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CHAPTER 14/ MANUAL THERAPY IN PATIENTS WITH LOW BACK PAIN / 153
A
B
FIG. 14-2. Mobilization without impulse of the lumbar spine (A) and mobilization without impulse using
the postisometric relaxation of the antagonistic muscle groups (B) also described as neuromuscular
therapy (NMT). C: Arrow indicates the direction of isometr ic muscle contraction. D: Arrow indicates the
direction of mobilization. (From Dvor ak J, Dvorak V, Schneider W , et al.Musculoskeletal medicine (manual therapy), 3rd English ed. Stuttgart/New York: G. Thieme Verlag, 2004, with permission.)
C
D
FIG. 14-3. Schematic drawing of the function of intersegmental rotatory muscles. (From Dvorak J, Dvorak V, Schneider W, et al. Musculoskeletal medicine (manual therapy), 3rd English ed. Stuttgar t/New
York:G. Thieme Verlag, 2004, with permission.)
154 /SECTION II/ALTERNATIVES TO TRADITIONAL NONOPERATIVE TREATMENT
right. These techniques then attempt to increase spinal
motion by stretching the incriminated shortened muscles
and restoring mobility (Tables 14-1, 14-2).
CLINICAL MODEL FOR USE OF MANUAL
THERAPY
Rehabilitative efforts for low back pain, especially when
chronic, often present both a diagnostic and therapeutic
challenge. Many practitioners of manual therapy have
found it useful to approach to this complex clinical presentation by addressing specific clinical parameters first. They
then attempt to integrate the findings (or lack thereof)
within the greater clinical context. Three major domains of
decision making have been identified as important when
considering manual therapy for patients with lo w back pain
or sciatica. These domains of diagnosis, in turn, are often
further subdivided into specific subcategories.
According to this diagnostic approach there are three
separate but interrelated thought processes involved
when formulating a diagnosis for a patient where manual therapy is being considered. The f irst domain, the
“structural diagnosis,” refers to specific organic pathology and relies on the ability to define an objective veri-
fiable pathologic lesion (e.g., disc herniation), osteoporosis, spondylosis, spinal stenosis, spondylolisthesis,
and others. The second domain refers to a “functional
diagnosis” that is based on both manual and functional
performance tests including such findings as muscle
spasm or muscular contraction, gross range of motion,
focal intersegmental restrictions in motion, spinal biomechanics, posture, and gait. The third level of information in the diagnostic process is the domain of the
patient’s “pain perception” including those that exacerbate or decrease the pain and the psychosocial issues
that affect pain.
This model infers that the resolution or diminution of
a patient’s pain can only occur when there is improvement
on all three domains. The practitioner of manual therapy,
using this model, will often include specific and individually tailored rehabilitation ex ercises along with carefull y
chosen passive physical therapeutic modalities all the
while being cognizant of the patient’s psychosocial situation. The unique clinical setting of the manual medicine
practitioner, where there is physical contact with the
patient and often multiple office visits, allows for a closer
doctor-patient interaction than is commonly noted in conventional medical practices.
TABLE 14-1. Overview of some of the most commonly used manual therapy techniques
Manual therapies
Manual medicine techniques Therapeutic massage
Mobilization with impulse without impulse Soft tissue techniques techniques
Thrust techniques Counterstrain technique Ar ticulator y technique Swedish-type massage
1. Chiropractic adjustment Craniosacral technique Deep pressure technique Effleurage (stroking)
2. Osteopathic Thrust Functional technique Diaphragmatic release Pétrissage (kneading)
Terminology Muscle energy technique Lymphatic pump technique Friction (rubbing)
Thrust is also known as: Myofascial release technique Mesenteric release Tapotement (percussion)
1. High-velocity/low Ligamentous release Pectoral release Acupressure
impulse technique or technique Stretch techniques: Lateral, Bindegewebsmassage
2. Manipulation (nonspecific, Myofascial trigger point linear, diagonal, etc. Deep tissue massage
general term) technique Traction Lymphatic massage
a
As with any classification, this table should be used as a general guide rather than a definitive one,
since there is a considerable amount of overlap among the v arious manual medicine techniques, as well
as with some of the massage techniques.
Visual techniques Reflexology
Remarks: Remarks: Remarks:
The nonthrusting techniques Soft tissue techniques are There are numerous types
Mobilization Common massage
Shiatsu
Sports massage (variation
Combined techniques
Neuromuscular treatment I Integrating/movement
Neuromuscular treatment II approaches
Neuromuscular treatment III 1. Alexander technique
2. Feldenkrais method
3. Rolfing
4. Many others
typically take into account used for preparation or of massage approaches
articular and/or soft tissue can be used independently. with even more variations
motion restrictions.
