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Abstract
BACKGROUND Chronic nonspecific low back pain (LBP) is very common; it is defined as pain without a recognizable etiology that lasts for more than three months. Some clinical practice guidelines suggest that acupuncture can offer an effective alternative therapy. This review is a split from an earlier Cochrane review and it focuses on chronic LBP. OBJECTIVES To assess the effects of acupuncture compared to sham intervention, no treatment, or usual care for chronic nonspecific LBP. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, two Chinese databases, and two trial registers to 29 August 2019 without restrictions on language or publication status. We also screened reference lists and LBP guidelines to identify potentially relevant studies. SELECTION CRITERIA We included only randomized controlled trials (RCTs) of acupuncture for chronic nonspecific LBP in adults. We excluded RCTs that investigated LBP with a specific etiology. We included trials comparing acupuncture with sham intervention, no treatment, and usual care. The primary outcomes were pain, back-specific functional status, and quality of life; the secondary outcomes were pain-related disability, global assessment, or adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently screened the studies, assessed the risk of bias and extracted the data. We meta-analyzed data that were clinically homogeneous using a random-effects model in Review Manager 5.3. Otherwise, we reported the data qualitatively. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 33 studies (37 articles) with 8270 participants. The majority of studies were carried out in Europe, Asia, North and South America. Seven studies (5572 participants) conducted in Germany accounted for 67% of the participants. Sixteen trials compared acupuncture with sham intervention, usual care, or no treatment. Most studies had high risk of performance bias due to lack of blinding of the acupuncturist. A few studies were found to have high risk of detection, attrition, reporting or selection bias. We found low-certainty evidence (seven trials, 1403 participants) that acupuncture may relieve pain in the immediate term (up to seven days) compared to sham intervention (mean difference (MD) -9.22, 95% confidence interval (CI) -13.82 to -4.61, visual analogue scale (VAS) 0-100). The difference did not meet the clinically important threshold of 15 points or 30% relative change. Very low-certainty evidence from five trials (1481 participants) showed that acupuncture was not more effective than sham in improving back-specific function in the immediate term (standardized mean difference (SMD) -0.16, 95% CI -0.38 to 0.06; corresponding to the Hannover Function Ability Questionnaire (HFAQ, 0 to 100, higher values better) change (MD 3.33 points; 95% CI -1.25 to 7.90)). Three trials (1068 participants) yielded low-certainty evidence that acupuncture seemed not to be more effective clinically in the short term for quality of life (SMD 0.24, 95% CI 0.03 to 0.45; corresponding to the physical 12-item Short Form Health Survey (SF-12, 0-100, higher values better) change (MD 2.33 points; 95% CI 0.29 to 4.37)). The reasons for downgrading the certainty of the evidence to either low to very low were risk of bias, inconsistency, and imprecision. We found moderate-certainty evidence that acupuncture produced greater and clinically important pain relief (MD -20.32, 95% CI -24.50 to -16.14; four trials, 366 participants; (VAS, 0 to 100), and improved back function (SMD -0.53, 95% CI -0.73 to -0.34; five trials, 2960 participants; corresponding to the HFAQ change (MD 11.50 points; 95% CI 7.38 to 15.84)) in the immediate term compared to no treatment. The evidence was downgraded to moderate certainty due to risk of bias. No studies reported on quality of life in the short term or adverse events. Low-certainty evidence (five trials, 1054 participants) suggested that acupuncture may reduce pain (MD -10.26, 95% CI -17.11 to -3.40; not clinically important on 0 to 100 VAS), and improve back-specific function immediately after treatment (SMD: -0.47; 95% CI: -0.77 to -0.17; five trials, 1381 participants; corresponding to the HFAQ change (MD 9.78 points, 95% CI 3.54 to 16.02)) compared to usual care. Moderate-certainty evidence from one trial (731 participants) found that acupuncture was more effective in improving physical quality of life (MD 4.20, 95% CI 2.82 to 5.58) but not mental quality of life in the short term (MD 1.90, 95% CI 0.25 to 3.55). The certainty of evidence was downgraded to moderate to low because of risk of bias, inconsistency, and imprecision. Low-certainty evidence suggested a similar incidence of adverse events immediately after treatment in the acupuncture and sham intervention groups (four trials, 465 participants) (RR 0.68 95% CI 0.46 to 1.01), and the acupuncture and usual care groups (one trial, 74 participants) (RR 3.34, 95% CI 0.36 to 30.68). The certainty of the evidence was downgraded due to risk of bias and imprecision. No trial reported adverse events for acupuncture when compared to no treatment. The most commonly reported adverse events in the acupuncture groups were insertion point pain, bruising, hematoma, bleeding, worsening of LBP, and pain other than LBP (pain in leg and shoulder). AUTHORS' CONCLUSIONS We found that acupuncture may not play a more clinically meaningful role than sham in relieving pain immediately after treatment or in improving quality of life in the short term, and acupuncture possibly did not improve back function compared to sham in the immediate term. However, acupuncture was more effective than no treatment in improving pain and function in the immediate term. Trials with usual care as the control showed acupuncture may not reduce pain clinically, but the therapy may improve function immediately after sessions as well as physical but not mental quality of life in the short term. The evidence was downgraded to moderate to very low-certainty considering most of studies had high risk of bias, inconsistency, and small sample size introducing imprecision. The decision to use acupuncture to treat chronic low back pain might depend on the availability, cost and patient's preferences.
