The diagnosis and treatment of patients with chronic low-back pain by traditional Chinese medical acupuncturists

Methodological concerns when designing trials for the efficacy of acupuncture for the treatment of pain

The aim of all clinical research must surely be to assess an intervention or process or relationship between variables, ultimately in order to be able to improve clinical practice and healthcare for patients/consumers. As such, evidence gathered must have external validity (generalisability) and it must be relevant to clinical practice. It can be seen therefore that research into acupuncture for pain relief is an inherently difficult task, which requires much sensitivity and careful planning in order to minimise error when drawing conclusions. The researcher needs to adequately address problems such as sample size, blinding, randomisation and appropriate use of control and treatment. It is also most important to be able to clarify that the placebo (if used) is credible to the patient. The field of acupuncture has been overwhelmed with hundreds of sub-standard trials and much doubt still surrounds the issue of efficacy. Few good quality rigorous trials exist to support the use of acupuncture for pain relief in general. It has also been noted that the question of long-term efficacy has not been assessed by the many trials and this needs to be addressed prior to its acceptance. Further well conducted rigorous trials are therefore needed, utilising the lessons learnt through the substantial number of previous trials, in order to adequately assess the efficacy of acupuncture for painful conditions. Such trials must therefore: Utilise a placebo control. Be randomised and stratified. Ensure patient blinding. Use self completed outcome measures and blinded assessors. Have sufficient and well validated outcome measures. Check credibility of treatment. Have a well defined entry criteria which includes a single condition only. Have a long term follow up. Enrol sufficient subjects, the number to be determined by a power calculation. Provide adequate acupuncture treatment as would be found in clinical practice. Be group comparative so as to negate any carry-over effects. In this way good quality trials can be undertaken which will yield reliable results and therefore add meaningful data to the body of knowledge appertaining to the effectiveness of acupuncture.

Pain prevalence, experiences and management strategies among the elderly in taiwanese nursing homes

The purpose of this study was to explore pain prevalence, experiences, and self-care management strategies among elderly residents of nursing homes in Taiwan. Stratified random sampling was used to recruit participants (n=150). In these elderly nursing home residents, pain prevalence was 65.3% and the average number of pain sites was 3.24 (SD=2.59). The mean pain intensity was 3.86 (SD=1.90) and pain interference was 4.30 (SD=2.28). "Aching" was the word most commonly used (77.6%) to describe pain. Most participants (54.21%) took prescribed medications for dealing with pain; doctors were the main information source for this self-care strategy. Although participants reported severe bouts of pain, they used limited self-care pain management strategies. Since health care providers play an important role in helping the elderly to manage pain, the authors recommend training nursing home staff to perform regular pain assessments and providing current knowledge about pain assessment and management strategies.

Auricular Acupuncture in the Treatment of Cocaine/Crack Abuse: A Review of the Efficacy, the Use of the National Acupuncture Detoxification Association Protocol, and the Selection of Sham Points

BACKGROUND

The United Kingdom has had a significant increase in addiction to and use of cocaine among 16-29-year olds from 6% in 1998 to 10% in 2000. In 2000, the United Kingdom had the highest recorded consumption of "recent use" cocaine in Europe, with 3.3% of young adults. Acupuncture is quick, inexpensive, and relatively safe, and may establish itself as an important addiction service in the future.

AIM

To select investigations that meet the inclusion criteria and critically appraise them in order to answer the question: "Is acupuncture effective in the treatment of cocaine addiction?" The focus shall then be directed toward the use of the National Acupuncture Detoxification Association (NADA) protocol as the intervention and the selection of sham points for the control group.

DATA SOURCES

The ARRC database was accessed from Trina Ward (M. Phil. student) at Thames Valley University. AMED, MEDLINE and Embase were also accessed along with "hand" searching methods at the British Library.

INCLUSION AND EXCLUSION CRITERIA

People addicted to either cocaine or crack cocaine as their main addiction, needle-acupuncture, single-double-blinded process, randomized subjects, a reference group incorporating a form of sham points.

EXCLUSION CRITERIA

use of moxibustion, laser acupuncture, transcutaneous electrical nerve stimulation (TENS) electroacupuncture or conditions that did not meet the inclusion criteria.

QUALITY ASSESSMENT

The criteria set by ter Riet, Kleijnen and Knipschild (in 1990); Hammerschlag and Morris (in 1990); Koes, Bouter and van der Heijden (in 1995), were modified into one set of criteria consisting of 27 different values.

RESULTS

Six randomized controlled trials (RCTs) met the inclusion criteria and were included in this review. All studies scored over 60 points indicating a relatively adequate methodology quality. The mean was 75 and the standard deviation was 6.80. A linear regression analysis did not yield a statistically significant association (n = 6, p = 0.11).