a
of Swedish massage)
CHAPTER 14/ MANUAL THERAPY IN PATIENTS WITH LOW BACK PAIN / 155
TABLE 14-2. Comparison of the ter ms “manipulation” and “mobilization” showing continental differences
Europe USA Comments
Manipulation Refers usually to the thrusting A rather general term, which may When possible, and in order to
Mobilization Refers essentially to any type Usually refers to the various It is best to qualify the type of
From Dvorak J, Dvorak V, Schneider W. (eds). Manual medicine 1984. Heidelberg: Springer Verlag,
1984, and Dvorak J., et al.Manual medicine: diagnostics and therapy, 3rd English ed. Stuttgart:Thieme
Publisher, 2004, with permission.
techniques, which are also refer to any therapeutic avoid confusion, the newer
known as high-velocity/low- procedure in which the hands terminology of “mobilization-withamplitude techniques or the are used to treat the patient, impulse” (= thrust = high“mobilization-with-impulse” including thrust techniques. velocity/low-amplitude [HVLA]
techniques. technique)
or
Chiropractic adjustment is a “mobilization-without-impulse”
generic term with over 100 (= nonthrust techniques) should
sub-techniques, including the be used.
high-velocity/low-amplitude
(HVLA) thrust and the low-force
techniques.
Osteopathic manipulative
treatment (OMT) encompasses
the entire spectrum of manual
therapies from thrust to
nonthrust, including the soft
tissue techniques.
of induced tissue or joint nonthrusting and soft tissue mobilization used.
movement which is then techniques.
qualified by describing the
presence or absence of
impulse forces (thrust vs.
nonthrust techniques,
respectively).
INDICATIONS AND CONTRAINDICATIONS FOR
SPINAL MANIPULATION
The appropriate application of manual medicine procedures, as with any other treatment approach, requires not
only theoretical knowledge and training about the indications and contraindications of a particular technique, but
also a high level of technical skill and experience by the
practitioner (1–3). Unfortunately the identification of the
patient likely to respond to manual therap y is not yet clear.
This lack of information has, as in the case of many medical procedures, led to reliance on consensus conferences
to determine the indications for manual medicine.
In 1990, the RAND Corporation, which has produced
appropriateness guidelines for several health care
provider groups, convened two expert panels to help
establish indications for spinal manipulation for back
pain conditions (4). These indications, when appropriately applied, would include by far the majority of
patients with low back problems (4). These panels stated
that, in the absence of contraindications, a short trial of
therapy using spinal manipulation for patients with lower
back pain with or without sciatica was appropriate.
The absolute or relative contraindications to manual therapy identified by these panels included progressive neuro-
logic deficits from any cause, the most common of which
are disc herniation, space-occupying lesions, and progressive spinal stenosis. Other contraindications include segmental hypermobility due to pathologic and traumatic fractures, acute rheumatoid inflammatory joint disease,
destructive bone lesions secondary to tumor or infection,
and bleeding disorders due to metabolic, congenital, or
medication causes. Some of these conditions may show
some symptomatic relief because of manual therapy as long
as the mobilizations and the therapeutic massage techniques are carefully chosen and cautiously applied.
Major complications from manual therapy applied to
the lumbar spine appear to be extremely rare. There
have been a few case reports of cauda equina syndrome
following lumbar manipulation (5) but it is not yet evident whether the cases would have progressed in the
natural course of the disc herniation or were directly
affected by a manipulation. Thus far there are no good
data indicating spinal manipulation can adversely affect
lumbar discs. The risk of irreversible cauda equina syndrome was estimated by Shekelle et al. (6) to be as low
as 1 in 100 million lumbar spine manipulations, but this
estimate was based only on reported cases and presumably there are a number of additional cases w here a temporal relationship exists.
156 /SECTION II/ALTERNATIVES TO TRADITIONAL NONOPERATIVE TREATMENT
One point that is evident from both clinical practice
and the scientific literature is that manual therapy is not a
panacea and not all patients with low back pain respond
with reduction of symptoms. Explanations for this variation in patient responses include three possibilities (7):
(a) an inadequate workup of the patient’s symptoms leading to a wrong diagnosis; (b) the unnecessary or inappropriate application of manual therapy (the diagnosis may
have been correct but treatment was “wrong”); and (c)
the probability that, for many patients with lo w back pain,
there may be no current adequate treatment.
EFFECTIVENESS OF MANUAL THERAPY IN
THE TREATMENT OF BACK PAIN SYNDROMES
One of the difficulties in performing randomized clinical trials to determine the effectiveness of manual therapy is the ability to perform a double-blind study and the
inability to establish a placebo treatment. This is not
unique to the manual therapies, but is true of all active
treatment approaches including the physical therapies
and exercise. The comparison of manual medicine treatment approaches with other treatment interventions and
the development of placebos based on touching the
patient or performing massage, however, have allowed
certain conclusions to be drawn regarding effectiveness
of the manual therapies relative to no treatment and to
many of the common approaches to patients with low
back pain. Currently there are more than 45 randomized
clinical trials, more than almost any other treatment
approach to low back pain, that have attempted to evaluate the effectiv eness of the manual and manipulati ve therapies. There are also over 50 reviews of the studies that
have been published in peer-reviewed journals. It is only
possible to list a few of these in a short chapter on the
topic and to discuss some of the key findings and conclusions from these papers.
