­si­ble ex­plana­t­ions for the ef­fec­tiveness of sim­u­lat­ed ac­u­punc­ture, the au­thors not­ed. Su­per­fi­cial stimula­t­ion of ac­u­punc­ture points may di­rectly stim­u­late phys­i­o­logical pro­cesses that re­sult in re­duced pain and im­proved func­tion. Al­ter­na­tive­, 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.”

* * *

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Three types of acupuncture therapy—including one described as only “simulated” acupuncture—appeared more effective than usual care for chronic low back pain in a new study, researchers report. The study appears in the May 11 issue of the research journal Archives of Internal Medicine. Back pain costs Americans at least $37 billion annually, according to the researchers. 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. Curiously, 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. Normal acupuncture is a traditional Chinese technique involving inserting thin needles into the skin at selected points to treat various ailments. Practitioners say this procedure helps bring the body’s energy into balance. Western scientists tend to be skeptical of such ideas. Nonetheless, some studies have indicated that for whatever reason, acupuncture is helpful for some conditions. The new study included an individually tailored acupuncture program, standard acupuncture therapy and a simulation involving toothpicks at key acupuncture points The researchers, Daniel C. Cherkin of Group Health Center for Health Studies, Seattle, and colleagues, compared four different types of treatment in a randomized clinical trial involving 638 adults of average age 47. All had chronic low back pain and underwent a seven-week treatment. 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 experienced a clinically meaningful improvement, compared with 39 percent of those receiving usual care, the study found. At the one-year follow-up, 59 percent to 65 percent of those in the acupuncture groups reported an improvement in function compared with 50 percent in the “usual care” group. There are several possible explanations for the effectiveness of simulated acupuncture, the authors noted. 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.”