Letters to the Editor
Acupuncture for Chronic Back Pain: What Level of Evidence?
Am Fam Physician. 2010 Oct 15;82(8):869-878.
Original Article: Acupuncture for Pain
Issue Date: September 1, 2009
Available at: http://www.aafp.org/afp/2009/0901/p481.html
to the editor: In the article on acupuncture for treatment of pain, the author states: “A common finding has been that both sham and actual acupuncture improve pain, and the differences between the treatments do not reach statistical significance.” A 2009 trial drew the same conclusion: “Collectively, these recent trials provide strong and consistent evidence that real acupuncture needling using the Chinese meridian system is no more effective for chronic back pain than various purported forms of sham acupuncture.”1
Consistent evidence from randomized controlled trials has demonstrated that acupuncture is no better than the placebo sham acupuncture. Yet, the author asserts that the use of acupuncture for treatment of back pain is backed by level “A” evidence, defined as “consistent, good-quality patient-oriented evidence.” In an online comment to an article in BMJ, Dr. Colquhoun stated: “Such is the delusional nature of much alternative medicine that when the test is failed, the conclusion isn't that the treatment doesn't work, but that the test doesn't work and must be replaced with one that is easier to pass (until such time as you get the answer you wanted in the first place).”2
In a desire to present information regarding treatments designated as complementary and alternative medicine (CAM), the editors of American Family Physician seem willing to suspend the usual criteria for evidence-based medicine, without explicitly stating that good scientific research somehow should not apply to CAM. Family physicians were among the first practitioners to embrace evidence-based medicine. We should not be the first to reject it when it gives the “wrong” answers, no matter how a therapy is labeled.
1. Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009;169(9):858–866.
2. Colquhoun D. (2009, September 2) If your treatments can't pass the test, the test must be wrong. Message posted to: http://www.bmj.com/cgi/eletters/339/sep01_2/b3335#219673.
in reply: As I attempted to briefly summarize in the article, research on acupuncture is difficult. An excellent resource on acupuncture research is the book Acupuncture Research: Strategies for Establishing an Evidence Base.1 Most research protocols standardize acupuncture therapy in a way that does not mirror the usual practice of acupuncture, which is individualized based on many factors (e.g., Chinese rather than Western medicine diagnosis; acupuncturists' training and experience). For many pain problems, it is not unusual for nontraditional modern acupuncture techniques such as percutaneous nerve stimulation and intramuscular stimulation (sometimes referred to as “dry needling”) to be combined with, or used instead of, traditional “Qi-moving” acupuncture treatment. Sham acupuncture usually involves skin puncture with acupuncture needles at locations different from standard acupuncture. Because the mechanisms of acupuncture are not well understood, sham treatments that include skin puncture may be more active than intended by the investigators. Examples of improved methods of sham acupuncture that do not involve skin puncture exist,2 but have not been widely used. Therefore, it is not surprising that many studies find that both sham and standard acupuncture benefit patients. In most of these studies, standard acupuncture effects are greater than sham acupuncture effects, but the difference between standard and sham acupuncture may not reach statistical significance. Given these and other limitations of research methods, it is difficult to interpret single studies, and therefore I emphasized reviewing meta-analyses and systematic reviews of multiple studies.
Level A evidence can come from one or more randomized controlled trials or from meta-analyses or systematic reviews of available RCTs and other studies. In the case of acupuncture for low back pain, I believed that the meta-analysis3 and Cochrane review4 that I cited in the article met this standard. In the meta-analysis, for the primary outcome of short-term relief of chronic pain, acupuncture was found to be significantly more effective than sham treatment, standardized mean difference, 0.54 (95% confidence interval [CI], 0.35 to 0.73; seven trials), and no additional treatment, standardized mean difference, 0.69 (CI, 0.40 to 0.98; eight trials). The plain language summary of the Cochrane review states: “For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months.”4
1. MacPherson H, Hammerschlag R, Lewith G, Schnyer R, eds Acupuncture Research: Strategies for Establishing an Evidence Base Edinburgh: Churchill Livingstone/Elsevier; 2007:261
2. Martin DP, Sletten CD, Williams BA, Berger IH. Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial. Mayo Clin Proc. 2006;81(6):749–757.
3. Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain [published correction appears in Ann Intern Med. 2005;142(11):950–951]. Ann Intern Med. 2005;142(8):651–663.
4. Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry needling for low back pain. Cochrane Database Syst Rev. 2005; (1):CD001351.
editor's note: According to a survey conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics, nearly one half of adults have used CAM during their lifetime.1 The intent of American Family Physician's CAM series is not to further endorse the clearly prevalent use of CAM therapies and modalities, but rather to inform physicians about the therapies their patients may be using and the evidence behind them. We hold CAM reviews to the same standard of evidence labeling as other reviews. In Dr. Kelly's article, references 9 through 15, which supported the use of acupuncture in back pain, included several RCTs, systematic reviews, and a meta-analysis, which would warrant an evidence level A for any review article. Although Dr. Kelly discusses the controversy over sham acupuncture in his article, including a footnote in the Strength of Recommendation Taxonomy (SORT) table about the insufficient difference between traditional and sham therapies would have been a key clarification. Regardless, if a patient asks me if acupuncture provides pain relief for back pain, my answer will still be “yes.”
1. Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data. 2004;343:1–19.
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