In a recent randomized clinical trial (RCT) for using acupuncture treatment of low back pain, a total of 638 adults with chronic mechanical low back pain were randomized to individualized acupuncture, standardized acupuncture, simulated acupuncture (toothpick), or usual care. Ten treatments were provided over 7 weeks by experienced acupuncturists. The primary outcomes, back-related dysfunction (Roland-Morris Disability Questionnaire score; range, 0-23) and symptom bothersomeness (0-10 scale), were assessed at baseline and after 8, 26, and 52 weeks.
As a result, the outcomes at each time point (two months, half a year and one year) show that patients in the individualized acupuncture, standardized acupuncture and simulated acupuncture (toothpick) group are recovering much better than that patients in the usual care group. But patients in the two real acupuncture groups (the individualized acupuncture, standardized acupuncture) are not doing better than those in the simulated acupuncture (toothpick) group. It gives rise a question whether acupuncture represents placebo or nonspecific effects (1).
After carefully read the articles, we (me and Dr. Yang, former Chairperson of the California State Acupuncture Board) found that there are some questions that need to be addressed, which the RCT designers definitely ignored during their practice. Here is the letter we wrote to the Editor-in-Chief.
To the Editor:
We read Cherkin DC, et al’s (1) paper with great interest. There is no surprise for us to see the result that there was no difference between the really acupuncture group and the “simulated” acupuncture group. Because the “simulated” acupuncture is not a proper control to test the effectiveness of acupuncture.
Historically, acupuncture needles have been crafted from stone, bamboo, bone, and porcelain before the eventual invention of metal needles. It is of noteworthy value to mention that the ancient writing of “针”(needle) was “箴 ”. The radical, in this case the upper part of the word, denotes bamboo (2). Further, these bamboo needles were used in similar ways as the authors described in their simulated acupuncture trial.
What this short tangent into history means for Cherkin DC, et al’s paper is that bamboo needles were indeed once used in place of metal ones in the practice of acupuncture to achieve the same results as what modern-day acupuncturists hope to achieve with metal needles. Therefore, it is not surprising to see the similar results of these two groups in this clinical trial. Moreover, these similar data should definitely not be used to discredit the usefulness of acupuncture, since they are both forms of acupuncture.
As it stands, the only conclusion that could be drawn from Cherkin DC, et al’s clinical trial is the following: There is no noticeable difference in the effectiveness between metal needles that puncture the skin and bamboo needles that do not puncture the skin for minor cases of lower back pain.
We stress the italicized portion because it is clear that the authors chose not to use more severe cases of lower back pain. For example, patients with sciatica, a very common but much more tough case of low back pain had been excluded from their trial. These cases are more difficult to treat, and require puncturing through the skin. Minor cases of lower back pain can often be treated without puncturing—and in fact without needles—as seen in the usefulness of acupressure, where points are pressed externally by hand. Therefore, it would be much more significant for this clinical trial if such severe cases of low back pain had been included.
Xibin Liang, Ph.D., L.Ac.
Benjamin Yang, O.M.D., L.Ac.
Reference:
1. Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE, Delaney K, Hawkes R, Hamilton L, Pressman A, Khalsa PS, Deyo RA. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009 May 11;169(9):858-66.
2. Shanghai College of Traditional Chinese Medicine. Acupuncture and Moxibustion. People’s Health Press, Beijing 1974, P268