An example of the type of study that has been
attempted to look at the effectiveness of manual therapy
is a prospective randomized clinical study by Koes et al.,
published in 1992 (8), where 256 patients with chronic
low back pain were referred for one of four categories of
treatment (manipulation, physical therapy, placebo, or
treatment by a general practitioner). The patients in the
manipulation group and those in the active physical therapy group show ed a more fa v orab le outcome at the 3- and
6-week follow-up than those who had been assigned to
either the placebo group or treatment by the general practitioner. Howev er , by 12 weeks the differences had almost
entirely disappeared. Yet, patients in the manual medicine
group had received less treatment (5.4 treatment sessions
versus 14.7 treatments) than those in the physical therapy
group, and the authors thought that this might be
regarded as a considerable advantage. The acceptance of
the treatment was greater by the patients in the manual
medicine group than in the other treatment groups. In a
follow-up paper, the authors noted that improvement in
the main complaint was larger with manipulative therapy
(4.5 times) than with physiotherapy (3.8 times) after 12
months’follow-up (difference 0.9; 95% confidence interval 0.1 to 1.7). Manipulative therapy also resulted in
larger improvements in physical functioning (difference
0.6; −0.1 to 1.3). The authors concluded that manual therapy and physiotherapy are better than general practitioner
and placebo treatments, and that manipulative therapy is
slightly better than physiotherapy after 12 months. These
observations are similar to those presented in the retrospective study by Patijn (9).
Triano et al. (10) elected to use a sham manipulation as
a control group in an attempt to create a placebo. These
authors reported on a prospective clinical trial of 145
patients who had experienced chronic back pain who
were randomized into three groups according to specific
manipulation, sham manipulation, and a group who received instruction materials. Two-week follow-up
revealed that the group that had received specific manipulation showed a signif icantly lower visual analog pain
scale value and a greater willingness to participate in
rehabilitation, that is there was a greater trust in actively
participating in their program. The recent study by Aure
et al. (11), on the other hand, looked at the issue as to
whether manual therapy was, as effective as well- established treatment approaches such as exercise. They evaluated patients with chronic low back pain randomized to
either exercise or manipulation with 1-year follow-up to
compare the effect of manual therapy to exercise therapy
in work-disabled patients. Although improvement was
observed in both groups, the manual therapy group
showed signif icantly greater improvement than the exercise therapy group in all outcome variables. Immediately
after the 2-month treatment period, 67% in the manual
therapy group and 27% in the exercise therapy group had
returned to work.
Reviews of the literature on the manual therapies have
included meta-analyses, reviews grading the methodologic quality of the clinical trials, and the use of evidence tables and best evidence synthesis such as that
done through the Cochrane Collaboration. Koes et al.
have published a series of reviews of the scientific literature over the past 12 years using a described method of
ranking the quality of the clinical trials. This group performed one of the earliest meta-analyses of the manipulation literature in 1991. Unfortunately 36 of the randomized clinical studies that they reviewed were thought to
have low methodologic quality scores. They noted that
approximately half of the studies indicated a positive
result for manual medicine approaches on patients suffering from various disorders although the most favorable
results were often in the studies with low methodologic
scores. Similar observations were made when evaluating
studies that looked at the evidence in favor of other treatments such as physical therapy and training therapy (12),
CHAPTER 14/ MANUAL THERAPY IN PATIENTS WITH LOW BACK PAIN / 157
and the evidence for these common treatment approaches
was often less than that for the manual therapies. In 1991,
Shekelle et al. (4), in a very detailed and critical evaluation of the randomized clinical trials, came to a similar
conclusion with a slightly different emphasis. These
authors thought that spinal manipulation had been
demonstrated to be of short-term benefit in certain
patients, particularly those with uncomplicated acute
lower back pain. They based this conclusion on a metaanalysis of a subset of seven clinical trials in which recovery at 3 weeks could be compared with that of other
therapies. The pooled estimate showed a 17% higher likelihood of recovery in fa vor of spinal manipulation. Again,
a substantial number of trials were excluded from the
meta-analysis by these investigators because most of the
published randomized clinical trials at the time had used
outcomes measured on a quantitative scale, such as pain
and disability, rather than dichotomous outcomes.
The most comprehensive systematic reviews involving
an array of different treatments for low back pain have
been performed by van Tulder et al. (13,14) on a regular
basis over the past few years with regular re-analysis of the
newer trials. These authors have assessed the methodolo gic
quality of the trials and used specific evidence-based rules
to determine the presence and strength of evidence of efficacy. They concluded that for acute low back pain there
was evidence to suggest that spinal manipulation is better
than placebo, physical therapy, exercise, and short-wave
diathermy. For chronic lower back pain, they found strong
evidence that spinal manipulation was better than placebo,
and moderate evidence that it was better than the treatment
offered by a general practitioner, massage, bed rest, and
analgesics. Bronfort et al. (15) published a systematic
review of the efficacy of spinal manipulation emphasizing
the magnitude of treatment effects compared to other treatments in determining the strength of evidence. These
authors elected to set aside the conclusions by the investigators of the individual randomized clinical trials and to
focus on the data only. Their analysis reached a conclusion
similar to that of van Tulder et al. in that there is evidence
of short-term eff icacy for spinal manipulation in patients
with both acute and chronic lower back pain.