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Affiliation(s)
- Jinglan Mu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- School of Chinese Medicine, The University of Hong Kong, Hong Kong, China
| | - Andrea D Furlan
- Institute for Work & Health, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Wai Yee Lam
- School of Chinese Medicine, The University of Hong Kong, Hong Kong, China
| | - Marcos Y Hsu
- Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Zhipeng Ning
- School of Chinese Medicine, The University of Hong Kong, Hong Kong, China
| | - Lixing Lao
- School of Chinese Medicine, The University of Hong Kong, Hong Kong, China
- Virginia University of Integrative Medicine, Fairfax, Virginia, USA
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Wang SQ, Chen M, Wei X, Gao XX, Zhao GD. Clinical research on lumbar oblique-pulling manipulation in combination with sling exercise therapy for patients with chronic nonspecific low back pain. Rev Assoc Med Bras (1992) 2019; 65:886-892. [PMID: 31340321 DOI: 10.1590/1806-9282.65.6.886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/09/2019] [Indexed: 11/22/2022] Open
Abstract
SUMMARY OBJECTIVE: To investigate clinical curative effects of lumbar oblique-pulling manipulation in combination with sling-exercise-therapy training on chronic nonspecific lower back pain. METHODS: A total of 60 patients with chronic nonspecific lower back pain in the Outpatient Department were included in this study. These patients were randomly divided into two groups: the observation group and the control group. The control group adopted a single sling-exercise-therapy training three times a week, while the observation group adopted lumbar oblique-pulling manipulation in combination with manipulation treatment once a week. The course of treatment lasted for four weeks. RESULTS: (1) Before and after treatment, the ODI score was compared within the group. A remarkable statistical significance was observed from the third day (P<0.05). At the third month of follow-up, the difference in ODI scores between these two groups was statistically significant (P<0.05). (2) Before and after treatment, it was observed that differences in VAS scores from the third day were statistically significant (P<0.05). (3) The difference in muscle strength between these two groups had remarkable statistical significance in the third month of follow-up (P<0.05). CONCLUSION: The effective rehabilitation function of lumbar oblique-pulling manipulation in combination with sling-exercise-therapy training in patients with CNLBP is superior to that of sling-exercise-therapy training alone.
