BehindTheMedspeak: Toothpick Acupuncture

Long story short: It works as well as the real thing .

Why pay more?

Here's an article from the May 12, 2009 Guardian to get you started.

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Acupuncture needles can improve back pain — and so can toothpicks

Acupuncture can lead to lasting improvements for people with long-term low back pain, according to a new study - but so can simulated acupuncture using toothpicks pressed against skin. These findings suggest that penetrating the skin with needles may not be necessary for the treatment to work.

What do we know already?

Low back pain is extremely common. Up to 85 percent of people in the UK have back pain at some point in their lives, and about 5 million people see their GP for back pain each year. Most people's back pain improves in less than two weeks, but some have pain for three months or more. Long-term back pain is harder to treat, leading many people to seek out alternative therapies, such as acupuncture.

Acupuncture uses very fine needles placed into specific points around the body (called acupuncture points). Some doctors think acupuncture helps the body to release natural chemicals that block the feeling of pain. Some studies have found that acupuncture can ease the symptoms of low back pain, and help people move more freely.

But most studies have been fairly short, so it's unclear how long the benefits of acupuncture last. Also, some research has found that shallowly inserting needles into non-acupuncture points can also improve low back pain, raising questions about how acupuncture actually works. To explore these issues further, researchers have now looked at how real acupuncture compares with simulated acupuncture that doesn't pierce the skin, in both the short and long term.

What does the new study say?

The study included 638 adults with long-term low back pain who were randomly assigned to receive one of the following four treatments over seven weeks:

• 10 acupuncture sessions that were tailored to them individually
• 10 acupuncture sessions that weren't tailored, but instead followed a standard approach for low back pain
• 10 sessions of simulated acupuncture, which involved applying a toothpick inside a needle-guide tube to acupuncture points, to mimic insertion, stimulation and removal of needles
• Usual care provided by a GP, with no real or simulated acupuncture added.

People who had real or simulated acupuncture wore eye masks to conceal which treatment they were receiving.

After eight, 26 and 52 weeks, the participants were interviewed about their symptoms and how much the pain was hampering their usual activities (their level of dysfunction). They were also asked to rate how troublesome their pain was on a scale of zero (not troublesome at all) to 10 (extremely troublesome).

Overall, people who had either real or simulated acupuncture had less pain and were less hampered in their activities than those who had only usual care. Acupuncture that was tailored to the individual didn't seem to help any more than standard or simulated acupuncture.

After eight weeks:

• 60 percent of people who had real or simulated acupuncture had improvements in how much activity they could do, compared with only 39 percent of those receiving usual care
• Pain scores improved by 1.6 to 1.9 points in people who had real or simulated acupuncture, compared with 0.7 points for those receiving usual care.

After one year:

• 59 percent to 65 percent of people who'd received real or simulated acupuncture had improvements in how much they could do, compared with 50 percent in the usual care group. There was no significant difference between the groups in pain scores.

Tell me more about the study's findings

The study also looked at how much pain medicine people used, and whether they'd cut down on activities because of their back pain.

• When interviewed after eight weeks, 59 percent of people in the usual-care group reported using pain medicine in the previous week, compared with 47 percent of those who'd had real or simulated acupuncture. This difference between groups continued after 26 and 52 weeks.
• When interviewed at 52 weeks, 18 percent of people in the usual-care group reported cutting down on activities for more than a week in the previous month, compared with 5 percent to 7 percent in the real and simulated acupuncture groups.

How reliable are the findings?

The study was large and carefully done, so its findings should be fairly reliable. But it leaves several questions unanswered. For example, if simulated acupuncture works as well as acupuncture with needles, it is possible that both groups felt better because they believed the treatment would help them (the placebo effect). Or there may be something else about both treatments which helped. It also raises the question of how acupuncture might work, if needle insertion is not necessary.

Also, the research doesn't tell us how acupuncture compares with other treatments for long-term back pain, such as physiotherapy and exercise.

Where does the study come from?

The study was done by researches in California and Washington State, and was funded by the US National Institutes of Health and the National Center for Complementary and Alternative Medicine. It was published in a medical journal called the Archives of Internal Medicine, which is owned by the American Medical Association.

What does this mean for me?

If you've had low back pain for more than three months, you may wish to try acupuncture. This study shows that it may provide pain relief and help you get on with your usual activities. Some of these improvements may be long lasting. You may also find you're less reliant on painkillers.

But bear in mind that this could be a placebo effect, and a modified treatment that doesn't pierce the skin may work equally well.

Also, there is good evidence that a variety of other treatments work well for long-term back pain. These include non-drug treatments such as exercise, multidisciplinary programmes and behaviour therapy.

What should I do now?

If you'd like to try acupuncture, be sure to find a qualified practitioner. Acupuncture is usually a safe treatment, but it is possible to get an infection if the needles haven't been properly sterilised.

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Here's the abstract of the paper published in the May 11, 2009 issue of the Archives of Internal Medicine.

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A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain

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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This site features a video interview with Daniel Cherkin, Ph.D, who led the study.