SUMMARY
Although manual therapy is one of the oldest and most
widely practiced treatments for low back pain, there has
been a rapid growth over the past 20 years in its acceptance and use on an international basis. This is primarily
due to the publication of a large number of clinical trials,
most of which suggest that this therapeutic approach is
at least as efficacious as other established treatment
approaches and is more efficacious than placebo and
usual medical care.
There remain, however, numerous unanswered questions concerning manual therapy. The exact physiologic
effects and mechanisms of manual therapy are not
known. The relative effectiveness of the choice of manual therapy approach depends primarily on the training
and experience of the clinician. Current experimental
and clinical research is beginning to look at these issues
and hopefully, within the near future, it will be possible
to identify the patient who would most likely benefit
from manual therapy and to explain the mechanism
through which the treatment effect is achieved.
REFERENCES
1. Dvorak J, Dvorak V, Schneider W, et al. Musculoskeletal medicine
(manual therapy), 3rd English ed. Stuttgart/New York: G. Thieme Verlag, 2004.
2. Lewit K. Nebenwirkungen und kontraindikationen der manuellen therapie im bereich der halswirbelsaeule. Manuelle Medizin, 1987;25
(2092):42–43.
3. Schneider W. Muskulaere dysbalance. Der informierte Arzt, Gazette
Medicale, 1988;2(1077):66–70.
4. Shekelle PG, Adams AH, Chassin M. The appropriateness of spinal
manipulation for low-back pain: indications and ratings by a multidisciplinary expert panel. Santa Monica, CA: RAND Corporation, 1991.
5. Haldeman S, Rubinstein SM. Cauda equina syndrome in patients
undergoing manipulation of the lumbar spine. Spine 1992;17(12):
1469–1473.
6. Shekelle PG, Adams AH, Chassin MR, et al. Spinal manipulation for
low-back pain. Ann Intern Med 1992;117(7):590–598.
7. Kraft GH. The physiatric approach to upper limb pain syndromes. In:
Physical medicine and rehabilitation clinics of North America.
Philadelphia: WB Saunders, 1996.
8. Koes BW, Bouter LM, van Mameren H, et al. The effecti v eness of manual therapy, physiotherapy, and treatment by the general practitioner for
nonspecific back and neck complaints: a randomized clinical trial.
Spine 1992;17:1:28–35.
9. Patijn J, Durinck JR. Effects of manual medicine on absenteeism. J
Manual Med 1991;6(2):49–53.
10. Triano JJ, McGregor M, Hondras MA, et al. Manipulative therapy versus
education programs in chronic low back pain. Spine 1995;20:948–955.
11. Aure OF, Nilsen JH, Vasseljen O. Manual therapy and exercise therapy
in patients with chronic low back pain: a randomized, controlled trial
with 1-year follow-up. Spine 2003;28(6):525–531; discussion 531–532.
12. Koes BW, Assendelft WJ, Van der Heijden GJ, et al. Spinal manipulation and mobilisation for back and neck pain: a blinded review. Br Med
J 1991;303:1298–1303.
13. van Tulder MW, K oes BW, Bouter LM. Conservative treatment of acute
and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine
1997;22(18):2128–2156.
14. van Tulder MW, Koes BW, Metsemakers JF, et al. Chronic low back
pain in primary care: a prospective study on the management and
course. Fam Pract 1998;15(2):126–132.
15. Bronfort G, Haldeaman S. Spinal manipulation in patients with lumbar
disc disease. Spine Surg 1999;11(2):97–103.
CHAPTER 15
Acupuncture and Reflexology
Marianne L. Magnusson and Malcolm H. Pope
COMPLEMENT AR Y AND AL TERN A TIVE
MEDICINE IN TREATMENT OF LOW BACK PAIN
Despite the increased use and acceptance of complementary and alternative medicine (CAM), there is relatively
little information available concerning efficacy. A survey
of 542 patients attending 16 family practice clinics was
conducted to determine patients’ reasons for using CAM
and the impact of CAM on health and well-being (1).
Approximately 21% of the patients used one or more
forms of CAM, of which the most common were chiropractic (34.5%), herbal remedies (26.7%), and massage
therapy (17.2%). In spite of poor evidence for eff icacy,
CAM is used for low back pain (LBP) more frequently
than for any other indication. Expert opinions on the use
of CAM for LBP could therefore be helpful until more
randomized controlled trials (RCTs) are available. Ernst
and Pitller (2) sent a questionnaire to 50 clinical experts
on LBP to assess the perceived clinical effectiveness of
CAM for four categories of LBP. The conclusions were
that expert opinion is in favor of the effectiveness of
acupuncture for acute uncomplicated LBP, whereas
homeopathy was perceived ineffective for LBP.