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Affiliation(s)
- Shang-Quan Wang
- Wangjing Hospital of China Academy of Chinese Medical Sciences, China
| | - Ming Chen
- Wangjing Hospital of China Academy of Chinese Medical Sciences, China
| | - Xu Wei
- Wangjing Hospital of China Academy of Chinese Medical Sciences, China
| | - Xin-Xia Gao
- Wangjing Hospital of China Academy of Chinese Medical Sciences, China
| | - Guo-Dong Zhao
- Wangjing Hospital of China Academy of Chinese Medical Sciences, China
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Cotchett MP, Landorf KB, Munteanu SE, Raspovic AM. Consensus for Dry Needling for Plantar Heel Pain (Plantar Fasciitis): A Modified Delphi Study. Acupunct Med 2018; 29:193-202. [DOI: 10.1136/aim.2010.003145] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Hypothesis Plantar heel pain (plantar fasciitis) is a common and disabling condition. A variety of treatment options are available to patients with plantar heel, however the evidence for these treatments is generally weak and the best way to manage plantar heel pain remains unclear. Trigger point dry needling is increasingly used as an adjunct therapy for musculoskeletal pain. In patients with plantar heel pain this technique is thought to improve muscle activation patterns, increase joint range of motion and alleviate pain. However, there have been no randomised controlled trials that have evaluated the effectiveness of dry needling for plantar heel pain. Methods In order to develop a treatment protocol to evaluate the effectiveness of dry needling for plantar heel pain we conducted a three stage modified Delphi process using a web-based survey technique. Over a series of three iterations, 30 experts (participants) worldwide indicated their level of agreement on specific issues relating to the use of dry needling for plantar heel pain including their treatment rationale, needling details and treatment regimen. Consensus for a dry needling protocol for plantar heel pain was achieved when >60% of participants (IQR ≤ 1.0 category on 5-point Likert scale) agreed the protocol was adequate. Results The response rate was 75% (n=30), 100% (n=30) and 93% (n=28) in the first, second and third rounds respectively. Round 1 helped generate a list of 10 items that were deemed important for developing a dry needling protocol for plantar heel pain. These 10 items were subsequently presented in Round 2. Of these, 5 of the 10 items met the criteria to be included in a dry needling protocol for plantar heel pain that was presented in the final round, Round 3. Items that did not meet the criteria were either removed or amended and then presented in Round 3. In the final round, 93% of participants (IQR range = 1) agreed the proposed dry needling protocol for plantar heel pain was adequate. The protocol can now be used in future research projects designed to evaluate the effectiveness of dry needling for plantar heel pain.
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Affiliation(s)
- Matthew P Cotchett
- Department of Podiatry and Musculoskeletal Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Karl B Landorf
- Department of Podiatry and Musculoskeletal Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Shannon E Munteanu
- Department of Podiatry and Musculoskeletal Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Anita M Raspovic
- Department of Podiatry and Musculoskeletal Research Centre, La Trobe University, Melbourne, Victoria, Australia
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Liang YD, Li Y, Zhao J, Wang XY, Zhu HZ, Chen XH. Study of acupuncture for low back pain in recent 20 years: a bibliometric analysis via CiteSpace. J Pain Res 2017; 10:951-964. [PMID: 28479858 PMCID: PMC5411170 DOI: 10.2147/jpr.s132808] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Acupuncture has been applied to relieve low back pain (LBP) in many countries. However, a bibliometric analysis of the global use of acupuncture for LBP is rare. Objective The aim of this study was to demonstrate the state of the art and trends concerning the global use of acupuncture for LBP in recent 20 years. Methods Literature relating to acupuncture for LBP from 1997 to 2016 was retrieved from Web of Science. CiteSpace was used to analyze country/institution, cited journals, authors/cited authors, cited references, and keywords. An analysis of counts and centrality was used to reveal publication outputs, countries/institutions, core journals, active authors, foundation references, hot topics, and frontiers. Results A total of 958 references were obtained, and the total number of publications continually increased over the investigated period. Journal articles (662) were the most frequently occurring document type. The most productive country and institution in this field was the USA (342) and Harvard University (47), respectively. The J Altern Complem Med (69) was the most productive journal, and Pain (636) was the most cocited journal, which reflected the nature of the research. The Haake’s (2007) article (cocitation counts: 130) and the Cherkin’s (2001) article (centrality: 0.59) were the most representative and symbolic references, with the highest cocitation number and centrality, respectively. Cherkin was the most influential author, with the highest number of publications of 25 and a cocitation number of 226. The four hot topics in acupuncture for LBP were research method, evaluation, economy, and comprehensive therapy. The three frontier topics were intervention, test reliability, and prevalence. Conclusion This study provides an insight into acupuncture for LBP and valuable information for acupuncture researchers to identify new perspectives on potential collaborators and cooperative institutions, hot topics, and research frontiers.
