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Acupuncture for back pain, a poor quality trial

PainSci » bibliography » Cherkin et al 2009
Tags: treatment, acupuncture, back pain, controversy, mind, manual therapy, modalities, debunkery, traditional Chinese medicine, vitalism, pain problems, spine

Three pages on PainSci cite Cherkin 2009: 1. The Complete Guide to Low Back Pain2. Does Acupuncture Work for Pain?3. Massage Therapy Kinda, Sorta Works for Back Pain

PainSci commentary on Cherkin 2009: ?This page is one of thousands in the bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

More than 600 participants were either given standard acupuncture treatments or simulated acupuncture. Although this study has been widely reported as if it was a controlled comparison of acupuncture to “standard medical treatment” for back pain, in fact it is not controlled (or blinded), and does not have the power to prove that acupuncture works for back pain.

The apparent difference between real and fake acupuncture they observed was minor. Nevertheless, the authors are excessively friendly to acupuncture and declare it to be “effective” in their conclusion in spite the obvious poverty of the data. In particular, they gloss over the damning implications of their most important finding: what little effect they think they found had nothing at all to do with needle placement. Acupuncture means nothing if needle placement doesn’t matter. The interpretation of Dr. Steven Novella is much more sensible: “The only reasonable scientific conclusion to draw from this is that acupuncture does not work.” For Dr. Novella’s meticulous and expert analysis, see Acupuncture Does Not Work for Back Pain (Part I).

~ Paul Ingraham

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

BACKGROUND: Acupuncture is a popular complementary and alternative treatment for chronic back pain. Recent European trials suggest similar short-term benefits from real and sham acupuncture needling. This trial addresses the importance of needle placement and skin penetration in eliciting acupuncture effects for patients with chronic low back pain.

METHODS: A total of 638 adults with chronic mechanical low back pain were randomized to individualized acupuncture, standardized acupuncture, simulated acupuncture, or usual care. Ten treatments were provided over 7 weeks by experienced acupuncturists. The primary outcomes were back-related dysfunction (Roland-Morris Disability Questionnaire score; range, 0-23) and symptom bothersomeness (0-10 scale). Outcomes were assessed at baseline and after 8, 26, and 52 weeks.

RESULTS: At 8 weeks, mean dysfunction scores for the individualized, standardized, and simulated acupuncture groups improved by 4.4, 4.5, and 4.4 points, respectively, compared with 2.1 points for those receiving usual care (P < .001). Participants receiving real or simulated acupuncture were more likely than those receiving usual care to experience clinically meaningful improvements on the dysfunction scale (60% vs 39%; P < .001). Symptoms improved by 1.6 to 1.9 points in the treatment groups compared with 0.7 points in the usual care group (P < .001). After 1 year, participants in the treatment groups were more likely than those receiving usual care to experience clinically meaningful improvements in dysfunction (59% to 65% vs 50%, respectively; P = .02) but not in symptoms (P > .05).

CONCLUSIONS: Although acupuncture was found effective for chronic low back pain, tailoring needling sites to each patient and penetration of the skin appear to be unimportant in eliciting therapeutic benefits. These findings raise questions about acupuncture's purported mechanisms of action. It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or nonspecific effects.

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