REFLEXOLOGY
Furlan et al. (3) conducted a Cochrane Review on massage therapy. Four randomized controlled trials met the
inclusion criteria. Two trials were of high and two were of
low methodolo gic quality. None evaluated massage as the
main intervention. Rather, it was the control intervention
in studies evaluating manipulation, electric stimulation,
and a lumbar corset. There was limited evidence showing
that massage is less effective than manipulation immediately after the first session and moderate evidence showing it is less effective than transcutaneous electric nerve
stimulation (TENS) during the course of sessions in
relieving pain and improving activity. At the completion
of treatment and at 3 weeks after discharge there was no
difference among massage and manipulation, electric
stimulation, or corsets, but this evidence is limited. The
reviewers concluded that there is insufficient evidence to
recommend massage as a stand-alone treatment for nonspecific LBP.
Reflexology has been in existence for many thousands
of years and can be considered a type of massage. It was
first practiced in India, China, and Egypt and then introduced to the West at the beginning of the 20th centur y as
zone therapy (4). It was suggested that pressure on specific par ts of the body could have an anesthetizing effect
on a related area. The body is divided into 10 equal vertical zones, and pressure on one part of a zone is said to
affect all structures within that zone. It was taught that
“bioelectric energy” flowed through these zones to
“reflex points” in the hands and feet. In the 1930s, the
zone therapy was refined into what was termed “foot
reflexology,” which suggests that “congestion” or tension
in any part of the foot mirrors “congestion” or tension in
a corresponding part of the body (5).
Charts with organs superimposed on the foot, hand, or
ear are used to map these points. The reflexologist looking
for constrictions or painful areas probes the theoretical
reflex points by using the charts to determine what body
part corresponds to that area of the foot (or hand or ear,
etc.). There are areas that are said to correspond with the
lumbar spine. Several products (e.g., sandals, shoe inserts,
foot massage devices) are sold based on this theory.
Jarvis (6) concluded, because of a carefully conducted
trial, that reflexology could not reliably f ind conditions
known to be present and thus was not predictive or therapeutic. Jarvis concludes that reflexology has little potential for direct harm, but can mislead people into believing
that it can be used for screening or having real therapeutic value. No scientific trials were found that showed any
value of reflexology for lumbar spine problems. Jarvis
advises us to be skeptical of therapeutic claims beyond
the ability of foot massage for relaxation.
158
CHAPTER 15/ACUPUNCTURE AND REFLEXOLOGY / 159
ACUPUNCTURE
Acupuncture, a form of Eastern medicine that has been
practiced for many centuries, is the stimulation of special
“points” on the body, usually by the insertion of fine needles. Originally there were 365 such points, corresponding to the days of the year, but the number identif ied by
proponents during the past 2,000 years has increased
gradually to over 2,000 (7). Acupuncture uses the meridian systems of the body (Chinese system of energy flow
in the body) to promote healing and treat injury and disease. Through the insertion of needles into well-def ined
acupuncture sites, the nervous system is stimulated to
release chemicals in the muscles, spinal cord, and brain.
These chemicals will either change the experience of
pain, or they will trigger the release of other chemicals
and hormones that influence the body’s own internal regulating system. The improved energy and biochemical
balance produced by acupuncture results in stimulating
the body’s natural healing abilities, and in promoting
physical and emotional well-being. The use of heat and
electric stimulation at the acupuncture sites is thought to
augment the therapeutic effect of needling and is used
particularly in treating chronic pain (8).
The following mechanisms have been proposed to
explain acupuncture’s presumed action on pain: The effects
of acupuncture, particularly on pain, are partially explicable within a conventional physiologic model, which suggests that acupuncture stimulates A
fibers entering the
δ
dorsal horn of the spinal cord. This mediates segmental
inhibition of pain impulses carried in the slower, unmyelinated C fibers and, through connections in the midbrain
enhances descending inhibition of C fiber pain impulses at
other levels of the spinal cord. This helps explain why
acupuncture needles in one part of the body can affect pain
sensation in another region. Acupuncture is also said to
stimulate release of endorphins and other neurotransmitters such as serotonin. This is likely to be another mechanism for the effects of acupuncture, such as in acute pain
(8). Another explanation is the “gate theory”, which suggests that if pain fibers car ry impulses from an acupuncture site, impulses from a painful body organ will be
unable to reach the brain. Attention can be diverted from a
symptom by stimulating or irritating another part of the
body. Psychological mechanisms—including suggestion,
operant conditioning, and other psychological mechanisms—may be involved in the placebo effect.