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Affiliation(s)
- Yu-Dan Liang
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou
| | - Ying Li
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou
| | - Jian Zhao
- Longgang District People's Hospital of Shenzhen, Shenzhen
| | - Xiao-Yin Wang
- Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou, People's Republic of China
| | - Hui-Zheng Zhu
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou
| | - Xiu-Hua Chen
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou
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New Independent Thermobalancing Treatment with Therapeutic Device for Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Nephrourol Mon 2017. [DOI: 10.5812/numonthly.44694] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Liu L, Skinner MA, McDonough SM, Taylor KGM, Baxter GD. Does the dose of Traditional Chinese Medicine acupuncture in addition to usual care affect outcomes for adults with chronic low back pain? Protocol for a randomized controlled feasibility study. PHYSICAL THERAPY REVIEWS 2016. [DOI: 10.1080/10833196.2015.1107365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Greenlee H, Crew KD, Capodice J, Awad D, Jeffres A, Unger JM, Lew DL, Hansen LK, Meyskens FL, Wade JL, Hershman DL. Methods to Standardize a Multicenter Acupuncture Trial Protocol to Reduce Aromatase Inhibitor-related Joint Symptoms in Breast Cancer Patients. J Acupunct Meridian Stud 2015; 8:152-8. [PMID: 26100070 DOI: 10.1016/j.jams.2015.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 03/23/2015] [Indexed: 11/29/2022] Open
Abstract
Robust methods are needed to efficiently conduct large, multisite, randomized, controlled clinical trials of acupuncture protocols. The Southwest Oncology Group (SWOG) S1200 trial is a randomized, controlled (i.e., sham-controlled and waitlist-controlled) trial of a standardized acupuncture protocol for treating aromatase inhibitor (AI)-associated arthralgias in early-stage breast cancer patients (n = 228). The primary objective of this study was to determine whether true acupuncture administered twice weekly for 6 weeks, as compared to sham acupuncture or a waitlist control, reduced AI-associated joint pain at 6 weeks as assessed by patient reports. The study was conducted at 11 institutions across the United States. The true acupuncture protocol was developed using a consensus-based process. The true acupuncture and the sham acupuncture protocols each consisted of 12 sessions administered for 6 weeks, followed by one weekly session for 6 weeks. The true acupuncture protocol used standardized protocol points, and the standardized acupoints were tailored to a patient's joint symptoms. The similarly standardized sham acupuncture protocol utilized superficial needling of nonacupoints. Standardized methods were developed to train and monitor acupuncturists and included online and in-person training, study manuals, monthly phone calls, and remote quality assurance monitoring throughout the study period. The research staff similarly received online and in-person training and monthly phone calls.
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Affiliation(s)
| | | | | | | | - Anne Jeffres
- Columbia University Medical Center, New York, USA
| | - Joseph M Unger
- SWOG Statistical Center/Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Danika L Lew
- SWOG Statistical Center/Fred Hutchinson Cancer Research Center, Seattle, USA
| | | | | | - James L Wade
- Cancer Care Specialists of Central Illinois/Heartland NCORP, Decatur, USA
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Gurung T, Ellard DR, Mistry D, Patel S, Underwood M. Identifying potential moderators for response to treatment in low back pain: A systematic review. Physiotherapy 2015; 101:243-51. [PMID: 25769189 DOI: 10.1016/j.physio.2015.01.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 01/17/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Identifying which patients with non-specific low back pain are likely to gain the greatest benefit from different treatments is an important research priority. Few studies are large enough to produce data on sub-group effects from different treatments. Data from existing large studies may help identify potential moderators to use in future individual patient data meta-analyses. OBJECTIVE To systematically review papers of therapist delivered interventions for low back pain to identify potential moderators to inform an individual patient data meta-analysis. DATA SOURCES We searched MEDLINE, EMBASE, Web of Science and Citation Index and Cochrane Register of Controlled Trials (CENTRALhttp://www.cochrane.org/editorial-and-publishing-policy-resource/cochrane-central-register-controlled-trials-central) for relevant papers. DATA EXTRACTION AND DATA SYNTHESIS We screened for randomised controlled trials with ≥500 or more participants, and cohort studies of ≥1000 or more participants. We examined all publications related to these studies for any reported moderator analyses. Two reviewers independently did risk of bias assessment of main results and quality assessment of any moderator analyses. RESULTS We included four randomised trials (n=7208). Potential moderators with strong evidence (p<0.05) in one or more studies were age, employment status and type, back pain status, narcotic medication use, treatment expectations and education. Potential moderators with weaker evidence (0.05<p≤0.20) included gender, psychological distress, pain/disability and quality of life. CONCLUSION There are insufficient robust data on moderators to be useful in clinical practice. This review has identified some important potential moderators of treatment effect worthy of testing in future confirmatory analyses.
