Acupuncture mitigates chronic low back pain 20% better than conventional care

Patients improved 47% with acupuncture, 44% with sham and 27% with standard care.

Link  http://www.orthosupersite.com/view.asp?rID=24920

By Susan M. Rapp
ORTHOPAEDICS TODAY INTERNATIONAL 2007; 10:14
November 2007

Acupuncture was more effective at treating chronic low back pain than conventional care in a semi-blinded randomized, controlled study conducted at outpatient centers across Germany. Sham acupuncture, however, worked about as well as the actual procedure, the study results showed.

There was an approximate 20% better result at follow-up for the acupuncture and sham acupuncture groups than for the standard care group, investigators concluded.

The German acupuncture trials for chronic low back pain - GERAC - involved 1,162 patients divided into three treatment groups, all of whom had chronic low back pain (LBP) for 8 years, mean (age range, 18 to 86 years).

Investigator Michael Haake, MD, PhD, an orthopaedic surgeon, described the study as controversial. "The results are controversial because on the one hand we could show acupuncture is very good in clinical use. It is much better than standard care and a 20% difference in a clinical trial in our patients is enormous," he said. "But, on the other hand, there is the question: What is acupuncture? Or is it justified learning traditional Chinese medicine since the needling at non-acupuncture points is as good as traditional Chinese acupuncture?"

Three groups
The study was published in Archives of Internal Medicine in September.

Investigators administered verum acupuncture to 387 patients using traditional Chinese techniques and superficial needling to 387 patients, where they shallowly placed acupuncture needles at body points not typically used for acupuncture. The 388 patients randomized to the study's conventional care arm received a combination of medicine, physiotherapy and exercises.

Individuals with previous surgery or acupuncture for LBP, as well as others, such as patients with spinal fractures, were excluded.


Primary outcomes
Outcomes were obtained at 6 months post-treatment via telephone. Patients were rated using the Hanover functional ability questionnaire, which is specific for back function, and three items from the Von Korff chronic pain grade scale (CPGS).

Patients and observers were blinded to pain criteria used.

Success was defined as 33% or more improvement in the CPGS and 12% or more in Hanover scores.

The more commonly used Visual Analog Scale and Oswestry low back disability scale were secondary outcome measures. Haake said they used the Hanover questionnaire over the Oswestry scale because it was validated for telephone use.

Groups' response
Patients who needed a post-treatment pain remedy beyond "rescue medicine" the study allowed were designated nonresponders and excluded from the final results. "If you exclude this rescue medication or pain injections, you will get a better response rate in all three groups of about 20% in every group," yet the differences between response rates for all groups remained the same, Haake said.

Response rates were 47%, 44% and 27% for acupuncture, sham acupuncture and conventional care, respectively. After omitting effects of rescue medicine, response rates were about 65% for acupuncture and 45% for conventional care, he said.

All interventions lasted about 30 minutes and were administered in two sessions per week for 5 weeks. Those with a partial 10% to 50% pain reduction on the CPGS could opt for up to five more treatments.

Standard of care
Patients in the conservative care group received the well-established care that was similar to care noted in other German studies, Haake said. "The conventional therapy in the GERAC trial was very good compared to the normal status here in Germany," he told Orthopedics Today. Guidelines used were up to date, did not limit medication use and allowed 10 sessions of active treatment from a physiotherapist.

Haake noted study findings would very likely be applicable to similar patients with chronic LBP elsewhere.

For more information:
Michael Haake, MD, PhD, can be reached at the Clinic for Orthopaedics and Trauma Surgery, SLK-Clinic Heilbronn GmbH, Am Plattenwold 1, Bad Friedrichshall, Germany 74177; +49-7136-281537; email: michael.haake@slk-kliniken.de. He has no direct financial interest in any companies or products mentioned in this article.
References:

Haake M, Müller H-H, Schade-Brittinger C, et al. German acupuncture trials (GERLAC) for chronic low back pain. Arch Intern Med. 2007;167:1892-1898.
Haake M, Müller H-H, Schade-Brittinger C, et al. The German multicenter, randomized, partially blinded, prospective trial of acupuncture for CLBP: A preliminary report on the rationale and design of the trial. J Altern Complement Med. 2003; 9(5):763-77