Theory and Practice
Acupuncture is based on ancient Chinese medical philosophy, which views illness quite differently than contemporary science (9). In ancient China, diseases were
not systematically described or classified (10). Internal
organs, which were felt to be intermediaries between the
body and nature, were assigned qualities representing
emotional states, colors, and seasons. Some organs, such
as the “triple warmer,” were imaginary. There were no
concepts of modern physiology, biochemistry, nutrition,
or mechanisms of healing. There was no knowledge of
the existence of cells, the circulation of the blood, the
function of nerves, or the existence of hormones. Knowledge of anatomy was incomplete.
Diagnosis
Traditional Chinese diagnosis does not correlate with
modern scientific concepts. An ill person was considered
out of balance with nature and its two opposing forces,
yin and yang. Yin represented the feminine, passive, or
accepting qualities and yang the masculine, aggressive,
or forceful ones. Diseases were not described or named.
Diagnoses were made from examining the pulse (of
which there were supposedly six variations) and the
tongue, which was said to v ary in appearance with certain
disease states.
Treatment
Although the details of practice differ between schools,
all traditional acupuncture theory is based on the concept
of yin and yang. Illness is seen as excess or deficiency in
various exogenous and endogenous pathogenic factors,
and treatment is aimed at restoring balance. This reestablishing of “balance” and “harmony” supposedly occurs as
symptoms improve. Since there was no formal study of
diseases or description of their natural history , the ancient
Chinese could rarely determine how an illness actually
improved. Treatments were chosen by trial and error, and
perpetuated by personal experience. Since there were no
scientific criteria for success or failure, the judgment that
“healing” had taken place was based on the word of the
therapist or the patient.
Acupuncture points were assigned to “meridians” on
the surface of the body . These supposedly represent channels through which flows the life force, “Ch’i” (or “Qi”).
Insertion of needles at the designated points was said to
increase or decrease the flow of Ch’i to achieve a more
normal and harmonious state (7).
The life force, Ch’i, has no basis in human physiology.
The meridians are imaginary; their locations do not relate
to internal organs, and therefore do not relate to human
anatomy. Acupuncture points are also imaginary. (Various
acupuncture charts give different locations for the
points.) These concepts continue to form the basis of
modern acupuncture therapy even though extremely
sophisticated methods are used to measure its reputed
biochemical effects. Although scientific methods may be
applied to biochemical studies, many published reports
are based solely and uncritically on clinical anecdotes
and tradition (11). In conclusion, the existence of “merid-
160 /SECTION II/ALTERNATIVES TO TRADITIONAL NONOPERATIVE TREATMENT
ians,” “acupuncture points,” or Ch’i has never been scientifically validated.
VARIATIONS AND OFFSHOOTS OF
ACUPUNCTURE
Acupressure
Acupressure uses firm digital pressure on trigger or
acupuncture points. Shiatsu, a modified form of acupressure, is a form of Japanese traditional medicine (12).
Auriculotherapy
Auriculotherapy is based on the notion that the body and
organs are represented on the ear (13). Needles are placed
in the imaginary points representing the diseased organs.
There is no scientific evidence that these points exist or
that auriculotherapy has any therapeutic value (14).
Staplepuncture
In staplepuncture, staples are placed at acupuncture
points on the ear, typically to aid smoking cessation or
drug withdrawal.
PROS AND CONS OF ACUPUNCTURE
The World Health Organization recognizes the use of
acupuncture in the treatment of a wide range of medical
problems including neurologic and muscular disorders:
1. Digestive disorders: gastritis and hyperacidity, spastic colon, constipation, diarrhea.
2. Respiratory disorders: sinusitis, sore throat, bronchitis, asthma, and recurrent chest infections.
3. Neurologic and muscular disorders: headaches,
facial tics, neck pain, rib neuritis, frozen shoulder,
tennis elbow, and various forms of tendonitis, LBP,
sciatica, and osteoarthritis.
4. Urinary, menstrual, and reproductive problems.
5. Smoking cessation.
The National Council Against Health Fraud (NCAHF)
believes:
1. Acupuncture is an unproved modality of treatment.
2. Its theory and practice are based on primitive and
fanciful concepts of health and disease that bear no
relationship to present scientific knowledge.
3. Research during the past 20 years has failed to demonstrate that acupuncture is effectiv e against an y disease.
4. Perceived effects of acupuncture are probably due to
a combination of expectation, suggestion, counterirritation, operant conditioning, and other psychological mechanisms.
5. The use of acupuncture should be restricted to appropriate research settings.
6. Insurance companies should not be required by law
to cover acupuncture treatment.
7. Licensure of lay acupuncturists should be phased out
(15).
EVIDENCE OF ACUPUNCTURE EFFICACY
Symptom relief with acupuncture is difficult to assess
because there is no objective standard of measurement.
Double-blind studies comparing the insertion of needles at
acupuncture points and at other points (“sham acupuncture”) are difficult to design. If an experienced acupuncturist locates the points, the practitioner’s expectations may
be transmitted to the patient. If an inexperienced person
inserts the points, misplaced needles may undermine the
results. Moreover, practitioners may differ about the location of the points, so it may be difficult to find a patch of
skin that has not been labeled an “acupuncture point.”