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Affiliation(s)
- Tara Gurung
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK.
| | - David R Ellard
- Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK.
| | - Dipesh Mistry
- Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK.
| | - Shilpa Patel
- Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK.
| | - Martin Underwood
- Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK.
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Hao X(A, Xue CC, Dong L, Zheng Z. Factors Associated with Conflicting Findings on Acupuncture for Tension-Type Headache: Qualitative and Quantitative Analyses. J Altern Complement Med 2013; 19:285-97. [DOI: 10.1089/acm.2011.0914] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Xinyu (Alan) Hao
- Traditional & Complementary Medicine Program, Health Innovations Research Institute and School of Health Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Charlie Changli Xue
- Traditional & Complementary Medicine Program, Health Innovations Research Institute and School of Health Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Lin Dong
- Traditional & Complementary Medicine Program, Health Innovations Research Institute and School of Health Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Zhen Zheng
- Traditional & Complementary Medicine Program, Health Innovations Research Institute and School of Health Sciences, RMIT University, Bundoora, Victoria, Australia
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Yun M, Shao Y, Zhang Y, He S, Xiong N, Zhang J, Guo M, Liu D, Luo Y, Guo L, Yan J. Hegu acupuncture for chronic low-back pain: a randomized controlled trial. J Altern Complement Med 2012; 18:130-6. [PMID: 22339101 DOI: 10.1089/acm.2010.0779] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Acupuncture has long been employed for the treatment of chronic low back pain (CLBP). However, very few studies have characterized the effectiveness of the different acupuncture modes for CLBP. METHODS In total, 187 patients with CLBP participated in this study. Eligible patients were randomized to Hegu acupuncture, Standard acupuncture, or Usual Care groups. Eighteen (18) treatments were provided over 7 weeks. Back-related dysfunction and symptom severity were assessed by the Roland-Morris Disability Questionnaire (RMDQ) and the Visual Analogue Scale (VAS), which were collected at baseline and at 8 and 48 weeks after beginning the treatment. Repeated-measures analysis of variance (ANOVA) was employed for factorial analyses. RESULTS Significant differences were found between follow-up and the baseline scores (p<0.05). The Hegu acupuncture group had higher RMDQ scores (8 weeks, 5.3 versus 2.1; 48 weeks, 5.7 versus 3.3; p<0.001 for both) and VAS scores (8 weeks, 1.5 versus 0.5; 48 weeks, 2.6 versus 1.6; p<0.001 for both) compared with the usual care group. The standardized acupuncture group also had higher RMDQ scores (8 weeks, 4.2 versus 2.1; 48 weeks, 4.6 versus 3.3, p<0.001 for both) and VAS scores (8 weeks, 1.3 versus 0.5; 48 weeks, 2.4 versus 1.6, p<0.001 for both) compared with the Usual Care group. The Hegu group had higher RMDQ scores (8 weeks, p<0.05; 48 weeks, p<0.001) and VAS scores (48 weeks, p<0.05) compared with the standardized group. There was a significant difference between the Hegu and standardized acupuncture groups in repeated-measures ANOVA (p<0.05). Across the three testing points, significant differences were found in the RMDQ and VAS scores between the usual care group and both treatment groups (p<0.001). CONCLUSIONS Both acupuncture modes have beneficial and persistent effectiveness against CLBP compared with the usual care group; Hegu acupuncture is significantly more effective than standardized acupuncture, especially in the long term.
