Acupuncture Tops Conventional Therapy for Low-Back Pain
By Charles Bankhead, Staff Writer, MedPage Today
BOCHUM, Germany, Sept. 24 -- Acupuncture offers an effective alternative to conventional therapy for low-back pain, investigators here reported.
Almost twice as many patients responded to acupuncture versus conventional therapy, Heinz G. Endres, M.D., of Ruhr-University Bochum, and colleagues reported in the Sept. 24 issue of Archives of Internal Medicine.
However, sham acupuncture worked just as well as verum, or true, acupuncture, they reported.
"Acupuncture constitutes a strong alternative to multimodal conventional therapy," the authors concluded. "Acupuncture gives physicians a promising and effective treatment option for chronic low-back pain, with few adverse effects or contraindications."
As for the equally good results with fake or real acupuncture, the authors said, "The superiority of both forms of acupuncture suggests a common underlying mechanism that may act on pain generation, transmission of pain signals, or processing of pain signals by the central nervous system and that is stronger than the action mechanism of conventional therapy."
Used to treat many medical conditions, acupuncture has a controversial role in the management of low-back pain, although a recent Cochrane review concluded that it might be useful as an adjunct to other therapies (Cochrane Database Syst Rev 2005;(1):CD001351).
Dr. Endres and colleagues reported findings from what they believe to be the first randomized, controlled trial of verum versus sham acupuncture for treatment of low-back pain. The German Acupuncture Trials involved clinicians in 340 outpatient practices and included 1,162 patients who had a history of low-back pain lasting an average of eight years.
The patients were treated with either verum or sham acupuncture or conventional therapy, which consisted of a combination of drugs, physical therapy, and exercise. Verum acupuncture consisted of 10 30-minute sessions of treatment according to principles of traditional Chinese medicine. Patients assigned to sham acupuncture received superficial needling at non-acupuncture points.
The primary outcome was six-month response rate, with response defined as at least 33% improvement on three pain-related items on the Von Korff Chronic Pain Grade Scale or 12% improvement on the back-specific Hanover Functional Ability Questionnaire.
At the end of the study, 47.6% of patients in the verum acupuncture group had responded, as had 44.2% in the sham acupuncture group, and 27.4% in the group that received conventional therapy. Both acupuncture groups had significantly higher response rates compared with conventional therapy (P<0.001).
The inferiority of conventional therapy to both acupuncture groups "raises questions about qualitative and quantitative aspects of conventional therapy," the authors stated. Even so, results with conventional therapy exceeded those observed in a previous German-based study of routine care for low-back pain.
They also pointed out that "the effectiveness of sham acupuncture and the principle of nihil nocere suggest that a discussion is called for about the necessary depth of insertion of acupuncture needles."
The finding that both sham and true acupuncture relieved back pain is puzzling, commented Rex Marco, M.D., an orthopedic surgeon at the University of Texas Health Science Center in Houston. He speculated that the sham needling could have triggered endorphin release or other potentially therapeutic effects. The sham procedures also could have had an unexpectedly large placebo effect.
Alternatively, he said, the pain-relieving benefits of sham acupuncture might have been emotional or psychological in nature.
"It's possible that the physical contact during the sham procedures had a relaxing or soothing effect that helped relieve the pain," said Dr. Marco. "Maybe the contact and interaction with the acupuncturist was beneficial. It's really impossible to know why the sham procedures had a therapeutic effect. For that matter, it's entirely possible that the sham and true procedures worked through similar or the same underlying mechanisms."
The findings are at odds with previous studies that have shown a difference between true and sham acupuncture, said Eric Manheimer, a clinical research associate at the University of Maryland in Baltimore. More than one study has shown at least a trend in favor of true acupuncture.