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Acupuncture and Chronic Back Pain

Sam Cassady

9/20/2006

                                      

                                                                                             

 

 

 

“Acupuncture relieves chronic low back pain more effectively and in a more lasting way than conventional orthopedic treatments (Molsberger et al., 2002)…Oh Really?? Let’s find out!

 

 

Introduction

 

Back pain is one of the most common conditions plaguing people in Western societies, affecting more than 31 million people in the United States, with costs in healthcare and lost productivity exceeding $50 billion annually. For those of us who suffer from chronic back pain, it often seems as if the constant hurt is life-controlling.  A simple massage or ice-pack can work miracles on an aching lower back.  Other conventional therapies include rest and relaxation, physical therapy, electrical stimulation (E-stem), ultra-sound, and medication. Unfortunately, these therapies are often ineffective. Aside from major surgery, there is little that can be done to permanently alleviate the symptoms. Furthermore, long-term use of anti-inflammatory drugs can lead to gastritis and ulcers, and excessive use of some analgesics can damage the liver. http://www.bastyrcenter.org/content/view/365/

 

 

 

What is Acupuncture?    

                                                                                      

Acupuncture was developed as long as 4,000 years ago in China as a component of Traditional Chinese Medicine (TCM).  It is used as a treatment method for a broad range of injuries and diseases. Chinese doctors believed that illness was due to an imbalance of energy in the body. Ancient practices such as acupuncture, Qigong, and the use of various herbs are claimed to restore balance. Illness is attributed to imbalance or interruption of chi (the life force that circulates throughout the body).

Acupuncture is loosely defined as stimulation, primarily by the use of solid needles, of (first) traditionally and (later) clinically defined points on and beneath the skin, in an organized fashion for therapeutic and/or preventive purposes.  Acupuncture treatment is applied to numerous ‘acupuncture points,’ or ‘acu-points’, that are located around the body. While there were originally 365 acu-points, one for each day of the year, clinical expertise has identified components that have seen this number rise to about 2,000.  The needles are used to stimulate the body's 14 major meridians, or energy-carrying channels, in the attempt to overcome illnesses and conditions by correcting these imbalances. http://www.webmd.com/acupuncture

 

How does it work?

A Fundamental Problem: No-one knows!

 

Herein lays the main problem with acupuncture treatment: no one really knows quite how it works!

However, there are several potentially viable theories. One theory, the Gate-Theory of Pain, suggests that “pain impulses are blocked from reaching the spinal cord or brain at various ‘gates’ to these areas.” http://www.quackwatch.org/01QuackeryRelatedTopics/acu.html . The concept of counter-pain, that pain inflicted in one spot takes away pain from another spot due to psychological factors, is another possible explanation. Other theories suggest that the placebo effect, external suggestion (hypnosis), and cultural conditioning are important factors.

The most widely accepted theory of how Acupuncture actually works is known as the endorphin theory.  Endorphins are our body’s natural ‘painkillers,’ which are found in and released by the central nervous system. Many acu-points are near nerves. When stimulated, these nerves cause a dull ache or feeling of fullness in the muscle. The stimulated muscle sends a message to the central nervous system (the brain and spinal cord), causing the release of endorphins (morphine-like chemicals produced in our own bodies during times of pain or stress). Endorphins, along with other neurotransmitters (body chemicals that modify nerve impulses), block the message of pain from being delivered up to the brain.  http://www.acupuncture.com/education/theory/acuintro.htm

This is exactly what we (those in pain) are looking for!