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Affiliation(s)
- Mingdong Yun
- Chengdu Military General Hospital, Chengdu, Sichuan, PR China
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Pressman AR, Avins AL, Hubbard A, Satariano WA. A comparison of two worlds: How does Bayes hold up to the status quo for the analysis of clinical trials? Contemp Clin Trials 2011; 32:561-8. [PMID: 21453792 PMCID: PMC4477745 DOI: 10.1016/j.cct.2011.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 03/08/2011] [Accepted: 03/15/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is a paucity of literature comparing Bayesian analytic techniques with traditional approaches for analyzing clinical trials using real trial data. METHODS We compared Bayesian and frequentist group sequential methods using data from two published clinical trials. We chose two widely accepted frequentist rules, O'Brien-Fleming and Lan-DeMets, and conjugate Bayesian priors. Using the nonparametric bootstrap, we estimated a sampling distribution of stopping times for each method. Because current practice dictates the preservation of an experiment-wise false positive rate (Type I error), we approximated these error rates for our Bayesian and frequentist analyses with the posterior probability of detecting an effect in a simulated null sample. Thus for the data-generated distribution represented by these trials, we were able to compare the relative performance of these techniques. RESULTS No final outcomes differed from those of the original trials. However, the timing of trial termination differed substantially by method and varied by trial. For one trial, group sequential designs of either type dictated early stopping of the study. In the other, stopping times were dependent upon the choice of spending function and prior distribution. CONCLUSIONS Results indicate that trialists ought to consider Bayesian methods in addition to traditional approaches for analysis of clinical trials. Though findings from this small sample did not demonstrate either method to consistently outperform the other, they did suggest the need to replicate these comparisons using data from varied clinical trials in order to determine the conditions under which the different methods would be most efficient.
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Treatment expectations and preferences as predictors of outcome of acupuncture for chronic back pain. Spine (Phila Pa 1976) 2010; 35:1471-7. [PMID: 20535051 PMCID: PMC2895682 DOI: 10.1097/brs.0b013e3181c2a8d3] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Preplanned secondary analysis of data from participants receiving acupuncture in a randomized clinical trial. OBJECTIVE To determine whether patients' expectations of and preferences for acupuncture predict short and long-term treatment outcomes for persons with chronic back pain. SUMMARY OF BACKGROUND DATA Although accumulating evidence suggests that patient expectations and treatment preferences may predict treatment outcomes, few studies have examined this relationship for acupuncture. METHODS Four hundred seventy-seven acupuncture-naïve participants with chronic low back pain who were randomized to 1 of 3 acupuncture or simulated acupuncture treatments were the focus of this analysis. Ten treatments were provided during a 7-week period, and participants were masked to treatment assignment. Before randomization, participants provided expectations regarding treatment success, impressions, and knowledge about acupuncture and treatment preferences. Outcomes of interest were functional status (Roland score) and symptom bothersomeness at 8 and 52 weeks postrandomization, obtained by telephone interviewers masked to treatment assignment. RESULTS Persons with high pretreatment expectations for the success of acupuncture were more likely to report greater general expectations for improvement, a preference for acupuncture, having heard acupuncture was a very effective treatment and having a very or moderately positive impression of acupuncture. However, none of these variables was a significant predictor of improvement in back-related symptoms or function at 8 or 52 weeks. After 1 treatment, participants' revised expectations of treatment success were only associated with back-symptoms at the end of treatment. After 5 treatments, revised expectation of success was predictive of both symptoms and function at 8 and 52 weeks. CONCLUSION Pretreatment expectations and preferences for acupuncture were not found predictive of treatment outcomes for patients with chronic back pain. These results differ from previous studies evaluating acupuncture for chronic back pain. These inconsistent results suggest that the relationship between expectations and outcomes may be more complex than previously believed.
