cherkin et al archintmed2009

cherkin et al archintmed2009 - ORIGINAL INVESTIGATION A...

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ORIGINAL INVESTIGATION A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain Daniel C. Cherkin, PhD; Karen J. Sherman, PhD; Andrew L. Avins, MD, MPH; Janet H. Erro, RN, MN; Laura Ichikawa, MS; William E. Barlow, PhD; Kristin Delaney, MPH; Rene Hawkes, BA; Luisa Hamilton, MD; Alice Pressman, MS; Partap S. Khalsa, DC, PhD; Richard A. Deyo, MD, MPH Background : Acupuncture is a popular complemen- tary and alternative treatment for chronic back pain. Re- cent European trials suggest similar short-term benefits from real and sham acupuncture needling. This trial ad- dresses the importance of needle placement and skin pen- etration in eliciting acupuncture effects for patients with chronic low back pain. Methods : A total of 638 adults with chronic mechani- cal low back pain were randomized to individualized acu- puncture, standardized acupuncture, simulated acupunc- ture, or usual care. Ten treatments were provided over 7 weeks by experienced acupuncturists. The primary out- comes were back-related dysfunction (Roland-Morris Dis- ability 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 acupunc- ture groups improved by 4.4, 4.5, and 4.4 points, respec- tively, 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). Symp- toms 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 dys- function (59% to 65% vs 50%, respectively; P =.02) but not in symptoms ( P ² .05). Conclusions : Although acupuncture was found effec- tive 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 find- ings raise questions about acupuncture’s purported mechanisms of action. It remains unclear whether acu- puncture or our simulated method of acupuncture pro- vide physiologically important stimulation or represent placebo or nonspecific effects. Trial Registration : Identifier: NCT00065585 Arch Intern Med. 2009;169(9):858-866 A MERICANS SPEND AT LEAST $37 billion annually on medical care for back pain, 1,2 and our economy suffers another $19.8 bil- lion in lost worker productivity. 3 There is no evidence that escalating expenses for spine care have improved self-assessed health status.
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cherkin et al archintmed2009 - ORIGINAL INVESTIGATION A...

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