Back pain is one of the most common reasons people see a health care
provider. It has been estimated that up to 80% of the world's population will
suffer from back pain at some point in their lives, with the lower back as the
most common location of pain.
Although most episodes of low back pain last less than two weeks, research has
shown that recurrence rates for low back pain can reach as high as 50% in the
first few months following an initial episode.
1,2
While there is no definitive way to resolve lower back pain, the use of
acupuncture to treat this condition has increased dramatically in the past few
decades, based in a large extent to placebo-controlled studies that have
validated it as a reliable method of pain relief. The results of a recent study
published in the Clinical Journal of Pain3 provide further
proof that acupuncture is a safe and effective procedure for low-back pain, and
that it can maintain positive outcomes for periods of six months or longer
without producing the negative side-effects that often accompany more
traditional pain remedies.
Drs. Christer Carlsson and Bengt Sj˜lund of the Lund University Hospital in
Sweden recruited 50 patients (33 women, 17 main) from a tertiary level pain
clinic for their study. The median age of the participants was 49.8; each
patient had been suffering chronic low back pain for a minimum of six months and
had tried a variety of other therapies (such as corsets, nerve blocks, drugs and
physiotherapy) to treat their condition, but to no avail.
Subjects were randomly assigned to a manual acupuncture group, an
electroacupuncture group or a placebo group. Treatment sessions lasted a total
of 20 minutes each and were delivered once per week for eight weeks, with the
same amount of time and care given to all patients in each group. A followup
treatment was given after two months, and a tenth and final treatment was given
after an additional two months.
In the manual group, local points on the lower back and distal points on the
lower limbs, forearms and hands were used. The number of needles used per
patient increased from an average of eight during the first session to as many
as 18 during the third or fourth session. Needles were stimulated three times
during each session to attain de qi.
A slightly different protocol was used on patients receiving
electroacupuncture. Patients in this group received manual stimulation only
during the first few sessions, followed by electrical stimulation of four
needles in the low back in subsequent sessions. A similar number of needles as
used in the manual acupuncture group were inserted and activated by hand.
The placebo group was given mock stimulation using what the researchers
termed an "impressive" -- but disconnected - stimulator attached to two large
electrodes. The electrodes were placed on the skin over the most painful areas
in the lower back. During mock stimulation, flashing lamps from the machine were
displayed and made visible to the patient to give the illusion that treatment
was being delivered. Throughout the study,
patients recorded pain levels and other measurements in small booklets called
pain diaries. Among the variables measured were pain intensity (recorded twice
daily on a visual analog scale from 0 to 100, 100 being severe as possible);
intake of analgesics (recorded daily); sleep quality (scored on a scale of
"good," "slightly disturbed by pain" or "badly disturbed by pain"); and activity
level. These diaries were compiled and their results analyzed by a nurse
practitioner at the end of the study.
In addition, assessments were performed by an independent observer who did
not know which type of acupuncture each patient received. These assessments were
taken at four intervals: baseline, one month, three months and six months after
the treatment period. These assessments consisted of a clinical interview and
physical examination, after which the observer classified the patient's pain as
improved, unchanged, or worse.
"Significant" Changes Observed in Acupuncture Patients
Analysis of the pain diaries revealed "significant" differences between
acupuncture and placebo patients at the one-, three- and six-month intervals
following treatment, all of which favored acupuncture as a more effective form
of pain relief. For example, in the acupuncture group, both morning and evening
pain scores were lower than baseline measurements and continued to decrease for
the duration of treatment. In the placebo group, however, pain scores were
several points higher after one month than they were at baseline, and continued
to remain higher than the baseline scores throughout the study.
Activity levels were also markedly improved in the acupuncture group.
Fourteen acupuncture patients and seven placebo patients had been on sick leave
(either part-time or full-time) prior to the start of the study. By the time the
tenth acupuncture treatment was delivered, six of the acupuncture patients on
sick leave had returned to part-time or full-time work; another six were retired
but still reported improved activity levels. In comparison, only one patient in
the placebo group showed an improvement in activity; another patient actually
regressed to being put on full sick leave.
Furthermore, acupuncture patients experienced less episodes of sleep
disturbance than their placebo-treated counterparts. Before the study, 30
acupuncture patients and 12 placebo patients reported sleep disturbances due to
pain. The researchers reported that the sleep pattern was "significantly less
disturbed after the treatment period" in the acupuncture group, but that there
was "no significant difference in sleep disturbance" in the placebo patients.