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Lee JH, Park HJ, Lee H, Shin IH, Song MY. Acupuncture for chronic low back pain: protocol for a multicenter, randomized, sham-controlled trial. BMC Musculoskelet Disord 2010; 11:118. [PMID: 20540806 PMCID: PMC2896349 DOI: 10.1186/1471-2474-11-118] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 06/14/2010] [Indexed: 12/19/2022] Open
Abstract
Background Use of acupuncture has widely increased in patients with chronic low back pain. However, the evidence supporting its efficacy remains unclear. In this article, we report the design and the protocol of a multi-center randomized sham-controlled trial to treat chronic low back pain. Our goal is to verify the effect of acupuncture on chronic low back pain. Methods/Design This study is a multi-center randomized sham-controlled trial with 2 parallel arms. Participants included in the study met the following criteria: 1) low back pain lasting for at least the last 3 months, 2) a documented ≥ 5 points on a 10 cm visual analog scale for bothersomeness of low back pain at the time of screening and 3) between 18 and 65 years of age. Participants were blinded to the real and sham acupuncture treatments. The real acupuncture treatment group received real acupuncture 2 times a week, during a total of 12 sessions over 6 weeks. The control group received sham acupuncture during the same period. In order to assess the primary and secondary outcome measures, the participants were asked to fill out a questionnaire at the baseline and 6, 8, 12 and 24 weeks after starting the treatments. The primary outcome was measured using the visual analog scale for bothersomeness of low back pain at 8 weeks after the initiation of treatments. Discussion The result of this trial (which will be available in 2010) will demonstrate the efficacy of using acupuncture to treat chronic low back pain. Trial registration This study is registered with the U.S. National Institutes of Health Clinical Trials registry: NCT00815529
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Affiliation(s)
- Jun-Hwan Lee
- Department of Oriental Rehabilitation Medicine, College of Oriental Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul 130-701, Republic of Korea.
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Sherman KJ, Hawkes RJ, Ichikawa L, Cherkin DC, Deyo RA, Avins AL, Khalsa PS. Comparing recruitment strategies in a study of acupuncture for chronic back pain. BMC Med Res Methodol 2009; 9:69. [PMID: 19860906 PMCID: PMC2774333 DOI: 10.1186/1471-2288-9-69] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 10/27/2009] [Indexed: 11/25/2022] Open
Abstract
Background Meeting recruitment goals is challenging for many clinical trials conducted in primary care populations. Little is known about how the use of different recruitment strategies affects the types of individuals choosing to participate or the conclusions of the study. Methods A secondary analysis was performed using data from participants recruited to a clinical trial evaluating acupuncture for chronic back pain among primary care patients in a large integrated health care organization. We used two recruitment methods: mailed letters of invitation and an advertisement in the health plan's magazine. For these two recruitment methods, we compared recruitment success (% randomized, treatment completers, drop outs and losses to follow-up), participant characteristics, and primary clinical outcomes. A linear regression model was used to test for interaction between treatment group and recruitment method. Results Participants recruited via mailed letters closely resembled those responding to the advertisement in terms of demographic characteristics, most aspects of their back pain history and current episode and beliefs and expectations about acupuncture. No interaction between method of recruitment and treatment group was seen, suggesting that study outcomes were not affected by recruitment strategy. Conclusion In this trial, the two recruitment strategies yielded similar estimates of treatment effectiveness. However, because this finding may not apply to other recruitment strategies or trial circumstances, trials employing multiple recruitment strategies should evaluate the effect of recruitment strategy on outcome. Trial registration Clinical Trials.gov NCT00065585.
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Affiliation(s)
- Karen J Sherman
- Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101, USA.
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Sherman KJ, Cherkin DC, Ichikawa L, Avins AL, Barlow WE, Khalsa PS, Deyo RA. Characteristics of patients with chronic back pain who benefit from acupuncture. BMC Musculoskelet Disord 2009; 10:114. [PMID: 19772583 PMCID: PMC2758834 DOI: 10.1186/1471-2474-10-114] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 09/21/2009] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Although many clinicians believe there are clinically important subgroups of persons with "non-specific" low back pain, such subgroups have not yet been clearly identified. As part of a large trial evaluating acupuncture for chronic low back pain, we sought to identify subgroups of participants that were particularly responsive to acupuncture. METHODS We performed a secondary analysis of data for the 638 participants in our clinical trial comparing different types of acupuncture to usual care to identify baseline characteristics that predicted responses to individualized, standardized, or simulated acupuncture treatments. After identifying factors that predicted improvements in back-related function or symptoms, we determined if these factors were more likely to predict improvement for those receiving the acupuncture treatments than for those receiving usual care. This was accomplished by testing for an interaction between the prognostic factors and treatment group in four models: functional outcomes (measured by the Roland-Morris Disability Scale) at 8 and 52 weeks post-randomization and symptom outcomes (measured with a numerical rating scale) at 8 and 52 weeks. RESULTS Overall, the strongest predictors of improvement in back function and symptoms were higher baseline levels of these measures, receipt of an acupuncture treatment, and non-use of narcotic analgesics. Benefit from acupuncture compared to usual care was greater with worse pre-treatment levels of back dysfunction (interaction p < 0.004 for the functional outcome, Roland Morris Disability Scale at 8 weeks). No other consistent interactions were observed. CONCLUSION This secondary analysis found little evidence for the existence of subgroups of patients with chronic back pain that would be especially likely to benefit from acupuncture. However, persons with chronic low back pain who had more severe baseline dysfunction had the most short-term benefit from acupuncture.