Chronic pain is often cyclic, with periods of relief. Since
people often request help when their pain is most severe,
spontaneous improvement may occur, independent of the
treatment (16). The natural history of most acute pain is
that it improves with time and no intervention. Thus, there
may be reports of improvement of symptoms from any
intervention. There is general agreement that 30% to 35%
of subjects’ pain improves from suggestion or placebo
effect alone. Thus, measuring a small difference between
placebo and acupuncture requires a large number of subjects to show as little difference as 25%. People who volunteer for acupuncture may have a conscious or unconscious bias toward the procedure and thus may be more
prone to suggestion.
RESEARCH EVIDENCE
Richardson and Vincent analyzed 28 studies on the
effect of acupuncture on pain. All were published
between 1973 and 1986 in English language peerreviewed journals. Fifteen showed no difference in effectiveness between acupuncture and control groups. Thirteen showed some effectiveness for acupuncture over
control groups, but not all controls were the same. (Some
were compared to sham acupuncture, some to medical
therapy, etc.) Overall, the differences were small (17,18).
The NCAHF Task Force on Acupuncture evaluated the
above studies, as well as more recent ones, and found that
reported benefits varied inversely with quality of the
experimental design. The greater the benefit claimed the
worse the experimental design. Most studies that showed
positive effects used too few subjects to be statistically
significant. The best designed experiments—those with
the highest number of controls on variables—found no
difference between acupuncture and control groups (15).
In 1989 Dutch epidemiologists reported similar conclusions in 91 separate clinical trials of acupuncture for various disorders. They also found that the stricter the con-
CHAPTER 15/ACUPUNCTURE AND REFLEXOLOGY / 161
trols, the smaller the difference between acupuncture and
control groups (19).
Research evidence also shows that acupuncture has
greater effects than placebo. Randomized trials have
found that true acupuncture is more effective in relieving
pain than a “sham” technique, such as inserting needles
away from true points (however, the aforementioned disagreement about the localization of points should be considered). Of the numerous studies on nausea, a condition
that readily lends itself to placebo controlled trials,
almost all show that stimulating true acupuncture points
is more effective than stimulating false points. Studies
showing that acupuncture can af fect anesthetized animals
provide further evidence that its effects probably cannot
be explained purely in psychological terms (7).
It is less clear whether acupuncture has clinically
important benef its in the conditions for which it is typically used. Much of the research evidence comes from
hospital-based studies of acute conditions such as postoperative pain rather than studies of chronic conditions in
primary care. Moreover, most trials have had small numbers of patients and only short-term follow-up. Overall,
evidence from several randomized controlled trials supports the use of acupuncture in pain conditions, particularly migraine, headache, and postoperative pain. Such
trials also provide e vidence of an effect of acupuncture in
substance misuse, nausea, and stroke. Trials of acupuncture in asthma and hay fever have produced conflicting
results. Systematic reviews and randomized controlled
trials suggest that acupuncture is probably not of benefit
for stopping smoking, tinnitus, or obesity.
ACUPUNCTURE AND LBP
The use of acupuncture to treat LBP has increased dramatically in the past few decades. In spite of this, there is
very sparse scientific documentation of outcomes from
these treatments. In one study, 12 patients suffering
chronic LBP were treated with both acupuncture and
TENS. The order of treatments was balanced, and changes
in the intensity and quality of pain were measured with the
McGill Pain Questionnaire. Pain relief was produced in
both groups and lasted between 23 hours for TENS and 40
hours for acupuncture. The difference between the treatments was not statistically significant. According to the
authors, both methods could be equally effecti ve, and probably have the same underlying mechanism of action (20).
However, as there was no pure control treatment group the
pain relief could be a Hawthorne effect or the two treatments were equally effective or ineffective.
Carlsson and Sjölund (21) randomly assigned 50
patients who had been suffering chronic LBP for a minimum of 6 months and had tried a variety of other therapies to a manual acupuncture group, an electroacupuncture group, or a placebo group. Treatment was delivered
once per week for 8 weeks and follow-up treatments
after 6 months or longer. The placebo group was given
mock stimulation. An independent and blinded-to-treatment assessment (clinical interview, physical examination) at baseline and at follow-ups at 1, 3, and 6 months
classified the patient’s pain as improved, unchanged, or
worse. Subjectively, patients reported pain intensity at
the follow-ups. At the 1-month independent assessment,
16 of 34 patients in the acupuncture group and 2 of 16 in
the placebo group improved (p < .05). There was also a
significant decrease of pain intensity at 1 and 3 months
in the acupuncture group. Sleep pattern was less disturbed and total intake of analgesics dropped dramatically after the treatment period in the acupuncture group,
but not in the placebo patients. After 6 months, 14
acupuncture patients and two placebo patients were still
improved (p < .05). There was no difference between
types of acupuncture.
