Chief complaint: Acute low back pain since August 16.
History: He woke up with severe pain in his low back and right buttock. The pain was described as "the worst pain" he ever had in his life. His wife drove him to ER where he was diagnosed "pinched nerve" and received a local injection and oral pain medications which included Ibuprofen and Vicodin. He had a follow up the next day with his family physician who told him that he had to continue to take the medicine for 12 weeks for the "pinched nerve". He was also told that fortunately it was not disc problem. He was so disappointed at the conventional medical approach-taking pain meds for 3 months that he decided to try acupuncture. His wife searched internet and found my office. Thanks to the high tech and my patients' testmonials.
Physical exam: a slightly overweighted gentleman limped into my office. Decreased range of motion of lumbar spine. Right lower extremity-diminished patellar tendon reflex (1/4); weakended big toe dorsiflexion (3/5); positive straight leg raise; decrease sensation on dorsum.
Impression: Acute LBP; Sciatica; Degerative disc diseases; Radiculopathy
Plan: Acupuncture-MCT on Stomach, Kidney and Bladder channels. 2xweek for 2 weeks. Patient is expected to improve and go to physical therapy. Heat for 20 min. at home followed by gentle stretch of hamstrings.
Thoughts of the day...
- What causes so many back pain patients in America?
- Who would like to settle for pain meds for 12 weeks?
- Why did physicians say "pinched nerve" not "disc problem"?
- When will acupuncture become the first line treatment for back pain?
If you are scientific, please read along...
Acupuncture Clinical Trials Highlights: In a recent trial published in the Archives of Internal Medicine 169(9), 858 May 2009, "A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain"1 Dan C herkin and colleagues compared acupuncture, simulated acupuncture, and usual care for chronic low back pain to explore three important questions in relation to this common condition: 1) Is acupuncture more effective than usual medical care alone; 2) is real acupuncture is more effective than simulated (noninsertive) acupuncture; and 3) is individualized acupuncture more effective than standardized acupuncture.
Participants (n=638) diagnosed with chronic low back pain (cLBP), were randomized to one of four groups: individualized acupuncture, standardized acupuncture (expert panel prescribed protocol), simulated acupuncture (standardized acupuncture points stimulated with a toothpick), or usual medical care. Participants received 8 treatments over 7 weeks and the primary outcomes, back-related dysfunction (Roland-Morris Disability Questionnaire) and symptom bothersomeness (0-10 scale), were assessed at 8, 26 and 52-weeks.
Results indicate that all three acupuncture treatments significantly outperformed usual care, with no differences between acupuncture groups. Based on the results the authors concluded: "For clinicians and patients seeking a relatively safe and effective treatment for a condition for which conventional treatments are often ineffective, various methods of acupuncture point stimulation appear to be reasonable options…" yet state "…for cLBP, tailoring needling sites to each patient and penetration of the skin appear unimportant in eliciting therapeutic benefits."
Looking at each of the 3 stated goals, some point s are worth highlighting:
Aim 1 (Is acupuncture more effective than usual medical care alone?)
1) Yes, acupuncture is more effective than usual care alone for cLBP. Participants in the acupuncture groups not only demonstrated substantial benefits in dysfunction and symptoms but the effects were long-lasting at the 26 & 52-week follow-up visits.
2) A more relevant framework is to determine if acupuncture is at least as effective as usual medical care, but with less side effects and cost-savings.
a. In support of this, participant-reported use of medications for back pain was significantly reduced in the acupuncture groups as compared to usual care.
Aim 2 (Is real acupuncture more effective than simulated acupuncture?)
1) No, the effects therefore may be due to "non-specific" treatment effects.
a. The authors cite studies of "placebo-effects" tied to patient-practitioner interaction and the increased "placebo" effect with various sham interventions; e.g. larger effect with sham surgery vs. placebo pills.
i. As an aside, recent studies in biomedicine report the inability of vertebroplasty to outperform placebo for the treatment of back pain due to osteoporotic fractures.2, 3 It’s doubtful that these findings will lead to the cessation of vertebroplasty being recommended, in fact many commentaries are being published that call into question the validity of the results. The findings by Cherkin et al should be viewed in a s imilar light, resulting in further inquiry into the mechanisms of action for acupuncture.
2) An alternative explanation is that the set of acupoints deemed most important for the treatment of cLBP can be effectively stimulated without the insertion of acupuncture needles.
b. Cherkin et al appropriately refer to this intervention as simulated not sham acupuncture and cite the use of blunted needles as means of treatment dating back 2,000 years. Would the finding have been the same if the protocol called for acupressure at this set of acupoints?
i. An RCT comparing acupressure to physical therapy for the treatment of cLBP suggests the answer would be yes.4
Aim 3 (Is individualized acupuncture more effective than standardized acupuncture?)
1) No, it appears that the standardized set of acupoints developed for this trial is as effective as individualized acupuncture protocols for cLBP.
c. This finding may or may not translate to:
i. Other acupuncture point protocols for cLBP;
ii. Other chronic pain conditions;
iii. Conditions outside of the realm of chronic pain, e.g. depression.
The study by Cherkin et al raises important questions regarding the use of acupuncture for chronic low back pain in the clinical setting. As such, we echo the conclusions regarding the need for further study to determine the relative contributions of an acupuncture treatment. As a means of assessing theses contributions we suggest a f ocus on the effects of both specific & non-specific needling effects and specific & non-specific non-needling effects, as recently proposed by Dr. Helene Langevin (see diagram 1).
Reference List
- Cherkin DC, Sherman KJ, Avins AL et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med 2009; 169(9):858-866.
- Buchbinder R, Osborne RH, Ebeling PR et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 2009; 361(6):557-568.
- Kallmes DF, Comstock BA, Heagerty PJ et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 2009; 361(6):569-579.
- Hsieh LL, Kuo CH, Lee LH, Yen AM, Chien KL, Chen TH. Treatment of low back pain by acupressure and physical therapy: randomised controlled trial. BMJ 2006; 332(7543):696-700.