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Affiliation(s)
| | | | | | - Andrew L Avins
- Division of Research, Northern California Kaiser Permanente, Oakland, USA
| | - William E Barlow
- Group Health Research Institute, Seattle, USA
- Cancer Research and Biostatistics, Seattle, USA
| | - Partap S Khalsa
- Division of Extramural Research and Training, National Center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, USA
| | - Richard A Deyo
- Deparment of Family Medicine, Oregon Health and Science University, Portland, USA
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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. ARCHIVES OF INTERNAL MEDICINE 2009; 169:858-66. [PMID: 19433697 PMCID: PMC2832641 DOI: 10.1001/archinternmed.2009.65] [Citation(s) in RCA: 288] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Acupuncture is a popular complementary and alternative treatment for chronic back pain. Recent European trials suggest similar short-term benefits from real and sham acupuncture needling. This trial addresses the importance of needle placement and skin penetration in eliciting acupuncture effects for patients with chronic low back pain. METHODS A total of 638 adults with chronic mechanical low back pain were randomized to individualized acupuncture, standardized acupuncture, simulated acupuncture, or usual care. Ten treatments were provided over 7 weeks by experienced acupuncturists. The primary outcomes were back-related dysfunction (Roland-Morris Disability Questionnaire score; range, 0-23) and symptom bothersomeness (0-10 scale). Outcomes were assessed at baseline and after 8, 26, and 52 weeks. RESULTS At 8 weeks, mean dysfunction scores for the individualized, standardized, and simulated acupuncture groups improved by 4.4, 4.5, and 4.4 points, respectively, compared with 2.1 points for those receiving usual care (P < .001). Participants receiving real or simulated acupuncture were more likely than those receiving usual care to experience clinically meaningful improvements on the dysfunction scale (60% vs 39%; P < .001). Symptoms improved by 1.6 to 1.9 points in the treatment groups compared with 0.7 points in the usual care group (P < .001). After 1 year, participants in the treatment groups were more likely than those receiving usual care to experience clinically meaningful improvements in dysfunction (59% to 65% vs 50%, respectively; P = .02) but not in symptoms (P > .05). CONCLUSIONS Although acupuncture was found effective for chronic low back pain, tailoring needling sites to each patient and penetration of the skin appear to be unimportant in eliciting therapeutic benefits. These findings raise questions about acupuncture's purported mechanisms of action. It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or nonspecific effects.
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Affiliation(s)
- Daniel C. Cherkin
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
| | - Karen J. Sherman
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
| | - Andrew L. Avins
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
| | - Janet H. Erro
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
| | - Laura Ichikawa
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
| | - William E. Barlow
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
| | - Kristin Delaney
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
| | - Rene Hawkes
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
| | - Luisa Hamilton
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
| | - Alice Pressman
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
| | - Partap S. Khalsa
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
| | - Richard A. Deyo
- Center For Health Studies, Seattle, WA (Dr. Cherkin , Dr. Sherman , Ms. Erro , Ms. Ichikawa , Ms. Delaney , Ms. Hawkes , Dr. Barlow ); Division of Research, Northern California Kaiser Permanente, Oakland, CA (Dr. Avins, , Ms. Hamilton , Ms. Pressman ); Cancer Research and Biostatistics, Seattle, WA (Dr. Barlow, ); Division of Extramural Research and Training, National center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda, MD (Dr. Khalsa, ; Oregon Health and Science University, Dept of Family Medicine, Portland, OR (Dr. Deyo, )
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