 

Chronic Pain

 

Chronic pain was originally defined as pain that has lasted 6 months or longer. But now pertains to pain which lasts longer than the normal amount of time associated with a particular injury. This constant (or intermittent) pain seems to have outlived its purpose, as it does not help the body to prevent injury. http://en.wikipedia.org/wiki/Chronic_pain

 

Chronic pain is not only a physical malady; with the associated pain also comes social, emotional, and financial burdens. According to the Ohio State University Medical Center, “Chronic pain has been said to be the most costly health problem in US. Increased medical expenses, lost income, lost productivity, compensation payments, and legal charges are some of the negative economic consequences of chronic pain.” http://medicalcenter.osu.edu/chronic pain

 

 

Acupuncture as a treatment for Chronic Pain

 

 

 

Supporting Studies

 

è In a recent randomized controlled study, 123 patients who had been diagnosed with chronic neck pain were assigned at random to be administered acupuncture or a nerve-stimulating placebo over 5 sessions in 3 weeks – their conclusion was that “the improvements in quality of life, active neck mobility, and reduced rescue medication were clinically and statistically significant” (Vas et al, 2006). 

So maybe it does really work?!

èIn the largest group study to date (as of Sept. 1, 2006!), acupuncture was found to ease pain and improve back function, as well as offer a cost-efficient alternative to modern medicine.  Said Dr. Claudia Witt, "Acupuncture should be considered a viable option in the management of patients with chronic low back pain," (Witt et al, 2006). Out of a total 11,630 patients with chronic back pain, the study randomly assigned 1,549 patients to acupuncture and 1,544 to a control group.  The remainder of the patients (8,537) was integrated into a non randomized acupuncture group – they were chosen as so because they had more severe baseline symptoms. The study lasted for a three-month duration, in which up to 15 treatments were administered, and the patients were followed for three months after the treatment.

Immediately following the treatment, patients who were administered acupuncture showed significantly better back function:  52.6 percent responded to treatment, while only 26.8 percent of the control group claimed the same improvement.  Those nonrandom patients showed improvements that were similar to those seen in the random patients.  After 6 months, symptoms were in remission, but still better than they were prior to the study (Witt et al, 2006).  Thus, acupuncture is an aid, not a cure!

 

è Within a 2005 meta-analysis, Manheimer et al assessed 33 randomized, controlled trials comparing needle acupuncture with sham acupuncture, other sham treatments, no additional treatment, or another active treatment for patients with low back pain.  For the primary outcome of short-term relief of chronic pain, the meta-analyses showed that acupuncture is significantly more effective than both sham treatment and no additional treatment by 58%; long term efficacy was shown to be 61% more than the sham treatment. 

 

Also included in the analysis where 3 studies of acupuncture against pain medications, and acupuncture was found to be more efficient in alleviating pain 66% of the time. (Manheimer et al, 2005).

Acupuncture effectively relieves chronic low back pain!

 

 

èIn 2002, Gilbertson et al showed that acupuncture had a significant affect on patients with chronic shoulder pain.  The trial consisted of 40 patients who were randomly assigned to receive either acupuncture or a control (placebo-acupuncture) group.  All of the patients thought they were receiving real acupuncture. Pain intensity, analgesic use, range of motion, and quality of life were monitored for four months, with four months of follow-up.  The study concluded that in patients with chronic should pain, real acupuncture compared to sham acupuncture offered significantly greater improvement via: (1) lower pain level, (2) less analgesic use, (3) range of motion, and (4) patient satisfaction (Gilbertson et al, 2003).

 More of the same – It Works!

 

 

 

 

Opposing Studies

èA double-blinded placebo-controlled trial was presented by Mendelson and Selwood in 1983.  77 patients were enrolled and monitored by questionnaire for improvement.  The placebo (sham) was in the form of superficial placement of needles in sites that were not significant to acupuncture. Their work showed no difference in efficacy between acupuncture and placebo:  a reduction in the pain score for acupuncture at 26 percent and 22 percent for placebo.  In fact, they concluded that the placebo component was more important clinically than the physiological effects of acupuncture itself. (Mendelson et al., 1983).

Maybe it doesn’t work at all?

 

èIn a 1990 meta-analysis, 51 controlled clinical studies on the effectiveness of acupuncture in chronic pain were considered. The studies were reviewed on a systematic 100 point scale based upon four main categories: (a) comparability of prognosis, (b) adequate intervention, (c) adequate effect measurement and (d) data presentation. The quality of even the better studies proved to be mediocre. No study earned more than 62% of the maximum score. The results from the better studies (greater than or equal to 50% of the maximum score) are highly contradictory. (ter Riet et al, 1990).

