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At Issue: The role of acupuncture in the treatment of low back pain
Orthopedics Today asked orthopedists and spine care specialists the following question: How should doctors and their patients interpret a study that showed sham and traditional acupuncture helped relieve chronic low back pain better than standard nonoperative care?
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Scott D. Boden, MD
This study suggests that acupuncture may play a role in chronic low back pain treatment, but the conclusions must be interpreted with care. One of the challenges of any such study is distinguishing a placebo effect, which could have been the case with the true or sham acupuncture.
Other studies have shown a placebo response can be as high as 45%.
Another issue is the fact that this was only a 6-month endpoint, and chronic low back pain is often a waxing and waning disorder, so longer follow-up might reveal that the apparent benefit would not be sustained (otherwise known as regression to the mean). Alternatively, the conclusion could be that the traditional Chinese acupuncture points are less important than once thought and the beneficial effect comes from nonspecific stimulation by needles of the skin, rather than specific neural pathways.
For more information:
- Scott D. Boden, MD, is a member of the Orthopedics Today Editorial Board. He can be reached at 59 Executive Park South, Suite 300, Atlanta, GA 30329; 404-778-7143; e-mail: Scott.Boden@emoryhealthcare.org. He is a consultant for Medtronic Biologics.
Steven R. Garfin, MD
The results of the study, if assessing acupuncture vs. conventional therapy for chronic low back pain, do not surprise me. Conventional therapy, in a group that has a mean of 8 years of chronic low back pain, should not be expected to be particularly successful. The patients most likely have had attempts at nonoperative care including activity alteration, anti-inflammatories, physical therapy, and/or other modalities.
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I do not know enough about acupuncture to comment definitively on the results of the verum vs. sham procedures. My understanding is that there is, in general, a 30% to 60% positive response rate for acupuncture, for all of the pains/diagnoses that are treated with that mode of treatment. This is somewhere above pure placebo (30%), but not into a definitively helpful/good-excellent range (about 70%).
Personally, I do not know what acupuncture does and whether traditional acupuncture is performed exactly the same, in the same anatomic areas, by all acupuncturists. Independent of where the needles are placed, it is unclear to me. I am sure to many other scientists/physicians as well, exactly what is occurring with acupuncture. Is it chemically induced pain relief with the biologic chemicals released because the needles pass through the skin into an area that stimulates chemical release or alteration, or is it mental (stimulating chemical release or activation, or psychologic) based on the anticipation of the treatment, or are specific nerves or nerve endings targeted based on the location where the needles are placed?
This study suggests that it is unrelated to where the needles are placed. Superficial needling, as well as more specific “anatomic” positioning, seems to have the same effect. This, to me, suggests it may be related to a response mechanism from passing needles through the skin, or some mentally induced changes (chemical and/or psychologic) related to the anticipation, or the observation, by the patient of the procedure itself.
I often tell my patients with chronic low back pain they can try acupuncture. It is perhaps 30+% successful. It has no risk limitations, but there may be financial costs to the patient, as many insurances do not pay acupuncture.
For more information:
- Steven R. Garfin, MD, chairman of the department of orthopedic surgery, UC-San Diego School of Medicine can be reached at 200 West Arbor Drive, San Diego, CA 92103; 619-543-5944; e-mail: sgarfin@ucsd.edu.
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Charles Sorbie, MD
Much therapeutic value has been claimed for acupuncture since it became popularized in North America during the late 1960’s. Claims for its value as a method for surgical anesthesia were discounted within the next decade by reliable studies conducted by clinicians and neurophysiologists. My observations in 1978 of surgery in Chinese operating rooms using acupuncture did not convince me that it could reduce sensitivity to pain sufficient for surgical procedures to be performed with the comfort of local or general anesthesia.
However, a pain therapy that has survived for at least 2 millenia cannot be entirely ignored or dismissed as having no value. Haake et al appear to have convincing figures for the response rates from the surface insertion of needles in the back to reduce the symptoms of chronic low back pain.
How acupuncture works is obscure. The traditional “verum” acupuncture (from “verus”: real, true, in this case using the Ying and Yang lines) may be explained by the gait-control theory put forward by Melzack and Wall in 1965 (Science. 1965;150(699):971-979). Skin neuro-stimulation may activate the body’s pain-inhibitory system, in some people more than others, for example using the repeated sharp stimulus of TENS or randomly placed needles as the authors have shown. But it simply can’t cure the pathological basis for the chronic low back pain, nor last forever. Yet, if this harmless, nontoxic (vs. pharmaceutical) treatment gives some patients relief of pain — we shouldn’t knock it.
For more information:
- Charles Sorbie, MB, ChB, RCS, professor of surgery, Queen’s University, is a member of the Orthopaedics Today International Editorial Board. He can be reached at Richardson House, 102 Stuart St., Kingston, Ontario K7L 3N6; 613-533-2661; e-mail: sorbiec@kgh.kari.net.