CONCLUSIONS

This review could not confirm that acupuncture was an effective treatment for cocaine abuse. The NADA protocol of five treatment points still offers the acupuncturist the best possible combination of acupuncture points based upon Traditional Chinese Medicine. Throughout all the clinical trials reviewed, no side-effects of acupuncture were noted. This paper calls for the full set of 5 treatment points as laid out by the NADA to be included as the treatment intervention. Points on the helix, other than the liver yang points, should be selected as sham points for the control group.

Clinical Research on Acupuncture: Part 2. Controlled Clinical Trials, an Overview of Their Methods

There is almost universal agreement that the quality of clinical trials of acupuncture is poor. There is an urgent need to improve their quality. The author develops here a list of 45 criteria important in the design, implementation, and writing up of controlled clinical acupuncture trials. This list has been compiled after examining the quality assessment criteria used in meta-analyses and systematic reviews of acupuncture, general publications on clinical trial designs and methodological considerations specific to acupuncture trials. Each criterion is discussed with recommendations about use and implementation. Additionally, each criterion is discussed relative to their importance in three types of acupuncture trial, acupuncture versus sham acupuncture, acupuncture versus standard therapy and acupuncture versus no treatment or wait-list. It is hoped that this exploration and systematic presentation of the 45 criteria will contribute to improving the quality of clinical trials of acupuncture. Improved trial quality will lead to greater ease interpreting the results of trials, especially in systematic reviews.

Acupuncture for low back pain: traditional diagnosis and treatment of 148 patients in a clinical trial

AIMS

To assess patterns of diagnosis, including concordance, and treatment within a clinical trial of traditional acupuncture for low back pain.

SETTING

In a pragmatic randomised controlled clinical trial, 148 patients with low back pain, of between 4 weeks and 12 months duration, were randomised to the offer of individualised acupuncture and received up to 10 treatments.

METHODS

Standardised diagnosis and treatment records were completed by practitioners for 148 patients. The diagnosis was based on three pre-defined low back pain syndromes. For a subgroup of patients, one of the six practitioners then independently re-examined the patients, blind to the original diagnosis. The diagnostic inter-rater reliability was assessed in terms of percentage congruent classifications and Cohen's Kappa. Structured interviews of practitioners established further details about practice styles.

RESULTS

The most commonly diagnosed syndrome associated with low back pain was Qi and Blood Stagnation (88% of patients), followed by Kidney Deficiency (53%) and Bi Syndrome (28%), with more than one syndrome being identified for 65% of patients. For the subgroup examined twice, practitioner concordance was reasonable: between 47 and 80% of classifications were congruent, while Kappa values lay between 0 ("the same as chance") and 0.67 ("good"). Practitioners provided 1269 treatments in total, using 177 different acupuncture points. Most commonly used channels were Bladder and Gall Bladder, and the commonest points were BL-23 and the two lowest Huatuojiaji points. Auxiliary treatments were utilised by all practitioners to varying degrees.

CONCLUSIONS

Diagnostic concordance among practitioners was reasonable, and clear themes emerged for treatment. Further research is required to develop a flexible trial protocol with scope for individualised treatment.

Acupuncture for tennis elbow: an E-mail consensus study to define a standardised treatment in a GPs' surgery

Acupuncture is a possible alternative treatment for tennis elbow in general practice. Rigorous investigation of its effectiveness is needed by means of a randomised controlled trial. Before undertaking a trial, a consensus is required on the best treatment protocol. Therefore, a modified Delphi Process was undertaken by e-mail, consisting in three iterative rounds. Fourteen acupuncture trainers initially reported details of their normal treatment that were then incorporated into a treatment plan. This was circulated once for further suggestions and finally for agreement. Consensus was achieved from all 14 participants who responded to the third round.

How traditional Chinese medicine acupuncturists would diagnose and treat chronic low back pain: results of a survey of licensed acupuncturists in Washington State

OBJECTIVES

This survey was undertaken to learn how Traditional Chinese Medicine acupuncturists' diagnose and treat patients with chronic low back pain in order to develop a standardized treatment for a clinical trial of that condition.

DESIGN

We surveyed a randomly selected group of 56 acupuncturists in Washington State, USA about styles of acupuncture they used for treating chronic low back pain, diagnoses made, and key features of treatment for this condition.

RESULTS

While substantial variability existed among practitioners, there was agreement on several broad features of treatment including: the use of local and distal acupuncture points (86% of practitioners), the use of acupuncture points on the meridians traversing the back (especially the UB meridian, 90%) the use of acupoints determined by palpation (82%), the importance of eliciting de qi (60%), and of providing up to eight treatments for achieving therapeutic results (79%).

CONCLUSION

The use of practitioner surveys can enhance the systematic development of acupuncture treatment protocols and should be part of this process in future clinical trials of common conditions.