Kalauokalani et al. (22) analyzed 135 patients with
chronic LBP who received acupuncture or massage in a
randomized trial. Before randomization, study participants
were asked to describe their expectations regarding the
helpfulness of each treatment on a scale of 0 to 10. The
primary outcome was level of function at 10 w eeks as measured by the modified Roland Disability Scale. Improved
function was observed for 86% of the participants with
higher expectations for the treatment they receiv ed as compared with 68% of those with low er e xpectations ( p < .01).
Furthermore, patients who expected greater benef it from
massage than from acupuncture were more likely to experience better outcomes with massage than with acupuncture, and vice versa (p < .03). The study suggests that
patient expectations may influence clinical outcome independently of the treatment itself. In contrast, general optimism about treatment, divorced from a specific treatment,
is not strongly associated with outcome.
Cherkin et al. (23) randomized 262 patients with persistent LBP to receive traditional Chinese medical
acupuncture (n < 94), therapeutic massage (n < 78), or
self-care educational materials (n < 90). Telephone interviewers masked to treatment group assessed symptoms
and dysfunction. Follow-up was available for 95% of
patients after 4, 10, and 52 weeks, and none withdrew for
adverse effects. Treatment groups were compared after
adjustment for pre-randomization covariates using an
intent-to-treat analysis. At 10 weeks, massage was significantly superior to self-care on the symptom (p < .01) and
the disability scale (p < .001). Massage was significantly
superior to acupuncture on the disability scale (p < .01).
After 1 year, massage was not better than self-care but
was better than acupuncture on the symptom and dysfunction scales (p < .002 and p < .05, respectively). The
massage group used the least medications and had the
lowest costs of subsequent care (p < .05). Therapeutic
massage was effecti v e for persistent LBP, pro viding longlasting benefits. Traditional Chinese medical acupuncture
was relatively ineffective.
162 /SECTION II/ALTERNATIVES TO TRADITIONAL NONOPERATIVE TREATMENT
A systematic review to assess the effects of acupuncture as treatment of nonspecific LBP was conducted by
van Tulder et al. (24). Eleven studies were included, of
which only two were of high quality. In the review, van
Tulder et al. disagree with the original authors’ conclusions in 7 of the 11 studies. According to v an T ulder et al.,
there was no difference between acupuncture and control
in seven trials. Acupuncture was superior in only two
studies, whereas the results were unclear in the remaining
two trials. Thus, 9 of the 11 studies could not show that
acupuncture was more effective than placebo or sham
acupuncture, nor with trigger-point injection or TENS.
The reviewers’ conclusions were that this systematic
review did not indicate that acupuncture is effective for
the treatment of back pain.
A meta-analysis by Ernst et al. (25), of randomized
controlled trials on acupuncture for back pain involving
data from nine studies, showed improvement with acupuncture compared with control intervention with an
odds ratio of 2.30 (95% confidence interval 1.28 to 4.13).
It was concluded that collectively, the data implied that
acupuncture is superior to various control interventions,
although there was insufficient evidence to prov e whether
it is superior to placebo.
Although both studies, which virtually used the same
RCTs, conclude that there is not enough evidence to
prove acupuncture more effective than any other treatment, they present contradicting results. This is due to the
different methods of assessing methodologic quality and
of summarizing the results that were chosen. Because of
the low quality, methodologic problems, and in some trials, the use of an invalid acupuncture treatment, van Tulder et al. used a qualitative analysis, which took into
account the levels of evidence rather than a statistical
pooling across trials. Ernst et al. used a meta-analysis and
quantitatively pooled the results from the trials.
SAFETY OF ACUPUNCTURE
As with all CAM, the absence of a formal system for
reporting adverse effects means that acupuncture’s safety
is difficult to assess. The definition of adverse effect
varies and both under- and over-reporting occur. Most
adverse effects are relatively minor events such as bruising and dizziness but more serious events have been
reported such as hepatitis and pneumothorax (26,27). A
prospective study of over 55,000 acupuncture treatments
given in a college for medically trained acupuncturists
confir ms that acupuncture is probably safe in qualif ied
hands (28). Only 63, mostly minor, adverse events were
identified, and no cases of serious adverse events such as
pneumothorax, infection, or spinal lesions were reported,
although these have been described in the literature (27).
The adverse effects of acupuncture are probably
related to the nature of the practitioner’s training. A sur-
vey of 1,135 Norwegian physicians revealed 66 cases of
infection, 25 cases of punctured lung, 31 cases of
increased pain, and 80 other cases with complications
(29). A parallel survey of 197 acupuncturists, who are
more apt to see immediate complications, yielded 132
cases of fainting, 26 cases of increased pain, 8 cases of
pneumothorax, and 45 other adverse results (29).
In summary , because the quality of the RCTs that e valuated acupuncture was generally poor, the effectiveness
of acupuncture for treating acute or chronic back pain is
unclear. However, acupuncture seems to be relatively safe
(30).
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