The efficacy of acupuncture in the treatment of chronic pain remains doubtful!

 

* èA systematic review by Dr. Maurits van Tulder revealed that no clear conclusion could be made as to the effectiveness of acupuncture in the management of back pain.  Eleven randomized controlled studies were reviewed.  Results indicated acupuncture to be: 1) not more effective than trigger-point injections and transcutaneous electrical nerve stimulation and 2) not more effective than placebo or sham acupuncture (van Tulder et al, 1999).

* Not all studies are conclusive, indicating some uncertainty. 

 

Evaluating Acupuncture

  Evaluating acupuncture is a daunting task.  Researchers wanting to do so must take numerous factors into account, including establishing which type of placebo/sham is most effective, how to administer the acupuncture, and how to evaluate pain. More studies of these responses will add to our understanding and will help researchers to develop better clinical trials in the future.

http://www.bastyrcenter.org/content/view/365/

 

Conclusion

It has been around 4,000 years from the time when acupuncture was created, and it has continued to be used ever since for a broad range of conditions with few adverse side effects.  There are obviously differing opinions about acupuncture and its effectiveness in treating chronic pain.  However, there is clearly more substantial evidence leading towards acceptance of this traditional medicinal practice.  This claim has been supported by significant statistical data.  The above supporting studies only add to the already prevalent amount of information that acupuncture certainly is an acceptable treatment option for chronic pain, although a few studies have produced negative results.  Those who refute the claim that acupuncture does alleviate chronic pain appear to cite more inconclusive evidence than fact – a sort of ‘innocent until proven guilty’ approach.  Since there is more evidence for good than harm, then, objectively, acupuncture seems to be worthwhile. However, as the absolute physiological basis for acupunctures’ alleviating pathways remains undefined, accepting acupuncture as treatment maintains certain risks.  Much research is currently being done to do so. The onset of modern technology - such as Magnetic Resonance Imaging (MRI) and specific protein trackers – will certainly expedite the process. Still, until a definitive biological groundwork for acupuncture is determined, it will remain outside the realm of universally accepted medical practices.

 

 

 

References

Gilbertson, B., Wenner, K., Russell, L.C. “Acupuncture and arthroscopic acromioplasty. Journal of Orthopedic Research. 2003. 21:752-758.

 

Manheimer E, White A, Berman B, et al. “Meta-analysis: acupuncture for low back pain.” Annals of Internal Medicine. 2005. 142:651-663.

 

Mendelson G, Selwood TS, Kranz H, Loh TS, Kidson MA, Scott Ds. “Acupuncture: treatment of chronic back pain. A double-blind placebo-controlled trial”.   Journal of Medicine. 741: 49-55.

 

Molsberger AF, Mau J, Pawelec DB, Winkler J. “Does acupuncture improve the orthopedic management of chronic low back pain - a randomized, blinded,        controlled trial with 3 months follow up”. Pain. 2002. 99:579-87.

 

ter Riet G, Kleijnen J, Knipschild P. “Acupuncture and chronic pain: a criteria-based meta-analysis”. Journal of Clinical Epidemiology. 1990. 43(11):1191-9.

 

van Tulder, Maurits W., et al.The Effectiveness of Acupuncture in the Management of Acute and Chronic Low Back Pain: A Systematic Review Within the            Framework of the Cochrane Collaboration Back Review Group”.  Spine. June 1, 1999. 24(11):1113.

 

Witt, et al. “Pragmatic Randomized Trial Evaluating the Clinical and Economic Effectiveness of Acupuncture for Chronic Low Back Pain”. American Journal of            Epidemiology 2006. 164(5):487-496.

 

Barrett, Stephen. “Be Wary of Acupuncture, Qigong, and "Chinese Medicine"”. Jan. 29, 2004.              http://www.quackwatch.org/01QuackeryRelatedTopics/acu.html

 

 

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