“Acupuncture using toothpicks which don't break the skin is as effective as using needles which penetrate to nerve points,” the Daily Mirror reported. It said a study had used several different types of acupuncture to treat chronic low back pain. The researchers found all types of acupuncture “performed better than Western remedies, including drugs”.
This well designed and conducted study has shown that acupuncture can improve ability to function in people with chronic low back pain compared to usual care (which included medication and physical therapy). It also found it might not be necessary to puncture the skin or tailor the therapy to the individual. These results are only applicable to people with uncomplicated low back pain with no identifiable cause. As chronic low back pain is difficult to treat, this study suggests that acupuncture may be a reasonable treatment option for some people.
Where did the story come from?
The research was carried out by Dr Daniel C Cherkin and colleagues from the Center for Health Studies in Seattle, Washington and other research centres in the US. The work was funded by the National Institutes of Health and the National Center for Complementary and Alternative Medicine. The acupuncture needles were donated by Lhasa OMS Inc. The study was published in the peer-reviewed medical journal Archives of Internal Medicine .
What kind of scientific study was this?
This randomised controlled trial compared acupuncture, simulated acupuncture and usual care for chronic low back pain.
The researchers enrolled 641 adults aged 18 to 70 years who had experienced uncomplicated low back pain for between three and 12 months and who had never tried acupuncture before. To be eligible, the participants had to have rated their back pain as at least a three on a scale ranging from zero to 10 (with zero signifying least bothersome and 10 signifying most bothersome).
The researchers excluded those whose pain was caused by specific causes such as cancer, those for whom acupuncture might be dangerous and those with other conditions that might complicate treatment.
The participants were randomly put into four groups: individualised acupuncture, standardised acupuncture, simulated acupuncture or usual care. Individualised and standardised acupuncture were ‘real’ acupuncture treatments, while simulated acupuncture was a ‘sham’ treatment.
The acupuncture was given by experienced acupuncturists twice weekly for three weeks, then weekly for four weeks (10 sessions in total). The acupuncture involved just needles and not electrostimulation, moxibustion, herbs or other non-needle treatments. Participants who received individualised treatment had the positioning of their needles based on traditional Chinese medical diagnostic techniques. Different acupuncturists determined where the needles should go for each patient and delivered the treatment. Needles were placed in the skin to a depth of 1-3cm. Standardised acupuncture used the number and positioning of needles (eight points on the low back and leg) considered effective for chronic low back pain by experts.
For simulated acupuncture, the acupuncturist used a toothpick pressed against the skin to mimic the sensation of a needle entering and leaving the skin at the same eight points used in the standardised acupuncture treatment. This method was designed to mimic closely the sensation of having acupuncture. Previous research has shown that it is successful in making patients with low back pain who have never had acupuncture think they had received real acupuncture.
The usual care group received the care their doctors prescribed. This may have included medical treatments or physical therapies. All participants received a booklet on self-care, including information on managing back pain flare-ups, exercise and lifestyle medication. The researchers used standard scales to assess how much their ability to perform daily activities was affected by their back pain (the level of back-related dysfunction) and how bothersome the symptoms were at the beginning and end of treatment (eight weeks), and at 26 and 52 weeks.
Three participants were further excluded from the analysis, leaving 638 participants. Of these, 95% completed eight-week follow-up, and 91% completed 26-week and 52-week follow-ups.
What were the results of the study?
At the start of the study, participants had an average back dysfunction score of 10.6 (score range zero to 23). All groups showed improvements in dysfunction at the end of the eight-week treatment period.
After eight weeks of treatment the researchers found that all forms of acupuncture (individualised, standardised, simulated) reduced back-related dysfunction compared with usual care (acupuncture reduced score by about 4.5 points and usual care by 2.1 points on a 23-point scale). There was no statistically significant difference between the three acupuncture groups. There was little change in scores between eight and 52 weeks, with no difference between the acupuncture groups, and the usual care group continuing to have worse dysfunction than the acupuncture groups.
What interpretations did the researchers draw from these results?
The researchers conclude that although acupuncture did reduce chronic low back pain, whether or not needle sites were tailored to the individual patient or whether the needles actually pierced the skin did not appear to be important.
They say this brings into question how acupuncture is thought to have an effect, and that it is still unclear whether acupuncture actually has a biological effect or whether it acts as a placebo. They conclude that acupuncture may be a reasonable option for doctors and patients looking for a relatively safe and effective treatment, especially as conventional treatments for chronic low back pain are often ineffective.
What does the NHS Knowledge Service make of this study?
The strengths of this study include its randomised allocation of participants into treatment groups, the inclusion of a credible ‘sham’ acupuncture treatment as well as a usual care control group and a high level of follow-up for a long period of time. Its findings suggest that although acupuncture may reduce back-related dysfunction, this may not be due to biological effects. There are some points to note:
- The study included people with uncomplicated chronic low back pain with no serious identifiable cause. As such, the results may not apply to people with acute low back pain (for less than three months) or low back pain from other identified causes, including those with nerve root pain and sciatica.
- It is possible that simulated acupuncture does have some biological effect, and this may explain why no differences between the acupuncture methods were found.
- The acupuncture used in the study used only needles and involved minimal interaction between the acupuncturist and patient, therefore the results may not be representative of effects that would be seen with acupuncture including more interaction or other aspects of treatment, such as applying electrical currents through the needles.
Analysis by Bazian
Edited by NHS Website
Links to the headlines
The Times, 12 May 2009
Daily Mail, 12 May 2009
The Daily Telegraph, 12 May 2009
Daily Mirror, 12 May 2009
Links to the science
Arch Intern Med 2009; 169: 858-866
Cochrane Database Syst Rev 2005, Issue 1