Interesting study. I believe that one reason why acupuncture (whether simulated or actual) is effective is that it speeds the healing process. Thus, it is logical, when attempting to show that participants report better results than standard treatment with acupuncture, it is due to the increase of lymph, blood, and Qi circulation to the injured area, speeding the rate at which the body heals. It may even be that acupuncture assists a better circulation of adult stem cells to the area for internal renewal, which is happening all the time anyway (though possibly at a less efficient rate without acupuncture).
—Laurie Morse, LAc, MTOM

I appreciate Dr. Stern's comments and agree that replicating the study to reach similar conclusions would be a good step toward evidence-based medicine for acupuncture. I find it curious that the assumption of the "placebo effect" is very often associated with acupuncture. I find that to be true of any medicine—standard or complementary—as it's the nature of humanity. One of the best arguments against acupuncture being placebo is that it also works on animals, a group that the placebo effect doesn't usually show up in. Nonetheless, whether placebo is part of the effect of acupuncture is probable, but I don't think it's the whole picture.

I wonder what Dr. Stern meant by "clear cut improvement". Did he mean a removal of all symptoms? I would be inclined to say that after 8 weeks a level of improvement is quite reasonable and I would look for clear cut improvement after a greater length of time, say 6-9months, depending on the chronic nature of pain for each patient. I think a "level of improvement" is welcome to anyone in pain. We have to remember that healing back pain is alongside usually, constant and all-day use of the core of a body. The body's job of healing injured tissue in addition to the ongoing repair of micro-tears that are renewed without our conscious awareness can be quite a load some days. A two-steps-forward, one-step-back process, if you will.

It's encouraging that studies continue to reflect positive results in the relief of pain using acupuncture. As well, it's encouraging that people continue to seek out acupuncture even without a large amount of evidence-base.

Some patients shy away from alternative medicine because it's not scientifically proven. However, a recent study may change a few minds. A research team found that acupuncture delivered more back pain relief to patients than mainstream treatments, such as physical therapy—even if toothpicks were used instead of needles.

The Study
The research findings, published in the May 11, 2009, issue of the Archives of Internal Medicine are part of the largest acupuncture and back pain study ever conducted in the US.

A total of 638 patients, all of whom had chronic mechanical low back pain, participated in the study. The researcher team separated the participants into four groups. Over a 7-week period, they observed how different acupuncture treatments, along with mainstream treatments, compared in reducing back pain.

One group received standard acupuncture treatment, where an acupuncturist inserts needles into specific points that are known to be effective at reducing back pain. Another group received individually-prescribed acupuncture treatments, where needling sites are tailored to the patient.

A third group underwent simulated acupuncture, in which an acupuncturist used toothpicks instead of needles. The toothpicks did not pierce the skin, as in a typical acupuncture treatment, but it targeted the standard acupuncture points.

A fourth group received "usual care" or more traditional back pain treatments, including physical therapy and medication.

Throughout the 7-week course of treatment, all four groups were allowed to use conventional treatments to help control their pain. For example, people in the simulated acupuncture group could still take aspirin during the study. The

Results
At 8 weeks, the researchers found that 60% of the patients who underwent actual or simulated acupuncture functioned better than they had before, compared to 39% of those receiving usual care. To determine the degree of pain relief, the researchers gave the participants pre- and post-treatment questionnaires that help measure the level of pain the patients experienced.

Interestingly, there was no significant difference in the pain-relieving benefits of traditional acupuncture (using needles) versus simulated acupuncture (using toothpicks).

"It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or nonspecific effects," wrote the researchers.

A Spine Professional's Opinion
Jack Stern, MD, PhD, is a neurosurgeon in White Plains, NY, who also has a background in holistic medicine. Dr. Stern is a co-founder of the Center for Holistic Medicine at United Hospital in New York City, one of the country's first in-hospital holistic care centers.

Dr. Stern has an interest in studies of evidence-based medicine (meaning treatments that are proven by science), particularly when they extend into the realm of alternative and complementary medicine. But he also believes that, at least right now, there is no good way of monitoring the effectiveness of such treatments. And because of that, many patients assume they aren't effective.

"My concern is that patients will cast out treatments that have been around for thousands of years because they can't be proven," he says. "I'm always disinclined to do these sorts of studies because I think some of it is beyond our ability to test, at least today. A lot of it has to do with the placebo effect."

Additionally, Dr. Stern believes some people may be confused by the study. It shows a level of effectiveness, but it doesn't show clear cut improvement.

"We conventionally think of acupuncture as needles that have to penetrate the skin, and it raises questions," Dr. Stern says. "Maybe it's simply the placement of the pressure. Maybe acupressure should have been considered. In any case, there's no real clarity. The study simply showed there was efficacy." (Efficacy refers to the treatment's effectiveness, or ability to work as expected.)

While the results could open more patients up to the idea of acupuncture and other alternative and complementary methods, the study lacks a definitive conclusion, according to Dr. Stern. He suggests replicating the study. And even though it is the largest ever conducted on the topic in the US, he believes testing a larger population will yield more illuminating results.

"While the efficacy is there, the study is still unclear to me," Dr. Stern said. "It lends more questions, but that leads to more important discoveries."

Regardless of the merits and drawbacks of the study, Dr. Stern believes complementing your traditional treatment plan with less mainstream methods, including acupuncture, can be an effective and safe treatment for patients with back pain.

View Sources

Cherkin DC, Sherman KJ, Avins AL, et al. A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain. Arch Intern Med. 2009;169(9):858-866.