Finally, total intake of analgesics dropped dramatically in the acupuncture
group, but not the placebo group. At the start of the study, patients in the
acupuncture group consumed an average of 31 pills per week; those in the placebo
group consumed an average of 23 pills. At the six-month follow-up, the number of
pills taken by placebo patients remained almost identical (21.5 per person per
week), but had dropped more than 28% to 21.4 pills per week in acupuncture
patients.
Independent examination by the blinded observer appeared to corroborate the
patients' pain estimates. One month after the initial treatment period, 16
acupuncture patients (but only two placebo patients) were judged to be improved.
After six months, 14 acupuncture patients (and only two placebo patients) were
still improved. Both types of acupuncture worked effectively; of the 14 patients
who showed improvement after six months, eight received manual acupuncture and
six received electrical stimulation.
One interesting result of the study was that acupuncture appeared to be most
effective in women. Of the 16 acupuncture patients judged to be "improved" at
the one-month follow-up, 15 were women. At the six-month follow-up, all 14
patients who were still improved were women. The researchers were at a loss to
explain this phenomenon, but hypothesized that it may be linked to estrogen
receptors in the central nervous system.
Treatment Works Best with Specific Types of Pain
In their discussion, Carlsson and Sj˜lund stated that the trial "demonstrated
a long-term pain-relieving effect of needle acupuncture compared with true
placebo in some patients with chronic low back pain." To substantiate this
claim, they highlighted several components that had been built into the study to
help validate its results. Among them:
- Only acupuncture na¤ve patients (those who had never received acupuncture
before) were selected for inclusion;
- Patients were informed at the start of the study that the treatment might
not be felt;
- An equal amount of time and care was spent on each patient from every
treatment group;
- The placebo treatment used in the trial (mock stimulation) was preferred
because, unlike sham acupuncture, needles were not inserted, which might have
inadvertently skewed the results from the placebo group; and
- The independent observer who performed assessments was never made aware of
which group each subject was in and specifically avoided asking any questions
about the type of treatment subjects received.
Taken together, the researchers concluded that these factors "seem sufficient
to establish a true placebo treatment in the current study." They added that
based on their latest study, in conjunction with the results of acupuncture
trials on other disorders, "there is now reasonable evidence that acupuncture
has a clinically relevant pain-relieving effect on certain forms of chronic
pain."
Carlsson and Sj˜lund also advised practitioners that just because acupuncture
works on certain types of back pain, it may not produce the same results on
every type. "It would be as correct to assess the effect of acupuncture on all
types of pain," they observed, "as it would be to study the effect of common
penicillin on all types of bacterial infections and calculate some form of
'average.'"
As to the specific type of pain, the researchers believe that based on
previously published papers, acupuncture may be most effective for low back pain
that is nociceptive (caused by an injury or disease outside the nervous system)
in origin. Determining the cause of pain, they feel, is paramount to using a
particular therapy for relief. As the scientists stated in their conclusion:
"Acupuncture does not seem to be a suitable treatment modality for
neuropathic pain. However, the clinical use of acupuncture is sometimes
indicated for the treatment of chronic nociceptive pain. Our study is the first
to show that acupuncture may have a long-term effect on chronic low back pain
superior to that of placebo · Therefore, it is vital that before acupuncture is
applied, a thorough analysis of the pain condition is performed to preclude the
indiscriminate, unnecessary, and costly use of this treatment technique."
References
- Moffett JK, Torgerson D, Bell-Syer S, et al. Randomised controlled trial of
exercise for low back pain: clinical outcomes, cost and preferences. British
Medical Journal July 31, 1999;319(7205):279-283.
- Nyiendo J, Haas M, Goodwin P. Patient characteristics, practice activities,
and one-month outcomes for chronic, recurrent low-back pain treated by
chiropractors and family medical physicians: a practice-based feasibility study.
Journal of Manipulative and Physiological Therapeutics May 2000;
23(4):239-45.
- Carlsson C, Sj˜lund B. Acupuncture for chronic low back pain: a randomized
placebo-controlled study with long-term follow-up. Clinical Journal of Pain 2001;17(4):296-305.
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